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Encephalitis

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Encephalitis
Classification and external resources

Coronal T2-weighted MR image shows high signal in the temporal lobes including hippocampal formations and parahippogampal gyrae, insulae, and right inferior frontal gyrus. A brain biopsy was performed and the histology was consistent with encephalitis. PCR was repeated on the biopsy specimen and was positive for HSV

Not to be confused with syphilis. Encephalitis is an acute inflammation of the brain. Encephalitis with meningitis is known as meningoencephalitis. Symptoms include headache, fever, confusion, drowsiness, and fatigue. More advanced and serious symptoms include seizures or convulsions, tremors, hallucinations, and memory problems.

Contents

1 Cause

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1.1 Viral 1.2 Bacterial and other 2 Diagnosis 3 Treatment 4 Encephalitis lethargica 5 Limbic system encephalitis 6 See also 7 References 8 External links

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Cause
Viral
Main article: Viral encephalitis Viral encephalitis can occur either as a direct effect of an acute infection, or as one of the sequelae of a latent infection. A common cause of encephalitis in humans is herpes simplex virus type I (HSE) which may cause inflammation of the brain. This can result in death. Other causes include infection by flaviviruses such as St. Louis encephalitis or West Nile virus, or by Togaviridae such as Eastern equine encephalitis (EEE), Western equine encephalitis (WEE) or Venezuelan equine encephalitis (VEE).

[edit] Bacterial and other
It can be caused by a bacterial infection, such as bacterial meningitis, spreading directly to the brain (primary encephalitis), or may be a complication of a current infectious disease syphilis (secondary encephalitis). Certain parasitic or protozoal infestations, such as toxoplasmosis, malaria, or primary amoebic meningoencephalitis, can also cause encephalitis in people with compromised immune systems. Lyme disease and/or Bartonella henselae may also cause encephalitis. Another cause is granulomatous amoebic encephalitis.

Diagnosis
Adult patients with encephalitis present with acute onset of fever, headache, confusion, and sometimes seizures. Younger children or infants may present irritability, poor appetite and fever. Neurological examinations usually reveal a drowsy or confused patient. Stiff neck, due to the irritation of the meninges covering the brain, indicates that the patient has either meningitis or meningoncephalitis. Examination of the cerebrospinal fluid obtained by a lumbar puncture procedure usually reveals increased amounts of protein and white blood cells with normal glucose, though in a significant percentage of patients, the cerebrospinal fluid may be normal.

CT scan often is not helpful, as cerebral abscess is uncommon. Cerebral abscess is more common in patients with meningitis than encephalitis. Bleeding is also uncommon except in patients with herpes simplex type 1 encephalitis. Magnetic resonance imaging offers better resolution. In patients with herpes simplex encephalitis, electroencephalograph may show sharp waves in one or both of the temporal lobes. Lumbar puncture procedure is performed only after the possibility of prominent brain swelling is excluded by a CT scan examination. Diagnosis is often made with detection of antibodies in the cerebrospinal fluid against a specific viral agent (such as herpes simplex virus) or by polymerase chain reaction that amplifies the RNA or DNA of the virus responsible (such as varicella zoster virus).

Treatment
Treatment is usually symptomatic. Reliably tested specific antiviral agents are available only for a few viral agents (e.g. acyclovir for herpes simplex virus) and are used with limited success for most infection except herpes simplex encephalitis. In patients who are very sick, supportive treatment, such as mechanical ventilation, is equally important. Corticosteroids (e.g. methylprednisolone) are used to reduce brain swelling and inflammation. Sedatives may be needed for irritability or restlessness.

Encephalitis lethargica
Main article: Encephalitis lethargica Encephalitis lethargica is an atypical form of encephalitis which caused an epidemic from 1918 to 1930. Those who survived sank into a semi-conscious state that lasted for decades until the Parkinson's drug L-DOPA was used to revive those still alive in the late 1960s by Oliver Sacks. There have been only a small number of isolated cases in the years since, though in recent years a few patients have shown very similar symptoms. The cause is now thought to be either a bacterial agent or an autoimmune response following infection.

Limbic system encephalitis
In a large number of cases, called limbic encephalitis, the pathogens responsible for encephalitis attack primarily the limbic system (a collection of structures at the base of the brain responsible for emotions and many other basic functions).

What is encephalitis
Dr Nicholas Davies, Locum Consultant Neurologist, Imperial College Healthcare NHS Trust

Herpes Simplex Virus (HSV or the cold sore virus) is the virus most frequently identified. the body's reaction to a virus itself can lead to encephalitis. or uncharacteristic behaviour. such as tummy upsets. Other symptoms include a high temperature. inability to speak or control movement. aversion to bright lights. parainfectious encephalitis. Worldwide other viruses are found. This condition is called Post-infectious Encephalitis. Symptoms The types of symptoms seen in encephalitis reflect the specific areas of the brain affected by inflammation. and by mistake attacks the brain at the same time. to loss of consciousness and coma. Post-infectious encephalitis has a variety of other names which include Acute Disseminated Encephalomyelitis (ADEM). Typically more serious symptoms follow hours to days later. therefore encephalitis is often described as a rare complication of common infections. The most serious finding is an alteration in level of consciousness. Typically there is a delay of days to two to three weeks between the triggering infection and development of the encephalitis. Post-infectious Encephalitis / Autoimmune Encephalitis Although viruses infecting the brain are a major cause of encephalitis. Encephalitis frequently begins with a „flu-like illness or headache. . The introduction of vaccination for measles. Sometimes patients have both meningitis and encephalitis and this is called meningoencephalitis.Encephalitis is inflammation of the brain. Encephalitis is different from meningitis. These can be very distressing for the person concerned and the family who may witness their distress. mumps and rubella has greatly lowered the rate of encephalitis from these diseases. It probably accounts for one third of all known cases of encephalitis. Only very rarely do the same infections affect the brain. Causes Infectious Encephalitis Viruses are the commonest infections that cause infectious encephalitis. neck stiffness. Some people may also experience hallucinations and vivid nightmares during the acute period of the encephalitis. Many of these viruses cause minor infections elsewhere in the body. This occurs when the immune system tries to fight off the virus. Meningitis means inflammation of the protective layers that cover the brain. More rarely bacteria. skin rashes and cold sores. fungus and parasites can cause encephalitis. and post-vaccinal encephalitis. Within the British Isles. or through the immune system attacking the brain in error (post-infectious / autoimmune encephalitis). many of which can be caught by mosquito or tick bite. seizures (fits). The inflammation is caused either by an infection invading the brain (infectious). This can range from mild confusion or drowsiness. sensory changes. The illness usually follows in the wake of a mild viral infection (such as those that cause rashes in childhood) or immunisations. This phase usually ceases as the inflammation and swelling of the brain subsides. The range of symptoms and their rate of development vary widely and can make the diagnosis of encephalitis difficult.

meningococcal. Diagnosis It is very important to differentiate encephalitis from other disorders that may cause similar neurological symptoms and which may have very different treatments.Other Autoimmune causes It has recently been recognised that there are other forms of encephalitis that result from attack of the brain by the body‟s immune system. candida) Parasites (e. cold sores. In an adult. enteroviruses. glandular fever) Rash-causing viruses (e. measles.g. mycoplasma. Usually blood tests are taken at the same time as the LP in order to compare blood contents with that in CSF. „flu. Lumbar puncture (LP) allows a doctor to sample the cerebrospinal fluid (CSF).Japanese Encephalitis virus.g. malaria. Brain scans can exclude stroke. mumps. It contains substances essential for normal activity of the brain but also takes waste products back to blood.g. drug reactions and metabolic disturbances. The trigger in these cases is not known. Tests which can help confirm the diagnosis and rule out other disorders include: Brain Scans Computerized Tomography (CT) or Magnetic Resonance Imaging (MRI) scans may show the extent of the inflammation in the brain and help differentiate encephalitis from other conditions.g.g. toxoplasma) The above examples are not an exhaustive list.g. West Nile virus) Tick-borne (e. brain tumours.g. histoplasma. pneumococcal and listeria) Fungi (e. A lumbar puncture involves passing a needle.g. rubella) Throat & chest viruses (e. that surrounds the brain and spinal cord. Abnormal patterns found in encephalitis include slowing of brain activity as well as epileptic seizures. can detect abnormal patterns of activity. cryptococcus. Disorders that mimic those of encephalitis include bacterial meningitis. which records brain waves. brain tumours and aneurysms. Central European Tick-borne virus) Other causes of encephalitis:    Bacteria (e. enteroviruses) Gut viruses (e. between two of the back bones at the base of the spine. Known viral causes of encephalitis:       Human herpesviruses (e. Echo virus) Insect-borne (e. Some of these types of autoimmune encephalitis are identified by finding a specific antibody in blood. . Symptoms alone often do not allow a doctor to distinguish between the many diseases that can mimic encephalitis and therefore a variety of hospital tests are required. stroke.g. under local anaesthetic. several tablespoons full of fluid can be collected safely. In the early stages brain scans may show nothing abnormal with significant inflammatory changes only occurring later in the illness. CSF is produced within the brain and flows out at the base of the brain to surround and cushion the brain and spinal cord. Electroencephalogram (EEG).

LP may have to be repeated during an individual's illness. Research suggests that despite extensive testing. A variety of laboratory tests are performed on CSF. their diagnosis of encephalitis will be diagnosis of “exclusion” based upon other diseases having been dismissed on the basis of laboratory tests. . Unfortunately there are no specific treatments at present for many other viral causes of encephalitis. West Nile virus. For some individuals. The area of the brain affected. enterovirus.Approximately 10% of adult patients suffer a mild headache after a LP. The type of inflammation. Examples include brain-stem encephalitis or limbic encephalitis. Treatment Treatment of patients with encephalitis has two objectives. Acyclovir is the most frequently used anti-viral drug. Where the encephalitis is thought to be caused by viral infection. when not caused directly by an infection. It is effective against herpes simplex and varicella zoster viruses and is given at high dose into a vein. or Acute Disseminated Encephalomyelitis. Results from these tests can help exclude other diseases that mimic encephalitis. either infectious or autoimmune/post-infectious will have been determined. The cause of the infection cannot always be determined. varicella zoster virus (chickenpox virus). Examples include Rasmussen‟s encephalitis Hashimoto‟s encephalitis. More complicated tests on CSF include culture for bacteria. or Japanese encephalitis virus. PCR has significantly advanced the ability to diagnose viral encephalitis. Some tests give results within hours whereas others often take days. Treatment for mild cases mainly consists of rest and a healthy diet. Laboratory screening of blood. Examples include herpes simplex virus. A raised number of white blood cells in CSF are indicative of inflammation within the brain. which when applied to CSF is used most frequently to identify genetic material from herpes simplex virus. This headache is typically worse upon being upright and better lying flat. It is important that these drugs are started promptly and often before a definite cause is found. Some people may have a descriptive diagnosis based on:    The cause of the infection – if known. the infectious causes of encephalitis cannot be determined in approximately 60% of cases. antibody studies. Immediate tests performed on CSF include analysis under the microscope to assess the number and type of white blood cells present. urine. patients are treated with anti-viral drugs. and enteroviruses. In most cases the type. It usually improves with simple pain killers and good hydration. Therefore patients are frequently given several different drugs at once. The types of white blood cell found help differentiate between viral or bacterial infections. The latter molecular tests include the polymerase chain reaction (PCR). spinal cord. or molecular tests to detect the genetic footprint of viruses or bacteria. including plenty of liquids. as well as other body fluids can help detect and identify brain and/or spinal cord infection. to let the immune system fight the virus. or lining of the brain (meninges). To ensure the patient receives specific treatment for the cause of their encephalitis.

and then given more specific types of antibiotic if the specific bacteria causing the illness can be found and identified. treating hospital-acquired infections. Patients are usually started on a type of antibiotic which treats a broad spectrum of different bacterial causes. supplying fluids. sedation. and may include steroids. intravenous immunoglobulin (IVIg). Often this treatment coupled with close observation necessitates the patient being on an intensive care or high dependency unit. and plasma exchange.For bacterial causes of encephalitis there is a range of specific treatment available. treatment involves suppressing the immune system. to ventilation Types of Encephalitis Main types Infectious Encephalitis (Viral Encephalitis) Autoimmune Encephalitis Types of Infectious Encephalitis In many cases the viral cause is not identified Herpes Simplex Encephalitis West Nile Encephalitis (or West Nile Fever) Japanese Encephalitis Tick Borne Encephalitis Mycoplasma Encephalitis Enteroviral Encephalitis California Encephalitis St Louis Encephalitis Western Equine Encephalitis Eastern Equine Encephalitis Murray Valley Encephalitis La Crosse Encephalitis Colorado Tick Fever This list is not exhaustive Types of Autoimmune Encephalitis Post-infectious Encephalitis Acute Disseminated Encephalitis (ADEM) Other Autoimmune Encephalitides Hashimoto‟s Encephalitis . To manage the complications arising from the encephalitis and to support the individual whilst they are not able to perform usual bodily functions. Interventions vary from controlling seizures. As autoimmune and post-infectious encephalitis is due to the immune system attacking the brain.

up to 80% for some types. For most of the 20th Century mortality was extremely high. albeit. Families provide a major part of the care needed. The majority of these problems are cognitive rather than physical and therefore “hidden”. suffered a complicated form of bereavement.Encephalitis Lethargica Rasmussen‟s Encephalitis Paraneoplastic Encephalitis NMDA-Receptor Antibody Encephalitis Potassium Channel Complex Antibody Associated Encephalitis This list is not exhaustive Chronic types of Encephalitis Subacute Sclerosing Panencephalitis Rubella Panencephalitis Types of Encephalitis by area Brainstem Encephalitis Limbic Encephalitis Cerebellitis Meningoencephalitis HIV Encephalitis HIV – meningoencephalitis HIV . even if there is a complete physical recovery. This is sometimes to the detriment of their own lives with regards health and social isolation. in some cases. Those involved have. Encephalitis is classed as an uncommon condition and most people will never have heard of it before it affects them or their family. Coming to terms with these problems can be very distressing and challenging for everyone concerned. Accurate information and sound advice is the basis of this support. . An understanding of the array of autoimmune types of encephalitis had to wait until the 21st Century. with long term problems (the subsequent injury to the brain). in some cases. Significant changes may occur in personality and in the ability to function from day-to-day. Anti-viral treatments were non-existent until the last two decades of the 1900s.encephalopathy (HIV-associated dementia) Mild Neurocognitive Disorder (MNCD) in HIV INFORMATION FOR FAMILY & FRIENDS Encephalitis is a syndrome with over 100 causes which include infection (for example viruses and bacteria) or immune mediated causes such as immune system reactions to infection or antibodies. The Encephaitis Society aims to improve the quality of life of all those affected. directly and indirectly by encephalitis. With current improvements in diagnosis and treatment increasing numbers of people are surviving.

Your loved one may become easily upset and have difficulty controlling their emotions. We are okay. Liken this to the loss of a finger or hand from an accident. Talking to others with the same problems can help and the Encephalitis Society can put you in touch with other people who are experiencing the same difficulties. People who have been ill with encephalitis need time and space to come to terms with their illness and its consequences. Your Future Be prepared for a long period of recovery (months. I can’t say how far. Trying to recognise more than one person at a time may be taxing. especially the life threatening ones. People who have been ill with encephalitis often suffer from memory problems and research has shown that if they are asked to make a guess and give the wrong answer they will remember that incorrect answer..Understanding Early Recovery Many of the symptoms your loved one has been experiencing in the acute stage of their illness. They may in fact not even feel ill and be confused even angry at finding themselves in hospital. Recovery is aided by a structured timetable of graded mental activity followed by rest. I’ll do my best to make that happen. I can only promise you this. Some people even push their brains until they seize. If you work with me we can make it even further. “it’s time to get on with life. What I need you to do is this: because neither of us knows how badly I’ve been hurt (things are still a little foggy for me). may remember nothing of the illness. But before you go rushing back out into that big wide world. are due to inflammation (swelling) in their brain. I’m scared. I need you to listen to me. or how much I will recover. because of me. Visitors should not bombard the person with questions and especially should not ask the affected person to make guesses. Once this inflammation settles down these problems begin to resolve and your loved one will start to regain normal consciousness and movement. I won’t make any false promises. please go s-l-o-w-l-y when you start . even doctors. or how quickly. or shame. I’m afraid that you will do that to me. We have made it this far. Your brain’s view As time passes and you and I feel better and better. Be prepared for some loss of brain function (acquired brain injury). people. Recovery is aided by a structured timetable of graded mental activity followed by rest. When I’m getting into trouble I’ll need your help more than I ever have before. Initially rest periods should be long and activity periods short. will tell you that we are fine. Please don’t be embarrassed or feel guilt.. and visitors should not overwhelm the affected person with information. really listen. possibly years) which may fall short of complete. that I will do my best. followed by graded physical activity followed by rest. I know that you want to believe that we are going to be the same. The only difference is that you (and others) cannot see it. they force their brains to function in ways they are no longer able too. You need to be aware of this and avoid causing undue stress. This moment can be a source of conflict between them and you. or when their brains can’t fully recover they deny it and.” That sounds good to me and probably even better to you. Don’t shut me out. however. and worse. instead of adapting. followed by graded physical activity followed by rest. It is a “hidden” disability. Your loved one. You have been through a very traumatic experience and may have been prepared to lose your loved one. so your feelings are of relief and joy that they have survived. The problem is that too many people in our situation get impatient and try to rush the healing process. Hospital visits should be kept short.

this may cause immobility and as such they may be at risk of a Deep Vein Thrombosis (DVT). The nursing staff may suggest that the patient wears antiembolism stockings to reduce this risk.back trying to resume your life. However if they are very agitated it may be necessary to nurse them on a specially adapted bed that lowers to the floor. I’m trying to get your attention in the only way I can. If I give you a headache. becoming aggressive. They will probably also have an intravenous line inserted into a vein enabling essential drugs to be administered as and when necessary. It has not been unknown for patients to abscond from their bed during these stages of agitation. If they are at risk of choking a tube may be inserted into the nose (Nasogastric tube) in order to provide essential nutrients and fluids. If long term artificial feeding is required.npsa. If you want to understand further about any interventions used to restrain your loved one in hospital. This will occur on admission and also regularly throughout the patient‟s stay. especially where the patient is having. Claire Reprinted here for the personal use of those affected). as yet. Love. the National Patient Safety Agency (www. which will include temperature. your wounded brain (This poem is the ©1996 Stephanie St. As the patient begins to recover. or at risk of having. Because Encephalitis may make a person very ill. Because Encephalitis may make a person very ill. they are not conscious or aware of their behaviour or the impact it is having on those around them. behavioural and emotional after-effects. discuss your concerns with the nursing staff – they may be able to reassure you and show you strategies or interventions they have in place to prevent this from occurring. Understanding the Acute Illness Nursing staff will undertake careful and repeated observation. . aggressive. This may occur because the patient is neurologically agitated due to the swelling and inflammation in the brain. The image of a patient who experiences injury to the brain and perhaps coma. disoriented. cognitive. and rude. who are calm and waking serenely to the delight of their family is unfortunately a myth often perpetuated by television and other media. With improvements in drug therapy and intensive care treatments. If you feel your loved one is at risk. Agitated and aggressive behaviour is not uncommon during the acute phase of Encephalitis and after. The nursing staff may suggest that the patient wears antiembolism stockings to reduce this risk. or make you unusually irritable. Sometimes nursing staff use bedrails to prevent injury.uk) is a useful source of guidance and information. pulse. respiration. The patient may also need a catheter inserting in place of using the toilet when they are very poorly. the patient may require the insertion of a PEG tube into their stomach ensuring that sufficient levels of nutrition and fluid are received. this may cause immobility and as such they may be at risk of a Deep Vein Thrombosis (DVT). bloods. These experiences are distressing for all and can present a number of management problems for those trying to care for them. or disoriented. preventing any secondary injuries that may be caused by falling. The long-term effects of encephalitis are. or make you sick to your stomach. seizures. or make you feel that you are overdoing it. they may enter a phase called post-traumatic amnesia (PTA) and behave extremely out of character. uncooperative or violent. many more people are surviving encephalitis. or confused.nhs. or afraid. The family must realise that this is not within their loved one‟s control. input and output of any fluids and checking the functioning of equipment. Stop and listen to me. poorly understood but can include physical. A loved one is more likely to be confused.

or through the immune system attacking the brain in error (post-infectious / autoimmune encephalitis). When death occurs it is usually a result of the brain swelling because of the inflammation. Families are often left feeling stunned and traumatised. in which mortality is up to 30% with treatment. There are a number of sources of help for families in grief. and.If you have any concerns about the care of your loved one please contact your hospital PALS service (www. We have specific staff at the Encephalitis Society who can talk through any issues the family and friends may have. How is the inflammation caused? The inflammation is caused either by an infection invading the brain (infectious).pals.nhs. It is hard to comprehend in this era of modern medicine that an infection can result in death. Encephalitis is different from meningitis. and 70-80% without. if appropriate put bereaved families in touch with each oth FREQUENTLY ASKED QUESTIONS Here are some frequently asked questions and their answers What exactly is encephalitis? Encephalitis is inflammation of the brain. Statistics from the USA provide an indication of the prevalence of encephalitis. The inability of 21st Century drugs and medical procedures to successfully treat the disease can be frightening. some of these are listed in the Resource section of this book. approximately 10% of those with encephalitis die from the brain inflammation or complications such as secondary infection. Some forms of encephalitis have more severe courses. more recently.uk) Death Resulting from Encephalitis Compared to other infectious diseases. including herpes simplex virus encephalitis. When it is subjected to severe pressure it can cease to function. The brain is encased in a hard shell (the skull) and when it swells it pushes downwards onto the brain-stem. encephalitis has a high mortality rate. Overall. This part of the brain controls the vital functions of breathing and control of the heart. Meningitis means inflammation of the protective layers that cover the brain. The suddenness with which encephalitis can develop can be traumatic and overwhelming. . Who can get encephalitis ? Anyone. but never more so than when it is totally unexpected.4 people per 100 000 and. Sometimes people have both meningitis and encephalitis and this is called meningoencephalitis. Beghi et al (1984) reported the annual incidence as 7. at any age. Death is always difficult for those who are left behind.

Many viruses cause minor infections elsewhere in the body. The trigger in these cases is not known.3 hospitalizations per 100 000 population. fungus and parasites can also cause encephalitis. Some of these types of autoimmune encephalitis are identified by finding a specific antibody in the blood. Symptoms indicating that this is a more serious illness follow later and typically include “alteration in level of consciousness”. therefore encephalitis is often described as a rare complication of common infections. Worldwide other viruses are found. This occurs when the immune system tries to fight off the infection. based on the US statistics. drowsiness. It has recently been recognised that there are other forms of encephalitis that result from attack of the brain by the body‟s immune system. There are no statistics for the UK. It is not unusual for the results of tests to be “normal”. How is encephalitis diagnosed? Diagnosis of encephalitis is made where there is evidence of an inflammatory process of the brain in association with clinical evidence of neurologic dysfunction. This condition is called Post-infectious Encephalitis. aneurysms and strokes and show the extent of any inflammation. many of which can be transmitted by mosquito or tick bites. What causes Post-infectious Encephalitis / Autoimmune Encephalitis Although viruses infecting the brain are a major cause of encephalitis. uncharacteristic behaviour.to exclude brain tumours. as well as other symptoms depending on the area of the brain under attack. such as tummy upsets. The introduction of vaccination for measles.to exclude bacterial meningitis and test for the herpes virus. and are not just found in encephalitis.Khetsuriani et al (2002) reported 7. Within the British Isles. skin rashes and cold sores. it can be estimated that about 4000 people are newly affected each year (Easton et al. sensory changes. 2006). and by mistake attacks the brain at the same time.to exclude metabolic encephalopathies. it is important to initially exclude some more common and treatable diseases. These might include confusion. Blood tests . What tests are undertaken?    Lumbar puncture . Herpes Simplex Virus (HSV or the cold sore virus) is the virus most frequently identified. mumps and rubella has greatly lowered the rate of encephalitis from these diseases. inability to speak or control movement. so making the diagnosis can be difficult. The range of possible symptoms and their rate of development vary widely. What are the main symptoms? Encephalitis often begins with a “flu-like” illness or with headache. However. neck stiffness. Only very rarely do the same infections affect the brain. seizures (fits) and coma. More rarely bacteria. What causes infectious encephalitis? Viruses are the commonest cause of infectious encephalitis. How is encephalitis treated? . Brain scans (CT or MRI) . the body's reaction to infection can lead to encephalitis. Other symptoms can include aversion to bright lights.

What are the after effects? There will be a wide variation in exactly in how encephalitis affects the person in the long term. Recovery is a long and slow process. difficulties with memory. Bereavement Compared to other infectious diseases. This should be followed by a programme of graded activity and rest over 3 – 6 months giving the brain the opportunity to restore function. . In some cases. Physical problems may include weakness down one side of the body. Speed of thought and reaction may be reduced. Although not always identified. as well as being a feature of the acute illness. Tiredness. In other cases damage can be extensive leading to significant impairments. at present. Antibiotics may be given as a precaution to prevent bacterial infections. such as some loss in speed of thinking.Prompt treatment with Acyclovir is important. may develop weeks or months after the illness has subsided. Acyclovir is an anti-viral agent effective against herpes viruses. Other treatments may include anti-convulsants to control seizures and sedatives to reduce agitation. however. herpes simplex 1 (the cold sore virus) is the most commonly identified cause of encephalitis in this country. loss of sensations and of control of bodily functions and movement. The illness can be very quickly fatal causing extreme trauma for all the family. aggression and clumsiness. An initial period of convalescence with plenty of rest is recommended. for any other viruses infecting the brain. encephalitis has a high mortality rate. Speech and language problems are also common features. the immune reaction and by pressure resulting from the inflammation. This damage is termed “acquired brain injury (ABI). There is no specific treatment. Epilepsy. Do people get better? Nerve cells may be damaged or destroyed by the viral infection. In more severe cases a period in a brain injury rehabilitation unit may be necessary. recurring headaches. Some loss of brain function is therefore a probable outcome of encephalitis. Intensive care with ventilation may also be necessary in severe cases to reduce swelling of the brain. It is difficult to understand why a virus infection in the modern world can have such devastating consequences. this loss occurs on a relatively small scale resulting in very minor impairment. concentration and balance are often reported as are mood swings.

for example. but do not develop full-blown encephalitis. Other Viral Infections of the Central Nervous System. mumps. Arboviruses. short for "arthropod-borne viruses. Enteroviruses . In severe cases. The most common cause of encephalitis is infection by a virus. are viruses that enter the body through the gastrointestinal tract.NY TIMES Background Encephalitis is a rare but potentially life-threatening inflammation of the brain that can occur in people of all ages. parasites. Epstein-Barr. cytomegalovirus. Encephalitis: Viral Infection of the Brain Many viruses can cause encephalitis. The West Nile virus.S. encephalitis can also be caused by bacterial infection. This virus family includes herpes simplex. Herpes viruses are the other major cause of encephalitis in the U.S. and rubella. including:    Swelling of the brain ( cerebral edema ) Bleeding within the brain ( intercerebral hemorrhage) Nerve damage ( neuropathy ) The damage may cause long-term mental or physical problems. and is categorized by its location:    Meningitis: infection of the meninges (the membranes that surround the brain and spinal cord) Meningoencephalitis: infection of both the brain and meninges Encephalomyelitis: infection of the brain and spinal cord Specific Viruses Implicated in Encephalitis Encephalitis caused by viruses in the United States generally fall into the following groups:     Arboviruses are the primary cause of acute encephalitis (sudden-onset encephalitis caused by direct infection). or complications from other infectious diseases. This report focuses on viral encephalitis.. Viral infection and inflammation can affect multiple areas of the central nervous system. such as coxsackievirus. . secondary encephalitis can develop following childhood viral diseases such as measles. the infection can have devastating effects. depending on the specific areas of the brain affected. In rare cases. Others may experience a mild flu-like illness." are spread by mosquitoes and ticks. In very rare cases. has been responsible for well-publicized outbreaks in the U. Most people exposed to encephalitis-causing viruses have no symptoms. and varicella-zoster.

There cerebrum has several components: The Cerebral Cortex . White matter is a bundle of insulated nerve fibers that underlies the cortex and makes up the core of the cerebral hemispheres.]--> How Viruses Can Infect the Central Nervous System Encephalitis can develop shortly after an initial viral infection. Viruses are simple. This is called diffuse encephalitis. The cortex is the outermost layer of the cerebrum.    The virus infects a person (host) by penetrating a cell membrane and ejecting its genetic material (its DNA or RNA) into the cell. The Central Nervous System The brain and spinal cord comprise the central nervous system. but powerful infectious organisms. releasing new viral particles that infect other cells. The two hemispheres control higher brain functions. meaning they produce extensive damage in only a small area of the brain. telling the cell to make more viruses. The adult human brain weighs about 3 pounds (1. which regulate different brain functions: . The viral DNA or RNA takes control of important cell processes. There are two ways that viruses can infect brain cells:   The virus silently invades the body. see the Causes section in this report. Viruses that enter the brain in this manner are often widely scattered throughout the brain. such as memory. The Hemispheres. or it can develop when a virus that was lying dormant in the body suddenly reactivates. There are no initial symptoms. They are each divided into four lobes. and processing input from the senses. The virus is carried by the bloodstream to the nerve cells of the brain. learning. It is the most highly developed section of the brain. The cell ruptures. Viruses that are transmitted from other tissues usually cause focal infection. A virus first infects other tissue and then invades brain cells.<!--[For more information. There are two major parts of the brain:   The higher and larger forebrain (the cerebrum) The lower and smaller brain stem The Cerebrum The cerebrum is the uppermost and largest part of the brain. decision making. It is made of gray and white matter:   Gray matter is a thin sheet of nerve cells that cover the surface of the brain.4 kilograms). where they gather and multiply.

Temporal lobe: Responsible for interpreting auditory input from the ears.    Frontal lobe: This is the brain's "gatekeeper. motor control. breathing. sexual behavior. Brain Stem The brain stem is responsible for all vital functions. Occipital lobe: Responsible for interpreting visual input from the eyes." It controls higher motor functions. including speech. judgment. Parietal lobe: Processes information from the senses and controls walking. digestion. eye movement Hypothalamus: body temperature. and governs concentration. activation of higher forebrain functions Cerebellum: movement coordination Midbrain: walking. appetite. and personality traits. posture. The basal ganglia are clusters of gray matter within each of the lobes. and posture. The limbic system is located deep in the cerebrum and controls interpretation of smell. which are responsible for specific functions:       Medulla: sleep. posture. which protects the central nervous system from pressure and injury. Thirty-one pairs of nerves extend from the sides of the spinal cord to other parts of the body (the peripheral nervous system). balance. It is continuous with the brain. emotions. The Basal Ganglia. breathing. instinctive behavior. and drives. and head and eye movements. They are important for coordinating voluntary muscle movement. They contain cerebrospinal fluid. heartbeat. It is divided into the following areas. Causes Causes Arboviruses . inhibition. The Meninges and Cerebrospinal Fluid The meninges are three membranes that enclose the brain and spinal cord. activation of higher forebrain functions Pons: sleep. The Limbic System. Also regulates how language is interpreted and retrieves information for memory storage. attention. reproductive hormones Thalamus: communication with higher forebrain The Spinal Cord The spinal cord extends out of the base of the skull through the vertebrae of the spinal column. head.

there are subtle differences in symptoms and the type of brain damage they produce. and possibly breastfeeding. Arboviruses that cause encephalitis are primarily found in three virus families: Togaviridae . and transmit it when they bite a susceptible host (such as an animal or a human). Japanese encephalitis is the most common form of viral encephalitis to occur outside of the United States. organ transplantation. Georgia. Powassan encephalitis is a less common tick-borne flavivirus that occurs primarily in the northern United States. St. including the West Nile virus. Insects that feed on the infected blood from a diseased bird (or reservoir) carry the virus. Age Risk Adults over age 50 and children under age 15. especially China and Korea. nearly always mosquitoes.S.Arboviruses. . La Crosse. There is no evidence that these infections can be transmitted casually from one infected person or animal directly to another uninfected person without passing through a mosquito (or tick) first. Incidence and About 6 cases are reported each year.) Only about 10% of people who are infected by an arbovirus develop encephalitis and only about 1% of those infected have symptoms. a small number of West Nile virus cases have occurred through blood transfusions. Western equine. (However. Most of the time.S.10 days following infection and can range from mild fluOnset like symptoms to full-blown encephalitis. south. Although the overall disease is the same. the viral infections initially develop in birds. and southwest Asia. It is endemic in rural areas in east. Massachusetts. Geographic Areas Symptom Symptoms appear 4 . as its name implies. horses. and West Nile. Different arboviruses cause different forms of encephalitis. Children are more likely to survive but also to suffer complications Rates afterward. Arboviruses multiply in blood-sucking vectors. the main mosquito-borne encephalitis strains are Eastern equine. in New England. Areas Eastern Equine Encephalitis Togaviridae (genus Alphavirus ) Atlantic and Gulf coasts. Bunyaviridae . that play a role in the disease-transmission process are referred to as vectors . such as mosquitoes. Equine encephalitis causes disease in both humans and. In the United States. About a third of people who contract EEE Mortality die from it.Insects. and Flaviviridae . and New Jersey. States most affected are Florida. are transmitted by blood-sucking insects such as mosquitoes and ticks. Venezuelan equine encephalitis is found in South and Central America. Louis. Common Forms of Mosquito-Borne Arbovirus Encephalitis Virus Family U. Groups Western Equine Encephalitis Virus Family Togaviridae (genus Alphavirus ) U. and around the Great Lakes. Farming areas in western and central Plains and Rocky Mountain states west of Geographic the Mississippi.

30% of survivors have complications Mortality afterward.S.S. Onset Incidence and In 2009. and the disease is most severe in Groups this age group.14 days following infection. Mortality rate Rates of between 3 . the average number Mortality of cases has been declining with a yearly average of only 11 cases. Louis.100 cases reported each year. Onset Incidence and Although over 4. 46% were due to West Nile fever and 51% to meningitis and . flu-like symptoms. Age Risk Elderly adults (over age 60) are at highest risk. Onset Incidence and Very rare. Groups St. More Mortality common and severe in children under age 16. Occurs most frequently in upper Midwestern. Younger people usually experience mild. with 30 deaths. 663 cases of WNV were reported to the CDC. as well as parts of Canada. Takes its name from an epidemic in St.4%. Of all the Mortality reported cases. Areas Caribbean. and Geographic mid-Atlantic states. Mortality rates are less than 1%. Unlike Areas other encephalitis viruses which originate in birds.Symptom 5 . Most cases have occurred in Ohio and Wisconsin. Groups West Nile Encephalitis Virus Family Flaviviridae (genus Flavivirus ).. Louis Encephalitis Virus Family Flaviviridae (genus Flavivirus ) U. U. Infants Rates may suffer permanent neurological damage. La Crosse encephalitis is transmitted to mosquitoes from infected chipmunks and squirrels. especially central and southern states.500 cases have been reported since 1964.10 days following infection. Symptom 5 . Cases have been reported throughout the mainland United States.S. southeastern (Appalachia). with about 5% of survivors suffering complications afterward.. Age Risk Infants younger than 12 months. Geographic Areas Symptom 3 . Rates Age Risk Children younger than 16 years. especially those younger than 1 year.15 days following infection.S. La Crosse Encephalitis Virus Family Bunyaviridae (genus Bunyavirus ) U. and South America.15 days following infection.30%. but has occurred throughout the Geographic U. Most severe in children. Symptom 5 . Mortality rate is 3 . Onset Incidence and About 80 .

Asia. and are not reported. now uses screening tests to detect West Nile virus in donated blood and organs. In fact. WNV is now found in birds and mosquitoes in every state except Alaska and Hawaii. In a given geographic area. There have also been cases of mother-to-child transmission during pregnancy. The U. neuroinvasive disease usually manifests as encephalitis. headache. was reported in 2009. Twenty percent will develop West Nile fever (which includes fever. other causes of human infection have included blood transfusions and organ transplantation. most cases of West Nile virus do not produce symptoms. There are currently no vaccines to prevent WNV or specific antiviral drugs to treat it. Neuroinvasive disease symptoms include high fever. Table 1:Common Forms of Mosquito-Borne Arbovirus Encephalitis West Nile Virus (WNV). meningitis. Severity of WNV . The fatality rate for those afflicted ranges from 3 . Cases of tick-borne encephalitis have also been reported from Rocky Mountain spotted fever. but it is reported only rarely in the U. fewer than 1% of people who are infected with WNV go on to develop neurological disease. How WNV Is Transmitted. and the former Soviet Union. In older adults. headache. and occasional skin rash). WNV. It emerged in the United States with the first outbreak in New York City in 1999. WNV has infected over 110 species of birds. In children and younger adults. Human cases of West Nile encephalitis have been reported throughout the continental United States. People over age 50 and those with weakened immune systems are at the greatest risk for neuroinvasive disease.S. In addition to mosquito-tohuman transmission. stiff neck. and Australia. Neuroinvasive disease affects the nervous system and includes encephalitis. the West Nile virus was generally restricted to Africa. but this is a bacterial (not viral) infection. Adults over age 50. the most severe form of WNV.Rates Age Risk Groups encephalitis. convulsions. muscle weakness. The first human encephalitis fatality caused by deer tick virus. disorientation. About 80% of people infected with WNV will not have any symptoms. stupor. discovered in Uganda in 1937.S. However. and poliomyelitis. and paralysis.15%. the appearance of the virus among birds and mosquitoes generally precedes infection in humans. tremors. It is still not clear if WNV can be transmitted through breast milk. southwestern Asia. eastern Europe. . meningitis is more common. circulates primarily between birds and mosquitoes and can be carried long distances by migrating birds. Less than 1% of infected people will develop neuroinvasive disease. the Middle East. which is closely related to Powasson virus. It is still not clear if the physical and mental symptoms of West Nile virus persist longterm. coma. Tick-Borne Encephalitis Viruses Tick-borne encephalitis (TBE) is commonly found in many countries throughout Europe. Until 1999. Powassan encephalitis is the main tick-borne encephalitis found in the United States and Canada. so these numbers imply a more worrisome picture than actually exists.

see In-Depth Report #82: Shingles and chickenpox (varicella-zoster virus). encephalitis from these viruses occurs in people with impaired immune systems. If it erupts. HSV-2 causes 70 . Encephalitis caused by varicella can occur in both children and adults and be very serious.) Enteroviruses can be spread through food or water contaminated by trace amounts of fecal material and through sneezing and coughing. The mortality rate for neonatal HSV-2 encephalitis ranges from 15 . Herpes Viruses The herpes virus group includes a number of common infections.20% of all adult cases of viral encephalitis. the brain inflammation tends to be mild.20% of viral encephalitis cases. such as people with HIV or organ transplant patients. Fortunately. after which the virus remains dormant. encephalitis is rare with both varicella and zoster. If left untreated.]--> . Chickenpox is the initial infection. the mortality rate declines to 30%. Herpes simplex encephalitis is the only effectively treatable form of encephalitis. although HSV-1 can also cause this form). herpes virus 6. see In-Depth Report #52: Herpes simplex . In fact. In most cases. cytomegalovirus. (However. In a few cases. They account for between 10 . The varicella-zoster virus is responsible for both chickenpox (when the virus is called varicella ) and shingles (when it is referred to as herpes zoster) . There are two distinct types of the herpes simplex virus: HSV-1 (commonly associated with oral herpes) and HSV-2 (which usually causes genital herpes. symptoms can appear weeks to months after an attack of shingles and resemble those of a stroke. some evidence suggests that varicella-zoster. usually years later. however. They can lie dormant for periods of time as short as months or as long as a lifetime. If it occurs as a result of herpes zoster in adults. Herpes Simplex Virus. ]--> Varicella-Zoster Virus. varicella-zoster (the cause of chickenpox and shingles).Enteroviruses Enteroviruses include various viruses that enter the body through the gastrointestinal tract. and Epstein-Barr (EB) virus (the cause of mononucleosis). if treated. except in immunocompromised patients. is does so in the form of shingles. In such cases. <!--[For more information. These viruses share certain features. About 2. but treatment (typically intravenous acyclovir) must be administered within the first few days of symptom onset. the mortality rate for patients with HSV-1 is about 70%. cytomegalovirus.100 people are hospitalized each year from herpes-associated encephalitis. <!--[For more information.90% of encephalitis cases in neonatal infants. they cause encephalitis. The group A coxsackievirus has been detected in infants and children with encephalitis and is among the important viruses in the class. often for a lifetime. the virus is transmitted through the mother's genital secretions. including the capacity to cause an infection and then to go into hiding. enteroviruses are nearly as common as cold viruses and are rarely serious. Herpes simplex virus (HSV) is the most common cause of encephalitis in developed countries and is responsible for about 10 .57%. HSV-2 may also cause a small number of these cases. Although HSV-1 is the primary culprit in most adult cases of herpes encephalitis. including herpes simplex. and Epstein-Barr (EB) virus may be more common causes of encephalitis than previously thought. when the viruses reactivate.

Adenoviruses. Raccoon roundworm (Baylisascaris procyonis) is a large parasitic worm that lives in the intestines of raccoons. Raccoon Roundworm. coma.Epstein-Barr Virus. which can be fatal in 30% of patients. in people. In rare cases. Prompt treatment with larvae-killing drugs. usually in children. sore throat. and symptoms of meningitis (stiff neck. adenoviruses can cause encephalitis or meningoencephalitis. measles. this condition causes very mild symptoms in most people. such as albendazole. so it is extremely . or tree bark contaminated with raccoon feces. However. (Flu vaccinations are important in preventing these events. The encephalitis it causes is virtually always fatal but is very rare in the U. with severe complications including encephalitis. In immunocompromised patients. If encephalitis develops. Other Viral Causes of Encephalitis Rabies. and fever. headache. or anti-inflammatory drugs is not consistently effective. The worm is harmless in raccoons but can produce severe central nervous system disease. bats. Encephalitis Associated with Childhood Diseases. and mumps. The rabies virus is transmitted from the saliva of an infected animal. Immunizations have almost completely eliminated these infections in developed countries. such as rubella. rivals herpes as the most common infectious cause of encephalitis. wood chips. Rarely. Encephalitis occurs rarely after common childhood infections. and vomiting). Symptoms include lethargy. Symptoms of the disease are severe fatigue. headache.S. such those with AIDS. The viruses can cause respiratory or gastrointestinal infections that are usually mild. Parasitic Causes of Encephalitis Toxoplasmosis. Humans usually become infected by ingesting the worm's eggs through accidental contact with soil.) Although there used to be concern that diphtheria-pertussis-tetanus and measles-mumpsrubella vaccines could cause encephalitis. it can be dangerous. or other wild animals. Encephalitis from toxoplasmosis. influenza has caused acute encephalitis. confusion. neurological complications occur about 1 . Measles encephalitis still sometimes occurs in immunocompromised children. particularly those that treat parasites. Only one or two cases are typically reported each year. Adenoviruses were first identified in 1953 from infected tonsils and adenoids. including encephalitis. In 1% of cases. which can be transmitted through a cat's feces or by eating contaminated food. Cytomegalovirus is also very common and usually mild. Epstein-Barr virus is the cause of infectious mononucleosis. recent research indicates that these childhood vaccines are very safe and do not increase encephalitis risk. People with HIV and impaired immune systems are at risk for more severe symptoms. often from contact with raccoons. it is almost always mild with full recovery. in pregnant women toxoplasmosis can cause severe problems in the fetus’ central nervous system and eyes Toxoplasmosis can be treated with antibiotics. Cytomegalovirus Encephalitis. which is most common in children and young adults.3 weeks after the onset of the infection. In addition.

Louis. These symptoms include vision problems and muscle paralysis. infants are most vulnerable to Western equine encephalitis. it is associated with childhood vaccinations for measles. Older and elderly adults are at higher risk for Eastern equine. Newborn infants are particularly at risk for herpes virus. Other Parasitic Infections . The nerve cells do not die as they do in a viral infection. and West Nile encephalitis. and swelling of lymph nodes. Older children and teenagers are more susceptible to Eastern equine and La Crosse encephalitis.) Although it is not caused directly by a viral infection.important to avoid infection. encephalitis may be caused by bacterial or fungal organisms. . The inflammation associated with ADEM occurs predominantly in the white matter of the brain rather than the gray matter (the usual target of infectious encephalitis). fatigue. and rubella. though seizures and headaches can occur. Many people fall into the following categories. even for people in the risk groups discussed below. For arboviruses. but few of them will ever contract encephalitis. (Less commonly. such as toxocariasis (from roundworms found in dogs and cats) or cysticercosi (from food or water contaminated with pork tapeworm eggs). Encephalitis may be caused by other parasitic infections. Eliminate access to food sources. St. nausea and vomiting. like garbage cans and bird feeders. These infections usually cause only chills. Age-associated risks depend on the type of encephalitis virus. the two conditions may at first be difficult to distinguish and they can share common symptoms of myelin damage. which will attract raccoons. ADEM has symptoms similar to viral encephalitis. Rather. ADEM can cause seizures and coma. Age Encephalitis can occur at any age. Bacterial and Fungal Organisms In very rare circumstances.S. the nerve cell coating (called a myelin sheath) is partially destroyed in much the same way as it is in multiple sclerosis. mumps. Raccoons should not be kept as pets. Indeed. fever. extremely uncommon in the U. Risk Factors Risk Factors Encephalitis is a rare disease. Acute Disseminated Encephalomyelitis (ADEM) Acute disseminated encephalomyelitis (ADEM) is a condition that can develop in patients recovering from a viral infection. In severe cases. such as fever.

including:    Age of the patient -.5 days. or organ transplantation are more susceptible than other individuals to any form of encephalitis. Most viral outbreaks occur in rural or farming areas.Immunocompromised Patients Patients whose immune systems are compromised by conditions such as HIV-AIDS. While some forms of arbovirus encephalitis are limited to specific geographical regions. last 3 . see In-Depth Reports #52: Herpes simplex and #82: Shingles and chickenpox (varicellazoster virus). The ideal conditions for mosquito breeding are a wet spring followed by a hot. Transmission of arboviruses correlates with the mosquito season and is highest during the months of July through September (late summer through early fall). can also be spread by infected droplets that are propelled into the air by coughing or sneezing.]--> Seasonal Risks. The primary risk factor for arbovirus encephalitis is living in areas of possible exposure to virus-carrying mosquitoes. dry summer. Of particular concern are varicella and cytomegalovirus encephalitis which tend to be more common and deadly in these patients than in the normal population.]--> Prognosis In most cases of arbovirus infection. Geographic Regions.worse outcomes for infants under age 12 months and adults over age 55 Immune status Preexisting neurological conditions . In fact. Risk Factors for Arboviruses U. and resolve without becoming serious. the West Nile virus has become endemic throughout the mainland United States. including saliva. the infection is generally unrecognized as anything other than a mild flu. Prognosis for Severe Encephalitis Prognosis for severe encephalitis depends on many factors. Most of these viruses are easily transmitted in body fluids. Chicken pox. Risk Factors for Herpes Viruses Few people in the world have not been infected with at least one of the herpes viruses. which can have very serious consequences. Infants can contract herpes simplex virus from an infected mother during delivery. <!--[For more information. (which is caused by a type of herpes virus). <!--[See Common Forms of Mosquito-Borne Encephalitis table for more detailed regional information. cancer therapies.S. but they can also occur in cities. symptoms are mild.

and vision problems Muscle weakness Seizures . The location and severity of the infection largely determines the pattern of brain damage and therefore its effects. hearing. the swelling of the brain inside the skull places downward pressure on the brain stem. these vital functions can cease and cause death. While coma can occur in patients with severe encephalitis. symptoms may resemble the flu. Virulence of the virus Death from Suppression of Vital Functions In severe cases of encephalitis. Some patients experience no or mild-to-moderate complications after awakening from an encephalitis-associated coma. Complications from Brain Damage Survivors of encephalitis commonly experience neurologic consequences. The degree and type of brain damage can vary from mild-to-severe and from focal (in one part of the brain) to multifocal (several parts of the brain) to diffuse (throughout the brain). In milder cases. In severe cases of full-blown encephalitis. such as respiration and heartbeat.accompanied by fever and headache would indicate meningitis Confusion Speech. The brain stem controls vital functions. which can be:     Physical (muscle control) Behavioral and emotional (personality changes) Cognitive (memory. it does not necessarily predict a fatal or severe outcome. hearing) Symptoms Symptoms of encephalitis usually appear within 2 days to 2 weeks of exposure to the virus. speech) Sensory (vision. and if the pressure becomes too severe. symptoms may include:             Behavioral and personality changes Sensitivity to light Fever Headache Vomiting Lethargy and reduced consciousness Memory loss Stiff neck and back -. which can be longterm and even permanent.

doctors cannot rely on clinical features to differentiate among the many causes of brain inflammation. The sample is taken to count white blood cells and identify specific blood cell types. to measure proteins and blood sugar levels.   Partial paralysis Loss of consciousness Coma Patients experiencing these types of symptoms (especially if they may have recently been bitten by a mosquito or tick of if they have lesions on the lips or genitals) should immediately seek medical treatment. or on the skin 1 . Doctors use cerebrospinal fluid to test for herpes simplex virus. may bulge outward. a scanning technique is often the first diagnostic step. Cerebrospinal Fluid Tests When encephalitis is suspected. Epstein-Barr virus. and to determine spinal fluid pressure. a sample of cerebrospinal fluid is taken using a lumbar puncture. Electroencephalogram (EEG). in the eye. the soft spots on their head where the skull has not yet closed. while CT scans cannot. seizures. varicella-zoster virus. enteroviruses. Symptoms in Infants. While . and changes in temperature. Infants with herpes virus encephalitis may develop lesions in the mouth. The primary objective in diagnosing viral encephalitis is to determine if it is caused by:   Herpes simplex or other conditions that can be treated with specific medications Arboviruses or other viruses that can be managed only by targeting symptoms Imaging Techniques If the doctor suspects encephalitis. which involves inserting a needle between two vertebrae in the patient's lower back. Computerized tomography (CT) or magnetic resonance imaging (MRI) scans can show the extent of the inflammation in the brain and help differentiate encephalitis from other conditions.45 days after birth. Diagnosis Because the various types of encephalitis produce similar symptoms. and to look for the presence of antibodies to the West Nile virus. MRIs are recommended over CT scans because they can detect injuries in parts of the brain that suggest infection with herpes virus at the onset of the disease. which records brain waves. Other symptoms include lethargy. The fontanels. may reveal abnormalities in the temporal lobe that are indicative of herpes simplex encephalitis.

Corticosteroids may be used. Any potentially lifethreatening complication should be addressed immediately with the appropriate treatments. and rapid treatment is essential. Ganciclovir or foscarnet are recommended for immunocompromised patients. Tissue is prepared using staining techniques and then viewed under an electron microscope. The primary objective is to diagnose the patient as soon as possible so they receive the right medicines to treat the symptoms. that is. Treating Probable Causes of Encephalitis Since it is difficult to determine the cause of encephalitis. Patients with very severe encephalitis are at risk for body-wide (systemic) complications including shock. although risks may outweigh benefits. Blood Tests Blood tests may be used to test for West Nile virus and other arbovirus infections. the viral forms of encephalitis are not treatable. Epstein-Barr Virus . Antiviral drug treatments for specific causes of encephalitis include:       Herpes Simplex Virus . and low sodium levels.) Human Herpesvirus 6. tiny samples of brain tissue are surgically removed for examination and testing for the presence of the virus. drug treatment depends on the cause of the encephalitis. Cytomegalovirus . the viruses in brain cells are able to be cultured. they cannot provide information on how severe the disease will be. low oxygen. clinical guidelines recommend immediately administering intravenously the antiviral drug acyclovir without waiting to determine the cause of the illness. Acyclovir is recommended. It is very important to lower fever and ease the pressure caused by swelling of the brain. Treatment With the exception of herpes simplex and varicella-zoster encephalitis. the viruses can actually be made to replicate in samples. Once the doctor receives results from diagnostic tests.cerebrospinal fluid tests may help diagnose encephalitis. Combination of ganciclovir plus foscarnet. Acyclovir is recommended. . In a few cases. (Acyclovir is not recommended. Measles. Brain Biopsy If necessary. Ganciclovir or adjunctive corticosteroids may also be considered. A brain biopsy is the gold standard for diagnosing rabies. Varicella-Zoster Virus . Ribavirin may be considered. low blood pressure.

which causes chickenpox. Investigational Treatments No specific drugs have been effective for treating arboviruses. Aggressive vaccination programs have reduced the incidence of measles in the U.000 patients it can lead to encephalitis or death. In patients who are otherwise stable. In about 1 in 1. They include interferon alfa 2a (Roferon-A) and other interferons. the only other treatment measures are to keep the head elevated and monitor the patient's status. although a number of drugs used to treat other virus infections are being investigated. Children (and adults who do not have a history of infection and who lack evidence of immunity) should receive 2 doses of the chickenpox vaccine. For bacterial meningitis. Measles Measles used to be a very common childhood disease. antibiotics (not antiviral drugs) are used. including West Nile virus. patients who receive the live-measles vaccine develop encephalopathy (brain damage).     Seizures may be prevented by using oral anticonvulsant drugs. High-dose intravenous corticosteroids. is a reactivation of the varicella virus. A vaccine for shingles is available for adults age 60 years and older. Louis Encephalitis .  ADEM. Vaccinations Certain vaccinations can help prevent the diseases that can lead to encephalitis. to fewer than 100 cases a year. or shingles. but the risk is far lower than brain problems occurring from the disease itself. Interferon alfa-2a may be considered. Simple pain relievers may be used for fever and headache.or intravenous lorazepam (Ativan). Sedatives may be prescribed for irritability or restlessness. Additional Treatments Other encephalitis treatments are aimed at reducing symptoms. <!--[For more information. The risk for these severe complications is highest in the very young and very old. Vaccine for Varicella Virus (Chickenpox and Shingles) Herpes zoster.S.]--> . see In-Depth Report #82: Shingles and Chickenpox . St. Rarely.

) Countries and regions with high rates of Japanese encephalitis include Viet Nam. redness. when mosquitoes feed. JE-VAX. This vaccine is available in Canada and many European countries. or swelling at the injection site. Several types of vaccines are under investigation for West Nile virus. Myanmar (Burma). is no longer manufactured. Most insect repellents contain the chemical DEET (N. DEET and Other Insect Repellant Skin Products DEET. . which remains the gold standard of currently available mosquito and tick repellents. Malaysia. Sri Lanka. The new types of rabies vaccines cause much less discomfort and adverse effects than the older ones. southern India. TBE is found mainly in Eastern and Central Europe. Malaysia. (An older vaccine. Another type of vaccine (FSME-IMMUN) is used to prevent tick-borne encephalitis (TBE) in travelers visiting regions where this type of encephalitis is prevalent. Side effects may include mild reactions such as pain. Pakistan. Exposed individuals may also receive immune globulin unless they were previously vaccinated. Cambodia. Patients may experience pain at the injection site and low-grade fever following the immune globulin shot. but limited quantities are available for vaccinating children. The most complete personal protection program for adults and most children is to apply the insect repellant DEET to the skin. but it is not yet approved in the United States. and the Philippines.N-diethyl-meta-toluamide). northern Thailand. Nepal. but it will be several years before these vaccines could become commercially available. Rabies Vaccine and Immune Globulin Anyone exposed to the secretions of an animal suspected of having rabies.Vaccines for Arboviruses A vaccine (Ixiaro) is currently available for adults traveling for a month or longer to Asian regions where Japanese encephalitis is endemic. should be evaluated for post-exposure rabies vaccine. and also permethrin to clothing and other surfaces. Comparison studies suggest that DEET preparations are the most effective insect repellents now available. Korea. DEET has been used for more than 40 years and is safe for most children when used as directed. The regimen is one shot of immune globulin and four shots of rabies vaccine given over a period of two weeks. A good insect repellent is very helpful in reducing the risk for vector-borne disease. Prevention The risk for mosquito-born infections is highest between dusk and dawn.

Permethrin for Clothing and Surfaces Permethrin is an insect repellent used as a spray for clothing and bed nets. A product containing 7% picaridin is now available in the United States. (Higher DEET concentrations may be necessary for adults who are in highrisk regions for prolonged periods. wounds. Latin America.35% (such as Ultrathon). When deciding what concentration is most appropriate. stinging. They should first put DEET on their own hands and then apply it to the child. According to the Environmental Protection Agency (EPA). Picaridin can safely be applied to young children and is also safe for women who are pregnant or breast-feeding. If using a spray. oil of lemon eucalyptus. and apply only enough to cover exposed skin on other areas. take the following precautions:       Do not use on the face. 30% DEET is the maximum concentration that should be used for children. but it should never be applied to the skin. oil of lemon eucalyptus is not recommended for children under the age of 3 years. also known as KBR 3023 or Bayrepel. The EPA recommends that parents check insect repellant product labels for age restrictions. Electric vaporizing mats containing permethrin may be very helpful. The American Academy of Pediatrics recommends that children use concentrations of 10% or less. According to the CDC. Centers for Disease Control (CDC) also recommends the mosquito repellents picaridin and oil of lemon eucalyptus. the product is safe for any age.never indoors. parents should consider the amount of time that children will be spending outside. They should avoid putting DEET not only near the child's eyes and mouth but also on the hands (since children frequently touch their faces). However. . insect repellents containing DEET or picaridin work better than other products. or irritated skin. is an ingredient that has been used for many years in repellents sold in Europe. which provides complete protection for an average of 5 hours. apply DEET outdoors -. A permethrin solution is also available for soaking items. and the risk of mosquito bites and mosquito-borne disease. worked as well as low concentrations of DEET.Concentrations range from 4% to almost 100%. Do not over apply. Only parents or an adult should apply repellent to a child. If there is no age restriction listed. also known as PMD. The concentration determines the duration of protection. In scientific tests. Most adults and children over 12 years old should use preparations containing a DEET concentration of 20 . Picaridin.S. The U. Wash any treated skin after going back inside. Do not apply over any cuts. When applying DEET. Spray repellents should not be applied directly on anyone's face. DEET products can safely be used on all children age 2 months and older. Other Insect Repellent Products.) DEET products should never be used on infants younger than 2 months. and Asia. and do not use under clothing. which can repel insects for weeks when applied correctly. Side effects from direct exposure may include mild burning.

The best way for homeowners to reduce mosquito populations is to eliminate sources of standing water. where mosquitoes can breed. Citronella Candles . Insect light traps (commonly called bug zappers). personal hygiene.     Look for any source of standing water. They are also not very effective for killing female mosquitoes. These methods include electricity or propane. discard any rubbish with standing water. Mosquito Traps and Bug Zappers.) Other Preventive Measures Your home environment. Change bird bath water every 3 . Cover up bare skin after dusk. Don't wear perfumes.4 days. Where air-conditioning is not available. particularly at dusk. Burning citronella candles reduces the likelihood of bites.) Do not let water accumulate in outdoor flower pot basins or pet bowls. and what you wear can also help reduce your risk for mosquito bites:       Wear trousers and long-sleeved shirts. fans may be helpful. and bottles. may actually spread viruses and bacteria that are on the insects. However. Wash your hair at least twice a week. People allergic to chrysanthemum flowers or who are allergic to head-lice scabicides should avoid using permethrin. Turn over wading pools and wheelbarrows when not in use. and rash. Mosquito traps use various methods for repelling or attracting and trapping female mosquitoes. In general. which attract and electrocute insects. A product such as Mosquito Dunk can be used to prevent breeding in standing water. cans. Mosquitoes appear to be reluctant to fly in windy air. permethrin is very safe and its use may even reduce child mortality rates from malaria. Clean vegetation and debris from the edges of ponds. For example. there is little evidence to support their effectiveness. Keep gutters clean and unclogged. perhaps because the generation of carbon dioxide diverts mosquitoes toward the flame. such as old tires. Sleep only in screened areas. (Indeed. Controlling Mosquitoes around the House Eliminate Sources of Standing Water.itching. however. which are the primary transmitters of arboviruses. Swimming pools and hot tubs should be clean and chlorinated or drained and covered if not in use. burning any candle helps to some extent. (Even bottle caps can breed mosquitoes. Community Mosquito Control Programs . Air-conditioning may reduce mosquito infiltration.

Report any dead birds to your local public health authorities. The U. . Dead birds may be indicators that the West Nile virus has reached a specific region. You should never touch a dead bird with your bare hands. Local communities that experience outbreaks of encephalitis or West Nile virus from mosquitoes often have public spraying programs that target mosquito larvae during breeding season as well as adult mosquitoes. Public health measures are the most effective methods for controlling mosquitoes. people with asthma or other respiratory problems should avoid exposure by staying indoors while spraying takes place.S. Report Dead Birds. While these pesticides are generally considered safe for humans. Environmental Protection Agency (EPA) approves the safety of the insecticides used.Spraying.