15/1/2017

EncephalitisClinicalPresentation:History,PhysicalExamination,Complications

Thissiteisintendedforhealthcareprofessionals

EncephalitisClinicalPresentation
Updated:Apr13,2016
Author:DavidSHowes,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...

PRESENTATION

History
Theclinicalpresentationandcoursecanbemarkedlyvariable.Theacuityandseverityofthepresentation
correlatewiththeprognosis.Ahistoryofmosquitoortickbitesorexposuretomouse/ratdroppingsshould
besought.Recognizingcertainmammaliananimalbite(s)associatedwithrabiesorexposuretoabatinan
enclosedspaceforwhichantirabiestreatmentwasnotobtainedisveryimportant.
Theviralprodromeistypicallyseveraldaysandconsistsoffever,headache,nauseaandvomiting,lethargy,
andmyalgias.Thespecificprodromeinencephalitiscausedbyvaricellazostervirus(VZV),EpsteinBarr
virus(EBV),cytomegalovirus(CMV),measlesvirus,ormumpsvirusincludesrash,lymphadenopathy,
hepatosplenomegaly,andparotidenlargement.DysuriaandpyuriaarereportedwithStLouisencephalitis.
ExtremelethargyhasbeennotedwithWestNileencephalitis(WNE).
Theclassicpresentationisencephalopathywithdiffuseorfocalneurologicsymptoms,includingthe
following:
Behavioralandpersonalitychanges,withdecreasedlevelofconsciousness
Neckpain,stiffness
Photophobia
Lethargy
Generalizedorfocalseizures(60%ofchildrenwithCE)
Acuteconfusionoramnesticstates
Flaccidparalysis(10%ofpatientswithWNE)
Ofnote,severeheadacheisnotalwaysfound.Lesscommonisthecomplaintofparaspinalbackache.
Symptomsofherpessimplexvirus(HSV)infectioninneonates(aged145d)mayincludelocalizedskin,
eye,ormouthlesionsintheearlyphaseofillnesswithencephalitis.Diminishedalertness,irritability,
seizures,andpoorfeedingdeveloplaterinthecourseofillness,anddisseminateddiseaseandshockare
latefindings.
Herpessimplexencephalitis(HSE)inolderchildrenandadultsisnottypicallyassociatedwithactive
herpeticeruptionsandischaracterizedbytheacuteonsetofmoreseveresymptomsofencephalitisearlyin
thecourseofillness.
Toxoplasmaencephalopathyaccountsforasmanyas40%ofHIVpositivepatientswithneurologicdisease
whopresentwithasubacuteheadache,findingsofsubtletoremarkableencephalopathy,and,often,focal
neurologicalcomplaints/findings.Rarely,thismaybethepresentingsymptomcomplexofprofoundimmune
suppressionduetoHIVinfection.

PhysicalExamination
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Lookforsupportingevidenceofviralinfection.Thesignsofencephalitismaybediffuseorfocal.Atthe
extremes,80%ofpatientswithHSEpresentwithfocalfindings.Typicalfindingsincludethefollowing:
Alteredmentalstatus
Personalitychangesareverycommon
Focalfindings,suchashemiparesis,focalseizures,andautonomicdysfunction
Movementdisorders(StLouisencephalitis,easternequineencephalitis[EEE],westernequine
encephalitis[WEE])
Ataxia
Cranialnervedefects
Dysphagia,particularlyinrabies
Meningismus(lesscommonandlesspronouncedthaninmeningitis)
Unilateralsensorimotordysfunction(postinfectiousencephalomyelitis[PIE])
FindingsofHSVinfectioninneonates(aged145d)mayincludethefollowing:
Herpeticskinlesionsoverthepresentingsurfacefrombirthorwithbreaksintheskin,suchasthose
resultingfromfetalscalpmonitors
Keratoconjunctivitis
Oropharyngealinvolvement,particularlybuccalmucosaandtongue
Encephalitissymptoms,suchasseizures,irritability,changeinlevelofattentiveness,bulging
fontanelles
Additionalsignsofdisseminated,severeHSVincludejaundice,hepatomegaly,andshock
Asnotedabove,Toxoplasmainfectioncausingencephalitisisfoundinimmunesuppressedpatients.They
exhibitsignificantencephalopathywithlethargyorpersonalitychanges,and75%presentmaypresentwith
focalneuropathology.

Complications
Encephalitismaybeassociatedwithanumberofcomplications,includingthefollowing:
Seizures
Syndromeofinappropriatesecretionofantidiuretichormone(SIADH)
Increasedintracranialpressure(ICP)
Coma
DifferentialDiagnoses
References

1.[Guideline]TunkelAR,GlaserCA,BlochKC,SejvarJJ,MarraCM,RoosKL,etal.Themanagement
ofencephalitis:clinicalpracticeguidelinesbytheInfectiousDiseasesSocietyofAmerica.ClinInfect
Dis.2008Aug1.47(3):30327.[Medline].
2.Final2008WestNileVirusActivityintheUnitedStates.CentersforDiseaseControlandPrevention.
Availableathttp://bit.ly/fATcE1.Accessed:April26,2009.
3.MacDonaldRD,KrymVF.WestNilevirus.Primerforfamilyphysicians.CanFamPhysician.2005Jun.
51:8337.[Medline].
4.YaoK,HonarmandS,EspinosaA,AkhyaniN,GlaserC,JacobsonS.Detectionofhuman
herpesvirus6incerebrospinalfluidofpatientswithencephalitis.AnnNeurol.2009Mar.65(3):25767.
[Medline].
5.BlochKC,GlaserC.Diagnosticapproachesforpatientswithsuspectedencephalitis.CurrInfectDis
Rep.2007Jul.9(4):31522.[Medline].
6.HayasakaD,AokiK,MoritaK.DevelopmentofsimpleandrapidassaytodetectviralRNAoftick
borneencephalitisvirusbyreversetranscriptionloopmediatedisothermalamplification.VirolJ.2013
Mar4.10(1):68.[Medline].
MediaGallery
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EncephalitisClinicalPresentation:History,PhysicalExamination,Complications

of0
Tables

Table.CerebrospinalFluidFindingsbyTypeofOrganism
Table.CerebrospinalFluidFindingsbyTypeofOrganism
CSFFinding
(Normal)

Pressure(515
cmwater)

Cellcounts,
mononuclear
cells/L

Preterm(025)

Term(022)

6mo+(05)

BacterialMeningitis

Increased

Normalcellcount
excludesbacterial
meningitis
Typically
thousandsof
polymorphonuclear
cells,butcounts
maynotchange
dramaticallyor
evenbenormal
(classicallyinvery
early
meningococcal
meningitisorin
extremelyill
neonates)
Lymphocytosiswith
normalCSF
chemistryresults
observedin15
25%ofpatients,
especiallyifcounts
<1000orifpatient
ispartiallytreated
About90%of
patientswith
ventriculoperitoneal
shuntsandCSF
WBCcount>100
cells/Lare
infected,though
CSFglucoselevel
oftennormal,and

http://emedicine.medscape.com/article/791896clinical#b1

ViralMeningitis*

FungalMeningitis

Normalormildly
increased

Normalormildly
increasedinmost
fungaland
tuberculousCNS
infections
PatientswithAIDS
andcryptococcal
meningitisareat
increasedriskof
blindnessanddeath
unlesspressure
maintainedat<30
cm

Usually<500,nearly
100%mononuclear
<48hours,clinically
significant
polymorphonuclear
pleocytosismaybe
indistinguishable
fromearlybacterial
meningitis,
particularlywithEEE
NontraumaticRBCs
in80%ofpatients
withHSV
meningoencephalitis,
though10%have
normalCSFresults

100sofmononuclear
cells

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EncephalitisClinicalPresentation:History,PhysicalExamination,Complications

bacteriaoftenless
pathogenic
Cellcountand
chemistrylevels
normalizeslowly
(days)with
antibiotics

Microorganisms
(none)

Gramstain80%
effective
Inadequate
decolorizationmay
cause
Haemophilus
influenzaetobe
mistakenforgram
positivecocci
Pretreatmentwith
antibioticsmay
affectstainuptake,
causinggram
positivespeciesto
appeartobegram
negativeand
decreaseculture
yieldbyanaverage
of20

Noorganism

Indiaink8090%
effectivefor
detectingfungi
AFBstain40%
effectiveforTB
increaseyieldby
stainingsupernatant
fromatleast5mLof
CSF

Normal

Sometimes
decreased
Inadditionto
fulminantbacterial
meningitis,TB,
primaryamebic
meningoencephalitis,
and
neurocysticercosis
causelowglucose
levels

Mildlyincreased

Increased>1000
mg/dL,withrelatively
benignclinical
presentation
suggestiveoffungal
disease

Glucose

Euglycemia
(>50%serum)
Decreased
Hyperglycemia
(>30%serum)

Protein

Preterm(65
150mg/dL)

Term(20170
mg/dL

Usually>150
mg/dL
Maybe>1000
mg/dL

6mo+(1545
mg/dL)
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EncephalitisClinicalPresentation:History,PhysicalExamination,Complications

*Somebacteria
(eg,
Mycoplasma,
Listeria,
Leptospira,
Borrelia
burgdorferi
[Lymedisease])
cause
alterationsin
spinalfluidthat
resemblethe
viralprofile.An
asepticprofile
isalsotypicalof
partiallytreated
bacterial
infections
(>33%,
especially
thosein
children,are
treatedwith
antimicrobials)
andofthe2
mostcommon
causesof
encephalitis
thearboviruses
andthe
potentially
curableHSV.

Wait4hours

afterglucose
load.

AFBacidfast
bacillusCSF
cerebrospinal
fluidEEE
easternequine
encephalitis
HSVherpes
simplexvirus
RBCred
bloodcellTB
tuberculosis
WBCwhite
bloodcell.

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ContributorInformationandDisclosures

Author
DavidSHowes,MDProfessorofMedicineandPediatrics,ResidencyProgramDirectorEmeritus,Section
ofEmergencyMedicine,UniversityofChicago,UniversityofChicago,ThePritzkerSchoolofMedicine
DavidSHowes,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Coauthor(s)
MarjorieLazoff,MDEditorinChief,MedicalComputingReview
MarjorieLazoff,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanMedical
InformaticsAssociation,AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWestern
ReserveUniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademy
ofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergency
Physicians,AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
StevenAConrad,MD,PhDChief,DepartmentofEmergencyMedicineChief,MultidisciplinaryCritical
CareService,Professor,DepartmentofEmergencyandInternalMedicine,LouisianaStateUniversity
HealthSciencesCenter
StevenAConrad,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChest
Physicians,AmericanCollegeofCriticalCareMedicine,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians,InternationalSocietyforHeartandLungTransplantation,LouisianaState
MedicalSociety,ShockSociety,SocietyforAcademicEmergencyMedicine,andSocietyofCriticalCare
Medicine
Disclosure:Nothingtodisclose.
RobinRHemphill,MD,MPHAssociateProfessor,Director,QualityandSafety,DepartmentofEmergency
Medicine,EmoryUniversitySchoolofMedicine
RobinRHemphill,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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EncephalitisClinicalPresentation:History,PhysicalExamination,Complications

JStephenHuff,MDAssociateProfessorofEmergencyMedicineandNeurology,Departmentof
EmergencyMedicine,UniversityofVirginiaSchoolofMedicine
JStephenHuff,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanAcademyofNeurology,AmericanCollegeofEmergencyPhysicians,andSocietyfor
AcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
ToddPritz,MDIntensivist,StAnthony'sMedicalCenterandStJohn'sMercyMedicalCenter
ToddPritz,MDisamemberofthefollowingmedicalsocieties:MassachusettsMedicalSocietyandSociety
ofCriticalCareMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhD,AdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeReferenceSalaryEmployment
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