Doctor Elects Not To Give HSV-Positive Patient Antiviral Medication

Victoria Negron

Written by
— Updated on March 1, 2018

Neurology Expert

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.

Question(s) For Expert Witness

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

Expert Witness Response E-036010

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.

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