We heard a case today for which the diagnosis was unclear. The patient presented with a febrile illness with odynophagia and headache accompanied by hallucination which was ascribed to group A streptococcus.
A review of the neurologic sequelae of GAS infection is available here. There has been a link between GAS infections and neuropsychiatric symptoms (primarily OCD and tic disorders) in children.
He was also treated for HSV encephalitis because of fever, headache, and the development of seizures. This was despite an initially negative HSV PCR. Many experts will continue treatment and repeat the LP in 3-7 days in patients in whom they have a high index of suspicion. This would be such a case. The ID Society of America has guidelines on the management of viral encephalitis available here. This article outlines the risk factors for severe disease and poor outcome in HSV encephalitis.
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