Acute haemolysis and renal failure after nomifensine overdosage.
Authors: L F Prescott, R N Illingworth, J A Critchley, I Frazer, M L Stirling
Journal: BMJ (1980)

Transolfactory spread of virus in herpes simplex encephalitis* Unlike most encephalitides, acute necrotising encephalitis caused by Herpesvirus hominis type I exhibits several unique features, including a tendency to affect the limbic system, often asymmetrically and resulting in maximal damage to one or other temporal lobe.In a recent case' herpesvirus was especially prevalent throughout the limbic system and in the necrotic olfactory bulbs, suggesting that transolfactory spread of virus may be important in pathogenesis.The next three cases were therefore similarly investigated. Case reportsCase 1-A 78-year-old man was admitted in coma after three days of rapidly progressive confusion and drowsiness.Examination showed neck stiffness, fever, and hypertension.The cerebrospinal fluid contained 25 x 109 red cells/I (25 000/mm3) and 82 x 106 white cells/i (82/mm3) (48% lymphocytes); normal glucose and protein concentrations; and negative Gram and Ziehl-Neelsen.He developed prolonged seizures, deteriorated, and died after five days.Case 2-A 66-year-old woman was admitted in coma after three weeks of gradually progressive dementia, right-sided weakness, and convulsions.V T-Case 3. Electronmicrograph of intranuclear inclusion bodies in cell of left olfactory bulb.Characteristic virions of herpes simplez are present, some of which (arrowed) show unusual swelling, loss of nucleic acid core, and partial fragmentation of thin nucleocapsids, presumably resulting from adenine arabinoside.x 26 000 (original magnification).Neck stiffness, right hemiplegia, and fever were present.CT brain scan was normal, and bilateral carotid angiograms showed brain swelling.Cerebro- spinal fluid contained 40 x 108 white cells/l (80%/ lymphocytes) and 2-8 g protein/l; Gram and Ziehl-Neelsen stains, culture, and complement fixation tests for herpes, mumps, and measles viruses gave negative results.She died four days after admission.Case 3-A 2+-year-old girl was admitted after a "febrile convulsion."She presented with pharyngitis, otitis media, fever, and a 12-hour history of left-sided facial twitching.The electroencephalogram and CT brain scan suggested encephalitis.Cerebrospinal fluid was normal.Viral studies, which included complement fixation tests on serum and cerebrospinal fluid, and culture of cerebrospinal fluid, throat, and rectal swabs gave negative results.Adenine arabinoside was started on the third day but she continued to deteriorate and died on the seventh day.In each of these cases the brain showed all the features characteristic of acute necrotising encephalitis, including unilateral swelling and necrosis of the temporal lobe, panencephalitis without inclusion bodies, and abundant herpes simplex virus on electron microscopy.Herpes simplex virus was especially prevalent in the left and right temporal lobes and throughout the limbic system in cases 1 and 2, but in case 3 the virus was more evenly distributed throughout both hemispheres.Interestingly herpes simplex virus was found in the necrotic olfactory bulbs (figure).Necrotic cells con- taining herpes simplex virus were found in both right and left bulbs in each case and were associated with pronounced degeneration of myelinated fibres and prominent astrocytosis and gliosis in the olfactory tracts.