HSV-2 Meningitis Presenting with Acute Hydrocephalus Ultimately Requiring Long Term CSF Diversion

Herpes simplex virus type 1 and 2 can infect the human nervous system causing meningitis and encephalitis. HSV meningitis tends to be benign, but HSF encephalitis can have a high morbidity and mortality despite treatment. We present a case of HSV meningitis leading to hydrocephalus without evidence of encephalitis. The patient had persistent hydrocephalus requiring long term CSF diversion despite successful treatment of the infection. A 57 year old African-American female presented with acute decline in sensorium secondary to hydrocephalus. HSV type 2 was isolated from the CSF by polymerase chain reaction (PCR). There was no evidence of infiltrative lesion in the brain parenchyma on MRI. She was treated with CSF diversion and antiviral therapy. The meningitis was successfully treated, but the patient required ventriculoperitoneal shunt placement due to persistent hydrocephalus. This is the second reported case of post HSV-2 meningitis presenting with acute hydrocephalus, and first reported case of persistent hydrocephalus following HSV-2 meningitis. Adult HSV-2 meningitis usually has a benign course. Hydrocephalus is rare sequelae of this condition. The patient in this case was treated for HSV meningitis, and the virus was cleared from the CSF upon repeat PCR testing. Aqueductal stenosis from ependymal inflammation may play a role in the pathophysiology of hydrocephalus. This is the first reported case of persistent hydrocephalus following HSV-2 meningitis that required a permanent CSF diversionary procedure. Viral etiology should be actively sought in a case of spontaneous and unexplained hydrocephalus, even in an adult.