Herpes simplex virus (HSV) encephalitis is the most common cause of nonendemic sporadic encephalitis in the United States. Treatment with acyclovir has been proven to reduce mortality by 50%. Antiviral therapy should be initiated immediately in patients with clinical suspicion of viral encephalitis and should not be delayed by serological confirmation of the diagnosis. The most common central nervous system complication of HSV encephalitis is seizures (38%), while intracranial hemorrhage is very rare (2.7%). We describe a case of a 59-year-old African American male who presented to the hospital after being found unresponsive for a day and was found to have HSV-1 encephalitis that was complicated by hemorrhagic conversion. Our patient's neurological status did not improve even with appropriate antiviral treatment with a 28-day course of intravenous (IV) acyclovir. Intracranial hemorrhage is a rare complication in patients with HSV encephalitis. Close monitoring of neurological status is recommended for signs of deterioration or lack of improvement, and further imagings are needed (as in our patient) to evaluate for neurological complications such as intracranial hemorrhage.

Bilateral vocal cord paralysis is a potentially life-threatening condition, depending on the position in which the vocal cords are paralyzed. When the vocal cords are fixed in adduction, patients develop respiratory distress, inspiratory stridor, aspiration, and minimal phonation deficits. This condition can result from acute injuries to the right and left recurrent laryngeal nerves, or from chronic bilateral recurrent laryngeal nerve palsy. The clinical presentation is variable with such nerve injuries. Traumatic injuries to the cervical spine are an uncommon cause of this condition. In this report, we describe a patient who developed progressive respiratory distress, inspiratory stridor, and dysphagia to liquids several weeks after suffering major trauma to the head and neck. Laryngoscopy revealed immobile bilateral vocal cords fixed in the paramedian position, resulting in severe airway obstruction that warranted an emergency tracheostomy.