VIRAL

ENCEPHALITIS
PRESENTED BY : DR. BAKHTAWAR SIDDIQ
PGR NEUROLOGY SGRH
What is Encephalitis?
• Inflammation of Brain tissue
• Greek word En–kephalos (in_brain) & it is inflammation)
Types:
• PRIMARY :

viral invasion of CNS

neuronal involvement > inclusion bodies on LM
viral particles on EM

• POST-INFECTIOUS : ADEM

Virus can’t be detected

Neurons spared
immune_mediated > perivascular inflammation & demyelination
CAUSES
• Herpes Simplex Virus
• Ebstein-Barr Virus
• Cytomegalovirus
• Varicella Zoster Virus
• West Nile Virus
• St. Louis Virus
• Japanese Encephalitis
• Measles
• Mumps
CAUSES
• Sporadic :

HSV Most common cause

treatable.

• Others:

Geographical Location
Clues from History
Clinical Clues
Geographical Location
• Japanese Encephalitis---Asia

• St.Louis Encephalitis Virus---North America

• West Nile Virus--- Most common in USA

• Eastern Equine Encephalitis ---North America

Historical Clues
1. Unusual exposure history & epidemiology :

• Arboviruses –when mosquitos are active

• Tick borne encephalitidies…Powassan virus (Ixodes Tick)
• Nipah Virus ---exposure to pigs or bats
• Hendra Virus---direct contact with Infected Horses
• Avian Vice ,rus --- Some association with ducks
• Lymphocytic Choriomeningitis---Rodent borne arenavirus (secretions of mice ,
rats , hamsters.
• Bornavirus Encephalitis---german breeders variegaterd Squirrels.
2. Seasonal Occurance
Clinical Clues
• Unvaccinated pt. + Mental Status changes + Parotitis = MUMPS

• Flaccid paralysis or Maculopapular Rash + ASOC = West Nile

• Tremors of eyelids, tongue, lips, extremeties = St. Louis / WNV

• Hydrophobia, aerophobia, pharyngeal spasms , hyperactivity = Rabies

Atypial presentation of Rabies =seizures, myoclonus, Cranial N.palsies.

• Grouped vesicles in Dermatomal pattern = VZV

Clinical Manifestations
• Fever
• Headache
• Altered mental status (subtleCompletely unresponsive)
• Seizures
• Focal Neurologic abnormalities: hemiparesis, C.N Palsies,
exaggerated reflexes, aphasia
• Confusion
• Agitation
Investigations
• CT SCAN
• MRI
• EEG
• CSF Analysis
Temporal Lobe:
HSV , VZV, EBV, HHV-6
Thalamus, Basal Ganglia:
Arbovirus
Post Infectious Encephalitis:
Hyper intense Multifocal lesions involving white Matter
CSF Analysis:
• Increased WBCs ---but less than 250/mm3
(lymphocytic Predominance)

• Elevated Proteins --- less than 150mg/dl

(usually 65 to 85 mg/dl)

• Glucose Normal
• RBCs if present suggest HSV Encephalitis
• CSF PCR--- HSV, VZV (Diagnostic)

• Normal CSF = 26%

• Normal Glucose=16%
DIFFERENTIAL DIAGNOSIS
• Infctious
• NonInfectious
 INFECTIOUS
• Tuberculosis
• Partially treated bacterial meningitis
• Listeria meningitis (occasionally)
• Spirochetal infection (syphilis, Lyme disease, leptospirosis)
• Rocky Mountain spotted fever
• Fungal infection (cryptococcosis, coccidioidomycosis, histoplasmosis)
• Mycoplasma pneumoniae
• Parameningeal infection (brain abscess, epidural or subdural abscess)
• Amebic infection
• Trypanosomiasis
• Toxoplasmosis
• Cerebral malaria (Plasmodium falciparum)
• Disseminated cat-scratch disease (Bartonella henselae)
• Whipple's Disease (Tropheryma whipplei)
• Legionellosis
 NON-INFECTIOUS
• Tumor (meningeal or parenchymal)
• Dural venous sinus thrombosis
• Sarcoidosis
• Cerebral vasculitis
• Behcet syndrome
• Drug-induced meningitis
• Nonsteroidal antiinflammatory drugs
• Sulfa drugs
• Antithymocyte globulin
• Intravenous immune globulin
• Migrainous syndromes with pleocytosis
• Autoimmune or paraneoplastic diseases (eg, those associated with vasculitis or the anti-NMDA
receptor)
EMPIRICAL THERAPY

• For HSV & VZV = Acyclovir 10mg/kg IV 8 Hourly (14 to 21 Days)

• Improve Hydration
• Should be started immediately if suspicion
Pathogen Specific Treatment
PROGNOSTIC FACTORS
• AGE <30 years----GOOD
• Depressed Conscious Level at presentation <6 GCS---BAD
• Duration of Disease Before Therapy
> 75% improved --- therapy within 2 Days
>65% improved---Therapy within 4 days
>50% improved ---Therapy within 5 days
HERPES SIMPLEX ENCEPHALITIS
• 10% of all the viral Encephalitis
• HSV-1 = 90%
• HSV-2 = 10%
• CSF PCR diagnostic for HSE

• Neuroimaging= T2 /FLAIR Hyperintensities in insula,Medial Temporal and Inferior

Frontal lobe
• EEG =PLED (Periodic Lateralizing Epileptiform Discharges)
Diffused slowing
Focal Temporal Spikes
BRAIN BIOPSY
• Grossly= Hemorrhagic Necrosis

• Histology = >HSV Antigen in infected cells

>COWDRY Type-A = acidophilic intranuclear inclusions
surrounded by halos and marginated
nuclear Chromatin.
HSV, VZV, Measles
BRAIN BIOPSY :