Long-term Motor and Cognitive Outcome of

Acute Encephalitis
WHATS KNOWN ON THIS SUBJECT: Encephalitis in children can
cause signicant neurologic sequelae, such as motor and
cognitive impairment. Previous reported data are based mostly
on questionnaires and clinical assessments.
WHAT THIS STUDY ADDS: Signicant cognitive impairment,
attention-decit/hyperactivity disorder, and learning disabilities
are common after childhood encephalitis. Even children who were
considered fully recovered may be signicantly affected.
Identiable pathogens, abnormal neuroimaging, and abnormal
neurologic examination on discharge are risk factors of poor
outcome.

abstract
OBJECTIVES: To examine the long-term motor and neurocognitive
outcome of children with acute encephalitis and to look at possible
prognostic factors.
METHODS: Children who were treated for acute encephalitis in 2000
2010 were reevaluated. All children and their parents were interviewed
by using structured questionnaires, and the children underwent full
neurologic examinations, along with comprehensive neurocognitive,
attention, and behavioral assessments.
RESULTS: Of the 47 children enrolled, 1 died and 29 had neurologic
sequelae, including motor impairment, mental retardation, epilepsy,
and attention and learning disorders. Children with encephalitis had
a signicantly higher prevalence of attention-decit/hyperactivity
disorder (50%) and learning disabilities (20%) compared with the
reported rate (5%10%) in the general population of Israel (P , .05)
and lower IQ scores. Lower intelligence scores and signicantly
impaired attention and learning were found even in children who
were considered fully recovered at the time of discharge. Risk
factors for long-term severe neurologic sequelae were focal signs in
the neurologic examination and abnormal neuroimaging on admission,
conrmed infectious cause, and long hospital stay.
CONCLUSIONS: Encephalitis in children may be associated with significant long-term neurologic sequelae. Signicant cognitive impairment,
attention-decit/hyperactivity disorder, and learning disabilities are
common, and even children who were considered fully recovered at
discharge may be signicantly affected. Neuropsychological testing
should be recommended for survivors of childhood encephalitis.
Pediatrics 2014;133:e546e552

e546

MICHAELI et al

AUTHORS: Orli Michaeli, MD,a Imad Kassis, MD,b Yael

Shachor-Meyouhas, MD,b Eli Shahar, MD,c and Sarit Ravid,
MDc
aDepartment of Pediatrics B, bPediatric Infectious Diseases Unit,
and cPediatric Neurology Unit, Meyer Childrens Hospital,
Rambam Health Care Campus, Haifa, Israel

KEY WORDS
attention-decit, encephalitis, intelligence, sequelae
ABBREVIATIONS
ADHDattention-decit/hyperactivity disorder
CIcondence interval
CNScentral nervous system
HSVherpes simplex virus
ORodds ratio
Dr Michaeli conducted the initial analyses and drafted the initial
manuscript; Dr Kassis conceptualized and designed the study,
and reviewed and revised the manuscript; Dr ShachorMeyouhas conceptualized the study, and reviewed and revised
the manuscript; Dr Shahar designed the data collection
questionnaires and reviewed and revised the manuscript; and
Dr Ravid conceptualized and designed the study, conducted the
initial analyses and examinations, and reviewed and revised the
manuscript. All authors approved the nal manuscript as
submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-3010
doi:10.1542/peds.2013-3010
Accepted for publication Dec 13, 2013
Address correspondence to Sarit Ravid, MD, Pediatric Neurology
Unit, Meyer Childrens Hospital, Rambam Health Care Campus,
Haifa 31096, Israel. E-mail: s_ravid@rambam.health.gov.il
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conicts of interest to disclose.

ARTICLE

Encephalitis is the presence of an inammatory process in the brain parenchyma associated with clinical
evidence of brain dysfunction.1 Diagnosis requires evidence of neurologic
dysfunction and central nervous system (CNS) inammation.2 Viruses are
the most frequently diagnosed infectious cause of encephalitis; bacteria,
fungi, and parasites are less common.3,4
The frequency and distribution of viruses or other infectious agents causing
encephalitis vary according to geographical region. In Asia, the major
identied cause of acute encephalitis is
the Japanese encephalitis virus.5 Tickborne encephalitis virus and enterovirus are common in the Western world.6,7
Data on long-term neurologic outcomes
in children with encephalitis are limited
and vary depending on the different
geographic areas and endemic agents.
In the majority of studies, data were
determined by using clinical follow-up
assessments at outpatient clinics8,9
and structured questionnaires10; only
a few studies used standardized cognitive and behavioral tests.1113 Previously reported neurologic sequelae
include developmental delay, motor
decits, epilepsy, and learning and behavioral problems.9,10,14
Information regarding prognostic factors of acute encephalitis in children is
sparse, and data vary between studies.
Several factors have been suggested as
indicative of poor outcome, such as
young age,8,11 deteriorating electroencephalography (EEG) ndings,11 focal
neurologic signs at discharge,9 low
Glasgow Coma Scale score on admission,8,15 and abnormal neuroimaging
results.9,15
The aim of the present study was to
evaluate the long-term sequelae of
acute encephalitis in children and to
look for predictors of long-term morbidity. Although most previous studies
were based on clinical assessments or
questionnaires, this study is distinctive
PEDIATRICS Volume 133, Number 3, March 2014

because it provides an objective neurocognitive performance assessment.

This information can help in offering
guidance in anticipatory counseling, as
well as emphasizing important aspects
for future follow-up.

METHODS
Study Population
Medical records of children and adolescents, aged 1 month to 18 years, admitted to Meyer Childrens Hospital in
Haifa, Israel, during the years 2000 to
2010 with a nal diagnosis of acute encephalitis were reviewed. The hospital
is the main tertiary center in the north
of Israel and serves a population of
280 000 children. Inclusion criteria included: (1) at least 1 symptom or sign
of cerebral dysfunction, such as altered mental status, motor or sensory
decits, or seizures; and (2) at least 1
of the following signs of inammation:
fever (.38C), white blood cell count
.15 3 103 cells/mL, C-reactive protein
level .10 mg/L, and cerebrospinal
uid cell count .6 cells/mL. Children
with meningoencephalitis, demyelinating disease, or any underlying neurologic, systemic, or metabolic disease
were excluded from the study. All eligible patients were contacted, by letter
and then by telephone, to ask whether
they would be willing to be followed up.
Fifty-eight patients fullled the inclusion criteria. Of those, 1 died during the
acute phase, 8 declined to be assessed,
and 3 could not be located. There was no
difference between those children regarding age at onset, gender, and presenting symptoms.
Written informed consent was obtained
from the parents during the follow-up
meeting. The study was approved by
the institutional review board.
Data Collection
A structured form was used to obtain
data from patients hospital records

regarding presenting symptoms and

signs, laboratory examinations, EEG
and neuroimaging studies, and clinical
ndings at discharge.
The causative organisms were identied according to serum virus antibody
titers (West Nile virus, mycoplasma,
Coxiella burnetii, and Bartonella species), and cerebrospinal uid polymerase chain reaction (herpes simplex
virus [HSV], herpesvirus 6, and enterovirus).
Outcome at discharge was classied
for all survivors as good, moderate, or
poor. Good outcome was dened as
having no neurologic sequelae. Moderate outcome was dened as having
minor to moderate sequelae, including
altered behavior or clinical signs not
affecting functions. Poor outcome was
dened as having severe neurologic sequelae that impair everyday functions.

Clinical, Motor, and Neurocognitive

Assessment
All the children were interviewed and
underwent thorough neurologic examination by a pediatric neurologist
during the follow-up visit. A structured
questionnaire was used to obtain information from parents regarding comorbid illnesses, medications, behavioral
problems, school performance, and
ability to perform daily activities.
The Kaufman Brief Intelligence Test16
was used to assess intelligence. This
standardized, individually administered test yields 3 scores: verbal, nonverbal, and the overall score, known as
the IQ composite. The mean 6 SD agebased standard score for each test is
100 6 15. Scores lower than 2 SDs
from the mean were considered as
retardation. Scores between 1 and 2
SDs from the mean were considered as
borderline intelligence.
The diagnosis of attention-decit/
hyperactivity disorder (ADHD) was based
on the criteria of the Diagnostic and

e547

Statistical Manual of Mental Disorders,

Fourth Edition.17 Clinical evaluation
was performed by a pediatric neurologist, using the patients history, interviews with the parents and child,
and examination during the visit. In
addition, attention and behavior were
measured by using the Conners Parent
Rating ScalesRevised.18
Long-term Outcome
The long-term outcome was classied
for all survivors as good, moderate, or
poor. Good outcome was dened as
having no neurologic sequelae. Moderate outcome was dened as having
moderate sequelae, including ADHD,
learning disabilities, or seizures affecting function but compatible with
independent living. Poor outcome was
dened as having severe neurologic
sequelae that impaired everyday functions, contrary to independent living.

Clinical Presentation, EEG, and

Neuroimaging Studies
The most common presenting symptoms were fever (73%) and altered
mental status (69%). Hemiparesis was
found in 13 (28%) patients and ataxia
in 6 (13%) patients. Eighteen (39%)
patients had seizures.
An etiologic agent was identied in 23
(50%) patients. The most common
pathogen was enterovirus (9 patients),
followed by HSV (6 patients).
EEG was performed on 31 patients; results were normal in only 3 (10%). Abnormal results on neuroimaging studies
were found in 39% of the patients
(Table 1).
At discharge, neurologic examination
was normal in 27 (58%) patients; 33% of
patients showed focal motor decits,
and 15% of patients had various levels
of cognitive impairment.

headaches (22%), tic disorder (22%),

and sleeping problems (19%). Five (11%)
children developed long-standing epilepsy, which was intractable in 4 (80%).
Only 4 (9%) children had residual motor
decits. Those children suffered from
spastic hemiparesis and were diagnosed with herpes encephalitis. On the
Kaufman Brief Intelligence Test, fullscale IQ .85 was found in only 69%
of patients, compared with 84% in
the general population, and 22% of
patients had a full-scale IQ #70, compared with 2.2% in the general population (Fig 1).
Twenty-three (50%) patients fullled the
criteria for ADHD. This rate is signicantly higher than the reported rate
(5%10%) in the general population of
Israel19 (P , .05). A substantial number
of patients had learning disorders
(20%) compared with the reported rate
(10%) in the general population of
Israel20 (P , .05), and 8 (17%) were
placed in special education classes.

Statistical Analysis

Long-term Motor and Cognitive

Outcome

Data were summarized as proportions

or means 6 SDs. x2 analysis was used
to test for qualitative variables, and
Students t test was used for quantitative variables.

Persisting symptoms were reported by

parents of 23 (50%) children. The most
common residual symptoms were behavioral problems (52%), recurrent

Overall, full recovery was found in only

17 (37%) patients. Moderate outcome
was found in 35% of children, and 13
(28%) children suffered from poor
outcome (Table 2).

TABLE 1 Initial Clinical Presentation, EEG,

Association Between Pathogen and

Long-term Neurologic Outcome

Multivariate analyses of the associations between clinical presentation,

pathogen, EEG and neuroimaging studies, and long-term outcome were conducted by using logistic regressions
with odds ratios (ORs) and 95% condence intervals (CIs). Analyses for the
total sample were adjusted for age and
gender. For all comparisons and analyses, a P value of ,.05 was used as the
cutoff point of statistical signicance.

RESULTS
A total of 46 patients (28 boys and 18
girls) were enrolled in our study. Mean
age at disease onset was 5 6 4.88 years
(range: 117 years), and mean time to
follow-up was 5.8 6 3.08 years (range:
111 years).

e548

MICHAELI et al

and Neuroimaging Studies in

Patients With Encephalitis
Characteristic

Value

Age, mean 6 SD, y

Focal neurologic signs
Hemiparesis
Ataxia
Cranial nerves
Coma
Seizures
Conrmed pathogen
EEG (n = 31)
Normal
Generalized d waves
Focal spikes or slow waves
Neuroimaging (n = 38)
Normal
Leptomeningeal enhancement
Cortical hyperdensity
Brain edema

5 6 4.88

Data are N (%), unless otherwise noted.

13 (28)
6 (13)
2 (4)
7 (15)
18 (39)
23 (50)
3 (10)
24 (77)
6 (19)
25 (66)
9 (24)
3 (8)
1 (2)

Of 23 patients with veried pathogens,

patients with HSV had the highest rate of
neurologic sequelae, including signicant motor decit (66%), mental retardation (50%), ADHD (66%), and epilepsy
(50%). However, patients with herpes
encephalitis were not the only ones
with an adversely affected prognosis.
Of the 40 patients excluding those with
HSV, ADHD was found in 18 (45%)
patients and mental retardation in 7
(17%) (Table 3). Overall, having a conrmed etiologic agent was signicantly
associated with being at risk for poor
long-term outcome (OR: 3.67 [95% CI:
1.115.68]; P = .04).

ARTICLE

FIGURE 1
Comparison of full-scale IQ of children with encephalitis versus the general population IQ.

Association Between Clinical

Presentation, EEG, and
Neuroimaging Studies and
Long-term Outcome

too small to give reasonable interpretations.

Predictors of poor long-term outcome

are summarized in Table 4. The strongest predictors included long hospital
stay (P = .004), abnormal neurologic
examination results at discharge (P =
.03), abnormal results on neuroimaging studies (P = .04), and conrmed pathogen (P = .04). Although
patients with seizures, abnormal neuroimaging ndings, and focal neurologic signs at presentation displayed
a tendency toward increased risk for
epilepsy, the number of patients was
TABLE 2 Long-term Motor and Cognitive
Outcomes
Outcome

N (%)

Persisting symptoms
Motor decit (hemiparesis)
Behavioral problems
ADHD
Learning disabilities
Epilepsy
Global IQ
Mental retardation (#70)
Below average (7184)
Average or above average ($85)
Overall long-term outcome
Good
Moderate
Poor

23 (50)
4 (9)
24 (52)
23 (50)
9 (20)
5 (11)
10 (22)
4 (9)
32 (69)
17 (37)
16 (35)
13 (28)

PEDIATRICS Volume 133, Number 3, March 2014

Association Between Outcome at

Hospital Discharge and Long-term
Outcome
Figure 2 shows the distribution of outcome at hospital discharge and at the
long-term follow-up visit. At hospital
discharge, 27 (59%) patients had apparently made a full recovery, whereas
6 (13%) had moderate neurologic sequelae and 13 (28%) had severe neurologic sequelae. Of the 13 children
with severe sequelae, 6 improved
(46%) and 3 (3%) fully recovered.
Conversely, of the 27 children who were
considered to have made a full recovery at time of discharge, only 13 had
a good long-term outcome. Four (15%)
had mental retardation, 4 (15%) had
learning disabilities, and 11 (41%) had
ADHD.

DISCUSSION
The major ndings of the present study
are that encephalitis in children can
lead to signicant long-term neurologic
sequelae, mainly reduced neurocognitive performance, behavioral problems, ADHD, and learning disabilities.
Overall, 50% of our patients suffered

from ADHD and 20% from learning

disabilities. These values are signicantly higher than the recent estimates
of ADHD (5%10%) and learning disability (10%) rates in Israel (P , .05).
Only 37% of the survivors had fully recovered, and 28% of the children were
left with severe neurologic disabilities
that impaired everyday functions, such
as motor decits, mental retardation,
and intractable seizures. Similar studies that investigate the long-term outcome of encephalitis are sparse, and
the results of long-term neurologic
sequelae vary with geographic location
and type of infectious pathogen. A
similar incidence of severe neurologic
sequelae was previously reported by
Wang et al,9 who found 25% signicant
morbidity, such as epilepsy, mental retardation, and focal neurologic signs,
in children who experienced acute encephalitis. In a study by Clarke et al,11
7 (35%) of 20 children who survived
acute encephalitis experienced moderate to severe neurologic impairment.
In contrast, an older study by Rautonen
et al8 found that only 6.7% of children
with encephalitis suffered from severe
damage and 90.5% were cured with no
or only minor sequelae. This study,
however, included only clinical follow-up
visits up to 6 months after discharge
and may therefore have underestimated neurocognitive sequelae that
could manifest at a later stage.
As noted earlier, the most common
sequelae in our study was ADHD, which
was found in 50% of patients. None of
our patients was diagnosed with ADHD
before the onset of disease, although
most were too young at disease onset
to manifest the characteristic clinical
symptoms. Because all patients were
healthy before the disease, we assumed
the same incidence of the disorder in
our study as in the general population.
Although the association between ADHD
and other brain insults, such as head
trauma,21,22 bacterial meningitis,23 and
e549

TABLE 3 Association Between Pathogen and Long-term Neurologic Outcome

N

Neurologic Sequelae (n)

Total N (%)a

Enterovirus

7 (78)

HSV

West Nile virus

Human herpesvirus 6
Mycoplasma pneumonia
Coxiella burnetii

3
1
1
1

Bartonella henselae
Epstein-Barr virus

1
1

Mental retardation (3), ADHD (5), tic

disorder (3), sleep disturbances (2), learning
disabilities (1), epilepsy (1)
Mental retardation (3), ADHD (4), motor decit (4),
tic disorder (3), sleep disturbances (3), epilepsy (3)
ADHD (1), headaches (1)
None
ADHD (1), tic disorder (1)
ADHD and learning disabilities (1), headaches
(1), sleep disturbances (1)
None
None

Pathogen

5 (83)
1 (33)
0 (0)
1 (100)
1 (100)
0 (0)
0 (0)

Percentage of subjects with neurologic sequelae.

TABLE 4 Prevalence ORs for Poor Prognosis According to Clinical Presentation, EEG, and
Neuroimaging Studies
Variable

OR (95% CI)

Female gender
Age at diagnosis
Focal neurologic signs at presentation
Coma at presentation
Admission to ICU
Seizures
Conrmed pathogen
Abnormal EEG
Abnormal neuroimaging results
Abnormal neurologic examination results at discharge
Hospital stay

0.49 (0.131.8)
0.89 (0.751.05)
1.8 (0.56.32)
1.67 (0.377.6)
1.25 (0.334.73)
2.33 (0.638.64)
3.67 (1.115.8)
2.75 (0.5214.63)
3.56 (0.9113.94)
3.11 (1.0712.89)
1.18 (1.051.32)

.39
.15
.35
.51
.74
.2
.04*
.24
.04*
.03*
.004*

* P , .05.

FIGURE 2
Association between outcome at hospital discharge and long-term outcome.

brain tumor,24 was previously reported,

little is known about its association with
infectious encephalitis. Behavioral anomalies similar to ADHD were rst described as a complication of encephalitis
e550

MICHAELI et al

after the inuenza epidemic of 1918.25

In their study on patients recovering
from CNS infections due to enterovirus
71, Gau et al26 reported a 20% incidence of ADHD, compared with 3% in

the control group. They suggested that

the infection may involve the prefrontostriatum-subcortical area of the brain
that relates to the core symptoms of
ADHD.27 After tick-borne encephalitis,
children had lower scores than control
subjects and relative impairment on
several attention/concentration tests.13
Impaired memory function and reduced
ability to concentrate was reported by
Fowler et al14 in children who survived
encephalitis. When assessed by using
computerized cognitive tests, these
children had slower reaction times but
no differences in working memory compared with control subjects. This association is important, because ADHD
symptoms may inuence school performance as well as peer and family
relationships. Early diagnosis of ADHD
symptoms will allow early educational
intervention and treatment if necessary.
Another important nding of our study
was the signicantly lower intelligence
scores in children after acute encephalitis. A full-scale IQ of .85 was found
in only 69% of patients, compared
with 84% in the general population,
whereas 22% of patients had a fullscale IQ of #70, compared with 2.2%
in the general population. There is little
information regarding cognitive function after viral encephalitis in children.
Similar signicantly lower IQ evaluations were previously reported by
Chang et al12 in children who contracted
enterovirus 71 encephalitis. In contrast, in a study from Germany, no
signicant difference was found in
intelligence or neuropsychological evaluations between children who experienced tick-borne encephalitis and
control subjects.13
Lower intelligence scores and impaired
attention and learning were found in
our study even in children who were
considered as fully recovered at the
time of discharge. Of 27 children who
were considered to have made a full
recovery at the time of discharge, 4

ARTICLE

(15%) had mental retardation, 11 (41%)

had ADHD, and 4 (15%) had severe
learning disability. A possible explanation for these ndings is that cognitive
recovery at discharge, especially in
young children, is usually based on level
of consciousness, awareness, and orientation. Neurocognitive parameters,
such as memory, attention, or comprehension, are not assessed, and future neuropsychological sequelae that
interfere with intelligence and learning
may thus be underestimated. In addition, cognitive decits at discharge may
not be evident until the demands increase during school years. Similar
late-onset cognitive sequelae were also
seen in other studies.14,28,29
Epilepsy is a known sequelae of CNS
infections. Furthermore, between 1%
and 5% of epilepsy causes have been
presumed to be due to CNS infections.30
Recurrent seizures, status epilepticus,
and multifocal spikes on EEG were previously reported as risk factors for
postencephalitic epilepsy in children.31,32
In our study, 5 children (11%) developed
long-term epilepsy; the condition was
intractable in 4 children (80%). Seizures,
abnormal neuroimaging ndings, and
focal neurologic signs at presentation
displayed a tendency toward increased
risk for epilepsy, but the number of
patients was too small to make a meaningful interpretation.
Potential risk factors for a poor neurologic outcome in our study were
identiable pathogens, abnormal imaging, abnormal neurologic examination at discharge, and longer hospital
stay. The cause of encephalitis was
found in 50% of our patients. This nding is consistent with previous studies,
in which an etiologic diagnosis was
made in 31% to 75% of cases.911,14,15
The most common pathogens in our
study were enterovirus, HSV, and West
Nile virus. Children with HSV encephalitis
had the worst outcome. One patient died,
and 5 of 6 survivors had severe neuroPEDIATRICS Volume 133, Number 3, March 2014

logic sequelae. These results are in line

with other recent studies that found
a high incidence of neurologic sequelae
in children with HSV encephalitis3335;
these sequelae were probably secondary to cortical necrosis and infarction.
However, all agents, even those previously considered benign, such as enterovirus,9,14 caused major neurologic
sequelae. Some 78% of our patients with
enterovirus encephalitis experienced
long-term neurologic sequelae, such as
mental retardation (33%) and ADHD
(55%). Enterovirus 71, a distinctive species of enterovirus that is common in the
Asia-Pacic region but not in our region,
has also been reported as being associated with ADHD and reduced cognitive
functioning.12,26
Several studies, as well as our study,
have shown the predictive value of abnormal neuroimaging on both shortterm7,36 and long-term9,10,37 outcomes of
childhood encephalitis. This nding may
be explained by irreversible parenchymal damage. Severe brain lesions may
also cause focal neurologic signs and
correlate with abnormal neurologic
examinations at discharge, which independently was found to be a predictor
for long-term neurologic sequelae.9
Long hospital stay was also associated
with poor prognosis in the present
study and most likely reects the severity of the disease. Other factors that
reect severity of disease, such as low
Glasgow Coma Scale score on admission,15,28,37 deep coma,28 and ICU admission,14 were previously found as
poor prognostic factors in other studies (although not in the present study).
Several authors have suggested that
young age is associated with a poor
long-term prognosis in children with
encephalitis.8,11,38 We did not observe
this correlation in our study.
Although the strength of our study is
the clinical examination and neuropsychological evaluations of the patients, it did have several limitations. As

a retrospective study, it is limited by the

quality of information regarding symptoms and signs, laboratory evaluation,
and treatment during admission available in hospital charts. Furthermore,
because medications were not given
according to a standardized protocol,
the impact of certain treatments, such
as steroids and intravenous immunoglobulin, could not be assessed. Similarly, because the diagnostic methods
for causative organisms and antibodies
for autoimmune encephalitis have
evolved during the last decade, higher
rates of causative organisms might be
found if those children were being
evaluated today. Nevertheless, the cause
of encephalitis was found in 50% of our
patients, which is consistent with previous studies.911,14,15 In addition, the
study was also limited by the highly
variable follow-up period. However, because attention and cognitive decits
may rst be evident years after disease
onset, their prevalence could be even
higher. Another limitation of our study is
the lack of a control group. Because all
patients were healthy before the disease, we compared the incidence of
cognitive impartment, learning disabilities, and ADHD with the incidence of
the general population, but it is not fully
controlled for age and socioeconomic
status.

CONCLUSIONS
Encephalitis in children may be associated with signicant long-term neurologic sequelae. Signicant cognitive
impairment, ADHD, and learning disabilities are common, and even children
who were considered fully recovered at
discharge may be signicantly affected.
Neuropsychological testing should be
recommended for survivors of childhood encephalitis. Patients with identiable pathogens, abnormal imaging,
abnormal neurologic examinations on
discharge, and long hospital stay have
an increased risk of a poor outcome.

e551

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