A 50-year-old Caucasian woman presented with severe throbbing headache, neck stiffness and photophobia for 1 day. She also had a 3 day history of flu-like symptoms as well as progressive difficulty with urination. On examination, she was febrile with neck stiffness. Kernig's and Brudzinski signs of meningismus were positive. She had normal sensation and power in the lower extremities. Deep tendon reflexes in the lower extremities were normal. Also, perianal sensation and anal tone were normal. She did not have genital lesions and denied past history of sexually transmitted infections.
Bladder scan revealed post void urine of 750 ml, and a Foley catheter was placed. (Fig. 1). Unenhanced head CT was negative for any acute intracranial pathology (infarct, hemorrhage or mass). Brain and spine MRI did not reveal any features suggesting myelitis or radiculitis (Fig. 2). CSF analysis showed WBC of more than 700, predominantly lymphocytes, glucose of 50 mg/dl, protein 150 mg/dl and a negative gram stain. CSF was negative for Myelin basic protein and oligoclonal bands.
Due to predominance of lymphocytes in the CSF and a negative gram stain, empiric antiviral therapy was initiated with a 10 day course of intravenous Acyclovir at 10 mg/kg three times a day. Although her headache and photophobia subsided within 48 hours; she continued to have urinary retention and required intermittent urinary catheterization. Urodynamic study was undertaken on day 5 of presentation which confirmed the presence of atonic bladder.
She was then started on Bethanechol and Tamsulosin. At this point CSF-PCR came back confirming HSV-2 infection. CSF was negative for HSV1, Listeria, Cryptococcus, Tuberculosis, and VDRL.
She showed excellent recovery of bladder function within 2 weeks of onset of symptoms. A follow-up visit at 6 months confirmed persistence of her recovery.