An inflammation of the brain

parenchyma, presents as diffuse and/or

focal neuropsychological dysfunction
Most commonly a viral infection with
parenchymal damage varying from
mild to profound

Encephalitis, Emedicine.com

Primary encephalitis
Post - infectious or Para - infectious
encephalitis

A text book of Infectious disease I,

Virus
Arbovirus : JEV & Dengue virus
Herpes virus (simplex , zoster)
Enteroviruses including coxsackie

virus, poliovirus, and echovirus

Other causes include varicella
(chickenpox), measles, mumps, rubella,
adenovirus, rabies
A text book of Infectious disease I,

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

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
30,000-50,000 cases reported each year

Encephalitis

Japanese Encephalitis

Bacteria
H. influenza
S. pneumoniae
N. meningitidis
M. tuberculosis
Mycoplasma pneumoniae

Others
Rickettsia, Spirochete & Malaria
A text book of Infectious disease I,

Measles
1: 2,000,000 dose , 6-15 day after

injection

Mump : Some species of virus

Report
Influenza
Japanese B encephalitis
Pertussis Whole cell
Rabies
A text book of Infectious disease I,

Initial Signs
Fever
Headache
Malaise
Anorexia
Nausea and Vomiting
Abdominal pain

Encephalitis, Emedicine.com

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
Encephalitis, Emedicine.com

Neurologic Signs
Most Common
Aphasia
Ataxia
Hemiparesis with hyperactive tendon
reflexes
Involuntary movements
Cranial nerve deficits (ocular palsies, facial
weakness)
Encephalitis, Emedicine.com

Patient History
Physical exam
Work up

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

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

Season
Japanese encephalitis : rainy season
Arbovirus infections are : summer and fall

Predisposing factors :
Immunosuppression caused by disease and/or

drug treatment
Organ transplant Opportunistic infections
HIV CNS infections
HSV-2 encephalitis and CMV infection

Drug ingestion and/or abuse

Trauma

 Focal 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

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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
Encephalitis, Emedicine.com

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
Encephalitis, Emedicine.com

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 )
A text book of Infectious disease I,

NB
-Term
-Preterm
Infant &
child

WBC/
mm3

Protein
(mg/dl)

CSF / blood
glucose
(%)

0-32
0-29

20-170
65-150

44-248
55-105

0-6

15-45

60-90

Update on infectious disease 2548,

WBC
pressure

Bacteri
a
Virus
TB

N,
N

pandy

No.

++ -
Trac
-
e
+++ -

Chemistry

Stain

Type

glu

prot

gram

AFB

PMN
L
L

L
N
L

N,

+
-

Viral meningitis meningoencephalitis pressure

Bacterial meningitis profile
Sugar
sugar Bacterial meningitis

24 -48
profile


bacterial meningitis

Some bacteria (eg, Mycoplasma, Listeria,

Leptospira, Borrelia burgdorferi [Lyme
disease]) cause alterations in spinal fluid
that resemble the viral profile
An aseptic profile is also typical of partially
treated bacterial infections (>33%,
especially those in children, are treated
with antimicrobials) and of the 2 most
common causes of encephalitisthe
arboviruses and the potentially curable HSV
Encephalitis, Emedicine.com

There are several techniques for

interpreting
Comparing the peripheral WBC and red

blood cell (RBC) count to that of the CSF

Allows one white blood cell for every 700
RBCs

Blood in the CSF increases the protein

and it is estimated that 1000 RBCs may
raise the CSF protein by 1 mg/dL
Pediatrics, Meningitis and Encephalitis, Emedicine.com

In any situation when a traumatic LP

occurs and the interpretation is
difficult, it is better to treat and wait for
the results of the CSF culture
When in doubt, treat and attempt the
LP later

Pediatrics, Meningitis and Encephalitis, Emedicine.com

Certain EEG wave patterns can suggest

encephalitis due to herpes
Unilateral or Bilateral periodic focal
spike with slow activity background

A text book of Infectious disease I,

Metabolic causes
Drug & Toxicology
Mass lesion
Epilepsy
Subarachnoid hemorrhage
Acute confusional migraine
Autoimmune : SLE
CNS Vasculitis
A text book of Infectious disease I,

Fever
Headache
AMS
Focal Neurologic Signs
Types of seizures
Blood: Leukocytosis
CSF: Pleocytosis
EEG: Diffuse slowing
MRI

Encephalopathy
Uncommon
Uncommon
Steady deterioration
Uncommon
Generalized
Uncommon
Uncommon
Common
Often normal

Encephalitis
Common
Common
May fluctuate
Common
Both
Common
Common
+Focal
Focal Abn.

No satisfactory treatment exists for the

relatively common acute arboviral
encephalitides, which vary in
epidemiology, mortality, and morbidity,
if not clinical presentation

Encephalitis, Emedicine.com

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
Encephalitis, Emedicine.com

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

A text book of Infectious disease I,

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

A text book of Infectious disease I,

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
Encephalitis, Emedicine.com

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-to-major learning disabilities,
memory impairment, neuropsychiatric
abnormalities, epilepsy, fine-motorcontrol deficits, and dysarthria
Encephalitis, Emedicine.com

Controlling mosquitoes : Dengue

Animal vaccination : Rabies virus
Human vaccination : JEV

Failure to consider HSE in the diagnosis

or to initiate administration of acyclovir
in a timely fashion

Current practice in
common Infectious
disease 2005


viral encephalitis



olfactory gustatory

hallucination

Profile : Viral encephalitis

Lymphocyte : 20 200/cm3 +/- PMN
Protein 50 -200 mg/dl
Normal CSF sugar (5% low)
In systematic review : RBC or

Xanthochromia

encephalitis

Viral encephalitis
Rabies & Dengue encephalitis : most no

pleocytosis or few < 30/ cm3

JE encephalitis : 30 360 Lymphocyte
predominant, rarely > 1000

LP

HSV encephalitis
Biopsy 4/98 no pleocytosis
Most in immunocompromised & LP in first

day of illness >>> PCR +

HSVE

cell
rule out

PCR negative

CT brain > 5
HSVE
CT brain
MRI
imaging of
choice

CSF PCR for HSV

5-7 PCR
acyclovir 10 -12 PCR


course PCR
acyclovir
PCR negative

> 24 -20oC 4oC

Confirm test


> 10
acyclovir > 5-7