Title : Incidental diagnosis of enterovirus encephalitis in a cheerleader following head trauma
Abstract:
We present a case of enterovirus encephalitis in a female cheerleader who presented to the emergency department (ED) with symptoms following a head injury. The case illustrates the importance of thorough evaluation and the unexpected diagnosis of viral encephalitis, which was identified through cerebrospinal fluid (CSF) analysis, despite an initial clinical presentation suggestive of traumatic injury. A 23-year-old female with a past medical history of iron-deficiency anemia, and narcolepsy presented to the emergency department with complaints of a headache and blurry vision following a recent head trauma. The patient reported sustaining trauma to her left face when a fellow cheerleader's elbow struck her supraorbital region twice. She experienced immediate significant pain, nausea, and feelings of instability following the injury. These symptoms persisted for several days and prompted a visit to an outside facility. At that time, a CT of the head and cervical spine were performed, both of which were negative for acute pathology. Her symptoms, however, did not improve, and she developed blurry vision. A week later, she visited an ophthalmologist who reported bilateral papilledema and recommended that she present to the ED for evaluation. Upon presentation to the ED, the patient was evaluated for the possibility of a post-traumatic process, including intracranial injury or venous thrombosis. An MRI and MRV of the brain were performed, which revealed no acute intracerebral processes or evidence of dural venous sinus thrombosis. Given the presence of papilledema and the patient's ongoing neurological symptoms, a lumbar puncture was performed. The CSF analysis revealed increased opening pressure, pleocytosis with lymphocytic predominance and decreased glucose concentration. The CSF studies were subsequently sent for viral PCR, which returned positive for enterovirus. The finding of pleocytosis with lymphocytic predominance, along with the positive enterovirus PCR in the CSF, was suggestive of viral (enteroviral) encephalitis. Empiric antibiotic therapy was immediately discontinued. Given the absence of any acute traumatic findings on neuroimaging and the presence of viral encephalitis, the patient's symptoms were ultimately attributed to enterovirus infection rather than the head trauma. Enterovirus encephalitis is a viral infection that can present with non-specific neurological symptoms, including headache, fever, and altered mental status. In this case, the patient's presentation with headache and papilledema initially raised concern for increased intracranial pressure, likely due to post-traumatic causes. However, the diagnostic workup, including lumbar puncture and CSF studies, revealed an unexpected viral etiology. This case demonstrates the incidental finding of enterovirus encephalitis in a young female athlete following head trauma. It emphasizes the need for a comprehensive evaluation in patients with persistent neurological symptoms, as conditions like viral encephalitis can present with overlapping symptoms, mimicking more common diagnoses such as post-traumatic headache or concussion. Early recognition and appropriate management are key to ensuring favorable outcomes in such cases.
