a 27-year - old man visited our hospital because of a sudden - onset generalized convulsion .
he had been overworking and had slept less than 5 hours a day for the previous month . a week prior to the hospital visit , the patient had developed a fever and generalized myalgia but had not taken any medicine .
high fever , anorexia , and generalized malaise appeared . on the day of the hospital visit , he could not be awakened , and he showed no responses to any stimulus .
finally , he developed a generalized tonic - clonic seizure that lasted for about three min and that was accompanied by cyanosis , upward eyeball deviation , and tongue biting . on physical examination at the emergency department , the patient s body temperature rose up to 38.7c .
he was confused and could not follow the examiner s verbal commands appropriately , and he often attempted to run out of the bed while yelling incomprehensible words and abuses .
neck stiffness was found on neurologic examination . positive or negative myoclonic jerk was not observed .
the cerebrospinal fluid ( csf ) was clear , and its pressure was measured at 16.0 cmh2o , with 20 leukocytes/l ( 95% lymphocytes ) , protein levels of 70.5 mg / dl , and normal glucose levels ( 63.0 mg / dl ) .
aspartate aminotransferase ( ast ) , alanine aminotransferase ( alt ) , and -glutamyl transpeptidase levels were increased to 441 , 1294 , and 460
total bilirubin and direct bilirubin levels were normal ( 0.6 mg / dl and 0.2 mg / dl , respectively ) .
seizure did not relapse after 30 min of continuous infusion of 15 mg / kg of phenytoin mixed with normal saline .
he regained consciousness on the second admission day and became fully conscious the following day .
intravenous acyclovir was given for two days because of the clinical suspicion of herpes encephalitis , which was discontinued after observing the clinical improvement and the detection of the igm antibody of hav .
the patient s score on the korean version of the mini - mental status examination ( k - mmse ) score was 30 on the fifth admission day .
serum and csf igm antibodies of herpes simplex type 1 , 2 , and varicella zoster were negative . polymerase chain reaction ( pcr ) of the csf for hav and enterovirus were also negative .
ast and alt levels decreased to 125 and 432 iu / l on the seventh admission day .
hav , which causes an acute inflammatory hepatitis , is a picornavirus , which is transmitted by the fecal - to - oral route .
the clinical spectrum varies from mild flu - like illness to fatality caused by acute fulminant hepatitis . in the anicteric form
, diagnosis may be delayed due to the atypical presentation of the disease . in general , the disease is preceded by flu - like prodromes , and the progression of the hepatitis symptoms and liver enzyme elevations is relatively rapid . in a week or so , liver enzymes stop elevating and gradually decrease to normal levels .
diagnosis can be made by the detection of the serum igm antibody of hav [ 46 ] .
common pathomechanisms are attributed to a disturbed detoxification process by the damaged liver and metabolic disturbances , such as fluid electrolyte imbalances .
our patient had a seizure in an early stage of the disease , and he showed no specific laboratory abnormalities other than liver enzyme elevations .
he showed neck stiffness and a clouding of consciousness that was accompanied by csf abnormalities that were compatible with encephalitis .
these findings support the diagnosis of encephalitis rather than that of toxic - metabolic disturbances due to the hepatitis .
after reviewing five cases , including the above report , altered consciousness and seizures are commonly manifested .
positive hav pcr results were reported in one case , of which csf cells and protein were normal .
the clinical courses were all benign ; all patients improved within a few days to a few weeks with supportive treatment [ 2,3,810 ] .
hav - associated encephalitis is a very rare disorder , which has not been reported in korea .
no specific radiological or eeg findings are observed . in particular , in the anicteric form of the disease , the diagnosis may be difficult without a clinical suspicion . when progressive liver enzyme elevations are observed in patients with encephalitis
 encephalitis is caused by multiple organisms , but rarely by the hepatitis a virus . 
 a 27-year - old man visited our hospital because of fever , altered consciousness , and seizures . on physical exam , a stuporous mentality and neck stiffness were found . on laboratory exam , elevated liver enzymes and cerebrospinal fluid abnormalities , including pleocytosis and elevated protein levels 
 were observed . 
 the hepatitis a virus ( hav ) igm antibody was also detected . 
 we conclude that these findings were compatible with encephalitis associated with hav and discuss the pathomechanisms . 