Case Report

ENCEPHALITIS
Presentator : Pirhot L M Y Siahaan

Supervisor : Dr. Hj. Melda Deliana Sp. A (K)

PEDIATRIC DIVISON HAJI ADAM MALIK HOSPITAL FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA 1

Definition
enkephalos + -it is inflammation meaning brain

Epidemiology
In United States at 3.5-7.4 per 100,000 persons per year Japanese virus encephalitis (JE), occurring principally in Japan, Southeast Asia, China, and India, is the most common viral encephalitis outside the United States.
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Etiology
Here are some of the more common causes of encephalitis:
Herpes viruses (HSV, VZV,EBV) Childhood infections (Measless, mumps, rubella) Arboviruses
Eastern equine encephalitis Western equine encephalitis St. Louis encephalitis La Crosse encephalitis West Nile encephalitis

Pathophysiology
Portals of entry are virus specific the virus replicates outside the CNS and gains entry either by HEMATOGENOUS SPREAD or by TRAVELING ALONG NEURAL (rabies, HSV, VZV) and olfactory (HSV) pathways across the blood-brain barrier, the virus enters neural cells, with resultant disruption in cell functioning, perivascular congestion, hemorrhage, and inflammatory response diffusely affecting gray matter disproportionately to white matter viruses that invade gray matter directly, acute disseminated encephalitis and postinfectious encephalomyelitis (PIE), secondary to measles (most common), Epstein-Barr virus (EBV), and CMV, are immune-mediated processes, which result in multifocal demyelination of perivenous white matter.
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Clinical Manifestation
high fever (102 F to 105 F [38.9 C to 40.6 C]), severe headache, and vomiting drowsiness disorientation seizures paralysis delirium coma.
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Examination
Laboratory Findings
Complete blood count (CBC) with differential: Findings are usually within the reference range
Condition Pressure (cmH2O) Normal Bacterial Meningitis Viral meningitis/enc ephalitis TB meningitis Cryptococcal meningitis 18-30 18-30 <500 100-200 9-18 20-50 Cell Count (WBC/mm3) 0-5 100-100.000 Lymph >80% PMN 9-20 10-500 Lymph (early PMN) Lymph Lymph <50 /N <40 /N 100-300 50-300
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Cell Type

Glucose (mg/dL) 50-75 <40 /N N

Protein (mg/dL) 15-40 10-1000

50-100

 Imaging NORMAL (to dfferentiate with SOL, intracranial haemorrhage) EEG characteristic paroxysmal lateral epileptiform discharges

Treatment
Increased intracranial pressure should be managed in the ICU setting with head elevation, gentle diuresis, mannitol, and hyperventilation. Seizures Phenytoin and valproic acid can be administered intravenously. Phenytoin and carbamazepine can be administered when oral or intragastric drug administration is possible. Benzodiazepines are also important when used to abort status epilepticus.
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 Medication :
No specific treatment is available for the arbovirus encephalitides Pharmacotherapy for herpesvirus encephalitis consists of acyclovir and vidarabine recombinant interferon alpha is currently being assessed in a trial for Japanese B encephalitis

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Prognosis
If the therapy is timely, the prognosis is good patient suffers from some symptoms even after the treatment (sequelae) When treatment is delayed, permanent brain damage or death is more likely, especially in very young children and older people
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Prevention
The most effective way to prevent viral encephalitis is to try to prevent the illnesses that can cause it. Keeping immunizations current for common childhood illnesses, such as measles, mumps, and chicken pox.

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Anamnesis
Personal Anamnesis

History of immunization
BCG DPT POLIO CAMPAK HEPATITIS Interpretation ::? :? :? :? : unclear

Name : Bendri Turnip Sex : Male Age : 1 month old BW : 2,7 kg BL : 50,3 cm Address : Jl. Date of hospitalized : March 8th 2009

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Anamnesis
Main problem : Black feces Analize :
It had been happened for three days ago , frequently 3x/ day, volume 10 - 15 cc/x. There are no blood that mix in feces, and no LENDIR Black vomiting has found about 3 days ago frequently 3x/ day, volume 5 cc/x, and there was a bloody vomitting right now Fever was founded since 2 weeks ago, high fever, sometimes the temperature increase and decrease, normally by giving antipyretic drugs. Jaudice (+) when her age was 2 weeks Pale (+) in 3 days ago Lazy to drink (+) 2 days ago Low pitched cry (+) 2 days ago Urinary abnormal, with tea appearance 1 weeks ago History of birth : spontan, helped with midwife, low age (8 month), spontaneus crying (-), blue baby?, shortness of breathing? Weight of the new born baby: 2500 gram History of food : formula milk: 0-1 weeks age. ASI: 1 weeks until now History of disease : This patent was delivered from the doctor in Deli Serdang hospital with the diagnose of
anemia ec?.

History of drugs : O2 and RL

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Physical Examination
Status present
Body weight : 2,7 kg, body length : 50,3 cm, axilla temperature : 37,9 oC Consciousness : CM Anemic (+), icteric (+), cyanotic (-), edema (-), dyspnoe (-)

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Status localisata
Head : oppened scalp, with icteric face Eyes : Inferior palpebra conjunctiva was pale, sclera (+) icteric, light reflexes +/+, pupils were isochoric Mouth : dry & pale muccouse Ears & nose : within normal limit. Neck : There were no lymph node enlargement ,nuchal rigidity (-). Chest : Fusiformic of simetrical, retraction was not seen, icteric (+) HR : 134 bpm, regulare, murmur (+) sistolik grade III/6 in LMCS ICR III-IV RR : 52 bpm, regulare, ronchi was not found Abdomen : distention was found, normal peristaltis sound, icteric (+)

Liver: palpated 6 cm bellow right arcus costa, smooth and sharp edge Spleen: palpated S 1-2 Extremities : pulse was 134 bpm, regulare, p/v was good, CTR < 3, pale (+), icteric (+) Genital : male, within normal limit. Refleks physiologic right left
APR/KPR Refleks pathologic +/+ +/+

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Laboratory finding at 3rd February 2009 Hb : 9,6 gr/dL Ht : 29,0% Leu : 10.800/mm3 Tromb : 188.000/mm3 Ureum/Cr : 21/0,7 GFR = 91,2 SGOT/SGPT : 17/7 KGD adrandom : 111 Na/K/Cl : 131/3,6/100

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 Treatment : Differential Diagnosis :

Neonatal Sepsis Neonatal Hepatitis
O2 0,5-1 L/i IVFD D5 % NaCl 0,225 % 4 gtt/i mikro Inj. Gentamycin 12 mg/24hours/iv skin test Inj. Ampicillin 125 mg/8 hours/iv skin test Transfused PRC 10cc/12 hours Diet ASI/NGT 50 cc/3 hours

Working Diagnosis :
Neonatal Sepsis

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 Planning :
Complete Blood Count, urin and feces analize Giemsa-stained thick or thin film of peripheral blood LFT/RFT Total/direct Billirubin Albumin CRP Blood culture & sensitivity test Screening hepatitis Blood glucose test Electrolit HST
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Follow up 4 5th February 2009

S Decreasing of consciousness (+), Fever (+) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 38 - 39oC BW : 32 kg GCS : 11 : e : 4 m : 3 v : 4 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (+) SF, retraction (-) HR : 120 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 120 bpm,regular, p/v was good BP : 110/70 mmHg

A DD/ Encephalitis
Meningoencephalitis Meningitis

P 02 3 L/i
Head elevation 30o IVFD D 5% NaCl 0,45% 10 gtt/i makro Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro Manitol 20% 24 gr/8 hours/iv 240 gtt/i mikro Paracetamol 3 x 500 mg (if needed) Diet SV 1750 Kkal with 60 gr protein

Consul to neurology 5th February 2009 Phenytoin : Loading dose : 20 mg/kgBB Maintenance : 5 mg/kgBB Manitol 20 % 24 gr/8 hours/iv Water Balance Chek blood electrolyte everday Mantoux test : LP : None (-), Pandy (-)
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Follow up 6 7th February 2009

S Decreasing of consciousness (+), Fever (-) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 36,8 - 37oC BW : 32 kg GCS : 10 : e : 4 m : 2 v : 4 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (+) SF, retraction (-) HR : 94 - 100 bpm, reg, murmur (-) RR : 28 - 36 tpm, reg, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 94 - 100 bpm,regular, p/v was good BP : 100/70 mmHg

A DD/ Encephalitis
Meningoencephalitis Meningitis

P 02 3 L/i
Head elevation 30o IVFD D 5% NaCl 0,45% 10 gtt/i makro Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro Manitol 20% 24 gr/8 hours/iv 240 gtt/i mikro Paracetamol 3 x 500 mg (if needed) Diet SV 1750 Kkal with 60 gr protein

Head CT Scan result : There was no SOL or intracranial haemorrhage Laboratory finding : WBC : 6,7 K/uL RBC : 3,70 M/uL Na : 136 HGB : 9,6 g/dL K : 4,2 HCT : 28,5% Ca : 7,8 MCV : 76,9 fL Cl : 103 MCH : 25,9 pg 22 PLT : 282 K/uL

Follow up 8 9th February 2009

S Increasing of consciousness (+), Fever (-) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 36,8 - 37oC BW : 32 kg GCS : 14 : e : 5 m : 5 v : 4 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (+) SF, retraction (-) HR :88 - 92 bpm, reg, murmur (-) RR : 24 - 30 tpm, reg, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 88 -92 bpm,regular, p/v was good BP : 100/70 mmHg

A DD/ Encephalitis
Meningoencephalitis Meningitis

P 02 3 L/i
Head elevation 30o IVFD D 5% NaCl 0,45% 10 gtt/i makro Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro Manitol 20% 24 gr/8 hours/iv 240 gtt/i mikro Paracetamol 3 x 500 mg (if needed) Diet SV 1750 Kkal with 60 gr protein

Laboratory finding : Na : 136 K : 4,2 Cl : 103

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Follow up 10 12th February 2009

S Decreasing of consciousness (-), Fever (-) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 36,8 - 37oC BW : 32 kg GCS : 14 : e : 5 m : 5 v : 4 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (-) SF, retraction (-) HR :88 - 92 bpm, reg, murmur (-) RR : 24 - 28 tpm, reg, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 88 - 92 bpm,regular, p/v was good BP : 100/70 mmHg

A DD/ Encephalitis
Meningoencephalitis Meningitis

P Head elevation 30o

IVFD D 5% NaCl 0,45% 10 gtt/i makro aff, using threeway Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro Manitol 20% 24 gr/8 hours/iv 240 gtt/i mikro aff Paracetamol 3 x 500 mg (if needed) Diet MII 1750 Kkal with 40 gr protein Physiotherapy

Consult to neurology : IVFD aff using threeway Manitol aff CSF analize : Colour : clear LDH : 46 Glukosa : 51 Protein : 16 pH : 8,5 Laboratory finding : Na : 140 Ca : 7,5 K : 4,45 24 Cl : 105

Follow up 13 15th February 2009

S Decreasing of consciousness (-), Fever (-), convulsion (-) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 36,8 - 37oC BW : 32 kg GCS : 15 : e : 5 m : 5 v : 5 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (-) Simetrical Fusiformis, retraction (-) HR :88 - 92 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 88 - 92 bpm,regular, p/v was good BP : 100/70 mmHg

A Encephalitis P Using threeway

Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro Paracetamol 3 x 500 mg (if needed) Diet MII 1750 Kkal with 40 gr protein Physiotherapy
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Follow up 16 17th February 2009

S Decreasing of consciousness (-), Fever (-), convulsion (-) O SP
Head Neck Thoraks Abdomen Extremitas Temp : 36,8 - 37oC BW : 32 kg GCS : 15 : e : 5 m : 5 v : 5 Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit Lymph node enlargment (-), nuchal rigidity (-) Simetrical Fusiformis, retraction (-) HR :88 - 92 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-) Soft and flexible, normal peristaltic sound Pulse : 88 - 92 bpm,regular, p/v was good BP : 110/70 mmHg

A Encephalitis P Using threeway

Inj. Cefotaxim 1gr/8 hours/iv Inj. Ampicillin 1 gr/6 hours/iv Phenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro tappering off Paracetamol 3 x 500 mg (if needed) Diet MII 1750 Kkal with 40 gr protein Physiotherapy

17th February 2009, the patient discharge (PAPS) from the hospital

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