A 34-year-old man presents with 3 days of fever, headache, behavioural change, and two focal seizures. MRI brain shows asymmetric signal change with haemorrhagic involvement of both temporal lobes. CSF shows lymphocytic pleocytosis with elevated red cells. What is the most appropriate immediate treatment?

• A Intravenous ganciclovir
• B Intravenous ceftriaxone and vancomycin
• C Oral valacyclovir
• D Intravenous acyclovir ✓

Explanation

Temporal lobe predilection with haemorrhagic necrosis and red cells in the CSF is classic for herpes simplex virus type 1 encephalitis, the commonest sporadic fatal encephalitis. Empirical intravenous acyclovir 10 mg/kg every 8 hours must start immediately, before PCR confirmation, because delay markedly increases mortality. Ceftriaxone and vancomycin treat bacterial meningitis, which does not produce focal temporal necrosis, and ganciclovir targets CMV.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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