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253 Dear Editor, A 62-year-old female patient presented to our emergency department due to fever and unconsciousness, which had gradually progressed over the last three days. Her medical history was unremarkable. At admission, vital signs revealed a fever of 38.7 °C. In a neurologic examination, the patient was evaluated as lethargic. She could give a verbal response as incomprehensible sounds and could not cooperate constantly. Kernig’s and Brudzinski’s signs were negative. Laboratory examinations showed mild leukocytosis (white blood cells: 12,400/dL, hemoglobin: 11.8 g/dL, platelets: 400,000/dL, C-reactive protein: 2.18 mg/L); other investigations including blood biochemistry, vitamin B12, and folic acid were within the normal limits. Diffusion-weighted imaging (DWI) was performed in the acute period, which showed high signal on DWI and an isointense signal on apparent diffusion coefficient sequences in the left temporal lobe, which was compatible with vasogenic edema (Figure 1). We attempted lumbar puncture (LP) twice, but failed due to technical problems. Therefore, with a preliminary diagnosis of encephalitis, broad-spectrum therapy of intravenous acyclovir 3x750 mg, ceftriaxone 2x2 g and ampicillin 4x3 g were initiated in the emergency department and the patient was hospitalized for follow-up and administration of maintenance therapy. In the following course, the neurologic examination of the patient was stable; however, on the third day of hospitalization, she had a generalized tonicclonic seizure. Intravenous 5 mg diazepam was administered, which provided cessation of seizure and the patient was transferred to our intensive care unit. However, she had one more generalized tonic-clonic seizure one hour later. After a prompt neurologic assessment, valproic acid 2x500 mg was initiated. It was a weekend and an electroencephalography (EEG) technician was not on duty. Hence, EEG was planned to be performed two days later within working hours. Nevertheless, a significant deterioration in the patient’s neurologic status was recognized soon after the seizures, such that she could only open her eyes to painful stimulus, there was no motor response, but a verbal response could be obtained (Glasgow Coma Score: 4). The third attempt of LP was successful and cerebrospinal fluid (CSF) investigations showed mild protein elevation [47 mg/dL (normal: 15-45)], and normal glucose levels. CSF microscopy examinations showed leukocytes as 180/mm3 and erythrocytes 50/mm3 supporting the diagnosis of encephalitis. Contrastenhanced magnetic resonance imaging (MRI) was recorded on the 4th day of hospitalization, which revealed an edematous lesion in the left uncus of the parahippocampal gyrus, anterior temporal lobe, and posterior part of the frontal lobe (Figure 2). EEG could be performed on the next day (5th day) of hospitalization, which showed a severe slowing of the background activity and 1.5-2 Hz, generalized, asymmetric, periodic discharges (PD) (GPD) in the bilateral hemisphere (Figure 3). With the possible diagnosis of non-

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Periodic Discharges in Herpes Encephalitis Presenting with Non-convulsive Status Epilepticus: A Detailed Demonstration of the Temporal Correlation Between EEG and Neurologic Status