ENCEPHALITIS

Dr.Hemant
(PT-NEURO)

Encephalitis

An inflammation of the brain parenchyma, presents as diffuse and/or focal neuropsychological dysfunction
Viral infection is the most common and important cause, with over 100 viruses implicated worldwide Incidence of 3.5-7.4 per 100,000 persons per year

CAUSES
VIRUS • Arboviruses – examples: Japanese encephalitis; St. Louis encephalitis virus; West Nile encephalitis virus; Eastern, Western and Venzuelan equine encephalitis virus; tick borne encephalitis virus • Herpes viruses – HSV-1, HSV-2, varicella zoster virus, cytomegalovirus, Epstein-Barr virus, human herpes virus 6 • Adenoviruses • Influenza A • Enteroviruses, poliovirus • Measles, mumps, and rubella viruses • Rabies • Bunyaviruses – examples: La Crosse strain of California virus • Reoviruses – example: Colorado tick fever virus • Arenaviruses – example: lymphocytic choriomeningitis virus

Japanese Encephalitis

Most important cause of arboviral encephalitis worldwide, with over 45,000 cases reported annually Transmitted by culex mosquito, which breeds in rice fields

Mosquitoes become infected by feeding on domestic pigs and wild birds infected with Japanese encephalitis virus Infected mosquitoes transmit virus to humans and animals during the feeding process

History of Japanese Encephalitis
  

1800s – recognized in Japan 1924 – Japan epidemic. 6125 cases, 3797 deaths 1935 – virus isolated in brain of Japanese patient who died of encephalitis 1938 – virus isolated from Culex mosquitoes in Japan 1948 – Japan outbreak 1949 – Korea outbreak 1966 – China outbreak Today – extremely prevalent in South East Asia 30,00050,000 cases reported each year

 


 

Causes

Bacteria
 H.
 S.

influenza

pneumoniae  N. meningitidis  M. tuberculosis  Mycoplasma pneumoniae

Others  Rickettsia, Spirochete & Malaria

Clinical manifestation

Initial Signs
 Fever  Headache  Malaise

 Anorexia
 Nausea

and Vomiting  Abdominal pain

Clinical manifestation

Developing Signs
Altered LOC – mild lethargy to deep coma  AMS – confused, delirious, disoriented  Mental aberrations :

 

hallucinations personality change behavioral disorders ; occasionally frank psychosis

Focal or general seizures in >50% severe cases.  Severe focused neurologic deficits

Clinical manifestation

Neurologic Signs
 Most

Common

 Aphasia  Ataxia  Hemiparesis

with hyperactive tendon reflexes  Involuntary movements  Cranial nerve deficits (ocular palsies, facial weakness)

Diagnosis
Patient History  Physical exam  Work up

Patient History

Prodromal illness, recent vaccination, development of few days → Acute Disseminated Encephalomyelitis (ADEM) Biphasic onset : systemic illness then CNS disease → Enterovirus encephalitis Abrupt onset, rapid progression over few days → HSV encephalitis

Patient History

Recent travel and the geographical :
› ›


Africa → Cerebral malaria Asia → Japanese encephalitis High risk regions of Europe and USA → Lyme disease

Recent animal bites → Tick borne encephalitis or Rabies Occupation

Forest worker, exposed to tick bites Medical personnel, possible exposure to infectious diseases

Patient History

Season


Japanese encephalitis : rainy season Arbovirus infections are : summer and fall Immunosuppression caused by disease and/or drug treatment Organ transplant → Opportunistic infections HIV → CNS infections

Predisposing factors :
› ›

HSV-2 encephalitis and CMV infection

Drug ingestion and/or abuse Trauma

Physical exam
neurological deficit → HSV encephalitis  Hallucination or aphasia → HSV encephalitis  Local paresthesia → Rabies encephalitis  Brain stem signs, Unilateral peripheral motor weakness or Cerebellar sign → Meliodosis  Eschar → Scrub typhus  Parotitis → Mumps  Systemic sign eg. Rash → Mycoplasma & Enterovirus
 Focal

Work up
 

CBC : usually within the reference range Electrolytes : usually within reference range
 Syndrome

of inappropriate secretion of antidiuretic hormone (SIADH)

Serum glucose : Use this level as a baseline for determining normal CSF glucose values

Work up

BUN/creatinine and liver function tests (LFTs) : Assess organ function and the need to adjust the antibiotic dose Platelet test and a coagulation profile : indicated in patients with chronic alcohol use, liver disease, or if DIC is suspected Urinary electrolyte test : Perform this assessment if SIADH is suspected Urine and/or serum toxicology screening

Work up

Lumbar puncture
 CSF

examination (Polymorphonuclear cells may predominate early in the illness but are replaced by mononuclear cells within hours)

  

Viral culture Viral PCR may identify the virus Serology tests antibodies to an specific virus → JEV, Dengue, Mycoplasma (4 fold rising )

CSF
 

It reveals 5-500 lymphocytes. The protein is mildly elevated The glucose is normal

EEG

Certain EEG wave patterns can suggest encephalitis due to herpes Unilateral or Bilateral periodic focal spike with slow activity background

Imaging

Differential diagnosis
    


 

Metabolic causes Drug & Toxicology Mass lesion Epilepsy Subarachnoid hemorrhage Acute confusional migraine Autoimmune : SLE CNS Vasculitis

Differential diagnosis
Encephalopathy Encephalitis

Fever
Headache AMS

Uncommon
Uncommon Steady deterioration

Common
Common May fluctuate

Focal Neurologic Signs
Types of seizures

Uncommon
Generalized

Common
Both

Blood: Leukocytosis
CSF: Pleocytosis EEG: Diffuse slowing

Uncommon
Uncommon Common

Common
Common +Focal

MRI

Often normal

Focal Abn.

Treatment

No satisfactory treatment exists for the relatively common acute arboviral encephalitides, which vary in epidemiology, mortality, and morbidity, if not clinical presentation

Treatment

Clinically distinguishing these acute arboviral encephalitis from the 2 potentially treatable acute viral encephalitis is important
 Herpes

simplex encephalitis (HSE), which is a sporadic and lethal disease of neonates and the general population  Less common varicella-zoster encephalitis, which is deadly in immunocompromised patients

Treatment

Specific treatment
 HSV

encephalitis : Neonate & infant Acyclovir 60 mg/kg/day IV div 8 hr 14 -21 days, Child & Adult 30 mg/kg/day 14 -21 days  Varicella zoster encephalitis : Acyclovir  CMV encephalitis : Gancyclovir or Foscanir  Others : depend on etiology

Treatment

Supportive treatment
 Reduce

intracranial pressure : restrict fluid , hyperventilation( if on ventilator), low body temperature , steroid ? (Mycoplasma )  Rest, nutrition, fluids (SIADH), antipyretic, Anticonvulsant  Acute psychosis : haloperidol

Prognosis

Depends the virulence of the virus and on variables associated with the patient's health status, such as extremes of age, immune status, and preexisting neurologic conditions Rabies, EEE, JE, and untreated HSE have high rates of mortality and severe morbidity, including mental retardation, hemiplegia, and seizures

Prognosis

The mortality rate in treated HSE averages 20% and is correlated with mental status changes at time of first dose of acyclovir Approximately 40% of survivors have minor-tomajor learning disabilities, memory impairment, neuropsychiatric abnormalities, epilepsy, fine-motorcontrol deficits, and dysarthria

Prevention
  

Controlling mosquitoes : Dengue Animal vaccination : Rabies virus Human vaccination : JEV

Medical/Legal Pitfalls

Failure to consider HSE in the diagnosis or to initiate administration of acyclovir in a timely fashion

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