Difficulties in the treatment of post-infectious epilepsy. Case from clinical practice

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Introduction. Herpetic encephalitis (HE), caused by herpes simplex viruses types 1 and 2 (HSV 1/2), is the most common encephalitis in developed countries. The incidence of GE is 0.2-04 per 100 thousand population, although some studies provide values ​​up to 1.2 per 100 thousand. Among etiologically verified cases of acute encephalitis, GE accounts for 14 to 20%. The disease is characterized by a very severe course. According to a number of authors (Gorelik E.Yu., Skripchenko N.V., Vilnits A.A., etc.), without specific etiotropic therapy, mortality from HE can reach 70%, but even with timely initiation of adequate therapy, mortality reaches 10 -25%, and 40-60% of survivors develop severe neurological disorders.
Target. To present a clinical case of post-infectious drug-resistant epilepsy.
Clinical case. Patient A., born in 2012, suffered encephalitis of herpetic etiology in May 2018, confirmed by laboratory data (positive PCR titers of cerebrospinal fluid for HSV type 1). The disease debuted with serial acute symptomatic convulsions, against which a clinical picture of cerebral edema and coma 2 developed. The girl was in the intensive care unit and was subjected to mechanical ventilation for 17 days. Subsequently, the condition stabilized. In August 2018, the girl developed focal epileptic seizures - motor tonic, hemiclonic, the frequency of which reached 5-6 times a day. In some cases, the attacks were accompanied by a feeling of fear, crying, laughter, muscle atonia with a sudden fall. The patient underwent EEG video monitoring, which revealed focal epileptiform activity in the temporal leads with amplitude predominance on the right. An MRI of the brain (six months after the process) showed symmetrical diffuse glial-atrophic changes in the frontotemporal regions and moderately severe open hydrocephalus. Later, a CT scan of the brain revealed signs of encephalomalacia in the fronto-parietal-temporal regions, partial atrophy of the brain substance, and compensatory moderate triventriculoventriculomegaly. After the diagnosis of post-infectious focal epilepsy was established, monotherapy with valproic acid was started at a dose of 35 mg/kg/day. Against this background, attacks persisted with a high frequency, and therefore a second drug, levetiracetam, was added at a dose of up to 40 mg/kg/day. However, even with polytherapy, it was not possible to achieve significant control over the attacks. The third drug was topiramate, which caused aggravation of the attacks. Then lacosamide was introduced into therapy at a dose of 100 mg/day. Against this background, attacks became less frequent to 1-2 times a week and predominantly developed upon awakening. The patient was consulted at the Federal State Budgetary Institution "Children's Research and Clinical Center for Infectious Diseases of the Federal Medical and Biological Agency." The diagnosis was made: “Herpetic encephalitis, sluggish course, right-sided hemiparesis, structural post-infectious epilepsy.” A repeated course of antiviral therapy (Viferon, acyclovir) was administered. The course of the disease was characterized by frequent attacks and increasing cognitive impairment. Multiple attempts to adjust therapy (lamotrigine, oxcarbazepine, clobazam) did not lead to remission of attacks. Kinematics were dominated by focal motor seizures with transition to bilateral tonic-clonic seizures.
Conclusions. Herpetic encephalitis is a severe infectious disease, which is one of the most common causes of the formation of post-infectious drug-resistant epilepsy, which is difficult to control when prescribing antiepileptic drug therapy, which, in fact, is demonstrated by the presented clinical case.

About the authors

Jujuna Murmanovna Tsotsonawa

Astrakhan State Medical University

Email: post@astgmu.ru
ORCID iD: 0000-0003-3275-5099
Russian Federation, 414000 Astrakhan, ul. Bakinskaya, 121

Natalia Alekseevna Shipilova

Astrakhan State Medical University

Author for correspondence.
Email: nataliasipilova3@gmail.com
ORCID iD: 0000-0003-3312-2963
SPIN-code: 1728-7015

Student 

Russian Federation, 414000 Astrakhan, ul. Bakinskaya, 121

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