Doctor Elects Not To Give HSV-Positive Patient Antiviral Medication

Case Overview

This case involves a young woman who presented to the ER with new-onset seizures. The patient suffered a stroke within a few hours of hospitalization and was treated for alcohol withdrawal seizures. While the young woman was in the hospital, there was concern from her doctors that she had HSV encephalitis. The neurologist decided to give her acyclovir preemptively. The next day, a craniotomy was performed for brain swelling and the patient was diagnosed with a stroke of unknown cause. The acyclovir was stopped and she was subsequently transferred to a rehab facility. While the patient was at the rehab facility, her blood culture came back positive for HSV. This was communicated to the rehabilitation doctor in charge of the patient, but the rehabilitation doctor elected not to re-start the acyclovir in spite of the neurologist’s recommendation. Following her discharge from the rehab center, the patient continued to have seizures and suffered severe brain damage. It was alleged that if the rehab doctor had re-started the acyclovir, the patient would not have suffered this brain damage. An expert neurologist with experience treating patients with HSV encephalitis, alcohol withdrawal seizures, and stroke was sought to review the records and address any potential lapses in the standard of care.

Questions to the Neurology expert and their responses

Please describe your work treating patients with HSV encephalitis and stroke.

I am a professor of neurology and neurocritical care at a west-coast university and a full time attending in the neuroscience ICU there. I am the program director of a neurocritical care fellowship and I've recently given a continuing medical educational (CME) seminar on the interface between neurology and the law. HSV encephalitis is always at the top of my differential diagnosis of a young patient presenting with seizures; not because it is necessarily the most common cause of the presentation, but because early recognition of the condition, and early treatment, profoundly impact the functional outcome. In our neurology ICU, we take care of more than 30 patients per year with encephalitis, with causes including HSV, HVZ, autoimmune encephalitis-including NMDAR antibody positive encephalitis, arbovirus encephalitis and viral meningitis. Our 17-bed ICU, for which I am a neurointensivist, has 5-10 patients on any given day who have had both acute ischemic and hemorrhagic stroke. We also care for patients with alcohol withdrawal syndromes on a regular basis. As an expert witness, I have reviewed one prior case of an individual who was not treated for HSV encephalitis in a timely fashion.

About the expert

This expert has over 30 years of experience in the field of neurology and neurocritical care. She earned her BA in philosophy from Oberlin College and her MD from Case Western Reserve University School of Medicine. She then completed a residency in internal medicine and a second residency in neurology at the University of California, San Francisco, followed by a fellowship in neurocritical care at the University of Cincinnati. Today, this expert is board certified in both neurology and neurocritical care. She is an active member of several professional societies, including the American Academy of Neurology, the Neurocritical Care Society, and the Society for Critical Care Medicine. This expert previously was the director of the headache and pain clinic at the University of Kentucky, the medical director of the Kentucky Neuroscience Institute, and an associate professor of neurology at Case Western Reserve University and the University of Kentucky. Currently, she serves as a professor of neurology and neurocritical care at a university and as an attending neurologist at a university-affiliated medical center in Oregon.

E-036010

Specialties:

Neurology

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