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Encephalitis

  • Author: David S Howes, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Apr 13, 2016
 

Practice Essentials

Encephalitis presents as diffuse or focal neuropsychological dysfunction. Although it primarily involves the brain, it often involves the meninges as well (meningoencephalitis). From an epidemiologic and pathophysiologic perspective, encephalitis is distinct from meningitis, though on clinical evaluation both can be present, with signs and symptoms of meningeal inflammation. It is also distinct from cerebritis.

Signs and symptoms

The viral prodrome typically consists of fever, headache, nausea and vomiting, lethargy, and myalgias. Manifestations associated with specific types of encephalitis include the following:

  • Encephalitis caused by varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), measles virus, or mumps virus: Rash, lymphadenopathy, hepatosplenomegaly, and parotid enlargement
  • St Louis encephalitis: Dysuria and pyuria
  • West Nile encephalitis (WNE): Extreme lethargy

The classic presentation is encephalopathy with diffuse or focal neurologic symptoms, including the following:

  • Behavioral and personality changes, with decreased level of consciousness
  • Neck pain, stiffness
  • Photophobia
  • Lethargy
  • Generalized or focal seizures (60% of children with California virus encephalitis [CE])
  • Acute confusion or amnestic states
  • Flaccid paralysis (10% of patients with WNE)

The signs of encephalitis may be diffuse or focal. Typical findings include the following:

  • Altered mental status
  • Personality changes (very common)
  • Focal findings (eg, hemiparesis, focal seizures, and autonomic dysfunction)
  • Movement disorders (eg, St Louis encephalitis, eastern equine encephalitis, and western equine encephalitis)
  • Ataxia
  • Cranial nerve defects
  • Dysphagia, particularly in rabies
  • Meningismus (less common and less pronounced than in meningitis)
  • Unilateral sensorimotor dysfunction (postinfectious encephalomyelitis)

Findings of herpes simplex virus (HSV) infection in neonates may include the following:

  • Herpetic skin lesions over the presenting surface from birth or with breaks in the skin, such as those resulting from fetal scalp monitors
  • Keratoconjunctivitis
  • Oropharyngeal involvement, particularly buccal mucosa and tongue
  • Encephalitis symptoms (eg, seizures, irritability, change in attentiveness, and bulging fontanelles)
  • Additional signs of disseminated, severe HSV include jaundice, hepatomegaly, and shock

Encephalitis may be associated with a number of complications, including the following:

  • Seizures
  • Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
  • Increased intracranial pressure (ICP)
  • Coma

See Clinical Presentation for more detail.

Diagnosis

Blood and urine tests that may be helpful include the following:

  • Complete blood count (CBC)
  • Serum electrolyte levels
  • Serum glucose level
  • Blood urea nitrogen (BUN) and creatinine levels
  • Urine electrolyte levels
  • Urine or serum toxicology screening

A lumbar puncture (LP) should be performed in all cases of suspected viral encephalitis.

Studies that may be ordered to identify the infectious agent include the following:

  • HSV cultures of suspicious lesions and a Tzanck smear
  • Viral cultures of CSF, including HSV
  • Blood cultures for bacterial pathogens
  • Complement fixation antibodies to identify arbovirus
  • Heterophile antibody and cold agglutinin testing for EBV
  • Serologic tests for Toxoplasma

Imaging modalities that may be helpful include the following:

  • CT
  • MRI
  • EEG

CSF analysis is essential. Parameters to be evaluated include the following:

  • Pressure
  • Cell counts
  • Microorganisms
  • Glucose
  • Protein

Brain biopsy is the diagnostic standard (96% sensitivity, 100% specificity).

See Workup for more detail.

Management

Management in the prehospital setting includes the following:

  • Evaluation and treatment for shock or hypotension
  • Airway protection (in patients with altered mental status)
  • Seizure precautions
  • Oxygen and IV access secured en route to the hospital (all patients)

In the emergency department (ED), beyond supportive care, viral encephalitides are not treatable, with the exceptions of HSV and VZV encephalitis. Important initial measures include the following:

  • Administration of the first dose or doses of acyclovir, with or without antibiotics or steroids, as quickly as possible; the standard for acute bacterial meningitis is initiation of treatment within 30 minutes of arrival
  • Consideration of an ED triage protocol to identify patients at risk for HSV encephalitis
  • Collection of laboratory samples and blood cultures before the start of IV therapy
  • Neuroimaging (eg, MRI or, if that is unavailable, contrast-enhanced head CT) before LP

Additional treatment considerations include the following:

  • Management of hydrocephalus and increased ICP
  • Treatment of systemic complications (eg, hypotension or shock, hypoxemia, hyponatremia, and exacerbation of chronic diseases)
  • Empiric treatment of HSV meningoencephalitis and VZV encephalitis

Clinical practice guidelines for treatment of encephalitis have been published by the Infectious Diseases Society of America (IDSA).[1]

See Treatment and Medication for more detail.

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Background

Encephalitis, an inflammation of the brain parenchyma, presents as diffuse and/or focal neuropsychological dysfunction. Although it primarily involves the brain, the meninges are frequently involved (meningoencephalitis).

From an epidemiologic and pathophysiologic perspective, encephalitis is distinct from meningitis, though on clinical evaluation both can be present, with signs and symptoms of meningeal inflammation, such as photophobia, headache, or stiff neck. It is also distinct from cerebritis. Cerebritis describes the stage preceding abscess formation and implies a highly destructive bacterial infection of brain tissue, whereas acute encephalitis is most commonly a viral infection with parenchymal damage varying from mild to profound.

Although bacterial, fungal, and autoimmune disorders can produce encephalitis, most cases are viral in origin. The incidence of encephalitis is 1 case per 200,000 population in the United States, with herpes simplex virus (HSV) being the most common cause. Considering the subacute and chronic encephalopathies, the emergency department (ED) physician is most likely to encounter toxoplasmosis in an immune-compromised host.

The relatively common acute arboviral encephalitides vary widely in epidemiology, mortality, morbidity, and clinical presentation, and no satisfactory treatment exists for these infections. However, attempts to distinguish these acute arboviral encephalitides from the treatable acute viral encephalitides due to herpes simplex or varicella are important.

Herpes simplex encephalitis (HSE), which occurs sporadically in healthy and immune-compromised adults is also encountered in neonates infected at birth during vaginal delivery and is potentially lethal if not treated. Varicella-zoster virus encephalitis (VZVE) is life threatening in immune-compromised patients. Swift identification and immediate treatment of HSE or VZVE can be lifesaving. From a risk-benefit standpoint, most authorities recommend initiating ED treatment with acyclovir in any patient whose central nervous system (CNS) presentation is suggestive of viral encephalitis, especially in the presence of fever, encephalopathy, or focal findings, and in all neonates who appear ill for whom a CNS infection is being considered.

See the following for more information:

West Nile encephalitis

In 1999, a late summer outbreak of West Nile encephalitis (WNE), an arbovirus not previously found in the United States, was implicated in several deaths in New York. By late summer 2002, West Nile virus had been identified throughout the eastern and southeastern United States. Following bird migration, the virus began to extend westward, and by April 2003, virus activity had been detected in 46 states and the District of Columbia.

An updated Centers for Disease Control and Prevention (CDC) report for 2007 (West Nile Virus Update) included information regarding viremic blood donors. Throughout the world, outbreaks of WNE have been associated with severe neurologic disease, though, in general, only 1 in 150 affected patients develop symptomatic WNE. By 2008, the number of cases reported to the CDC had dropped dramatically throughout the United States, owing to the decimation of the US crow bird population, a common host of the WNV, which is lethal to the American crow.[2]

For more information, see the CDC fact sheet on West Nile virus, links to state and local government web sites on West Nile virus, and the Environmental Protection Agency (EPA)/CDC article on mosquito control.

For clinical information on the Internet, see West Nile Virus: A Primer for the Clinician, from the August 6, 2002, issue of Annals of Internal Medicine. The Canadian equivalent, West Nile Virus: Primer for Family Physicians, was published on June 10, 2005, in Canadian Family Physician.[3]

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Pathophysiology

Portals of entry are virus specific. Many viruses are transmitted by humans, though most cases of HSE are thought to be reactivation of HSV lying dormant in the trigeminal ganglia. Mosquitoes or ticks inoculate arbovirus, and rabies virus is transferred via an infected animal bite or exposure to animal secretions. With some viruses, such as varicella-zoster virus (VZV) and cytomegalovirus (CMV), an immune-compromised state is usually necessary to develop clinically apparent encephalitis.

In general, the virus replicates outside the CNS and gains entry to the CNS either by hematogenous spread or by travel along neural pathways (eg, rabies virus, HSV, VZV). The etiology of slow virus infections, such as those implicated in the measles-related subacute sclerosing panencephalitis (SSPE) and progressive multifocal leukoencephalopathy (PML), is poorly understood.

Once across the blood-brain barrier, the virus enters neural cells, with resultant disruption in cell functioning, perivascular congestion, hemorrhage, and a diffuse inflammatory response that disproportionately affects gray matter over white matter. Regional tropism associated with certain viruses is due to neuron cell membrane receptors found only in specific portions of the brain, with more intense focal pathology in these areas. A classic example is the HSV predilection for the inferior and medial temporal lobes.

In contrast to viruses that invade gray matter directly, acute disseminated encephalitis and postinfectious encephalomyelitis (PIE), most commonly due to measles infection and associated with Epstein-Barr virus (EBV) and CMV infections, are immune-mediated processes that result in multifocal demyelination of perivenous white matter.

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Etiology

The cause of encephalitis is usually infectious in nature. Viral agents, such as HSV types 1 and 2 (the latter much more common in neonates than adults), VZV, EBV, measles virus (PIE and SSPE), mumps virus, and rubella virus, are spread through person-to-person contact. Human herpesvirus 6 may also be a causative agent.[4] The CDC has confirmed that WNV can be transmitted by means of organ transplantation and via blood transfusions.

Important animal vectors include mosquitoes and ticks, which spread the arbovirus group, and warm-blooded mammals, which are vectors for rabies and lymphocytic choriomeningitis (LCM).

Bacterial pathogens, such as Mycoplasma species and those causing rickettsial disease or catscratch disease, are rare and invariably involve inflammation of the meninges out of proportion to their encephalitic components. Encephalitis due to parasites and fungi other than Toxoplasma gondii are covered elsewhere.

Noninfectious causes include the demyelinating process in acute disseminated encephalitis.

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Epidemiology

United States statistics

Determining the true incidence of encephalitis is impossible, because reporting policies are neither standardized nor rigorously enforced. In the United States, several thousand cases of viral encephalitis are reported to the CDC each year, with an additional 100 cases a year attributed to PIE. These figures probably represent a fraction of the actual number of cases.

HSE, the most common cause of sporadic encephalitis in Western countries, is relatively rare; the overall incidence is 0.2 per 100,000, with neonatal HSV infection occurring in 2-3 per 10,000 live births.

The arbovirus group is the most common cause of episodic encephalitis, with a reported incidence similar to that of HSV. These statistics may be misleading in that most people bitten by arbovirus-infected insects do not develop clinically apparent illness and, of those who do, less than 10% develop overt encephalitis.

Arboviruses require an insect vector, which is generally present between June and October. The 2 most common arboviruses result in (1) St Louis encephalitis, found throughout the United States but principally in urban areas around the Mississippi River, and (2) the geographically misnamed California virus encephalitis (CE)—in particular, LaCross encephalitis (LAC)—which affects children in rural areas in states of the upper Midwest and North East.

Among the other arbovirus-caused encephalitides, the deadliest (and, fortunately, rarest) is eastern equine encephalitis (EEE), which is encountered in New England and surrounding areas; western equine encephalitis (WEE), a milder disease, is most common in rural communities west of the Mississippi River. Powassan virus is the only well-documented arbovirus transmitted by ticks.

Less common causes of viral encephalitis include VZV encephalitis, with an incidence of roughly 1 in 2000 infected persons. Measles produces 2 devastating forms of encephalitis: PIE, which occurs in about 1 in 1000 infected persons, and SSPE, occurring in about 1 in 100,000 infected patients. Rarest in the United States are the 0-3 unrelated annual cases of rabies encephalitis, typically a consequence of the immigration of an infected person from Mexico or Central America during the long incubation period of the rabies virus but prior to the onset of clinically apparent disease.

International statistics

Japanese virus encephalitis (JE), occurring principally in Japan, Southeast Asia, China, and India, is the most common viral encephalitis outside the United States.

Age-related differences in incidence

Individuals at the extremes of age are at highest risk, particularly for HSE. Neonatal HSE is a manifestation of disseminated infection type 1 or 2, whereas older infants, children, and adults are much more likely to have localizing CNS infection almost exclusively due to type 1, in a bimodal distribution of patients aged 5-30 years or older than 50 years.

St Louis encephalitis and WNE are more common and are most severe in patients older than 60 years; conversely, LAC is more common and is most severe in children younger than 16 years. EEE and WEE disproportionately affect infants while EEE disproportionately affects children and elderly persons.

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Prognosis

The prognosis is dependent on the virulence of the virus and the patient’s health status. Extremes of age (< 1 y or >55 y), immune-compromised status, and preexisting neurologic conditions are associated with poorer outcomes.

Untreated HSE has a mortality of 50-75%, and virtually all untreated or late-treatment survivors have long-term motor and mental disabilities. The mortality in treated HSE averages 20%, and the neurologic outcome correlates with the neurological disability present at the time of the first dose of acyclovir or comparable antiviral agents. Approximately 40% of survivors have minor-to-major learning disabilities, memory impairment, neuropsychiatric abnormalities, epilepsy, fine-motor-control deficits, and dysarthria.

Outcomes in arboviral JE and EEE are catastrophic, similar to untreated HSE, with high mortality and severe morbidity, including mental retardation, hemiplegia, and seizures. Other arboviruses cause substantially less morbidity and mortality. For example, St Louis encephalitis and WNE have a mortality rate of 2-20%, the higher rates found in patients older than 60 years. Long-term sequelae with St Louis encephalitis include behavioral disorders, memory loss, and seizures.

WEE is associated with few deaths and much less morbidity, although developmental delay, seizure disorder, and paralysis occasionally occur in children, and postencephalitic parkinsonism may occur in adults. CE is typically associated with mild illness, and most patients make a full recovery; however, the minority of patients with severe disease have a 25% chance of focal neurologic dysfunction. Death rates from WEE and LAC are less than 5%.

PIE secondary to measles is associated with a mortality rate approaching 40% of cases, with a high rate of neurologic sequelae in survivors. SSPE is uniformly fatal, although the disease course may last anywhere from several weeks to 10 years.

VZVE has a mortality of 15% in immune-competent patients and virtually 100% in immune-suppressed patients. The mortality for EBV encephalitis is 8%, with substantial morbidity found in approximately 12% of survivors.

Rabies encephalitis and acute disseminated encephalitis are virtually 100% fatal, although there are rare survivors reported in the medical literature.

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Patient Education

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Contributor Information and Disclosures
Author

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Marjorie Lazoff, MD Editor-in-Chief, Medical Computing Review

Marjorie Lazoff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Informatics Association, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center

Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Todd Pritz, MD Intensivist, St Anthony's Medical Center and St John's Mercy Medical Center

Todd Pritz, MD is a member of the following medical societies: Massachusetts Medical Society and Society of Critical Care 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 Reference Salary Employment

References
  1. [Guideline] Tunkel AR, Glaser CA, Bloch KC, Sejvar JJ, Marra CM, Roos KL, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008 Aug 1. 47(3):303-27. [Medline].

  2. Final 2008 West Nile Virus Activity in the United States. Centers for Disease Control and Prevention. Available at http://bit.ly/fATcE1. Accessed: April 26, 2009.

  3. MacDonald RD, Krym VF. West Nile virus. Primer for family physicians. Can Fam Physician. 2005 Jun. 51:833-7. [Medline].

  4. Yao K, Honarmand S, Espinosa A, Akhyani N, Glaser C, Jacobson S. Detection of human herpesvirus-6 in cerebrospinal fluid of patients with encephalitis. Ann Neurol. 2009 Mar. 65(3):257-67. [Medline].

  5. Bloch KC, Glaser C. Diagnostic approaches for patients with suspected encephalitis. Curr Infect Dis Rep. 2007 Jul. 9(4):315-22. [Medline].

  6. Hayasaka D, Aoki K, Morita K. Development of simple and rapid assay to detect viral RNA of tick-borne encephalitis virus by reverse transcription-loop-mediated isothermal amplification. Virol J. 2013 Mar 4. 10(1):68. [Medline].

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Table. Cerebrospinal Fluid Findings by Type of Organism
CSF Finding (Normal)Bacterial MeningitisViral Meningitis*Fungal Meningitis
Pressure (5-15 cm water)
  • Increased
  • Normal or mildly increased
  • Normal or mildly increased in most fungal and tuberculous CNS infections
  • Patients with AIDS and cryptococcal meningitis are at increased risk of blindness and death unless pressure maintained at < 30 cm
Cell counts, mononuclear cells/µL



Preterm (0-25)



Term (0-22)



6 mo+ (0-5)



  • Normal cell count excludes bacterial meningitis
  • Typically thousands of polymorphonuclear cells, but counts may not change dramatically or even be normal (classically in very early meningococcal meningitis or in extremely ill neonates)
  • Lymphocytosis with normal CSF chemistry results observed in 15-25% of patients, especially if counts < 1000 or if patient is partially treated
  • About 90% of patients with ventriculoperitoneal shunts and CSF WBC count >100 cells/µL are infected, though CSF glucose level often normal, and bacteria often less pathogenic
  • Cell count and chemistry levels normalize slowly (days) with antibiotics
  • Usually < 500, nearly 100% mononuclear
  • < 48 hours, clinically significant polymorphonuclear pleocytosis may be indistinguishable from early bacterial meningitis, particularly with EEE
  • Nontraumatic RBCs in 80% of patients with HSV meningoencephalitis, though 10% have normal CSF results
  • 100s of mononuclear cells
Microorganisms (none)
  • Gram stain 80% effective
  • Inadequate decolorization may cause Haemophilus influenzae to be mistaken for gram-positive cocci
  • Pretreatment with antibiotics may affect stain uptake, causing gram-positive species to appear to be gram-negative and decrease culture yield by an average of 20
  • No organism
  • India ink 80-90% effective for detecting fungi
  • AFB stain 40% effective for TB; increase yield by staining supernatant from at least 5 mL of CSF
Glucose



Euglycemia (>50% serum)



Hyperglycemia (>30% serum)



  • Decreased
  • Normal
  • Sometimes decreased
  • In addition to fulminant bacterial meningitis, TB, primary amebic meningoencephalitis, and neurocysticercosis cause low glucose levels
Protein



Preterm (65-150 mg/dL)



Term (20-170 mg/dL



6 mo+ (15-45 mg/dL)



  • Usually >150 mg/dL
  • May be >1000 mg/dL
  • Mildly increased
  • Increased >1000 mg/dL, with relatively benign clinical presentation suggestive of fungal disease
*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 encephalitis—the arboviruses and the potentially curable HSV.



Wait 4 hours after glucose load.



AFB—acid-fast bacillus; CSF—cerebrospinal fluid; EEE-eastern equine encephalitis; HSV—herpes simplex virus; RBC—red blood cell; TB—tuberculosis; WBC—white blood cell.



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