Journal of the Formosan Medical Association (2015) 114, 1295e1296

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CORRESPONDENCE

Glioblastoma masquerading as herpes

simplex encephalitis
Jianwen Wang, Benyan Luo*
Department of Neurology, First Affiliated Hospital, Zhejiang University School of Medicine,
Hangzhou, China
Received 30 April 2014; received in revised form 19 July 2014; accepted 29 July 2014

A 50-year-old man presented with headache, confusion,

and an episode of seizure. Two days prior to admission the
patient complained of headache without nausea, vomiting,
or fever. The day prior to admission his temperament
changed, he was easily irritated and seemed to have hallucinations or illusions. He was sometimes in a confused
state and experienced a 60-second seizure spell on the day
of admission. There was no remarkable family or personal
history. On admission, the patients vital signs were normal
but he was confused and could not answer questions or
follow verbal commands. The motor examination revealed
withdrawal of all extremities from noxious stimuli. Reflexes
were 2 throughout, and the plantar responses were flexor.
Signs for meningitis signs were negative.
An emergent computerized tomography (CT) scan of the
head showed a hypodense region in the left frontaleparietal
lobe. Lumbar puncture revealed the cerebral spinal fluid (CSF)
pressure was 200 mmH2O. Examination of the CSF showed
white blood cells of1/mL, protein levels of 0.68 g/L and
glucose levels of 3.4 mmol/L. Herpes simplex virus immunoglobulin G antibody in the CSF was positive. A brain magnetic
resonance imaging (MRI) obtained on the 2nd day showed high
T2 signal change affecting the left temporal and parietal lobes
and left thalamus. There were also scattered high T2 signal
change in both semioval centers and an abnormal lesion in the
Conflicts of interest: The authors have no conflicts of interest
relevant to this article.
* Corresponding author. Department of Neurology, First Affiliated
Hospital, Zhejiang University School of Medicine, No. 79, Qingchun
Road, Hangzhou, 310003, China.
E-mail address: benyanluo@163.com (B. Luo).

left frontaleparietal lobe consistent with widened VirchoweRobin space (Fig. 1). An electroencephalography was
abnormal showing nonspecific diffuse slowing. Routine laboratory studies including blood routine tests, live and renal
function, blood sugar, thyroid function, antinuclear antibody,
erythrocyte sedimentation rate, C-reactive protein, alphafetoprotein, carcinoembryonic antigen, were all unremarkable. The patient was treated with acyclovir and methylprednisolone under the suspicion of herpes simplex
encephalitis (HSE). Two weeks later, his symptoms mostly
resolved with mild memory and cognitive impairment. A
repeated brain MRI with gadolinium enhancement showed the
lesion in the left temporal and parietal lobes was slightly
resolved (Fig. 1). The patient was discharged home.
Two months later, the results of a third brain MRI scan
remained unchanged. Four and a half months later, the
patient was admitted with dizziness and underwent a
fourth brain MRI scan. The MRI revealed an increase in the
size of the left temporal and parietal lesion on T2-weighted
image. Two new heterogeneous contrast-enhancing lesions
were shown on gadolinium-enhanced T1 weighted images
(Fig. 1). The patient underwent a surgical resection of the
left parietal lesion. The diagnosis of glioblastoma was
confirmed on histopathologic findings.
Glioblastoma is a diffusely growing malignant brain
neoplasm with characteristic histological features, and a
few cases of glioblastoma can present as acute encephalitic
syndrome or encephalopathy. Whitley et al1 confirmed that
two out of 95 patients who were biopsy-negative for HSE had
glioblastoma. Rees and Howard2 reported three cases of high
grade glioma which mimicked acute viral encephalitis. Nam
et al3 reported another case with glioblastoma mimicked

http://dx.doi.org/10.1016/j.jfma.2014.07.012
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1296

J. Wang, B. Luo

Figure 1 (AD). Initial brain MRI showed high T2 signal change affecting the left temporal and parietal lobes and left thalamus,
and scattered high T2 signal change in both semioval center. The abnormal lesion in the left frontaleparietal lobe was consistent
with widened VirchoweRobin space. (EeH) Brain MRI obtained 2 weeks later showed the lesions in the left temporal and parietal
lobes were slightly resolved. (IeL) Brain MRI obtained 4.5 months later showed an increase in the size of the left temporal and
especially the left parietal lesion on T2-weighted image. (MeP) Gadolinium-enhanced T1 weighted image showed two new heterogeneous contrast-enhancing lesions in the left parietal and temporal lobe. MRI Z magnetic resonance imaging.

HSE and corticosteroid-induced temporal improvement.

There was one interesting case with the occurrence of HSE
and glioblastoma.4 In patients with indefinite diagnosis of
HSE, brain MRI follow-up is needed to document the evolution of the brain lesion and stereotactic brain biopsy is
necessary to confirm the pathologic diagnosis.

References
1. Whitley RJ, Cobbs CG, Alford Jr CA, Soong SJ, Hirsch MS,
Connor JD, et al. Diseases that mimic herpes simplex

encephalitis. Diagnosis, presentation, and outcome. JAMA 1989;

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2. Rees JH, Howard RS. High-grade glioma mimicking acute viral
encephalitise-three case reports. Postgrad Med J 1999;75:
727e30.
3. Nam TS, Choi KH, Kim MK, Cho KH. Glioblastoma mimicking
herpes simplex encephalitis. J Korean Neurosurg Soc 2011;50:
119e22.
4. Lins H, Kanakis D, Heinrichs T, Dietzmann K, Wallesch CW,
Mawrin C. Sudden progression of a glioblastoma in partial
remission? Clin Neurol Neurosurg 2004;106:335e6.