date 19/09/11

1. VIRAL ENCEPHALITIS DR.PRAVEEN NAGULA

2. INTRODUCTION Acute febrile illness plus altered level of consiousness Signs and symtpoms reflect the site of inflammation Impossible to distinguish reliably on the clinical grounds alone one type from other.

3. Etiology Sporadic cases -- immunocompetent patients HSV,VZV,EBV. Epidemics – arboviruses Alphavriuses – EEE ,western equine virus Flaviviruses – WNV,stlouis encephalitis Bunyaviruses NIPAH virus Toscana virus

5. Same as meninigtis of viral origin

6. Absent CSF pleocytosis –immunocompromised,glucocorticoid,malignancies

7. >5 cells/ul -90 % cases

8. >500 cells/ul – 10 % cases

9. >1000 cells /ul –mumps ,LCMV.ATYPICAL LYMPHOCYTES – EBV,CMV,HSV Mollaret cells –WNV Neutrophils -40% WNV,echovirus >20% RBC – HSV hemorrhagic encephalitis Decreased CSF glucose – MUMPS,LCMV

10. CSF PCR – Primary test for CMV,HSV,VZV,EBV Sensitive and specific for HSV Postivity increases with duration of illness Not affected by less than 1 week of therapy Next specific for enteroviruses Not established for EBV Less specific than AbIgM --WNV

11. MRI Increased signal intensity in frontotemporal,cingulate,linuglar regions on t2 weighted images 10 % may have normal MRI EEG – periodic complexes sharp and slow at regular intervals of 2-3 sec. Biopsy not reponding to treatment

13. DIFFERENTIAL DIAGNOSIS AMOEBIC ENCEPHALITIS***: Naegleriafowleri – 1 amoebic meningoencephalitis In immuno competent h/o swimming in potentially infected ponds. CSF nuetrophilicpleocytosis Hypoglycorrhachia Motile trophozoites –wet mount of warm fresh CSF. Mortality is 100% Acanthoemba--- chronic granulomatous illness

14. HSV encephalitis Olfactory ,gustatory hallucinations Anosmia Unusual or bizzarebehaviour Differentiation is important as specific treatment avialable. Temporal lobe intensity

15. rabies Encephalitis rabies (furious rabies) : Fever,fluctuatingconsciouness Autonomic hyperactivity Hydorphobia Aerophobia Paralytic dumb rabies Acute ascending paralysis Phobic spasms not seen in due to rabies from bat exposure…

16. Treatment ICU CARE ICP monitoring Fluid restriction Avoid hypotonic fluids Anticonvulsants Prevent apsiration Physiotherapy DVT prophylaxis

17. treatment Acyclovir start empirically 10 mg/kg IV every 8 hrs for 14 days 30 mg/kg/day Additional 7 days in case of positive CSF PCR at 14 days. Ganciclovir 5m g/kg bid foscarnet -CMV virus 60 mg/kg every 8 hrs Cidofovir – nucleotide analogue

18. THANK YOU

19. Sagittarian