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Updated: Nov 19 2016


  • Snapshot
    • A 42-year-old male presentswith confusion, headache, and fever. The patient is unable to answer questions. A head CT is negative for a space-occupying lesion or hemorrhage. An MRI is shown. A lumbar puncture is performed, with cerebral spinal fluid (CSF) analysis showing a lymphocytic pleocytosis and normal glucose. PCR of the CSF is positive for HSV-1.
  • Introduction
    • Brain parenchymal infection
      • abnormalities in brain functioning are expected
        • e.g., altered mental status, changes in personality, problems with speech and movement
        • this distinguishes encephalitis from meningitis
    • Typically caused by infection
      • viral (most cases)
        • herpes simplex virus (HSV)
          • most common cause
        • varicella virus (VZV)
        • epstein-barr virus (EBV)
        • measles, mumps, rubella
        • HIV
        • Japanese encephalitis virus
        • St. Louis encephalitis virus
        • West Nile virus
      • bacterial
        • toxoplasmosis
      • noninfectious
        • acute disseminated encephalitis
    • There can be both an infection of the brain parenchyma and meninges
      • leading to a meningoencephalitis
  • Presentation
    • Symptoms
      • seizues
      • fever
      • headache
      • nausea
      • vomiting
    • Physical exam
      • altered mental status
      • personality changes
      • focal neurological deficits
        • cranial nerve palsies
        • hemiparesis.
      • meningsmus
        • only in pure encephalitis
  • Evaluation
    • CT scan of the head
      • MRI is the preferred imaging modality for HSV encephalitis
    • Lumbar puncture
      • perform after head imaging
      • PCR
        • most accurate for herpes encephalitis
    • Brain biopsy
      • last resort
      • only if etiology is unknown
  • Differential
    • Intracranial malignancy
      • primary or metastatic
    • Medication side-effects
    • Paraneoplastic or autoimmune disease
      • anti-NMDA receptor encephalitis
  • Treatment
    • Treatment is dependent on etiology
      • HSV encephalitis
        • initiate acyclovir immediately
        • can be considered with VZV encephalitis
        • associated with a reduction in morbidity and mortality
        • foscarnet in acyclovir-resistant herpes
  • Prevention, Prognosis, and Complications
    • 50 - 75% mortality in untreated HSV encephalitis
    • < 1 or > 55 years old and immunocompromised is associated with poorer outcome
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