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Viral encephalitis is associated with significant morbidity and mortality, particularly when appropriate management is omitted as a result of delayed diagnosis. A case of herpes simplex virus type 1 (HSV-1) encephalitis is presented, demonstrating that the presentation of confusion, speech difficulties and fever with non-specific early brain CT appearances can easily be misdiagnosed as pneumonia with stroke. This case highlights the need for increased awareness of HSV-1 encephalitis among emergency physicians and radiologists, given that the early spectrum of clinical and CT findings can mimic the more common diagnoses of sepsis and stroke.

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A 57-year-old man presented with a 2-week history of confusion and low-grade fever. His history included alcoholism, hypertension, type 2 diabetes mellitus and a left internal capsular infarct. Ten years earlier he had presented with multiple cerebral abscesses and cerebrospinal fluid (CSF) rhinorrhoea. A biopsy of the abscess at that time had cultured Streptococcus pneumoniae which responded to i.v. antibiotics, but he had refused surgery.On this admission, a computed tomography scan showed fluid in the sinuses, pneumocephalus, and an air-fluid level suggestive of an abscess (Fig. 1). Lumbar CSF showed increased protein, a neutrophilia of 13 × 10 9 /L, glucose 1.2 mmol/L and no growth on culture. CSF antigens for Haemophilus influenzae, S. pneumoniae, Group B streptococci and Neisseria meningitides were negative, as were blood cultures. A transoesophageal echocardiogram showed no abnormality.The patient was commenced on ceftriaxone, metronidazole and penicillin. Following endoscopic closure of a left sphenoid sinus CSF leak he made a good recovery and returned to his former place of residence.With the increasing use of antibiotics there has been a reduction in the incidence of complications from paranasal sinusitis. 1 Despite this, 40% of cerebral abscesses are due to sinusitis 2 and, as this case illustrates, untreated sinusitis can still have devastating consequences. REFERENCES 1 Gallagher RM, Gross CW, Phillips CD. Suppurative intracranial complications of sinusitis. Laryngoscope 1998; 108 (II Part I): 1635-42. 2 Chalstrey S, Pfleiderer AG, Moffat DA. Persisting incidence and mortality of sinogenic cerebral abscess: a continuing reflection of late clinical diagnosis. J R Soc Med 1991; 84: 193-5. Figure 1Non-contrast head computed tomography scan showing a large quantity of gas in the ventricular system accompanied by an abscess in the right mid-parietal area.