ENCEPHALITIS

Definition Encephalitis means inflammation of brain parenchyma. Viruses are the commonest cause for encephalitis. Etiology Acute viral encephalitis Herpes simplex, ECHO, mumps and varicella zoster, measles Japanese encephalitis in South East sia. !abies rbovirus are an important cause of encephalitis Often, viral etiolo"y is presumed but never confirmed Pathology #nflammation can occur in the cortex, $hite matter, basal "an"lia and brain stem, and the distribution of lesions varies $ith the type of virus. #n herpes simplex encephalitis, the temporal lobes are usually primarily affected. #nclusion bodies may be present in the neurons and "lial cells and there is an infiltration of polymorphonuclear cells in the perivascular space. %here is neuronal de"eneration and diffuse "lial proliferation, often associated $ith cerebral oedema Clinical features cute onset of headache, fever, focal neurolo"ical si"ns &aphasia and'or hemiple"ia( and seizures. )isturbance of consciousness ran"in" from dro$siness to deep coma supervenes early and may advance dramatically. *enin"ism occurs in many patients +ocal si"ns, seizures and coma. Differential diagnosis ,acterial menin"itis $ith cerebral oedema Cerebral venous thrombosis Cerebral abscess cute disseminated encephalomyelitis &see belo$( Cerebral malaria Investigations C% and *! ima"in" sho$ diffuse areas of oedema, often in the temporal lobes EE- sho$s characteristic slo$ $aves, $hich are useful in some cases CSF sho$s excess lymphocytes, but polymorphonuclear cells may predominate in the early sta"es. %he protein content may be elevated but the "lucose is normal

 Virolo"ical investi"ations of the CS+, includin" .C! for viral )/ , may reveal the causative or"anism. ,rain biopsy is occasionally performed anage!ent . Herpes simplex encephalitis responds to aciclovir 01 m"'2" i.v. 34hourly for 546 $ee2s. nticonvulsant treatment is often necessary raised intracranial pressure is treated $ith dexamethasone 3 m" 054hourly .rophylactic immunization a"ainst Japanese encephalitis is advised for travellers to endemic areas in sia. "#AIN$STE ENCEPHALITIS %his presents $ith ataxia, dysarthria, diplopia or other cranial nerve palsies. %he CS+ is lymphocytic, $ith a normal "lucose. %he causative a"ent is presumed to be viral Listeria monocytogenes may cause a similar syndrome S%"AC%TE SCLE#&SIN' PANENCEPHALITIS %his is a rare, chronic, pro"ressive and eventually fatal neurolo"ical disease caused by the measles virus. #t occurs in children and adolescents, usually many years after the primary virus infection. %he CS+ may sho$ a mild lymphocytic pleocytosis and the EE- is distinctive, $ith periodic bursts of triphasic $aves. lthou"h there is persistent measles4specific #"- in serum and CS+, antiviral therapy is ineffective and death ensues $ithin years P#&'#ESSI(E %LTIF&CAL LE%C&ENCEPHAL&PATH) Common causes are #)S, 7ymphoma, leu2emia or carcinomatosis. #t is an infection of oli"odendrocytes by human polyomavirus JC, $hich causes $idespread demyelination of the $hite matter of the cerebral hemispheres. Clinical si"ns include dementia, hemiparesis and aphasia $hich pro"ress rapidly, usually leadin" to death $ithin $ee2s or months *!# sho$in" diffuse hi"h si"nal in the cerebral $hite matter. CE#E"#AL A"SCESS Definition "rain a*scess is a focal, suppurative infection $ithin the brain parenchyma, typically surrounded by a vascularized capsule Cere*ritis is often employed to describe a nonencapsulated brain abscess Etiology ,rain abscess may develop

&0( )irect spread from a conti"uous cranial site of infection, such as paranasal sinusitis, otitis media, mastoiditis, or dental infection. &5(Head trauma or a neurosur"ical procedure. &6( Hemato"enous spread from a remote site of infection 8p to one4third of brain abscesses are associated $ith otitis media and mastoiditis Oto"enic abscesses occur predominantly in the temporal lobe &99 to :9;( and cerebellum &51 to 61;( Co!!on organis!s Otitis media and mastoiditis include streptococci, ,acteroides spp., .. aeru"inosa, .ara nasal sinusitis 44 streptococci &especially S. milleri(, Haemophilus spp., ,acteroides spp. Pathogenesis and Histopathology #ntact brain parenchyma is relatively resistant to infection< preexistin" brain ischemia, necrosis, or hypoxia appears to be a prere=uisite for effective bacterial invasion. Various sta"es of cerebral abcesses are 0. Early cere*ritis stage &days 0 to 6( is characterized by a perivascular infiltration of inflammatory cells. 5. late cere*ritis stage &days > to ?(, pus formation leads to enlar"ement of the necrotic center, 6. Early capsule for!ation &days 01 to 06(, is characterized by the formation of a capsule that is better developed on the cortical than on the ventricular side of the lesion >. late capsule for!ation &day 0> and beyond(, is defined by a $ell4formed necrotic center surrounded by a dense colla"enous capsule Clinical features Classic clinical triad of headache, fever, and a focal neurolo"ic deficit cutely $ith fever, headache, menin"ism and dro$siness, but more commonly presents over days or $ee2s as a cerebral mass lesion $ith little or no evidence of infection. Seizures raised intracranial pressure and focal hemisphere si"ns occur alone or in combination. clinical presentation of a brain abscess depends on its location Si"ns of raised #C. *enin"ismus is not present unless the abscess has ruptured into the ventricle or the infection has spread to the subarachnoid space. Investigations 7umbar puncture is potentially hazardous in the presence of raised intracranial pressure, and C% should al$ays precede it.

 C% reveals sin"le or multiple lo$4density areas, $hich sho$ rin" enhancement $ith contrast and surroundin" cerebral oedema *!# is better than C% for demonstratin" abscesses in the early &cerebritis( sta"es and is superior to C% for identifyin" abscesses in the posterior fossa %here may be an elevated $hite blood cell count and ES! in patients $ith active local infection. Differential Diagnosis Subdural empyema, ,acterial menin"itis, Viral menin"oencephalitis T#EAT ENT Hi"h4dose parenteral antibiotics and neurosur"ical draina"e. Empirical therapy of community4ac=uired brain abscess in an immunocompetent patient typically includes a third4"eneration cephalosporin &e."., cefotaxime or ceftriaxone( and metronidazole. ll patients should receive a minimum of @ to 3 $ee2s of parenteral antibiotic therapy .atients should also receive prophylactic anticonvulsant therapy because of the hi"h ris2 of seizures. #ntravenous dexamethasone therapy &01 m" every @ h( is usually reserved for patients $ith substantial periabscess edema and associated mass effect and increased #C. Sur"ical treatment by burr4hole aspiration or excision may be necessary, especially $here the presence of a capsule may lead to a persistent focus of infection. Prognosis mortality rate remains at 01451; despite an improvement in available sur"ical and medical treatments !ead neurocysticercosis+ polio!yelitis+ ra*ies