viral encephalitis
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VIRAL ENCEPHALITIS
DR.PRAVEEN NAGULA
INTRODUCTION
Acute febrile illness plus altered level of consiousness
Signs and symtpoms reflect the site of inflammation
Impossible to distinguish reliably on the clinical grounds alone one type from other.
Etiology
Sporadic cases -- immunocompetent patients HSV,VZV,EBV.
Epidemics – arbovirusesAlphavriuses – EEE ,western equine virusFlaviviruses – WNV,st louis encephalitisBunyaviruses
NIPAH virusToscana virus
Lab investigations
CSF examination : To be done in all cases Same as meninigtis of viral origin Absent CSF pleocytosis –
immunocompromised,glucocorticoid,malignancies >5 cells/ul -90 % cases >500 cells/ul – 10 % cases >1000 cells /ul –mumps ,LCMV.
ATYPICAL LYMPHOCYTES – EBV,CMV,HSV
Mollaret cells –WNV
Neutrophils -40% WNV,echovirus
>20% RBC – HSV hemorrhagic encephalitis
Decreased CSF glucose – MUMPS,LCMV
CSF PCR –Primary test for CMV,HSV,VZV,EBVSensitive and specific for HSVPostivity increases with duration of illnessNot affected by less than 1 week of therapyNext specific for enterovirusesNot established for EBVLess specific than Ab IgM --WNV
MRI Increased signal intensity in
frontotemporal,cingulate,linuglar regions on t2 weighted images
10 % may have normal MRI
EEG – periodic complexes sharp and slow at regular intervals of 2-3 sec.
Biopsy not reponding to treatment
DIFFERENTIAL DIAGNOSIS
AMOEBIC ENCEPHALITIS***:Naegleria fowleri – 1 amoebic meningoencephalitisIn immuno competenth/o swimming in potentially infected ponds.CSF nuetrophilic pleocytosisHypoglycorrhachiaMotile trophozoites –wet mount of warm fresh
CSF.Mortality is 100% Acanthoemba--- chronic granulomatous illness
HSV encephalitis
Olfactory ,gustatory hallucinationsAnosmiaUnusual or bizzare behaviourDifferentiation is important as specific treatment
avialable.Temporal lobe intensity
rabies
Encephalitis rabies (furious rabies) :Fever,fluctuating consciounessAutonomic hyperactivityHydorphobiaAerophobiaParalytic dumb rabies Acute ascending paralysisPhobic spasms not seen in due to rabies from bat
exposure…
Treatment
ICU CAREICP monitoringFluid restrictionAvoid hypotonic fluidsAnticonvulsantsPrevent apsirationPhysiotherapyDVT prophylaxis
treatment
Acyclovir start empirically10 mg/kg IV every 8 hrs for 14 days30 mg/kg/dayAdditional 7 days in case of positive CSF PCR at
14 days.Ganciclovir 5m g/kg bidfoscarnet -CMV virus 60 mg/kg every 8 hrsCidofovir – nucleotide analogue
THANK YOU
Sagittarian
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