key: cord-0883073-v02zqu61
authors: R, Traynor; B, Shanahan; J, Walsh; A, Ryan; G, Pope
title: STROKE, COVID-19 INFECTION OR HERPES SIMPLEX ENCEPHALITIS: A DIAGNOSTIC DILEMMA
date: 2022-02-11
journal: Ulster Med J
DOI: nan
sha: 6cdd44204467357ac958dc23c35a94e7c1d8afb0
doc_id: 883073
cord_uid: v02zqu61

nan

0.03%, and is an ophthalmic emergency that might lead to permanent visual loss if left untreated. 2 During 2007-2010, of the 95265 DESPNI episodes with Tropicamide dilation, 2 cases were identified, giving the risk of 1 in 31 755 and annual incidence was 0.75 cases. 3 The recommendations to DESPNI included clear instructions of AAC symptoms and emphasising the need for urgent treatment should they occur. This was after peer-to-peer education regarding AAC awareness in ophthalmic screening healthcare programme.

This audit aims to assess the incidence and management of AAC occurring within 72 hours of DESPNI attendance with tropicamide mydriasis between 01/09/2016 to 28/02/2021. A retrospective case-note review was carried out, cross referencing medical and DESPNI records, to identify relevant AAC episodes occurring within 72 hours of a DESPNI visit with mydriasis. The standards were extracted from 'Ophthalmic Services Guidance Eye Drops Instillation by Unregistered Health Care Professionals for use within NHS Ophthalmic Services'. For this current audit, 159 patients were identified as having had AAC during 01/09/2016 to 28/02/2021. Only one had AAC within 72 hours of DESPNI's tropicamide dilation and was successfully managed. Over the 54 months period of observation, 206334 patients were screening by DESPNI with a dilation rate of approximately 75%, so altogether 154750 patients were dilated. The incidence of AAC within the screening programme was calculated to be 1 event per 154750 episodes. The annual incidence of angle closure was 0.2 cases per year. This improves our ability to inform patients of the low risk of AAC within DESPNI. The AAC incidence within DESPNI was calculated to be 1 event per 154750 episodes, this is less than reported in other publications such as the populationbased Rotterdam Study, where AAC incidence was 3 in 10 000 following tropicamide mydriasis. 4 We advocate the provision of clear instructions to patients in diabetic screening regarding access to emergency ophthalmic care following dilation to prevent visual loss in this rare event. ) . From the outset we maintained a broad differential. Given the presenting features, stroke, encephalomeningitis and Covid-19 infection were at the forefront of our differential. She was empirically treated with IV acyclovir, ceftriaxone and dexamethasone while awaiting results of lumbar puncture. Following diagnosis she continued on acyclovir alone. This patient gradually recovered with no residual symptoms although she reported retrograde amnesia of her initial presentation. Follow up MRI showed a resolving process.

Herpes Simplex virus (HSV) is responsible for 19% of cases of infectious encephalitis. [1] It represents significant morbidity and mortality to patients with a one year mortality rate of 14%. [2] Typically, patients present with symptoms of fever, headache and confusion although speech disturbance can be seen in 57% and focal neurological deficit in 26% of cases. [3] Encephalitis is a known mimic of stroke and atypical presentations can often be misdiagnosed. In some cases this has led to inappropriate treatment with alteplase and in others misdiagnosis can lead to delay in initiating appropriate treatment. [4] The emergence of Covid-19 has further confounded this area. Neurological manifestations of Covid-19 can been seen in up to 25% of patients.

[5] On MRI, unilateral medial temporal lobe oedema, a recognised finding in HSV encephalitis, has been demonstrated in patients with Covid-19 in the absence of HSV.

[6] This overlap in features risk delay in initiation of correct treatment for patients.

We feel this case is of particular interest as it highlights the importance of maintaining an open mind when managing a patient who has an atypical combination of symptoms particularly in the context of the current pandemic.

Laryngotracheobronchitis or croup, whilst common in childhood, is rare in adults. We present an unusual clinical presentation of infection with Sars-COV-2, COVID-19 Laryngotracheobronchitis.

A 52-year-old female presented to the Emergency Department with a three day history of progressive fatigue, hoarseness and dysphagia. On examination she was sitting forward, breathing quietly, aphonic and drooling. She had mild bilateral cervical lymphandenopathy. Flexible nasendoscopy showed mild supraglottic oedema and erythema, but no airway compromise. Chest xray demonstrated "steeple sign" (Figure 1) indicative of laryngotracheobronchitis or "croup."

She had a mild inflammatory response demonstrated by a C-Reactive Protein of 15mg/L. There were no symptoms to necessitate a COVID-19 test had she not attended hospital, however her polymerase chain reaction (PCR) for SARS-CoV-2 resulted positive, with viral PCR for Influenza A & B, and Respiratory Syncytial Virus (RSV) all negative. The presumed diagnosis was of COVID-19 Laryngotracheobronchitis. Treatment was supportive, in the form of intravenous fluids, humidified oxygen and intravenous Erect Chest X-ray of the patient demonstrating the typical "steeple sign associated with laryngotracheobronchitis

Diabetic retinopathy as detected using ophthalmoscopy, a nonmydriatic camera and a standard fundus camera

Angle closure glaucoma in the Northern Ireland Diabetic Retinopathy Screening Programme

Risk of acute angleclosure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study

UK Health Protection Agency (HPA) Aetiology of Encephalitis Study Group, et al. Causes of encephalitis and differences in their clinical presentations in England: a multicentre, population-based prospective study

Herpes simplex encephalitis in Sweden

Herpes simplex virus encephalitis: clinical manifestations, diagnosis and outcome in 106 adult patients

Asadi-Pooya AA, Simani L. Central nervous system manifestations of COVID-19: A systematic review

The authors declare no conflict of interest. This project was funded by The Wellcome Trust.Dr Matthew O'Donnell 1 , Professor Augusto Azuara-Blanco 1,2 , Prof Tunde Peto 1,2