15/1/2017

Encephalitis:PracticeEssentials,Background,Pathophysiology

Thissiteisintendedforhealthcareprofessionals

Encephalitis
Updated:Apr13,2016
Author:DavidSHowes,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...

OVERVIEW

PracticeEssentials
Encephalitispresentsasdiffuseorfocalneuropsychologicaldysfunction.Althoughitprimarilyinvolvesthe
brain,itofteninvolvesthemeningesaswell(meningoencephalitis).Fromanepidemiologicand
pathophysiologicperspective,encephalitisisdistinctfrommeningitis,thoughonclinicalevaluationbothcan
bepresent,withsignsandsymptomsofmeningealinflammation.Itisalsodistinctfromcerebritis.

Signsandsymptoms
Theviralprodrometypicallyconsistsoffever,headache,nauseaandvomiting,lethargy,andmyalgias.
Manifestationsassociatedwithspecifictypesofencephalitisincludethefollowing:
Encephalitiscausedbyvaricellazostervirus(VZV),EpsteinBarrvirus(EBV),cytomegalovirus(CMV),
measlesvirus,ormumpsvirus:Rash,lymphadenopathy,hepatosplenomegaly,andparotid
enlargement
StLouisencephalitis:Dysuriaandpyuria
WestNileencephalitis(WNE):Extremelethargy
Theclassicpresentationisencephalopathywithdiffuseorfocalneurologicsymptoms,includingthe
following:
Behavioralandpersonalitychanges,withdecreasedlevelofconsciousness
Neckpain,stiffness
Photophobia
Lethargy
Generalizedorfocalseizures(60%ofchildrenwithCaliforniavirusencephalitis[CE])
Acuteconfusionoramnesticstates
Flaccidparalysis(10%ofpatientswithWNE)
Thesignsofencephalitismaybediffuseorfocal.Typicalfindingsincludethefollowing:
Alteredmentalstatus
Personalitychanges(verycommon)
Focalfindings(eg,hemiparesis,focalseizures,andautonomicdysfunction)
Movementdisorders(eg,StLouisencephalitis,easternequineencephalitis,andwesternequine
encephalitis)
Ataxia
Cranialnervedefects
Dysphagia,particularlyinrabies
Meningismus(lesscommonandlesspronouncedthaninmeningitis)
Unilateralsensorimotordysfunction(postinfectiousencephalomyelitis)
Findingsofherpessimplexvirus(HSV)infectioninneonatesmayincludethefollowing:
Herpeticskinlesionsoverthepresentingsurfacefrombirthorwithbreaksintheskin,suchasthose
resultingfromfetalscalpmonitors
Keratoconjunctivitis
Oropharyngealinvolvement,particularlybuccalmucosaandtongue
Encephalitissymptoms(eg,seizures,irritability,changeinattentiveness,andbulgingfontanelles)
Additionalsignsofdisseminated,severeHSVincludejaundice,hepatomegaly,andshock
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Encephalitismaybeassociatedwithanumberofcomplications,includingthefollowing:
Seizures
Syndromeofinappropriatesecretionofantidiuretichormone(SIADH)
Increasedintracranialpressure(ICP)
Coma
SeeClinicalPresentationformoredetail.

Diagnosis
Bloodandurineteststhatmaybehelpfulincludethefollowing:
Completebloodcount(CBC)
Serumelectrolytelevels
Serumglucoselevel
Bloodureanitrogen(BUN)andcreatininelevels
Urineelectrolytelevels
Urineorserumtoxicologyscreening
Alumbarpuncture(LP)shouldbeperformedinallcasesofsuspectedviralencephalitis.
Studiesthatmaybeorderedtoidentifytheinfectiousagentincludethefollowing:
HSVculturesofsuspiciouslesionsandaTzancksmear
ViralculturesofCSF,includingHSV
Bloodculturesforbacterialpathogens
Complementfixationantibodiestoidentifyarbovirus
HeterophileantibodyandcoldagglutinintestingforEBV
SerologictestsforToxoplasma
Imagingmodalitiesthatmaybehelpfulincludethefollowing:
CT
MRI
EEG
CSFanalysisisessential.Parameterstobeevaluatedincludethefollowing:
Pressure
Cellcounts
Microorganisms
Glucose
Protein
Brainbiopsyisthediagnosticstandard(96%sensitivity,100%specificity).
SeeWorkupformoredetail.

Management
Managementintheprehospitalsettingincludesthefollowing:
Evaluationandtreatmentforshockorhypotension
Airwayprotection(inpatientswithalteredmentalstatus)
Seizureprecautions
OxygenandIVaccesssecuredenroutetothehospital(allpatients)
Intheemergencydepartment(ED),beyondsupportivecare,viralencephalitidesarenottreatable,withthe
exceptionsofHSVandVZVencephalitis.Importantinitialmeasuresincludethefollowing:
Administrationofthefirstdoseordosesofacyclovir,withorwithoutantibioticsorsteroids,asquickly
aspossiblethestandardforacutebacterialmeningitisisinitiationoftreatmentwithin30minutesof
arrival
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Encephalitis:PracticeEssentials,Background,Pathophysiology

ConsiderationofanEDtriageprotocoltoidentifypatientsatriskforHSVencephalitis
CollectionoflaboratorysamplesandbloodculturesbeforethestartofIVtherapy
Neuroimaging(eg,MRIor,ifthatisunavailable,contrastenhancedheadCT)beforeLP
Additionaltreatmentconsiderationsincludethefollowing:
ManagementofhydrocephalusandincreasedICP
Treatmentofsystemiccomplications(eg,hypotensionorshock,hypoxemia,hyponatremia,and
exacerbationofchronicdiseases)
EmpirictreatmentofHSVmeningoencephalitisandVZVencephalitis
ClinicalpracticeguidelinesfortreatmentofencephalitishavebeenpublishedbytheInfectiousDiseases
SocietyofAmerica(IDSA).[1]
SeeTreatmentandMedicationformoredetail.

Background
Encephalitis,aninflammationofthebrainparenchyma,presentsasdiffuseand/orfocalneuropsychological
dysfunction.Althoughitprimarilyinvolvesthebrain,themeningesarefrequentlyinvolved
(meningoencephalitis).
Fromanepidemiologicandpathophysiologicperspective,encephalitisisdistinctfrommeningitis,thoughon
clinicalevaluationbothcanbepresent,withsignsandsymptomsofmeningealinflammation,suchas
photophobia,headache,orstiffneck.Itisalsodistinctfromcerebritis.Cerebritisdescribesthestage
precedingabscessformationandimpliesahighlydestructivebacterialinfectionofbraintissue,whereas
acuteencephalitisismostcommonlyaviralinfectionwithparenchymaldamagevaryingfrommildto
profound.
Althoughbacterial,fungal,andautoimmunedisorderscanproduceencephalitis,mostcasesareviralin
origin.Theincidenceofencephalitisis1caseper200,000populationintheUnitedStates,withherpes
simplexvirus(HSV)beingthemostcommoncause.Consideringthesubacuteandchronic
encephalopathies,theemergencydepartment(ED)physicianismostlikelytoencountertoxoplasmosisin
animmunecompromisedhost.
Therelativelycommonacutearboviralencephalitidesvarywidelyinepidemiology,mortality,morbidity,and
clinicalpresentation,andnosatisfactorytreatmentexistsfortheseinfections.However,attemptsto
distinguishtheseacutearboviralencephalitidesfromthetreatableacuteviralencephalitidesduetoherpes
simplexorvaricellaareimportant.
Herpessimplexencephalitis(HSE),whichoccurssporadicallyinhealthyandimmunecompromisedadults
isalsoencounteredinneonatesinfectedatbirthduringvaginaldeliveryandispotentiallylethalifnot
treated.Varicellazostervirusencephalitis(VZVE)islifethreateninginimmunecompromisedpatients.Swift
identificationandimmediatetreatmentofHSEorVZVEcanbelifesaving.Fromariskbenefitstandpoint,
mostauthoritiesrecommendinitiatingEDtreatmentwithacyclovirinanypatientwhosecentralnervous
system(CNS)presentationissuggestiveofviralencephalitis,especiallyinthepresenceoffever,
encephalopathy,orfocalfindings,andinallneonateswhoappearillforwhomaCNSinfectionisbeing
considered.
Seethefollowingformoreinformation:
CaliforniaEncephalitis
CBRNEVenezuelanEquineEncephalitis
EasternEquineEncephalitis
Encephalitis
HerpesSimplexEncephalitis
HIVAssociatedCytomegalovirusEncephalitis
JapaneseEncephalitis
St.LouisEncephalitis
VenezuelanEquineEncephalitis
ViralEncephalitis
WestNileEncephalitis
WesternEquineEncephalitis
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WestNileencephalitis
In1999,alatesummeroutbreakofWestNileencephalitis(WNE),anarbovirusnotpreviouslyfoundinthe
UnitedStates,wasimplicatedinseveraldeathsinNewYork.Bylatesummer2002,WestNilevirushad
beenidentifiedthroughouttheeasternandsoutheasternUnitedStates.Followingbirdmigration,thevirus
begantoextendwestward,andbyApril2003,virusactivityhadbeendetectedin46statesandtheDistrict
ofColumbia.
AnupdatedCentersforDiseaseControlandPrevention(CDC)reportfor2007(WestNileVirusUpdate)
includedinformationregardingviremicblooddonors.Throughouttheworld,outbreaksofWNEhavebeen
associatedwithsevereneurologicdisease,though,ingeneral,only1in150affectedpatientsdevelop
symptomaticWNE.By2008,thenumberofcasesreportedtotheCDChaddroppeddramaticallythroughout
theUnitedStates,owingtothedecimationoftheUScrowbirdpopulation,acommonhostoftheWNV,
whichislethaltotheAmericancrow.[2]
Formoreinformation,seetheCDCfactsheetonWestNilevirus,linkstostateandlocalgovernmentweb
sitesonWestNilevirus,andtheEnvironmentalProtectionAgency(EPA)/CDCarticleonmosquitocontrol.
ForclinicalinformationontheInternet,seeWestNileVirus:APrimerfortheClinician,fromtheAugust6,
2002,issueofAnnalsofInternalMedicine.TheCanadianequivalent,WestNileVirus:PrimerforFamily
Physicians,waspublishedonJune10,2005,inCanadianFamilyPhysician.[3]

Pathophysiology
Portalsofentryarevirusspecific.Manyvirusesaretransmittedbyhumans,thoughmostcasesofHSEare
thoughttobereactivationofHSVlyingdormantinthetrigeminalganglia.Mosquitoesorticksinoculate
arbovirus,andrabiesvirusistransferredviaaninfectedanimalbiteorexposuretoanimalsecretions.With
someviruses,suchasvaricellazostervirus(VZV)andcytomegalovirus(CMV),animmunecompromised
stateisusuallynecessarytodevelopclinicallyapparentencephalitis.
Ingeneral,thevirusreplicatesoutsidetheCNSandgainsentrytotheCNSeitherbyhematogenousspread
orbytravelalongneuralpathways(eg,rabiesvirus,HSV,VZV).Theetiologyofslowvirusinfections,such
asthoseimplicatedinthemeaslesrelatedsubacutesclerosingpanencephalitis(SSPE)andprogressive
multifocalleukoencephalopathy(PML),ispoorlyunderstood.
Onceacrossthebloodbrainbarrier,thevirusentersneuralcells,withresultantdisruptionincellfunctioning,
perivascularcongestion,hemorrhage,andadiffuseinflammatoryresponsethatdisproportionatelyaffects
graymatteroverwhitematter.Regionaltropismassociatedwithcertainvirusesisduetoneuroncell
membranereceptorsfoundonlyinspecificportionsofthebrain,withmoreintensefocalpathologyinthese
areas.AclassicexampleistheHSVpredilectionfortheinferiorandmedialtemporallobes.
Incontrasttovirusesthatinvadegraymatterdirectly,acutedisseminatedencephalitisandpostinfectious
encephalomyelitis(PIE),mostcommonlyduetomeaslesinfectionandassociatedwithEpsteinBarrvirus
(EBV)andCMVinfections,areimmunemediatedprocessesthatresultinmultifocaldemyelinationof
perivenouswhitematter.

Etiology
Thecauseofencephalitisisusuallyinfectiousinnature.Viralagents,suchasHSVtypes1and2(thelatter
muchmorecommoninneonatesthanadults),VZV,EBV,measlesvirus(PIEandSSPE),mumpsvirus,and
rubellavirus,arespreadthroughpersontopersoncontact.Humanherpesvirus6mayalsobeacausative
agent.[4]TheCDChasconfirmedthatWNVcanbetransmittedbymeansoforgantransplantationandvia
bloodtransfusions.
Importantanimalvectorsincludemosquitoesandticks,whichspreadthearbovirusgroup,andwarm
bloodedmammals,whicharevectorsforrabiesandlymphocyticchoriomeningitis(LCM).
Bacterialpathogens,suchasMycoplasmaspeciesandthosecausingrickettsialdiseaseorcatscratch
disease,arerareandinvariablyinvolveinflammationofthemeningesoutofproportiontotheirencephalitic
components.EncephalitisduetoparasitesandfungiotherthanToxoplasmagondiiarecoveredelsewhere.
Noninfectiouscausesincludethedemyelinatingprocessinacutedisseminatedencephalitis.
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Epidemiology
UnitedStatesstatistics
Determiningthetrueincidenceofencephalitisisimpossible,becausereportingpoliciesareneither
standardizednorrigorouslyenforced.IntheUnitedStates,severalthousandcasesofviralencephalitisare
reportedtotheCDCeachyear,withanadditional100casesayearattributedtoPIE.Thesefigures
probablyrepresentafractionoftheactualnumberofcases.
HSE,themostcommoncauseofsporadicencephalitisinWesterncountries,isrelativelyraretheoverall
incidenceis0.2per100,000,withneonatalHSVinfectionoccurringin23per10,000livebirths.
Thearbovirusgroupisthemostcommoncauseofepisodicencephalitis,withareportedincidencesimilarto
thatofHSV.Thesestatisticsmaybemisleadinginthatmostpeoplebittenbyarbovirusinfectedinsectsdo
notdevelopclinicallyapparentillnessand,ofthosewhodo,lessthan10%developovertencephalitis.
Arbovirusesrequireaninsectvector,whichisgenerallypresentbetweenJuneandOctober.The2most
commonarbovirusesresultin(1)StLouisencephalitis,foundthroughouttheUnitedStatesbutprincipallyin
urbanareasaroundtheMississippiRiver,and(2)thegeographicallymisnamedCaliforniavirusencephalitis
(CE)inparticular,LaCrossencephalitis(LAC)whichaffectschildreninruralareasinstatesoftheupper
MidwestandNorthEast.
Amongtheotherarboviruscausedencephalitides,thedeadliest(and,fortunately,rarest)iseasternequine
encephalitis(EEE),whichisencounteredinNewEnglandandsurroundingareaswesternequine
encephalitis(WEE),amilderdisease,ismostcommoninruralcommunitieswestoftheMississippiRiver.
Powassanvirusistheonlywelldocumentedarbovirustransmittedbyticks.
LesscommoncausesofviralencephalitisincludeVZVencephalitis,withanincidenceofroughly1in2000
infectedpersons.Measlesproduces2devastatingformsofencephalitis:PIE,whichoccursinabout1in
1000infectedpersons,andSSPE,occurringinabout1in100,000infectedpatients.RarestintheUnited
Statesarethe03unrelatedannualcasesofrabiesencephalitis,typicallyaconsequenceoftheimmigration
ofaninfectedpersonfromMexicoorCentralAmericaduringthelongincubationperiodoftherabiesvirus
butpriortotheonsetofclinicallyapparentdisease.

Internationalstatistics
Japanesevirusencephalitis(JE),occurringprincipallyinJapan,SoutheastAsia,China,andIndia,isthe
mostcommonviralencephalitisoutsidetheUnitedStates.

Agerelateddifferencesinincidence
Individualsattheextremesofageareathighestrisk,particularlyforHSE.NeonatalHSEisamanifestation
ofdisseminatedinfectiontype1or2,whereasolderinfants,children,andadultsaremuchmorelikelyto
havelocalizingCNSinfectionalmostexclusivelyduetotype1,inabimodaldistributionofpatientsaged5
30yearsorolderthan50years.
StLouisencephalitisandWNEaremorecommonandaremostsevereinpatientsolderthan60years
conversely,LACismorecommonandismostsevereinchildrenyoungerthan16years.EEEandWEE
disproportionatelyaffectinfantswhileEEEdisproportionatelyaffectschildrenandelderlypersons.

Prognosis
Theprognosisisdependentonthevirulenceofthevirusandthepatientshealthstatus.Extremesofage(<
1yor>55y),immunecompromisedstatus,andpreexistingneurologicconditionsareassociatedwith
pooreroutcomes.
UntreatedHSEhasamortalityof5075%,andvirtuallyalluntreatedorlatetreatmentsurvivorshavelong
termmotorandmentaldisabilities.ThemortalityintreatedHSEaverages20%,andtheneurologicoutcome
correlateswiththeneurologicaldisabilitypresentatthetimeofthefirstdoseofacyclovirorcomparable
antiviralagents.Approximately40%ofsurvivorshaveminortomajorlearningdisabilities,memory
impairment,neuropsychiatricabnormalities,epilepsy,finemotorcontroldeficits,anddysarthria.
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OutcomesinarboviralJEandEEEarecatastrophic,similartountreatedHSE,withhighmortalityand
severemorbidity,includingmentalretardation,hemiplegia,andseizures.Otherarbovirusescause
substantiallylessmorbidityandmortality.Forexample,StLouisencephalitisandWNEhaveamortalityrate
of220%,thehigherratesfoundinpatientsolderthan60years.LongtermsequelaewithStLouis
encephalitisincludebehavioraldisorders,memoryloss,andseizures.
WEEisassociatedwithfewdeathsandmuchlessmorbidity,althoughdevelopmentaldelay,seizure
disorder,andparalysisoccasionallyoccurinchildren,andpostencephaliticparkinsonismmayoccurin
adults.CEistypicallyassociatedwithmildillness,andmostpatientsmakeafullrecoveryhowever,the
minorityofpatientswithseverediseasehavea25%chanceoffocalneurologicdysfunction.Deathrates
fromWEEandLACarelessthan5%.
PIEsecondarytomeaslesisassociatedwithamortalityrateapproaching40%ofcases,withahighrateof
neurologicsequelaeinsurvivors.SSPEisuniformlyfatal,althoughthediseasecoursemaylastanywhere
fromseveralweeksto10years.
VZVEhasamortalityof15%inimmunecompetentpatientsandvirtually100%inimmunesuppressed
patients.ThemortalityforEBVencephalitisis8%,withsubstantialmorbidityfoundinapproximately12%of
survivors.
Rabiesencephalitisandacutedisseminatedencephalitisarevirtually100%fatal,althoughtherearerare
survivorsreportedinthemedicalliterature.

PatientEducation
Forpatienteducationresources,seetheBrainandNervousSystemCenterandtheBacterialandViral
InfectionsCenter,aswellasBrainInfection,WestNileVirus,Encephalitis,andTicks.
ClinicalPresentation
References

1.[Guideline]TunkelAR,GlaserCA,BlochKC,SejvarJJ,MarraCM,RoosKL,etal.Themanagement
ofencephalitis:clinicalpracticeguidelinesbytheInfectiousDiseasesSocietyofAmerica.ClinInfect
Dis.2008Aug1.47(3):30327.[Medline].
2.Final2008WestNileVirusActivityintheUnitedStates.CentersforDiseaseControlandPrevention.
Availableathttp://bit.ly/fATcE1.Accessed:April26,2009.
3.MacDonaldRD,KrymVF.WestNilevirus.Primerforfamilyphysicians.CanFamPhysician.2005Jun.
51:8337.[Medline].
4.YaoK,HonarmandS,EspinosaA,AkhyaniN,GlaserC,JacobsonS.Detectionofhuman
herpesvirus6incerebrospinalfluidofpatientswithencephalitis.AnnNeurol.2009Mar.65(3):25767.
[Medline].
5.BlochKC,GlaserC.Diagnosticapproachesforpatientswithsuspectedencephalitis.CurrInfectDis
Rep.2007Jul.9(4):31522.[Medline].
6.HayasakaD,AokiK,MoritaK.DevelopmentofsimpleandrapidassaytodetectviralRNAoftick
borneencephalitisvirusbyreversetranscriptionloopmediatedisothermalamplification.VirolJ.2013
Mar4.10(1):68.[Medline].
MediaGallery
of0
Tables

Table.CerebrospinalFluidFindingsbyTypeofOrganism
Table.CerebrospinalFluidFindingsbyTypeofOrganism
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CSFFinding
(Normal)

Pressure(515
cmwater)

Cellcounts,
mononuclear
cells/L

Preterm(025)

Term(022)

6mo+(05)

Encephalitis:PracticeEssentials,Background,Pathophysiology

BacterialMeningitis

ViralMeningitis*

FungalMeningitis

Increased

Normalormildly
increased

Normalormildly
increasedinmost
fungaland
tuberculousCNS
infections
PatientswithAIDS
andcryptococcal
meningitisareat
increasedriskof
blindnessanddeath
unlesspressure
maintainedat<30
cm

Normalcellcount
excludesbacterial
meningitis
Typically
thousandsof
polymorphonuclear
cells,butcounts
maynotchange
dramaticallyor
evenbenormal
(classicallyinvery
early
meningococcal
meningitisorin
extremelyill
neonates)
Lymphocytosiswith
normalCSF
chemistryresults
observedin15
25%ofpatients,
especiallyifcounts
<1000orifpatient
ispartiallytreated
About90%of
patientswith
ventriculoperitoneal
shuntsandCSF
WBCcount>100
cells/Lare
infected,though
CSFglucoselevel
oftennormal,and
bacteriaoftenless
pathogenic
Cellcountand
chemistrylevels
normalizeslowly
(days)with
antibiotics

Usually<500,nearly
100%mononuclear
<48hours,clinically
significant
polymorphonuclear
pleocytosismaybe
indistinguishable
fromearlybacterial
meningitis,
particularlywithEEE
NontraumaticRBCs
in80%ofpatients
withHSV
meningoencephalitis,
though10%have
normalCSFresults

100sofmononuclear
cells

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Microorganisms
(none)

Encephalitis:PracticeEssentials,Background,Pathophysiology

Gramstain80%
effective
Inadequate
decolorizationmay
cause
Haemophilus
influenzaetobe
mistakenforgram
positivecocci
Pretreatmentwith
antibioticsmay
affectstainuptake,
causinggram
positivespeciesto
appeartobegram
negativeand
decreaseculture
yieldbyanaverage
of20

Noorganism

Indiaink8090%
effectivefor
detectingfungi
AFBstain40%
effectiveforTB
increaseyieldby
stainingsupernatant
fromatleast5mLof
CSF

Normal

Sometimes
decreased
Inadditionto
fulminantbacterial
meningitis,TB,
primaryamebic
meningoencephalitis,
and
neurocysticercosis
causelowglucose
levels

Mildlyincreased

Increased>1000
mg/dL,withrelatively
benignclinical
presentation
suggestiveoffungal
disease

Glucose

Euglycemia
(>50%serum)
Decreased
Hyperglycemia
(>30%serum)

Protein

Preterm(65
150mg/dL)

Term(20170
mg/dL

Usually>150
mg/dL
Maybe>1000
mg/dL

6mo+(1545
mg/dL)

*Somebacteria
(eg,
Mycoplasma,
Listeria,
Leptospira,
Borrelia
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Encephalitis:PracticeEssentials,Background,Pathophysiology

burgdorferi
[Lymedisease])
cause
alterationsin
spinalfluidthat
resemblethe
viralprofile.An
asepticprofile
isalsotypicalof
partiallytreated
bacterial
infections
(>33%,
especially
thosein
children,are
treatedwith
antimicrobials)
andofthe2
mostcommon
causesof
encephalitis
thearboviruses
andthe
potentially
curableHSV.

Wait4hours

afterglucose
load.

AFBacidfast
bacillusCSF
cerebrospinal
fluidEEE
easternequine
encephalitis
HSVherpes
simplexvirus
RBCred
bloodcellTB
tuberculosis
WBCwhite
bloodcell.

BacktoList
ContributorInformationandDisclosures

Author
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Encephalitis:PracticeEssentials,Background,Pathophysiology

DavidSHowes,MDProfessorofMedicineandPediatrics,ResidencyProgramDirectorEmeritus,Section
ofEmergencyMedicine,UniversityofChicago,UniversityofChicago,ThePritzkerSchoolofMedicine
DavidSHowes,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Coauthor(s)
MarjorieLazoff,MDEditorinChief,MedicalComputingReview
MarjorieLazoff,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanMedical
InformaticsAssociation,AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWestern
ReserveUniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademy
ofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergency
Physicians,AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
StevenAConrad,MD,PhDChief,DepartmentofEmergencyMedicineChief,MultidisciplinaryCritical
CareService,Professor,DepartmentofEmergencyandInternalMedicine,LouisianaStateUniversity
HealthSciencesCenter
StevenAConrad,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChest
Physicians,AmericanCollegeofCriticalCareMedicine,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians,InternationalSocietyforHeartandLungTransplantation,LouisianaState
MedicalSociety,ShockSociety,SocietyforAcademicEmergencyMedicine,andSocietyofCriticalCare
Medicine
Disclosure:Nothingtodisclose.
RobinRHemphill,MD,MPHAssociateProfessor,Director,QualityandSafety,DepartmentofEmergency
Medicine,EmoryUniversitySchoolofMedicine
RobinRHemphill,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
JStephenHuff,MDAssociateProfessorofEmergencyMedicineandNeurology,Departmentof
EmergencyMedicine,UniversityofVirginiaSchoolofMedicine
JStephenHuff,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanAcademyofNeurology,AmericanCollegeofEmergencyPhysicians,andSocietyfor
AcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
ToddPritz,MDIntensivist,StAnthony'sMedicalCenterandStJohn'sMercyMedicalCenter
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Encephalitis:PracticeEssentials,Background,Pathophysiology

ToddPritz,MDisamemberofthefollowingmedicalsocieties:MassachusettsMedicalSocietyandSociety
ofCriticalCareMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhD,AdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeReferenceSalaryEmployment
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http://emedicine.medscape.com/article/791896overview

12/12