ENCEPHALITIS

WHAT IS ENCEPHALITIS?
• Acute inflammation of the brain.
• Children, elderly and those with a weak immune system are those who
are more prone to encephalitis.
• The treatment given and the chances to recovery depend completely on
the virus involved and how severe the inflammation is.
• Acute – encephalitis : affects brain directly
• Para - infectious : brain and spinal cord inflates two weeks into
contracting the virus or bacteria.
CAUSES
• The exact cause of encephalitis is unknown.
• Usually caused by a virus or sometimes even a bacterial infestation as
well as non infectious inflammatory conditions may cause encephalitis
• Few viruses that may be instrumental in causing encephalitis includes
1)Herpes simplex
2) Polio viruses
3) Mosquito – borne viruses
4)Tick – borne
5) Rabies
6) childhood viruses
IMMUNOLOGIC REACTION

• Encephalitis can occur as a secondary immunologic complication of certain viral infections or

vaccinations.
• Inflammatory demyelination of the brain and spinal cord can occur 1 to 3 wk later (as acute
disseminated encephalomyelitis); the immune system attacks one or more CNS antigens that
resemble proteins of the infectious agent.
• The most common causes of this complication used to be measles, rubella, chickenpox, and
mumps (all now uncommon because childhood vaccination is widespread); smallpox vaccine; and
live-virus vaccines (eg, the older rabies vaccines prepared from sheep or goat brain).
• In the US, most cases now result from influenza A or B virus, enteroviruses, Epstein-Barr virus,
hepatitis A or hepatitis B virus, or HIV. Immunologically mediated encephalitis also occurs in
patients with cancer and other autoimmune disorders.
• Encephalopathies caused by autoantibodies to neuronal membrane proteins (eg, N-methyl-d-
aspartate [NMDA] receptors) may mimic viral encephalitis.
• Some evidence suggests that anti-NMDA receptor encephalitis is a more common type of
encephalitis than was previously thought.
• It occasionally develops after encephalitis due to herpes simplex virus, even when the
encephalitis was successfully treated.
 PATHOLOGY
• Virus enters blood & reaches the parenchyma of brain, cortex, white matter, basal
ganglia & brainstem.
• Inclusion bodies are often present in neurons & glial cells &there is infiltration of
polymorphonuclear cells in perivascular space.
• There is neuronal degeneration & diffuse glial proliferation often associated with
cerebral edema & increased ICP.
• Thrombosis may occur in small arteries of brain.
• Tonsilar herniation (also called downward cerebellar herniation, the cerebellar tonsils
move downward through the foramen magnum possibly causing compression of the
lower brainstem and upper cervical spinal cord as they pass through the foramen
magnum.
• Increased pressure on the brainstem can result in dysfunction of the centers in the brain
responsible for controlling respiratory and cardiac function.
• The most common signs are headache, head tilt, and neck stiffness due to tonsillar
impaction.
• The level of consciousness may decrease and also give rise to flaccid paralysis may also
be seen due to raised ICP).
Who is at risk for encephalitis and
meningitis????
• Anyone—from infants to older adults—can get encephalitis or
meningitis.
• People with weakened immune systems, including those persons with
HIV or those taking immunosuppressant drugs, are at increased risk.
How are these disorders transmitted????
• Some forms of bacterial meningitis and encephalitis are contagious
and can be spread through contact with saliva, nasal discharge, feces,
or respiratory and throat secretions .
• Children who have not been given routine vaccines are at increased
risk of developing certain types of bacterial meningitis.
 TYPES OF ENCEPHALITIS
• Infectious encephalitis
• Autoimmune encephalitis
• Chronic encephalitis
• Limbic encephalitis
• HIV encephalitis
• Encephalitis Lethargica
 Infectious Encephalitis
• Viruses are the most common agents that cause Infectious Encephalitis.
• Herpes simplex virus (the cold sore virus) is the virus most frequently identified.
Herpes Simplex Encephalitis (Herpes simplex is a viral infection caused by the
herpes simplex virus.
Infections are categorized based on the part of the body infected:-
a) Oral herpes involves the face or mouth. It may result in small blisters in groups
often called cold sores or fever blisters or may just cause a sore throat.
b) Genital herpes, often simply known as herpes, may have minimal symptoms or
form blisters that break open and result in small ulcers. These typically heal
over two to four weeks. Tingling or shooting pains may occur before the
blisters appear. Herpes cycles between periods of active disease followed by
periods without symptoms. The first episode is often more severe and may be
associated with fever, muscle pains, swollen lymph nodes and headaches.
• Japanese Encephalitis (Japanese encephalitis (JE) is an infection of the
brain caused by the Japanese encephalitis virus (JEV). While most infections
result in little or no symptoms, occasional inflammation of the brain occurs.
In these cases symptoms may include headache, vomiting, fever, confusion,
and seizures. This occurs about 5 to 15 days after infection.
• Tick Borne Encephalitis (Tick-borne encephalitis (TBE) is a viral infectious
disease involving the central nervous system. The disease most often
manifests as meningitis, encephalitis, or meningo-encephalitis).
• West Nile Encephalitis (West Nile fever is a viral infection typically spread by
mosquitoes. In about 80% of infections people have few or no symptoms.
About 20% of people develop a fever, headache, vomiting, or a rash. In less
than 1% of people, encephalitis or meningitis occurs, with associated neck
stiffness, confusion, or seizures. Recovery may take weeks to months).
Autoimmune Encephalitis
• Autoimmune Encephalitis may be triggered by infection in
which case the term "Post-infectious Encephalitis" is used.
• ADEM( Acute Disseminated Encephalomyelitis ) is a Post-
infectious Encephalitis. The illness usually follows in the wake of
a mild viral infection (such as those that cause rashes in
childhood) or immunizations.
• Typically there is a delay of days to two to three weeks between
the triggering infection and development of the Encephalitis.
• It has recently been recognized that there are other types of
Autoimmune Encephalitis resulting from an attack of the brain
by the body's immune system.
Some of the known types of Autoimmune Encephalitis
are:
• Acute Disseminated Encephalomyelitis (ADEM)
• NMDA Receptor associated Encephalitis [N-methyl D-aspartate
(NMDA) ]
• Hashimoto’s Encephalopathy (also known as steroid responsive
encephalopathy associated with autoimmune thyroiditis (SREAT), is a
neurological condition characterized by encephalopathy, thyroid
autoimmunity, and good clinical response to steroids)
• Rasmussen Encephalitis (also known as chronic focal encephalitis
(CFE), is a rare inflammatory neurological disease, characterized by
frequent and severe seizures, loss of motor skills and speech,
hemiparesis (weakness on one side of the body), encephalitis
(inflammation of the brain), and dementia).
Chronic Encephalitis Subacute Sclerosing Panencephalitis

• It refers specifically to a type of Encephalitis which can follow natural (wild)

measles virus infection.
• After the initial measles infection, the virus lies passive in brain cells.
• It does not cause SSPE for several years (average 6 years) when
eventually an inflammatory response is initiated against the infected cells.
• It is more common in children younger than 2 years who have had primary
measles infection, although the condition (SSPE) manifests itself much later-
older children and adults.
• Unfortunately SSPE is a progressive form of Encephalitis without a cure.
Despite multiple attempts, no satisfactory treatment has been developed.
• In a few cases there has been remission following use of a certain drug or
drug combination. However most of those affected die within about 5 years of
diagnosis.
 Limbic Encephalitis
• The term ‘Limbic Encephalitis’ (LE) is used when the limbic areas of the brain
are inflamed (swollen) and consequently not functioning properly.
• HIV Encephalitis Human Immunodeficiency Virus (HIV) can affect the brain
in different ways. HIV-meningoencephalitis is infection of the brain and the
lining of the brain by the HIV virus.
• It occurs shortly after the person is first infected with HIV and may cause
headache, neck stiffness, drowsiness, confusion and/or seizures.
• HIV-encephalopathy (HIV-associated dementia) is the result of damage to
the brain by longstanding HIV infection. It is a form of dementia and occurs
in advanced HIV infection.
• Mild Neurocognitive Disorder is problems with thinking and memory in
HIV, however is not as severe as HIV-encephalopathy.
• Unlike HIV-encephalopathy it can occur early in HIV infection and is not a
feature of Aquired Immune Deficiency Syndrome - AIDS.
 Encephalitis Lethargica
• Encephalitis lethargica is a disease characterized by high fever, headache,
double vision ( abnormal eye movement) , delayed physical and mental
response, drowsiness leading to coma, muscular pains, tremors, neck
rigidity, behavioural changes & lethargy.
• The cause of encephalitis lethargica is unknown. Between 1917 to 1928, an
epidemic of encephalitis lethargica spread throughout the world, but no
recurrence of the epidemic has since been reported.
• Post-encephalitic Parkinson's disease may develop after a bout of
encephalitis-sometimes as long as a year after the illness.
 Symptomatology
Initial Signs
• Headache
• Malaise
• Anorexia
• Nausea and Vomiting
• Abdominal Pain
Symptoms
• Fever
• Headache
• Behavioral changes
• Altered level of consciousness
• Focal neurological deficits
• seizures
 Developing Signs
• Encephalitis with focus or diffused neurological symptoms
• Behavioral and personality changes.
• Decreased level of consciousness.
• Stiff neck, photophobia and lethargy.
• Generalized or localized seizure.
• Acute confusion or amnestic states.
• Flaccid paralysis(10%)
Neurological Signs
• Aphasia
• Ataxia
• Hemiparesis with hyperactive tendon reflexes
• Involuntary movements
• Cranial nerve deficits (ocular palsies, facial weakness)
In infants and young
children, signs and
symptoms might also
include:

• Bulging in the soft spots (fontanels) of an

infant's skull
• Nausea and vomiting
• Body stiffness
• Poor feeding or not waking for a feeding
• Irritability
Fontanelles - bulging
• A bulging fontanelle is an outward curving of an infant's soft spot (fontanelle). The skull is made up of many
bones, 8 in the skull itself and 14 in the face area.
• They join together to form a solid, bony cavity that protects and supports the brain. The areas where the bones
join together are called the sutures.
• The bones are not joined together firmly at birth. This allows the head to change shape to help it pass through
the birth canal.
• The sutures get minerals added to them over time and harden, firmly joining the skull bones together.
• In an infant, the space where 2 sutures join forms a membrane-covered "soft spot" called a fontanelle
(fontanel).
• The fontanelles allow for growth of the brain and skull during an infant's first year. There are normally several
fontanelles on a newborn's skull.
• They are located mainly at the top, back, and sides of the head. Like the sutures, fontanelles harden over time
and become closed, solid bony areas.
• The fontanelle in the back of the head (posterior fontanelle) most often closes by the time an infant is 1 to 2
months old.
• The fontanelle at the top of the head (anterior fontanelle) most often closes between 7 to 19 months.
• The fontanelles should feel firm and very slightly curved inward to the touch. A tense or bulging fontanelle
 Viral Encephalitis
Clinical symptoms

• Acute flu-like prodrome – High fever, severe headache

• Altered consciousness (lethargy, drowsiness, confusion, coma)
• Seizures – Focal neurological signs
• More subtle presentations :
A) Low grade fever
B) Speech disturbances (dysphasia, aphasia)
C) Behavioural changes
 DIAG NOSIS

a) Imaging Techniques

For suspected encephalitis scanning technique is often the first diagnostic

step.
• Computerized tomography (CT)
• Magnetic resonance imaging (MRI) scans can show the extent of the
inflammation in the brain and help differentiate encephalitis from other
conditions. MRIs are recommended over CT scans because they can
detect injuries in parts of the brain that suggest infection with herpes
virus at the onset of the disease, while CT scans cannot.
• Electroencephalogram (EEG), which records brain waves, may reveal
abnormalities in the temporal lobe that are indicative of herpes simplex
b) CEREBROSPINAL FLUID TESTS -

• Encephalitis is suspected, a sample of cerebrospinal fluid is taken using a

lumbar puncture.
• The sample is taken to count white blood cells and identify specific
blood cell types, to measure proteins and blood sugar levels, and to
determine spinal fluid pressure.
• Doctors use CSF to test for herpes simplex virus, Epstein- Barr virus,
varicella-zoster virus, entero-viruses, and to look for the presence of
antibodies to the West Nile virus.
• While cerebrospinal fluid tests may help diagnose encephalitis, they
cannot provide information on how severe the disease will be.
 c) BLOOD TESTS
• Blood tests may be used to test for West Nile virus and other arbovirus
infections.
• Blood and urine tests are used to isolate and identify viruses.
• Enzyme-linked immunosorbent assays (ELISA), including IgM-capture
ELISA (MAC-ELISA) and IgG ELISA, can identify viruses that cause
encephalitis soon after infection.
• Polymerase chain reaction (PCR) can identify small amounts of viral DNA.
 d) Brain Biopsy
• Tiny samples of brain tissue are surgically removed for examination and
testing for the presence of the virus.
• Tissue is prepared using staining techniques and then viewed under an
electron microscope.
• In a few cases, the viruses in brain cells are able to be cultured; that is,
the viruses can actually be made to replicate in samples.
• A brain biopsy is the gold standard for diagnosing rabies.
 Treatment
• The goals of treatment are to provide supportive care (rest, nutrition, fluids) to
help the body fight the infection, and to relieve symptoms.
• Reorientation and emotional support for confused or delirious people may be
helpful.
• Medications may include: Antiviral medications, such as acyclovir (Zovirax)
and foscarnet (Foscavir) -- to treat herpes encephalitis or other severe viral
infections (however, no specific antiviral drugs are available to fight
encephalitis)
• Antibiotics -- if the infection is caused by certain bacteria.
1. Anti-seizure medications (such as phenytoin) -- to prevent seizures.
2. Steroids (such as dexamethasone) -- to reduce brain swelling (in rare cases)
3. Sedatives -- to treat irritability or restlessness
4. Acetaminophen -- for fever and headache.
TREATING PROBABLE CAUSES OF ENCEPHALITIS

• Since it is difficult to determine the cause of encephalitis, and rapid treatment is

essential, clinical guidelines recommend immediately administering
intravenously the antiviral drug acyclovir without waiting to determine the
cause of the illness.
• Once the doctor receives results from diagnostic tests, drug treatment depends
on the cause of the encephalitis.
• Antiviral drug treatments for specific causes of encephalitis include: Herpes
Simplex Virus . Acyclovir is recommended
• Varicella-Zoster Virus - Ganciclovir or adjunctive corticosteroids may also be
considered.
• Epstein-Barr Virus : Corticosteroids may be used, although risks may
outweigh benefits. (Acyclovir is not recommended.)
• For bacterial meningitis, antibiotics (not antiviral drugs) are used.
 PROGNOSIS
▪ Acute phase of illness different from person to person &
Some recover with slight disability, others profound
disability and a few need residential care for a life time .
▪Degree and type of damage cause of inflammation
severity of the infection area affected delay in seeking
treatment
 Post Encephalitis Presentation
• Personality changes
• Physical difficulties
• Memory problems
• Emotional problems
• Problems with pain and other sensations
• Problems with daily living skills
• Fatigue
• Hormone problems
• Cognitive Problems
• Problems with new learning
• Inability to understand and communicate
• Epilepsy
• Inappropriate behavior and poor social skills.
 AIMS & OBJECTIVES
• Psychological support
• Prevent chest complications
• Prevent DVT
• Prevent bed sores
• Correct deformity
• Promote vital function
• Normalize tone
• Normalise postural reflexes
• Promote integration of sensory input
• Promote voluntary movement pattern
• Improve overall function
• Psychological support: Maintain a non threatening positive attitude, Good support, Gain
confidence of the patient, Counseling of family members & patient & Give information as
necessary only.
• Prevent chest complications: Breathing exercise, postural drainage & suctioning as required
• Cervical & thoracic mobility exercise: Thoracic expansion exercise, Strengthening of respiratory
 PHYSIOTHERAPY TREATMENT
PT assessment

• Presenting complains: Headache, nausea, vomiting, fever, convulsions, confusion, abnormal

movements.
• History: preceding infection, general weakness, frequent headache.
• Vitals: BP, PR, RR, Temperature abnormalities may be noted.
• Observation: Posture; abnormal posturing.
• Gait: abnormalities (may be ataxic)
• Limb attitude: abnormal attitude (synergies)
• Abnormal Respiratory pattern
• Higher function: Level of consciousness: altered sensorium, Orientation: confusion, Memory:
affected, Speech: dysarthria , aphasia, mutism, Cranial nerve assessment: features of lower
cranialnerve palsy will be seen, Sensory system: impaired, Tonal abnormalities will be seen, Reflexes:
exaggerated DTR, positive barbinski’s, presence of abnormal lower level reflexes(primitive reflexes)
• ROM: decreased range & flexibility
• Strength: decreased.
• Chest examination & Respiratory assessment: accumulation of
secretions, decreased chest expansion or abnormal respiratory pattern
may be seen.
• Gustatory examination: swallowing & speech
• Bladder & bowel involvement
• Functional disability
• Special test: kernig, brudjinski shows positive response
• Investigations: blood & CSF examination, CT or MRI, gram stain, serology
shows abnormal findings.
THERAPEUTIC TREATMENT
1) Prevent DVT :
• Active & passive ankle & toe exercises
• Active limb exercise
• Limb elevation
• Early mobilization as soon as possible
• Propped up position in bed & bed mobility exercise

2) Prevent bed sores

• Proper positioning with pads & cushions
• Use of water bed or foam mattress
• Regular inspection of the skin
• Use cotton clothing to absorb sweat
• Avoid dragging during transfer
• Regular turning & changing position
3) Correct deformity
• Proper positioning: If synergy is present, facilitation & inhibition
techniques
• Facilitatory tech : Vibration, stroking, joint approximation tech,
quickiceing, quick stretching etc.
• Inhibitory tech : Sustained stretching, pressure, neural warmth,
prolonged icing, joint traction Splinting & serial casting
 4) Promote vital function
• Improve respiratory capacity with positioning & techniques.
• Glossopharyngeal breathing exercise in respiratory paralysis
• Keeping the neck in slight flexion improves respiratory capacity
• Specific positioning increase air entry in targeted lobes
• Massage & mechanical pressure provides reflex stimulus to improve peristalsis (kneading/
stroking)
• Facilitate swallowing with positioning, right selection of food texture, oromotor stimulation
• Maintaining cardio respiratory endurance with active exercise of possible muscle work.
• Normalize tone: Facilitatory & inhibitory techniques
• Promote integration of sensory input : Stimulation by combined proprioceptive, visual
&auditory input , Cues & commands ,
• Demonstration of activity : Sensory re education if necessary, Training in different
environment.
• Promote voluntary movement pattern : Open kinematic chain exercise to improve mobility,
Close kinematic chain exercise to improve stability
5) Improve overall function
• Maintenance of physical activity
• Maintenance of CV endurance
• Early Return to activity or work