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ENCEPHALITIS

Definition • Encephalitis means inflammation of brain parenchyma. • Viruses are the commonest cause for encephalitis. Etiology Acute viral encephalitis • Herpes simplex, ECHO, mumps and varicella zoster, measles • Japanese encephalitis in South East sia. • !abies • rbovirus are an important cause of encephalitis  Often, viral etiolo"y is presumed but never confirmed Pathology #nflammation can occur in the cortex, $hite matter, basal "an"lia and brain stem, and the distribution of lesions varies $ith the type of virus. #n herpes simplex encephalitis, the temporal lobes are usually primarily affected. • #nclusion bodies may be present in the neurons and "lial cells and there is an infiltration of polymorphonuclear cells in the perivascular space. • %here is neuronal de"eneration and diffuse "lial proliferation, often associated $ith cerebral oedema Clinical features • cute onset of headache, fever, focal neurolo"ical si"ns &aphasia and'or hemiple"ia( and seizures. • )isturbance of consciousness ran"in" from dro$siness to deep coma supervenes early and may advance dramatically. • *enin"ism occurs in many patients • +ocal si"ns, seizures and coma. Differential diagnosis • ,acterial menin"itis $ith cerebral oedema • Cerebral venous thrombosis • Cerebral abscess • cute disseminated encephalomyelitis &see belo$( • Cerebral malaria Investigations • C% and *! ima"in" sho$ diffuse areas of oedema, often in the temporal lobes • EE- sho$s characteristic slo$ $aves, $hich are useful in some cases • CSF sho$s excess lymphocytes, but polymorphonuclear cells may predominate in the early sta"es. • %he protein content may be elevated but the "lucose is normal

may reveal the causative or"anism. $ith a normal "lucose. usually many years after the primary virus infection. includin" .rain abscess may develop . usually leadin" to death $ithin $ee2s or months • *!# sho$in" diffuse hi"h si"nal in the cerebral $hite matter. • %he CS+ is lymphocytic. 7ymphoma. • nticonvulsant treatment is often necessary • raised intracranial pressure is treated $ith dexamethasone 3 m" 054hourly • . leu2emia or carcinomatosis. diplopia or other cranial nerve palsies. pro"ressive and eventually fatal neurolo"ical disease caused by the measles virus.rophylactic immunization a"ainst Japanese encephalitis is advised for travellers to endemic areas in sia. "#AIN$STE ENCEPHALITIS • %his presents $ith ataxia.C! for viral )/ . antiviral therapy is ineffective and death ensues $ithin years P#&'#ESSI(E %LTIF&CAL LE%C&ENCEPHAL&PATH) • Common causes are #)S.• Virolo"ical investi"ations of the CS+.v. • Herpes simplex encephalitis responds to aciclovir 01 m"'2" i. typically surrounded by a vascularized capsule • Cere*ritis is often employed to describe a nonencapsulated brain abscess Etiology . CE#E"#AL A"SCESS Definition • "rain a*scess is a focal. • #t is an infection of oli"odendrocytes by human polyomavirus JC.rain biopsy is occasionally performed anage!ent . • #t occurs in children and adolescents. dysarthria.in serum and CS+. chronic. $ith periodic bursts of triphasic $aves. $hich causes $idespread demyelination of the $hite matter of the cerebral hemispheres. • %he CS+ may sho$ a mild lymphocytic pleocytosis and the EE. • . suppurative infection $ithin the brain parenchyma. • Clinical si"ns include dementia. • lthou"h there is persistent measles4specific #". 34hourly for 546 $ee2s. hemiparesis and aphasia $hich pro"ress rapidly.is distinctive. %he causative a"ent is presumed to be viral • Listeria monocytogenes may cause a similar syndrome S%"AC%TE SCLE#&SIN' PANENCEPHALITIS • %his is a rare.

acteroides spp. . &6( Hemato"enous spread from a remote site of infection • 8p to one4third of brain abscesses are associated $ith otitis media and mastoiditis • Oto"enic abscesses occur predominantly in the temporal lobe &99 to :9. otitis media. or dental infection. . Early cere*ritis stage &days 0 to 6( is characterized by a perivascular infiltration of inflammatory cells. fever.acteroides spp. . but more commonly presents over days or $ee2s as a cerebral mass lesion $ith little or no evidence of infection..( Co!!on organis!s • Otitis media and mastoiditis include streptococci. • Seizures raised intracranial pressure and focal hemisphere si"ns occur alone or in combination. 6. Pathogenesis and Histopathology • #ntact brain parenchyma is relatively resistant to infection< preexistin" brain ischemia. mastoiditis.( and cerebellum &51 to 61. 5. Haemophilus spp. late cere*ritis stage &days > to ?(. or hypoxia appears to be a prere=uisite for effective bacterial invasion. menin"ism and dro$siness. • . . • clinical presentation of a brain abscess depends on its location • Si"ns of raised #C. and a focal neurolo"ic deficit • cutely $ith fever. is defined by a $ell4formed necrotic center surrounded by a dense colla"enous capsule Clinical features • Classic clinical triad of headache. • Investigations • 7umbar puncture is potentially hazardous in the presence of raised intracranial pressure. and C% should al$ays precede it. late capsule for!ation &day 0> and beyond(. milleri(. pus formation leads to enlar"ement of the necrotic center.. headache.&0( )irect spread from a conti"uous cranial site of infection. Early capsule for!ation &days 01 to 06(. necrosis. • *enin"ismus is not present unless the abscess has ruptured into the ventricle or the infection has spread to the subarachnoid space. &5(Head trauma or a neurosur"ical procedure. aeru"inosa.ara nasal sinusitis 44 streptococci &especially S.. is characterized by the formation of a capsule that is better developed on the cortical than on the ventricular side of the lesion >. • Various sta"es of cerebral abcesses are 0. such as paranasal sinusitis.

Prognosis • mortality rate remains at 01451. • ll patients should receive a minimum of @ to 3 $ee2s of parenteral antibiotic therapy • . • #ntravenous dexamethasone therapy &01 m" every @ h( is usually reserved for patients $ith substantial periabscess edema and associated mass effect and increased #C. • Empirical therapy of community4ac=uired brain abscess in an immunocompetent patient typically includes a third4"eneration cephalosporin &e. • . Differential Diagnosis • Subdural empyema..• C% reveals sin"le or multiple lo$4density areas. • Viral menin"oencephalitis T#EAT ENT • Hi"h4dose parenteral antibiotics and neurosur"ical draina"e. $hich sho$ rin" enhancement $ith contrast and surroundin" cerebral oedema • *!# is better than C% for demonstratin" abscesses in the early &cerebritis( sta"es and is superior to C% for identifyin" abscesses in the posterior fossa • %here may be an elevated $hite blood cell count and ES! in patients $ith active local infection. • Sur"ical treatment by burr4hole aspiration or excision may be necessary.atients should also receive prophylactic anticonvulsant therapy because of the hi"h ris2 of seizures. despite an improvement in available sur"ical and medical treatments  !ead neurocysticercosis+ polio!yelitis+ ra*ies . especially $here the presence of a capsule may lead to a persistent focus of infection.".acterial menin"itis. cefotaxime or ceftriaxone( and metronidazole.