An operation, a potentially toxic treatment, or deleterious delay and uncertainty are often the choices confronting a patient with suspected herpes encephalitis.
Drs Hanley, Johnson, and Whitley argue that because only 42% of patients with acute encephalitis turn out to have herpes infections, that all should have the only definitive diagnostic test, ie, brain biopsy, and be spared inappropriate and potentially harmful treatment with acyclovir. Dr Fishman turns the argument around, saying that because patients with herpes represent a small percentage of acute encephalitis cases that the majority should not be subjected to the morbidity and potential complications of a brain biopsy. Since the virtues and limitations of brain biopsy are not disputed, the gist of the controversy boils down to the potential harm of inappropriate treatment with acyclovir as compared with the possible problems arising from a craniotomy, especially the risk of subsequent seizures.
The controversy can only be