Viral Encephalitis Differential Diagnoses

  • Author: Francisco de Assis Aquino Gondim, MD, MSc, PhD; more...
 
Updated: Aug 26, 2011
 
 

Diagnostic Considerations

See the following for complete information on these topics:

Other conditions to be considered include the following:

  • Myoclonus
  • Partial seizures with secondary generalization
  • Seizure, partial (focal)
  • Benign epilepsy syndromes
  • Pseudomigraine with CSF pleocytosis

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Francisco de Assis Aquino Gondim, MD, MSc, PhD  Associate Professor of Neurology, Department of Neurology and Psychiatry, St Louis University School of Medicine

Francisco de Assis Aquino Gondim, MD, MSc, PhD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Movement Disorders Society

Disclosure: Nothing to disclose.

Coauthor(s)

Florian P Thomas, MD, MA, PhD, Drmed  Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Gisele Oliveira, MD  Resident Physician, Department of Neurology, St Louis University School of Medicine

Gisele Oliveira, MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

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Table 1. Physiologic Roles of Known Viral Receptors
Virus Receptor Abbreviation/Synonym Function
Measles virusMembrane cofactor proteinCD46Regulates complement and prevents activation of complement on autologous cells
PoliovirusCD155hPVR/CD155Expressed on primary human monocytes; supports poliovirus replication in vivo
HSVHeparan sulfateNoneCell surface proteoglycans
Herpesvirus entry mediator AHve A, HVEMTNF receptor superfamily
Herpesvirus entry mediator BHve B, Human nectin-2, or Prr2alpha-Hve BParticipate in organization of epithelial and endothelial junctions
Herpesvirus entry mediator CHve C, nectin1delta, or Prr1-Hve CImmunoglobulin superfamily
TNFSF14hTNFSF14/HVEM-LTNF receptor superfamily
Rabies virusNicotinic AChR (a-bungarotoxin binding site)AChRNicotinic AChR
NCAMNCAM, CD56, D2CAM, Leu19, or NKH-1Cell adhesion glycoprotein of immunoglobulin superfamily
NGFRNGFRNGFR
p75 neurotrophin receptor (p75NTR)p75NTR
HIV-1CD4CD4T lymphocyte protein with helper or inducer function in immune system
CCR3CCR3Chemotactic activity
CCR5CCR5Coreceptor for macrophage-tropic strain
CCR6CCR65Chemotactic activity
CXCR4CXCR4Coreceptor for CD4
JC virusN-linked glycoprotein with alpha 2-6 sialic acidN-linked glycoproteinUnknown
Japanese B virus[4] Protein GRP78---ER-stress response protein
AChR—acetylcetylcholine receptor; CCR—chemokine receptor; HSV—herpes simplex virus; NCAM—neural cell adhesion molecule; NGFR—nerve growth factor receptor; TNF—tumor necrosis factor.
Table 2. Common Viral Encephalitides: Part 1
Virus (Family)Viral StructureTransmissionMortalitySpecific Clinical PatternsSequelaeSeason
HSV (herpesvirus)ds DNAUnknown70% if untreatedRare forms: subacute, psychiatric, opercular, recurrent meningitis



HSV-1: brainstem; HSV-2: myelitis



CommonAll year
VZV (herpesvirus)ds DNADirect contact (air), highly contagiousVariable; low in childrenRash, encephalitis in 0.1-0.2% of children with chickenpox; cerebellar ataxia (cerebellitis)Adults worse; cerebellitis goodLate winter, spring
Influenza virus (orthomyxovirus)ss RNADirect contact (air), highly contagiousUnknownReversible frontal syndrome in children; Guillain-Barré, myelitisParkinsonism (encephalitis lethargica)Usually winter
Enteroviruses (picornavirus)ss RNAFecal-oral routeLow; high for enterovirus 71Herpangina; hand, foot, mouth disease; enterovirus 71 causes rhombencephalitisMild, except for enterovirus 71Summer, fall; tropics: no season
Rabies virus (rhabdovirus)ss RNADogs, wild animals (eg, fox, wolf, skunk)Virtually 100%Paresthesias; confusion, spasms, hydrophobia; brainstem featuresMortality virtually 100%All year
ds—double strand; HSV—herpes simplex virus; ss—single strand; VZV—varicella-zoster virus.
Table 3. Common Viral Encephalitides: Part 2
Virus (Family)Viral StructureTransmissionMortalitySpecific Clinical PatternsSequelaeSeason
Lymphocytic choriomeningitis virus (arenavirus)ss RNARodentsLow (< 1%)Progressive fever and myalgia; orchitis; aseptic meningitis; leukopenia, thrombocytopeniaRareMore in winter
Lassa virus (arenavirus)ss RNARodents15%Multisystem disease; proteinuriaDeafness (one third)All year
Mumps virus (paramyxovirus)ss RNADirect contact (air), highly contagiousLowParotitis, pancreatitis, orchitis, aseptic meningitisFrequent sequelaeWinter and spring
Measles virus (paramyxovirus)ss RNADirect contact (air), highly contagious10%Characteristic rash; frequent EEG changes; myelitisFrequent: mental retardation, seizures, SSPEWinter and spring
Nipah virus (paramyxovirus)ss RNAPigs; bats40%Brainstem or cerebellar signs; segmental myoclonus, dysautonomiaSSPE-like syndrome?All year
ds—double strand; EEG—electroencephalographic; ss—single strand; SSPE—subacute sclerosing panencephalitis.
Table 4. Common Arboviral Encephalitides
Virus (Family) Vector Reservoir Mortality Specific Clinical Patterns Sequelae Season
Eastern equine virus (alphavirus)Aedes sollicitansBirds35%Severe, rapid progressionCommon, especially in childrenJune to



October



Western equine virus (alphavirus)Culex tarsalisBirds10%Classic encephalitisModerate in infants; low in othersJuly to



October



Venezuelan equine encephalitis virus (alphavirus)Mosquito speciesHorses, small mammals~ 0.4 %Low rate (4%) of CNS involvementMildRainy season
St Louis encephalitis virus (flavivirus)Culex pipiens,C tarsalisBirds2% in young people; 20% in elderly peopleSIADHMore in elderly peopleAugust to October
Japanese encephalitis virus (flavivirus)Culex taeniorhynchusBirds33% (50% in elderly people)Extrapyramidal features50% neuro psychiatric; parkinsonismSummer
West Nile virus (flavivirus)Culex,Aedes sppBirdsIn US: 12% (elderly people only)Motor or brainstem involvementUsually not prominentSummer
Far East encephalitis virus (flavivirus)Ixodes persulcatus (tick)Small mammals, birds20%Epilepsia partialis continuaFrequent; residual weaknessSpring to early summer
Central European encephalitis virus (flavivirus)Ixodes ricinus (tick)Small mammals, birdsLess common than in Far EastLimb-girdle paralysis (spine/medulla)Less common than in Far EastApril to October
Powassan virus (flavivirus)Ixodes cookei (tick)Small mammals, birdsHighSevere encephalitisCommon (50%)May to December
Dengue virus (flavivirus)Aedes sppMosquitoesLow, except hemorrhagicFlulike syndrome; rare CNS involvementMild, except for hemorrhagicRainy season
La Crosse virus (bunyavirus)Aedes triseriatusSmall mammalsLow (< 1%)Mild, primarily in childrenMild; seizuresSummer
Colorado tick fever virus (orbivirus)Dermacentor andersoni (tick)Small mammalsLowMild
CNS—central nervous system; SIADH—syndrome of inappropriate antidiuretic hormone secretion.
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