Acute encephalitis syndrome
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Transcript of Acute encephalitis syndrome
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Acute Encephalitis Syndrome
Yogiraj RayMD (Tropical Medicine)
Assistant professorCalcutta School of Tropical Medicine
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Case 1
• 15 years old boy from Dhapa, near Kolkata• Fever for 7days- initially low grade, then high grade
from next day with chills• Headache • 5 episodes of GTCS in 3 days. • Unconscious for 3 days• No rash/bleeding/ cough/ pain abdomen/ loose
motion/ dysuria/ history of travel.
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On Examination
• GCS: 5• Pupil : pin point (B/L)• Doll’s eye : Present• B/L basal crepts• Pulse: not palpable• Respiration: shallow, 38/min• Blood Pressure : Not recordable
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Your opinion & management
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Case Definition of Suspected case
• Acute onset of fever, not more than 5-7 days duration. • Change in mental status with/ without New onset of seizures (excluding febrile seizures) (Other early clinical findings – may include irritability,
somnolence or abnormal behaviour greater than that seen with usual febrile illness)
Important • In an epidemic situation fever with altered sensorium persisting for more than two hours with a focal
seizure or paralysis of any part of body, is encephalitis. • Presence of rash on body excludes Japanese Encephalitis. • AES with symmetrical signs and fever is likely to be cerebral Malaria.
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Case Classification
Probable Cases • Suspected case in close geographic and temporal relationship
to a laboratory-confirmed case of AES/JE in an outbreak Acute Encephalitis Syndrome due to other agent • A suspected case in which diagnostic testing is performed and
an etiological agent other than AES/JE is identified Acute Encephalitis Syndrome due to unknown agent • A suspected case in which no diagnostic testing is performed /
no etiological agent is identified / test results are indeterminate
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Laboratory-Confirmed case
A suspected case with any one of the following markers: • Presence of lgM antibody in serum and/ or CSF to a
specific virus including JE/Entero Virus or others • Four fold difference in lgG antibody titre in paired sera • Virus isolation from brain tissue • Antigen detection by immunofluroscence • Nucleic acid detection by PCR
In the sentinel surveillance network, AES/JE will be diagnosed by lgM Capture ELISA, and virus isolation will be done in National Reference Laboratory
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encephalitis
Vector borne• Japanese B• West Nile• Chandipura• Tick borne• Chikungunya• Dengue
Important others• HSV • Rabies• Nipah• VZV• Mumps• Measels• Enteoviruses• Poliomyelitis• HIV
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JE Epidemiology
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Mosquito
• In India, JE virus has been isolated from 17 mosquito species in wild caught specimens from different parts of the country.
• Maximum isolations have been recorded from Culex vishnui group consisting of Cx.tritaeniorhynchus, Cx.vishnui and Cx.pseudovishnui.
• Female mosquitoes get infected after feeding on a vertebrate host harbouring JE virus and after 9-12 days of extrinsic incubation period, they can transmit the virus to other hosts.
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• The ratio of overt disease to inapparent infection varies from 1:250 to 1:1000.
• Thus the cases of JE represent tip of the iceberg compared to the large number of inapparent infections.
• Usually the number of overt disease cases reported from each village is 1 or 2.
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Post Mortem Lesions JE• Pan-encephalitis• Infected neurons scattered
throughout CNS• Occasional microscopic
necrotic foci• Thalamus generally severely
affected• Basal ganglia, brain stem,
cerebellum, hippocampus & cerebral cortex
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SYMPTOMS• Incubation period: 5-15 days• Fever, headache, nausea, vomiting, myalgia• Altered mental status follows• Seizures in 66% esp. children. headache & meningismus more
common in adults• Tremor & involuntary movements common. • Mutism reported. • Fever subsides by 2nd week• Extrapyramidal symptoms develop later
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SIGNS• Varied neurologic signs • Generalised weakness, hypertonia, hyperreflexia • Papilloedema in <10% • Cranial nerve findings –33% (disconjugate gaze,cr. nv. palsy) • Extrapyramidal signs frequent(mask like facies,tremor, rigidity.
choreoathetoid movement) • May be loss of bowel & bladder control
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Mortality & morbidity
• An estimated 25% of the affected children die • Among those who survive, about 30-40% suffers
from physical & mental impairment
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MRI of brain-JE
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Schematic antibody responses in JE infection
All samples must be sent in cold chain
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Specimen collection and transportation
• Blood (serum) and Cerebrospinal fluid (CSF) are the specimens to be collected for JE diagnosis.
• Blood samples should be collected from suspected JE cases within 4 days after the onset of illness for isolation of virus and at least 5 days after the onset of illness for detection of IgM antibodies.
• A second, convalescent samples should be collected at least 10-14 days after the first sample for serology.
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Probable JE
• Encephalitis syndrome• CSF consistent with Viral Encephalitis• Elevated IgM antibody• Stable antibody
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Confirmed Case
• Suspected case plus• Any one or more of the following JE IgM in CSFOr 4 fold or greater rise of antibody titers in paired
sera (acute /convalescent)Or detection of virus, antigen or genome in tissue,
blood or other body fluids.
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Indications of Ventilatory Support
1. GCS<82. Very Shallow Respiration/ Severe Respiratory Distress3. Capillary Refilling time/ colour of Patient Not Improved4. Dusky Colour of body/ Cyanosis5. Needs continuous Bag and Mask (Ambu) respiration6. ABG Parameters7. ARDS with or without Sepsis
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Management of convulsions
Give anti convulsants if there was a history of convulsions and not given earlier, or convulsions are present. Number one to three are first drug of choice, if convulsions are not controlled.
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Maintenance Dose
• Phenobarbitone 3-8mg/kg/day I/V or oral• Phenytoin 5-8 mg/kg/day I/V or oral• Sodium Valproate 40-60mg/kg/day Oral• Levetiracetam 10 mg/kg twice a day
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Management of case 1
• ABC• Anticonvulsunt • Confirmed JE by CSF anti JE IgM antibody• Sepsis manage• Tracheostomy • Feeding jejunostomy • Pysiotherapy • Discharged with recovery (aphasia still there)
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Case 2
• 65 year male from Bankura H/O fever with vesicular eruption for 5 days
• Seizure 2 episode• Bizarre behavior with involuntary movement
• ???? Diagnosis
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Treatment
• No need for ventilator• Isolation • Aciclovir • Cured and discharged after 10 days
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Case 3
• Fever 3 days• Diffuse macular rash with island of clear skin 1
days• Sudden unconciousness 6 hours
Diagnosis??????
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• Diagnosed as dengue • CSF pleocytosis only• Looked for many causes• Iv antibiotic as per meningitis• Aciclovir
• Died after 3 days
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Case 4
• Fever for 15 days• Altered sensorium 3 days• Bizarre movement 10 days back which
recovered after 3 days• Admitted with GCS 10
• No need for CCU care
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• CSF s/o viral encephalitis• HSV PCR positive• IV Aciclovir for 21 days• Physitherapy• After 21 days: aphasia, ophthalmoplegia,
chorieform movement• Complete recovery after 40 days
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Case 5
• 25 yr old male b/l parotid enlargement with fever 7 days
• Testicular pain for 3 days• GCTS with status
• Admitted at CCU
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• Iv lorazepum • Phenytoin loading & maintenance• Add on Levetiracetam
• GCTS controlled but unconscious
• O2 by T-piece
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Recovery
• Supportive care• Physiotherapy
• RIBAVIRIN
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AES
• JE• HSV• VZV• Mumps• WNV• HIV related• Unclassified (???????) : keep them as AES
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Thank you