1
|
Bloch KC, Glaser C, Gaston D, Venkatesan A. State of the Art: Acute Encephalitis. Clin Infect Dis 2023; 77:e14-e33. [PMID: 37485952 DOI: 10.1093/cid/ciad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 07/25/2023] Open
Abstract
Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.
Collapse
Affiliation(s)
- Karen C Bloch
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Glaser
- California Department of Public Health, Richmond, California, USA
| | - David Gaston
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
2
|
Sonneville R, de Montmollin E, Contou D, Ferrer R, Gurjar M, Klouche K, Sarton B, Demeret S, Bailly P, da Silva D, Escudier E, Le Guennec L, Chabanne R, Argaud L, Ben Hadj Salem O, Thyrault M, Frerou A, Louis G, De Pascale G, Horn J, Helbok R, Geri G, Bruneel F, Martin-Loeches I, Taccone FS, De Waele JJ, Ruckly S, Staiquly Q, Citerio G, Timsit JF. Clinical features, etiologies, and outcomes in adult patients with meningoencephalitis requiring intensive care (EURECA): an international prospective multicenter cohort study. Intensive Care Med 2023; 49:517-529. [PMID: 37022378 DOI: 10.1007/s00134-023-07032-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/08/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE We aimed to characterize the outcomes of patients with severe meningoencephalitis requiring intensive care. METHODS We conducted a prospective multicenter international cohort study (2017-2020) in 68 centers across 7 countries. Eligible patients were adults admitted to the intensive care unit (ICU) with meningoencephalitis, defined by an acute onset of encephalopathy (Glasgow coma scale (GCS) score [Formula: see text] 13), a cerebrospinal fluid pleocytosis [Formula: see text] 5 cells/mm3, and at least two of the following criteria: fever, seizures, focal neurological deficit, abnormal neuroimaging, and/or electroencephalogram. The primary endpoint was poor functional outcome at 3 months, defined by a score of three to six on the modified Rankin scale. Multivariable analyses stratified on centers investigated ICU admission variables associated with the primary endpoint. RESULTS Among 599 patients enrolled, 589 (98.3%) completed the 3-month follow-up and were included. Overall, 591 etiologies were identified in those patients which were categorized into five groups: acute bacterial meningitis (n = 247, 41.9%); infectious encephalitis of viral, subacute bacterial, or fungal/parasitic origin (n = 140, 23.7%); autoimmune encephalitis (n = 38, 6.4%); neoplastic/toxic encephalitis (n = 11, 1.9%); and encephalitis of unknown origin (n = 155, 26.2%). Overall, 298 patients (50.5%, 95% CI 46.6-54.6%) had a poor functional outcome, including 152 deaths (25.8%). Variables independently associated with a poor functional outcome were age > 60 years (OR 1.75, 95% CI 1.22-2.51), immunodepression (OR 1.98, 95% CI 1.27-3.08), time between hospital and ICU admission > 1 day (OR 2.02, 95% CI 1.44-2.99), a motor component on the GCS [Formula: see text] 3 (OR 2.23, 95% CI 1.49-3.45), hemiparesis/hemiplegia (OR 2.48, 95% CI 1.47-4.18), respiratory failure (OR 1.76, 95% CI 1.05-2.94), and cardiovascular failure (OR 1.72, 95% CI 1.07-2.75). In contrast, administration of a third-generation cephalosporin (OR 0.54, 95% CI 0.37-0.78) and acyclovir (OR 0.55, 95% CI 0.38-0.80) on ICU admission were protective. CONCLUSION Meningoencephalitis is a severe neurologic syndrome associated with high mortality and disability rates at 3 months. Actionable factors for which improvement could be made include time from hospital to ICU admission, early antimicrobial therapy, and detection of respiratory and cardiovascular complications at admission.
Collapse
Affiliation(s)
- Romain Sonneville
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France.
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France.
- Service de Médecine Intensive-Réanimation, Hôpital Bichat-Claude Bernard, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
| | - Etienne de Montmollin
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Damien Contou
- Department of Intensive Care Medicine, Victor Dupouy Hospital, Argenteuil, France
| | - Ricard Ferrer
- Department of Intensive Care Medicine, Val d'Hebron University Hospital, Barcelona, Spain
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Kada Klouche
- Department of Intensive Care Medicine, Montpellier University Hospital, Montpellier, France
| | - Benjamine Sarton
- Department of Intensive Care Medicine, Purpan University Hospital, Toulouse, France
| | - Sophie Demeret
- Sorbonne University, AP-HP, Neurology Department, Neurological Intensive Care Unit, Pitié Salpêtrière Hospital, Paris, France
| | - Pierre Bailly
- Department of Intensive Care Medicine, Brest University Hospital, Brest, France
| | - Daniel da Silva
- Department of Intensive Care Medicine, Saint Denis University Hospital, Saint Denis, France
| | - Etienne Escudier
- Department of Intensive Care Medicine, Annecy Hospital, Annecy, France
| | - Loic Le Guennec
- Department of Intensive Care Medicine, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Russel Chabanne
- Department of Anesthesia and Intensive Care Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Laurent Argaud
- Department of Intensive Care Medicine, Lyon University Hospital, Lyon, France
| | - Omar Ben Hadj Salem
- Department of Intensive Care Medicine, Poissy-Saint Germain Hospital, Poissy, France
| | - Martial Thyrault
- Department of Intensive Care Medicine, Longjumeau hospital, Longjumeau, France
| | - Aurélien Frerou
- Department of Intensive Care Medicine, Pontchaillou Hospital, Rennes, France
| | - Guillaume Louis
- Department of Intensive Care Medicine, Metz Hospital, Metz, France
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - Janneke Horn
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Guillaume Geri
- Department of Intensive Care Medicine, Ambroise Paré University Hospital, Boulogne-Billancourt, France
| | - Fabrice Bruneel
- Department of Intensive Care Medicine, Versailles Hospital, Le Chesnay, France
| | | | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | | | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department of Neuroscience, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Jean-François Timsit
- Université Paris Cité, INSERM UMR 1137, 75018, Paris, France
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| |
Collapse
|
3
|
Wilms L, Weßollek K, Peeters TB, Yazdi AS. Infektionen mit Herpes‐simplex‐ und Varizella‐zoster‐Virus. J Dtsch Dermatol Ges 2022; 20:1327-1353. [DOI: 10.1111/ddg.14917_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Larissa Wilms
- Klinik für Dermatologie und Venerologie Helios Klinikum Krefeld
| | | | | | | |
Collapse
|
4
|
Wilms L, Weßollek K, Peeters TB, Yazdi AS. Infections with Herpes simplex and Varicella zoster virus. J Dtsch Dermatol Ges 2022; 20:1327-1351. [DOI: 10.1111/ddg.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 08/18/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Larissa Wilms
- Department of Dermatology and Venereology Helios Klinikum Krefeld Germany
| | - Katharina Weßollek
- Department of Dermatology and Allergology University Hospital RWTH Aachen Germany
| | | | - Amir Sadegh Yazdi
- Department of Dermatology and Allergology University Hospital RWTH Aachen Germany
| |
Collapse
|
5
|
Zhao Y, Ren B, Yu W, Zhang H, Zhao D, Lv J, Xie Z, Jiang K, Shang L, Yao H, Xu Y, Zhao G. Construction of an Assisted Model Based on Natural Language Processing for Automatic Early Diagnosis of Autoimmune Encephalitis. Neurol Ther 2022; 11:1117-1134. [PMID: 35543808 PMCID: PMC9338198 DOI: 10.1007/s40120-022-00355-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Early diagnosis and etiological treatment can effectively improve the prognosis of patients with autoimmune encephalitis (AE). However, anti-neuronal antibody tests which provide the definitive diagnosis require time and are not always abnormal. By using natural language processing (NLP) technology, our study proposes an assisted diagnostic method for early clinical diagnosis of AE and compares its sensitivity with that of previously established criteria. Methods Our model is based on the text classification model trained by the history of present illness (HPI) in electronic medical records (EMRs) that present a definite pathological diagnosis of AE or infectious encephalitis (IE). The definitive diagnosis of IE was based on the results of traditional etiological examinations. The definitive diagnosis of AE was based on the results of neuronal antibodies, and the diagnostic criteria of definite autoimmune limbic encephalitis proposed by Graus et al. used as the reference standard for antibody-negative AE. First, we automatically recognized and extracted symptoms for all HPI texts in EMRs by training a dataset of 552 cases. Second, four text classification models trained by a dataset of 199 cases were established for differential diagnosis of AE and IE based on a post-structuring text dataset of every HPI, which was completed using symptoms in English language after the process of normalization of synonyms. The optimal model was identified by evaluating and comparing the performance of the four models. Finally, combined with three typical symptoms and the results of standard paraclinical tests such as cerebrospinal fluid (CSF), magnetic resonance imaging (MRI), or electroencephalogram (EEG) proposed from Graus criteria, an assisted early diagnostic model for AE was established on the basis of the text classification model with the best performance. Results The comparison results for the four models applied to the independent testing dataset showed the naïve Bayesian classifier with bag of words achieved the best performance, with an area under the receiver operating characteristic curve of 0.85, accuracy of 84.5% (95% confidence interval [CI] 74.0–92.0%), sensitivity of 86.7% (95% CI 69.3–96.2%), and specificity of 82.9% (95% CI 67.9–92.8%), respectively. Compared with the diagnostic criteria proposed previously, the early diagnostic sensitivity for possible AE using the assisted diagnostic model based on the independent testing dataset was improved from 73.3% (95% CI 54.1–87.7%) to 86.7% (95% CI 69.3–96.2%). Conclusions The assisted diagnostic model could effectively increase the early diagnostic sensitivity for AE compared to previous diagnostic criteria, assist physicians in establishing the diagnosis of AE automatically after inputting the HPI and the results of standard paraclinical tests according to their narrative habits for describing symptoms, avoiding misdiagnosis and allowing for prompt initiation of specific treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00355-7.
Collapse
Affiliation(s)
- Yunsong Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Bin Ren
- Department of Information, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wenjin Yu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Haijun Zhang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Di Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Junchao Lv
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhen Xie
- College of Life Sciences and Medicine, Northwest University, Xi'an, China
| | - Kun Jiang
- Department of Information, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, Fourth Military Medical University, Xi'an, China
| | - Han Yao
- Department of Neurobiology, School of Basic Medicine, Fourth Military Medical University, Xi'an, China
| | - Yongyong Xu
- College of Life Sciences and Medicine, Northwest University, Xi'an, China.
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
- College of Life Sciences and Medicine, Northwest University, Xi'an, China.
| |
Collapse
|
6
|
Macher S, Bsteh G, Berger T, Höftberger R. Diagnostic approach and treatment regimens in adult patients suffering from antibody-mediated or paraneoplastic encephalitis. Curr Pharm Des 2022; 28:454-467. [PMID: 35100954 DOI: 10.2174/1381612828666220131093259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Identification of patients with antibody-mediated encephalitis poses a diagnostic challenge and any delay in that respect will increase the interval until initiation of immunotherapy and may negatively affect the patient´s clinical outcome. Within this review we focus on therapeutic strategies in antibody-mediated encephalitis and propose how to proceed with patients, who are suspected to have encephalitis of unknown origin. We further briefly outline differences in treatment of paraneoplastic and antibody-mediated encephalitis according to its pathomechanisms.
Collapse
Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Department of Neurology, Medical University of Vienna, Vienna, Austria; 2 Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Siciliano V, Rosà T, Del Vecchio P, D'Angelillo A, Brigida M, Longhitano Y, Zanza C, Santoro MC, Candelli M, Franceschi F, Piccioni A. Viral Encephalitis in Adults: A Narrative Review. Rev Recent Clin Trials 2022; 17:259-267. [PMID: 34792015 DOI: 10.2174/1574887116666211118141117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/14/2021] [Accepted: 09/22/2021] [Indexed: 02/08/2023]
Abstract
Viral infections of the central nervous system cause frequent hospitalization. The pathogenesis of viral encephalitis involves both the direct action of invading pathogens and the damage generated by the inflammatory reaction they trigger. The type of signs and symptoms presented by the patient depends on the severity and location of the ongoing inflammatory process. Most of the viral encephalitides are characterized by an acute development, fever, variable alterations in consciousness (confusion, lethargy, even coma), seizures (focal and generalized) and focal neurologic signs. The specific diagnosis of encephalitis is usually based on lumbar puncture. Cerebrospinal fluid examination should be performed in all patients unless absolutely contraindicated. Also, electroencephalogram and neuroimaging play a prominent role in diagnosis. Airway protection, ventilatory support, the management of raised intracranial pressure and correction of electrolyte disorders must be immediately considered in a patient with altered mental status. The only therapy strictly recommended is acyclovir in HSV encephalitis. The use of adjunctive glucocorticoids has poor-quality evidence in HSV, EBV, or VZV encephalitis. The role of antiviral therapy in other types of viral encephalitis is not well defined.
Collapse
Affiliation(s)
- Valentina Siciliano
- Department of Laboratory and Infectious Diseases, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Pierluigi Del Vecchio
- Department of Laboratory and Infectious Diseases, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Anna D'Angelillo
- Department of Laboratory and Infectious Diseases, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Mattia Brigida
- Department of Systems Medicine, Unit of Gastroenterology, Tor Vergata University, Rome, Italy
| | - Yaroslava Longhitano
- Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Department of Anesthesia and Critical Care, Alessandria, Italy
| | - Christian Zanza
- Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Department of Anesthesia and Critical Care, Alessandria, Italy
- Foundation of "Nuovo Ospedale Alba-Bra" and Department of Anesthesia, Critical Care and Emergency Medicine, Pietro and Michele Ferrero Hospital Verduno, Italy
- Department of Emergency Medicine, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Michele Cosimo Santoro
- Department of Emergency Medicine, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Marcello Candelli
- Department of Emergency Medicine, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
8
|
Miller AC, Koeneman SH, Arakkal AT, Cavanaugh JE, Polgreen PM. Incidence, Duration, and Risk Factors Associated With Missed Opportunities to Diagnose Herpes Simplex Encephalitis: A Population-Based Longitudinal Study. Open Forum Infect Dis 2021; 8:ofab400. [PMID: 34514018 PMCID: PMC8415533 DOI: 10.1093/ofid/ofab400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delays in diagnosing herpes simplex encephalitis (HSE) are associated with increased morbidity and mortality. The purpose of this paper is to determine the frequency and duration of diagnostic delays for HSE and risk factors for diagnostic delays. METHODS Using data from the IBM Marketscan Databases, 2001-2017, we performed a retrospective cohort study of patients with HSE. We estimated the number of visits with HSE-related symptoms before diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern of visits. Next, we used a simulation-based approach to compute the number of visits representing a delay, the number of missed diagnostic opportunities per case patient, and the duration of delays. We also investigated potential risk factors for delays. RESULTS We identified 2667 patients diagnosed with HSE. We estimated 45.9% (95% confidence interval [CI], 43.6%-48.1%) of patients experienced at least 1 missed opportunity; 21.9% (95% CI, 17.3%-26.3%) of these patients had delays lasting >7 days. Risk factors for delays included being seen only in the emergency department, age <65, or a history of sinusitis or schizophrenia. CONCLUSIONS Many patients with HSE experience multiple missed diagnostic opportunities before diagnosis.
Collapse
Affiliation(s)
- Aaron C Miller
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Scott H Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Alan T Arakkal
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Joseph E Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
- Division of Infectious Diseases, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
9
|
Untreated herpes simplex virus encephalitis without a fatal outcome. J Neurovirol 2021; 27:493-497. [PMID: 33788139 DOI: 10.1007/s13365-021-00968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
Herpes simplex virus encephalitis (HSE) is the most common sporadic fatal encephalitis. Although timely administered acyclovir treatment decreases mortality, neuropsychiatric sequelae is still common among survivors. Magnetic resonance imaging is frequently utilized for the diagnosis of HSE, which typically involves temporal lobe(s) and can be mixed with brain tumors involving the same area. Here, we report a case of HSE, who received acyclovir with a delay of 90 days because of presumptive tumor diagnosis and survived with minimal sequelae.
Collapse
|
10
|
Gurgel Assis MS, Fernandes Pedrosa TC, de Moraes FS, Caldeira TG, Pereira GR, de Souza J, Ruela ALM. Novel Insights to Enhance Therapeutics With Acyclovir in the Management of Herpes Simplex Encephalitis. J Pharm Sci 2021; 110:1557-1571. [PMID: 33450220 DOI: 10.1016/j.xphs.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
Acyclovir is an antiviral drug poorly absorbed in the gastrointestinal tract due to its hydrophilicity, with low oral bioavailability (~20%). Although acyclovir is prescribed in the management of herpes simplex encephalitis (HSE), the disease has a poor prognosis, particularly if the treatment is delayed, reaching mortality rates of 70% if left untreated. Thus, high acyclovir doses are administered by intravenous (IV) infusion, usually at a dosage of 10 mg kg-1 8-hourly in adults with normal renal function. However, the mortality related to HSE treated with acyclovir remains high (~20%) and permanent sequelae are commonly reported after 1 year (~50%). This review analyzed clinical trials following IV acyclovir administration. Novel insights aiming to improve drug bioavailability were reviewed, including acyclovir or its prodrugs, leading to the systemic distribution of the drug or drug targeting. Much research effort has been made to improve antiviral therapy, searching for delivery systems increasing acyclovir bioavailability by non-invasive pathways, such as oral and nasal pathways, or parenterally administered nanotechnology-based systems leading to drug targeting. Nanocarriers administered by non-invasive pathways represent feasible alternatives to treat HSE, even though not be industrially manufactured yet.
Collapse
Affiliation(s)
- Maria Silvia Gurgel Assis
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | | | - Fernanda Segurasse de Moraes
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - Tamires Guedes Caldeira
- Graduate Program in Pharmaceutical Sciences-CiPharma, School of Pharmacy, UFOP, Minas Gerais, Brazil
| | - Gislaine Ribeiro Pereira
- Faculty of Pharmaceutical Sciences, Federal University of Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brazil
| | - Jacqueline de Souza
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - André Luís Morais Ruela
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil.
| |
Collapse
|
11
|
Impact of FilmArray meningitis encephalitis panel on HSV testing and empiric acyclovir use in children beyond the neonatal period. Diagn Microbiol Infect Dis 2020; 97:115085. [PMID: 32559588 DOI: 10.1016/j.diagmicrobio.2020.115085] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/01/2020] [Accepted: 05/11/2020] [Indexed: 11/22/2022]
Abstract
Following implementation of the FilmArray meningitis and encephalitis panel, which enables rapid syndromic cerebrospinal fluid testing, HSV testing doubled in children >60 days with suspected central nervous system infection at Children's Hospital Colorado. Acyclovir initiation was unchanged, but duration decreased. Diagnostic and antimicrobial stewardship is needed for MEP optimization.
Collapse
|
12
|
Abstract
Herpes simplex virus 1 (HSV-1) can be responsible for life-threatening HSV encephalitis (HSE). The mortality rate of patients with HSE who do not receive antiviral treatment is 70%, with most survivors suffering from permanent neurological sequelae. The use of intravenous acyclovir together with improved diagnostic technologies such as PCR and magnetic resonance imaging has resulted in a reduction in the mortality rate to close to 20%. However, 70% of surviving patients still do not recover complete neurological functions. Thus, there is an urgent need to develop more effective treatments for a better clinical outcome. It is well recognized that cerebral damage resulting from HSE is caused by viral replication together with an overzealous inflammatory response. Both of these processes constitute potential targets for the development of innovative therapies against HSE. In this review, we discuss recent progress in therapy that may be used to ameliorate the outcome of patients with HSE, with a particular emphasis on immunomodulatory agents. Ideally, the administration of adjunctive immunomodulatory drugs should be initiated during the rise of the inflammatory response, and its duration should be limited in time to reduce undesired effects. This critical time frame should be optimized by the identification of reliable biomarkers of inflammation.
Collapse
|
13
|
Oud L. Herpes Simplex Virus Encephalitis: Patterns of Epidemiology and Outcomes of Patients Admitted to the Intensive Care Unit in Texas, 2008 - 2016. J Clin Med Res 2019; 11:773-779. [PMID: 31803321 PMCID: PMC6879041 DOI: 10.14740/jocmr4025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 12/01/2022] Open
Abstract
Background Patients with herpes simplex virus encephalitis (HSVE) often require admission to the intensive care unit (ICU) and have considerably worse outcomes than those not critically ill. The short-term outcomes of critically ill patients in the general population have markedly improved over the past decades. However, the population-level patterns of demand for critical care services among patients with HSVE have not been examined, and it is unknown whether there were corresponding outcome gains among those admitted to the ICU. Methods The Texas Inpatient Public Use Data File was used to identify hospitalizations with HSVE aged ≥ 18 years during 2008 - 2016. ICU admissions were identified using unit-specific revenue codes. The patterns of ICU utilization and those of short-term outcomes (with short-term mortality defined as in-hospital death or discharge to hospice) were examined across demographic strata and over time. Results Among 1,964 hospitalizations with HSVE, 1,176 (59.9%) were admitted to ICU (45.8% aged ≥ 65 years; 53.1% female, among ICU admissions). ICU utilization increased with age (from 47.9% (age 18 - 44 years) through 61.2% (older adults (age ≥ 65 years)); P = 0.0003 for trend), and increased over time only among older adults (odds ratio: 1.06/year (95% confidence interval (CI): 1.01 - 1.12)). Among ICU admissions, routine home discharge, transfer to a post-acute care facility, and short-term mortality occurred in 26.8%, 39.5%, and 18.7%, respectively; the corresponding outcomes for older adults were 10.6%, 51.4%, and 26.2%, respectively. The outcomes for the whole cohort of ICU admissions remained unchanged over time. Conclusions Adults with HSVE had high demand for critical care services, and those admitted to ICU had high short-term mortality and substantial residual morbidity among survivors, which remained unchanged over time. These findings can inform clinicians’ decision-making and discussions about goals of care with affected patients and their surrogates.
Collapse
Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, TX 79763, USA.
| |
Collapse
|
14
|
Balkhair A, Al Wahaibi A, Raniga S, Al Amin M, Ba Alawi F, El-Tigani M, Kumar S. Relapse of herpes simplex encephalitis in a patient with metastatic small cell lung cancer following scalp sparing whole brain radiotherapy. IDCases 2019; 18:e00626. [PMID: 31528539 PMCID: PMC6739592 DOI: 10.1016/j.idcr.2019.e00626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 11/29/2022] Open
Abstract
Herpes simplex virus is the most common cause of severe and potentially fatal sporadic encephalitis worldwide. Recurrence of neurologic symptoms after resolution of the initial episode of HSV encephalitis and despite adequate treatment with intravenous acyclovir is well recognized albeit rare. Most of these recurrences had no evidence of replicating virus and are immune in nature with only a minority of these recurrences representing true virologic relapses. Immunocompromised patients are predominantly at greater risk for virologic relapse of HSV encephalitis with potentially severe and at times fatal consequences. We describe a patient with small cell lung cancer and brain metastasis who underwent chemotherapy, treatment with dexamethasone and whole brain radiotherapy who subsequently suffered two episodes of HSV encephalitis three months and seven months after completion of radiotherapy and while on dexamethasone treatment.
Collapse
Affiliation(s)
- A Balkhair
- Department of Medicine, Infectious Diseases Unit, Sultan Qaboos University Hospital, Oman
| | - A Al Wahaibi
- Department of Medicine, Infectious Diseases Unit, Sultan Qaboos University Hospital, Oman
| | - S Raniga
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Oman
| | - M Al Amin
- Department of Medicine, Infectious Diseases Unit, Sultan Qaboos University Hospital, Oman
| | - F Ba Alawi
- Department of Microbiology andImmunology, Sultan Qaboos University Hospital, Oman
| | - M El-Tigani
- Department of Medicine, Neurology Unit, Sultan Qaboos University Hospital, Oman
| | - S Kumar
- Department of Medicine, Oncology Unit, Sultan Qaboos University Hospital, Oman
| |
Collapse
|
15
|
Jaquet P, de Montmollin E, Dupuis C, Sazio C, Conrad M, Susset V, Demeret S, Tadie JM, Argaud L, Barbier F, Sarton B, Chabane R, Daubin D, Brulé N, Lerolle N, Alves M, Da Silva D, Kalioubi AE, Silva S, Bailly P, Wolff M, Bouadma L, Timsit JF, Sonneville R. Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: a multicenter cohort study. Intensive Care Med 2019; 45:1103-1111. [PMID: 31292686 DOI: 10.1007/s00134-019-05684-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission. METHODS We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3-6 (indicating moderate-to-severe disability or death) on the modified Rankin scale. RESULTS Overall, 259 patients with a score on the Glasgow coma scale of 9 (6-12) and a body temperature of 38.7 (38.1-39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18-4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21-4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35-6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28-0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results. CONCLUSIONS In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.
Collapse
Affiliation(s)
- P Jaquet
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - E de Montmollin
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - C Dupuis
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - C Sazio
- Medical Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - M Conrad
- Medical Intensive Care Unit, Central Hospital, Nancy University Hospitals, Nancy, France
| | - V Susset
- Polyvalent Intensive Care Unit, Chambery Hospital, Chambery, France
| | - S Demeret
- Neurologic Intensive Care Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - J M Tadie
- Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - L Argaud
- Medical Intensive Care Unit, Edouard Herriot University Hospital, Lyon, France
| | - F Barbier
- Medical Intensive Care Unit, La Source Hospital, Orléans, France
| | - B Sarton
- Intensive Care Unit, Purpan University Hospital, Toulouse, France
| | - R Chabane
- Department of Perioperative Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - D Daubin
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - N Brulé
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - N Lerolle
- Medical Intensive Care Unit, CHU Angers, Angers University Hospital, Angers, France
| | - M Alves
- Polyvalent Intensive Care Unit, Poissy-Saint-Germain-en-Laye Hospital, Poissy, France
| | - D Da Silva
- Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France
| | - A El Kalioubi
- Medical Intensive Care Unit, Roger Salengro University Hospital, Lille, France
| | - S Silva
- Intensive Care Unit, Purpan University Hospital, Toulouse, France
| | - P Bailly
- Medical Intensive Care Unit, La Cavale Blanche University Hospital, Brest, France
| | - M Wolff
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - L Bouadma
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - J F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME, Paris Diderot University, Paris, France
| | - R Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, 46 Rue Henri Huchard, 75877, Paris Cedex, France. .,UMR1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France.
| | | |
Collapse
|
16
|
|
17
|
Cohen J, Sotoca J, Gandhi S, Yeshokumar AK, Gordon-Lipkin E, Geocadin RG, Frick KD, Probasco JC, Venkatesan A. Autoimmune encephalitis: A costly condition. Neurology 2019; 92:e964-e972. [PMID: 30674590 DOI: 10.1212/wnl.0000000000006990] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/22/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To assess the inpatient hospitalization burden and costs of patients with autoimmune encephalitis (AE) at a tertiary care institution. METHODS Adult inpatients with AE were identified retrospectively from July 1, 2005, to June 30, 2015. Demographic and clinical data were collected and analyzed. Billing data were compared to those of patients with herpes simplex encephalitis (HSE). Charges were adjusted for inflation. RESULTS Of 244 admissions for encephalitis reviewed, 63 patients met criteria for probable or definite AE. Thirty-one (49%) patients were antibody positive, and 27 (43%) were admitted to the intensive care unit (ICU). Median hospital charges per patient with AE were more than $70,000; median length of stay (LOS) was 15 days; and in-hospital mortality was 6%. Patients admitted to the ICU had substantially higher median hospital charges (ICU $173,000 per admission vs non-ICU $50,000 per admission, p < 0.001). LOS was strongly associated with charges and was driven by delay in diagnosis of AE, prolonged treatment courses, and lack of response to therapy. Compared with HSE, median hospital charges per patient with AE were nearly 4 times higher, median AE LOS was 3 times higher, and total charges over the study period were nearly twice as high. CONCLUSIONS Patients with AE used more inpatient health care resources per patient during a 10-year period than patients with HSE at our institution. ICU-admitted patients with AE were responsible for a substantially higher financial burden than non-ICU-admitted patients with AE. Our data underscore the need for the development of novel diagnostic and therapeutic modalities to improve patient outcomes and to decrease hospital burden in AE.
Collapse
Affiliation(s)
- Jesse Cohen
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Javier Sotoca
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Shikha Gandhi
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Anusha K Yeshokumar
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Eliza Gordon-Lipkin
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Romergyko G Geocadin
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Kevin D Frick
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - John C Probasco
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD
| | - Arun Venkatesan
- From the Johns Hopkins Encephalitis Center (J.C., S.G., E.G.-L., R.G.G., J.C.P., A.V.), Department of Neurology, and Departments of Neurosurgery and Anaesthesia/Critical Care (R.G.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Neurology Department (J.S.), IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Neurology and Pediatrics (A.K.Y.), Icahn School of Medicine at Mt. Sinai, New York, NY; Department of Neurology and Developmental Medicine (E.G.-L.), Kennedy Krieger Institute; and Johns Hopkins Carey Business School (K.D.F.), Baltimore MD.
| |
Collapse
|
18
|
Backman R, Foy R, Diggle PJ, Kneen R, Easton A, Defres S, McGill F, Michael BD, Solomon T. A pragmatic cluster randomised controlled trial of a tailored intervention to improve the initial management of suspected encephalitis. PLoS One 2018; 13:e0202257. [PMID: 30521521 PMCID: PMC6283633 DOI: 10.1371/journal.pone.0202257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 07/04/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether a tailored multifaceted implementation strategy improves the initial management of patients with suspected encephalitis. DESIGN Pragmatic two arm cluster randomised controlled trial. SETTING Hospitals within the United Kingdom. PARTICIPANTS Twenty-four hospitals nested within 12 postgraduate deaneries. Patients were identified retrospectively by searching discharge, microbiology, radiology and pharmacy records and included if they met clinical criteria or had a recorded suspicion of encephalitis. INTERVENTION An implementation strategy designed to overcome barriers to change, comprising local action planning, education and training, feedback on performance, a lumbar puncture pack and a range of optional components. OUTCOMES The primary outcome was the proportion of patients with suspected encephalitis undergoing diagnostic lumbar puncture within 12 hours of admission and starting aciclovir treatment within six hours. Secondary outcomes included the proportions of adults and children who had a lumbar puncture, who had appropriate cerebrospinal fluid investigations, and who had appropriate radiological imaging within 24 hours of admission. Data were collected from patient records for 12 months before and 12 months during the intervention period, and analysed blind to allocation. RESULTS 13 hospitals were randomised to intervention and 11 to control (no intervention), with 266 and 223 patients with suspected encephalitis identified respectively. There was no significant difference in primary outcome between intervention and control hospitals (13.5% and 14.8% respectively, p = 0.619; treatment effect -0.188, 95% confidence interval -0.927 to 0.552), but both had improved compared to pre-intervention (8.5%). CONCLUSION The improvement in both intervention and control arms may reflect overall progress in management of encephalitis through wider awareness and education. TRIAL REGISTRATION Controlled Trials: ISRCTN06886935.
Collapse
Affiliation(s)
- Ruth Backman
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter J. Diggle
- Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
- Department Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Rachel Kneen
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Ava Easton
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Encephalitis Society, Malton, North Yorkshire, United Kingdom
| | - Sylviane Defres
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Fiona McGill
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
| | - Benedict Daniel Michael
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Tom Solomon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | |
Collapse
|
19
|
Affiliation(s)
- Kenneth L Tyler
- From the Departments of Neurology, Medicine, and Immunology-Microbiology and the Section on Neuroinfectious Disease, University of Colorado School of Medicine, Aurora
| |
Collapse
|
20
|
Wagner JN, Kalev O, Sonnberger M, Krehan I, von Oertzen TJ. Evaluation of Clinical and Paraclinical Findings for the Differential Diagnosis of Autoimmune and Infectious Encephalitis. Front Neurol 2018; 9:434. [PMID: 29951031 PMCID: PMC6008545 DOI: 10.3389/fneur.2018.00434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/23/2018] [Indexed: 12/30/2022] Open
Abstract
Background: The differential diagnosis of autoimmune and infectious encephalitis is notoriously difficult. For this study, we compare the presenting clinical symptoms and paraclinical test results of autoimmune and infectious encephalitis patients. A clinical algorithm for the diagnosis of autoimmune encephalitis has recently been published. We test these Graus criteria on our cohort for diagnostic sensitivity and specificity within the first week of presentation. Methods: We included all patients seen at our department within a 10-year-period who were diagnosed with encephalitis. The discharge diagnoses served as the reference standard for testing the clinical algorithm for two conditions: use of all the clinical information available on a patient during the first week of hospital admission assuming undefined autoantibody status and microbiological test results (C1) vs. consideration of all the information available on a patient, including the results of serological and microbiological testing (C2). Results: Eighty-four patients (33 autoimmune, 51 infectious encephalitis) were included in the study. Fifty-one (17 autoimmune, 34 infectious) had a definite clinical diagnosis. The two groups differed significantly for the presence of headache, fever, epileptic seizures, and CSF cell-count at presentation. Application of the clinical algorithm resulted in a low sensitivity (58%) and very low specificity (8%) for the diagnosis of possible autoimmune encephalitis. The latter increased considerably in the subgroups of probable and definite autoimmune encephalitis. Whereas the sensitivity of the individual diagnostic categories was clearly time-dependent, the specificity rested foremost on the knowledge of the results of microbiological testing. Anti-CASPR2- and -LGI1-associated autoimmune encephalitis and tick-borne virus encephalitis presented particular diagnostic pitfalls. Conclusions: We define clinical symptoms and paraclinical test results which prove valuable for the differentiation between infectious and autoimmune encephalitis. Sensitivity and specificity of the clinical algorithm clearly depended on the amount of time passed after hospital admission and knowledge of microbiological test results. Accepting this limitation for the acute setting, the algorithm remains a valuable diagnostic aid for antibody-negative autoimmune encephalitis or in resource-poor settings. The initiation of immune therapy however should not be delayed if an autoimmune etiology is considered likely, even if the diagnostic criteria of the algorithm are not (yet) fulfilled.
Collapse
Affiliation(s)
- Judith N Wagner
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
| | - Ognian Kalev
- Department of Neuropathology, Kepler University Hospital, Linz, Austria
| | | | - Ingomar Krehan
- Department of Neurology 2, Kepler University Hospital, Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Linz, Austria
| |
Collapse
|
21
|
|
22
|
HSV-1 Encephalitis: High Index of Clinical Suspicion, Prompt Diagnosis, and Early Therapeutic Intervention Are the Triptych of Success-Report of Two Cases and Comprehensive Review of the Literature. Case Rep Med 2017; 2017:5320839. [PMID: 28900443 PMCID: PMC5576427 DOI: 10.1155/2017/5320839] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/07/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022] Open
Abstract
Herpes Simplex Virus (HSV) encephalitis is an acute infectious disease of the Central Nervous System (CNS), usually affecting the limbic structures, the median temporal cortex, and the orbitofrontal regions. Its annual incidence has significantly increased over the last 20 years and the mortality rate is 7%, if early diagnosed and treated, and 70%, if left untreated, while it is associated with high rates of morbidity. It should be noted that even when Cerebrospinal fluid (CSF) analysis seems normal, imaging studies are not specific and HSV Polymerase Chain Reaction (PCR) test is negative; the clinician should be more aggressive, if clinical presentation is indicative for HSV encephalitis, by administrating acyclovir early after patient's admission. The latter may be a vital intervention for the patient, modifying the patient's clinical course. Through the presentation of two cases of HSV-1 encephalitis that we managed in our department over the last 1 year and after systematic and comprehensive research of the relevant literature, we aim at showing the crucial role of medical history and physical examination, along with the high index of clinical suspicion, in order to make promptly the diagnosis and administer timely intravenous acyclovir, limiting the possibility of complications during the disease's course.
Collapse
|
23
|
Kaminski M, Grummel V, Hoffmann D, Berthele A, Hemmer B. The spectrum of aseptic central nervous system infections in southern Germany - demographic, clinical and laboratory findings. Eur J Neurol 2017. [PMID: 28636287 DOI: 10.1111/ene.13335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Aseptic infections of the central nervous system (CNS) are frequently observed in Germany. However, no study has systematically addressed the spectrum of aseptic CNS infections in Germany. METHODS Data on 191 adult patients diagnosed from January 2007 to December 2014 with aseptic meningitis or encephalitis/meningoencephalitis at our hospital were collected by chart review and analyzed for demographic, clinical and laboratory findings. Patients were stratified according to the causative virus and findings were compared between groups. RESULTS In our cohort, meningitis was caused in 36% by enterovirus (EV), 15% by herpes simplex virus (HSV), 12% by varicella zoster virus (VZV) and 5% by tick borne encephalitis (TBE). Encephalitis/meningoencephalitis was caused in 13% by HSV, 13% by VZV, and three out of 11 tested patients were positive for TBE. The highest incidence of EV infections was between 25 and 35 years and of HSV infections between 30 and 60 years. VZV infections had a bimodal distribution peaking below 30 and above 70 years. VZV and EV infections were more frequently observed during summer, whereas HSV infections showed no seasonal preference. Inflammatory changes in cerebrospinal fluid (CSF) were highest in HSV and lowest in EV infections. CONCLUSIONS Polymerase chain reaction tests for HSV, VZV and EV in CSF and TBE serology determined the causative virus in over 60% of tested patients. The age of affected patients, seasonal distribution, disease course and inflammatory changes in CSF differ between groups of patients affected by the most common viral infections.
Collapse
Affiliation(s)
- M Kaminski
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - V Grummel
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - D Hoffmann
- Institute of Virology, Technische Universität/Helmholtz Zentrum München, Munich, Germany
| | - A Berthele
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - B Hemmer
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| |
Collapse
|
24
|
Management of adult infectious encephalitis in metropolitan France. Med Mal Infect 2017; 47:206-220. [PMID: 28336304 DOI: 10.1016/j.medmal.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 02/06/2023]
Abstract
Infectious encephalitis is a severe disease leading to a high mortality and morbidity. The most frequent causes include Herpes simplex virus, Varicella Zoster virus, Listeria monocytogenes, and Mycobacterium tuberculosis. Urgent treatment is required (anti-infective therapy and nonspecific supportive care). The aim of this study was to define treatment strategy, empirical and after microbiological documentation at 48hours, through a systematic literature review.
Collapse
|
25
|
Fillatre P, Crabol Y, Morand P, Piroth L, Honnorat J, Stahl JP, Lecuit M. Infectious encephalitis: Management without etiological diagnosis 48hours after onset. Med Mal Infect 2017; 47:236-251. [PMID: 28314470 PMCID: PMC7131623 DOI: 10.1016/j.medmal.2017.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022]
Abstract
Introduction The etiological diagnosis of infectious encephalitis is often not established 48 hours after onset. We aimed to review existing literature data before providing management guidelines. Method We performed a literature search on PubMed using filters such as “since 01/01/2000”, “human”, “adults”, “English or French”, and “clinical trial/review/guidelines”. We also used the Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”. Results With Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”, we retrieved 223 and 258 articles, respectively. With search terms “encephalitis and corticosteroid”, we identified 38 articles, and with “encephalitis and doxycycline” without the above-mentioned filters we identified 85 articles. A total of 210 articles were included in the analysis. Discussion Etiological investigations must focus on recent travels, animal exposures, age, immunodeficiency, neurological damage characteristics, and potential extra-neurological signs. The interest of a diagnosis of encephalitis for which there is no specific treatment is also to discontinue any empirical treatments initially prescribed. Physicians must consider and search for autoimmune encephalitis.
Collapse
Affiliation(s)
- P Fillatre
- Service de maladies infectieuses et réanimation médicale, CHU Pontchaillou, 35000 Rennes, France
| | - Y Crabol
- Médecine interne, CHBUA site de Vannes, 56017 Vannes, France
| | - P Morand
- Virologie, CHU Grenoble Alpes, 38043 Grenoble cedex 9, France
| | - L Piroth
- Infectiologie, CHU de Dijon, 21000 Dijon, France
| | - J Honnorat
- Inserm U1028, CNRS UMR5292, équipe neuro-oncologie et neuro-inflammation (Oncoflam), centre de recherche en neurosciences (CRNL), université Lyon 1, 69500 Bron, France
| | - J P Stahl
- Service d'infectiologie, CHU de Grenoble, 38043 Grenoble cedex 9, France.
| | - M Lecuit
- Institut Pasteur, Biology of Infection Unit, CNR CCOMS Listeria, Inserm U1117, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Department of Infectious Diseases and Tropical Medicine, Necker-Enfants-Malades University Hospital, Institut Imagine, Assistance Publique-Hôpitaux de Paris, Paris, France
| |
Collapse
|
26
|
Bertrand A, Leclercq D, Martinez-Almoyna L, Girard N, Stahl JP, De-Broucker T. MR imaging of adult acute infectious encephalitis. Med Mal Infect 2017; 47:195-205. [PMID: 28268128 DOI: 10.1016/j.medmal.2017.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Imaging is a key tool for the diagnosis of acute encephalitis. Brain CT scan must be urgently performed to rule out a brain lesion with mass effect that would contraindicate lumbar puncture. Brain MRI is less accessible than CT scan, but can provide crucial information with patients presenting with acute encephalitis. METHOD We performed a literature review on PubMed on April 1, 2015 with the search terms "MRI" and "encephalitis". RESULTS We first described the various brain MRI abnormalities associated with each pathogen of acute encephalitis (HSV, VZV, other viral agents targeting immunocompromised patients or travelers; tuberculosis, listeriosis, other less frequent bacterial agents). Then, we identified specific patterns of brain MRI abnomalies that may suggest a particular pathogen. Limbic encephalitis is highly suggestive of HSV; it also occurs less frequently in encephalitis due to HHV6, syphillis, Whipple's disease and HIV primary infection. Rhombencephalitis is suggestive of tuberculosis and listeriosis. Acute ischemic lesions can occur in patients presenting with severe bacterial encephalitis, tuberculosis, VZV encephalitis, syphilis, and fungal infections. CONCLUSION Brain MRI plays a crucial role in the diagnosis of acute encephalitis. It detects brain signal changes that reinforce the clinical suspicion of encephalitis, especially when the causative agent is not identified by lumbar puncture; it can suggest a particular pathogen based on the pattern of brain abnormalities and it rules out important differential diagnosis (vascular, tumoral or inflammatory causes).
Collapse
Affiliation(s)
- A Bertrand
- Service de neuroradiologie diagnostique et fonctionnelle, groupe hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'hôpital, 75651 Paris cedex 13, France; Sorbonne universités, UPMC université Paris 06, Inserm, CNRS, institut du cerveau et la moelle (ICM), Inria Paris, Aramis project-team, 75013 Paris, France
| | - D Leclercq
- Service de neuroradiologie diagnostique et fonctionnelle, groupe hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'hôpital, 75651 Paris cedex 13, France
| | | | - N Girard
- Service de neuroradiologie, CHU La-Timone, AP-HM, 13015 Marseille, France
| | - J-P Stahl
- Service d'infectiologie, CHU de Grenoble, « European study Group for the Infections of the Brain (ESGIB) », 38043 Grenoble, France.
| | - T De-Broucker
- Service de neurologie, CH Saint-Denis, BP 279, 93205, France
| |
Collapse
|
27
|
Sili U, Tavsanli ME, Tufan A. Herpes Simplex Virus Encephalitis in Geriatric Patients. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0198-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
28
|
Abstract
PURPOSE OF REVIEW The goal of this review is to provide an update on current thinking regarding herpes simplex encephalitis (HSE), emphasizing new information about pathogenesis, diagnosis, and immune responses. Specific questions to be addressed are the following: (1) Is there a genetic predisposition to HSE? (2) What clinical approaches have the greatest impact on improving the long-term outcomes in patients with HSE? And (3) are there immune-mediated mechanisms that may account for relapsing HSE? RECENT FINDINGS Toll-like receptor 3 (TLR 3) plays an important role in innate immune responses, including generation of interferons. Multiple single-gene errors in TLR 3 interferon pathways have recently been described in children that result in increased susceptibility to HSE. Conversely, studies in both animal models and humans indicate that both cytolytic viral replication and immune-mediated responses (including cytotoxic T lymphocytes and immune mechanisms mediated by TLR 2) contribute to the pathology of HSV, suggesting possible new therapeutic approaches. In terms of treatment, data clearly indicate that a longer duration between onset of symptoms and initiation of effective antiviral therapy correlates directly with less favorable clinical outcome. Recurrent or relapsing HSE may occasionally occur, but recent observations indicate that many instances of "relapsing HSE", especially in children, are more often anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis triggered by the antecedent HSV infection. Innate immune responses are critical for defense against HSV; genetic defects in this system may predispose patients to HSE. During acute HSE, exuberant immune responses may contribute to the CNS pathology, suggesting that selective immunosuppressive therapy, coupled with potent antiviral drugs, may eventually play a role in the therapeutic management of HSV. While overall clinical outcomes of HSE remain suboptimal, the initiation of high-dose acyclovir therapy as early as possible in the course of the illness provides the best chance for a patient to survive with minimal neurologic damage. Distinguishing relapsing HSE from autoimmune anti-NMDAR antibody encephalitis is critically important because therapeutic approaches will be very different.
Collapse
Affiliation(s)
- John W Gnann
- Department of Medicine, Division of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Avenue, MSC 752, Charleston, SC, 29425, USA.
| | - Richard J Whitley
- University of Alabama at Birmingham, 303 CHB, 1600 7th Ave. S, Birmingham, AL, 35233-1711, USA
| |
Collapse
|
29
|
Infectious encephalitis: utility of a rational approach to aetiological diagnosis in daily clinical practice. Eur J Clin Microbiol Infect Dis 2016; 36:641-648. [PMID: 27888402 DOI: 10.1007/s10096-016-2840-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
In this study we attempt to assess the utility of a simplified step-wise diagnostic algorithm to determinate the aetiology of encephalitis in daily clinical practice and to describe the main causes in our setting. This was a prospective cohort study of all consecutive cases of encephalitis in adult patients diagnosed between January 2010 and March 2015 at the University Hospital Vall d'Hebron in Barcelona, Spain. The aetiological study was carried out following the proposed step-wise algorithm. The proportion of aetiological diagnoses achieved in each step was analysed. Data from 97 patients with encephalitis were assessed. Following a simplified step-wise algorithm, a definite diagnosis was made in the first step in 53 patients (55 %) and in 12 additional cases (12 %) in the second step. Overall, a definite or probable aetiological diagnosis was achieved in 78 % of the cases. Herpes virus, L. monocytogenes and M. tuberculosis were the leading causative agents demonstrated, whereas less frequent aetiologies were observed, mainly in immunosuppressed patients. The overall related mortality was 13.4 %. According to our experience, the leading and treatable causes of encephalitis can be identified in a first diagnostic step with limited microbiological studies. L. monocytogenes treatment should be considered on arrival in some patients. Additional diagnostic effort should be made in immunosuppressed patients.
Collapse
|
30
|
Dorsett M, Liang SY. Diagnosis and Treatment of Central Nervous System Infections in the Emergency Department. Emerg Med Clin North Am 2016; 34:917-942. [PMID: 27741995 PMCID: PMC5082707 DOI: 10.1016/j.emc.2016.06.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Central nervous system (CNS) infections, including meningitis, encephalitis, and brain abscess, are rare but time-sensitive emergency department (ED) diagnoses. Patients with CNS infection can present to the ED with nonspecific signs and symptoms, including headache, fever, altered mental status, and behavioral changes. Neuroimaging and CSF fluid analysis can appear benign early in the course of disease. Delaying therapy negatively impacts outcomes, particularly with bacterial meningitis and herpes simplex virus encephalitis. Therefore, diagnosis of CNS infection requires vigilance and a high index of suspicion based on the history and physical examination, which must be confirmed with appropriate imaging and laboratory evaluation.
Collapse
Affiliation(s)
- Maia Dorsett
- Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8072, St. Louis, Missouri 64110, USA
| | - Stephen Y. Liang
- Division of Emergency Medicine, Division of Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St. Louis, Missouri 63110, USA
| |
Collapse
|
31
|
Abstract
Waning immunity and declining anatomic and physiologic defenses render the elder vulnerable to a wide range of infectious diseases. Clinical presentations are often atypical and muted, favoring global changes in mental status and function over febrile responses or localizing symptoms. This review encompasses early recognition, evaluation, and appropriate management of these common infections specifically in the context of elders presenting to the emergency department. With enhanced understanding and appreciation of the unique aspects of infections in the elderly, emergency physicians can play an integral part in reducing the morbidity and mortality associated with these often debilitating and life-threatening diseases.
Collapse
Affiliation(s)
- Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8051, St Louis, MO 63110, USA.
| |
Collapse
|
32
|
Bradshaw MJ, Venkatesan A. Herpes Simplex Virus-1 Encephalitis in Adults: Pathophysiology, Diagnosis, and Management. Neurotherapeutics 2016; 13:493-508. [PMID: 27106239 PMCID: PMC4965403 DOI: 10.1007/s13311-016-0433-7] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Herpetic infections have plagued humanity for thousands of years, but only recently have advances in antiviral medications and supportive treatments equipped physicians to combat the most severe manifestations of disease. Prompt recognition and treatment can be life-saving in the care of patients with herpes simplex-1 virus encephalitis, the most commonly identified cause of sporadic encephalitis worldwide. Clinicians should be able to recognize the clinical signs and symptoms of the infection and familiarize themselves with a rational diagnostic approach and therapeutic modalities, as early recognition and treatment are key to improving outcomes. Clinicians should also be vigilant for the development of acute complications, including cerebral edema and status epilepticus, as well as chronic complications, including the development of autoimmune encephalitis associated with antibodies to the N-methyl-D-aspartate receptor and other neuronal cell surface and synaptic epitopes. Herein, we review the pathophysiology, differential diagnosis, and clinical and radiological features of herpes simplex virus-1 encephalitis in adults, including a discussion of the most common complications and their treatment. While great progress has been made in the treatment of this life-threatening infection, a majority of patients will not return to their previous neurologic baseline, indicating the need for further research efforts aimed at improving the long-term sequelae.
Collapse
Affiliation(s)
- Michael J Bradshaw
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arun Venkatesan
- Division of Neuroimmunology & Neuroinfectious Diseases, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
33
|
Wittstock M, Walter U. Akute neurologische Erkrankungen mit Leitsymptom Fieber. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0175-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
34
|
Singh TD, Fugate JE, Hocker S, Wijdicks EFM, Aksamit AJ, Rabinstein AA. Predictors of outcome in HSV encephalitis. J Neurol 2015; 263:277-289. [DOI: 10.1007/s00415-015-7960-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/25/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
|
35
|
Gnann JW, Sköldenberg B, Hart J, Aurelius E, Schliamser S, Studahl M, Eriksson BM, Hanley D, Aoki F, Jackson AC, Griffiths P, Miedzinski L, Hanfelt-Goade D, Hinthorn D, Ahlm C, Aksamit A, Cruz-Flores S, Dale I, Cloud G, Jester P, Whitley RJ. Herpes Simplex Encephalitis: Lack of Clinical Benefit of Long-term Valacyclovir Therapy. Clin Infect Dis 2015; 61:683-91. [PMID: 25956891 DOI: 10.1093/cid/civ369] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/12/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite the proven efficacy of acyclovir (ACV) therapy, herpes simplex encephalitis (HSE) continues to cause substantial morbidity and mortality. Among patients with HSE treated with ACV, the mortality rate is approximately 14%-19%. Among survivors, 45%-60% have neuropsychological sequelae at 1 year. Thus, improving therapeutic approaches to HSE remains a high priority. METHODS Following completion of a standard course of intravenous ACV, 87 adult patients with HSE (confirmed by positive polymerase chain reaction [PCR] for herpes simplex virus DNA in cerebrospinal fluid) were randomized to receive either valacyclovir (VACV) 2 g thrice daily (n = 40) or placebo tablets (n = 47) for 90 days (12 tablets of study medication daily). The primary endpoint was survival with no or mild neuropsychological impairment at 12 months, as measured by the Mattis Dementia Rating Scale (MDRS). Logistic regression was utilized to assess factors related to the primary endpoint. RESULTS The demographic characteristics of the 2 randomization groups were statistically similar with no significant differences in age, sex, or race. At 12 months, there was no significant difference in the MDRS scoring for VACV-treated vs placebo recipients, with 85.7% and 90.2%, respectively, of patients demonstrating no or mild neuropsychological impairment (P = .72). No significant study-related adverse events were encountered in either treatment group. CONCLUSIONS Following standard treatment with intravenous ACV for PCR-confirmed HSE, an additional 3-month course of oral VACV therapy did not provide added benefit as measured by neuropsychological testing 12 months later in a population of relatively high-functioning survivors. CLINICAL TRIALS REGISTRATION NCT00031486.
Collapse
|
36
|
Tyler KL. Editorial Commentary: Failure of Adjunctive Valacyclovir to Improve Outcomes in Herpes Simplex Encephalitis. Clin Infect Dis 2015; 61:692-4. [PMID: 25956893 DOI: 10.1093/cid/civ373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/04/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kenneth L Tyler
- Departments of Neurology, Medicine, and Immunology-Microbiology, University of Colorado School of Medicine, Aurora
| |
Collapse
|
37
|
Abstract
Background:Diagnosis of herpes simplex encephalitis (HSE) is based on clinical findings, MRI, and detection of herpes simplex virus (HSV) DNA in cerebrospinal fluid (CSF) using polymerase chain reaction amplification. Delays in starting treatment are associated with poorer clinical outcomes. We assessed the timing of initiation of acyclovir therapy in HSE.Methods:Inpatient databases from seven hospitals in Winnipeg, Manitoba were used to identify individuals diagnosed with encephalitis and HSE from 2004 to 2009. The time taken to initiate therapy with acyclovir and the reasons for delays were determined.Results:Seventy-seven patients were identified; 69 (90%) received acyclovir; in the others a non-HSV infection was strongly suspected. Thirteen patients were subsequently confirmed to have HSE. Acyclovir was initiated a median of 21 hours (3-407) after presentation in encephalitis cases, and a median of 11 hours (3-118) in HSE. The most common reason for delay was a failure to consider HSE in the differential diagnosis, despite suggestive clinical features. Where therapy was delayed in HSE patients, the decision to begin acyclovir was prompted by transfer of the patient to a different service (55%), recommendations by consultants (18%), imaging results (18%), and CSF pleocytosis (9%).Conclusions:Delays in initiating acyclovir for HSE are common, and are most often due to a failure to consider HSE in a timely fashion on presentation. In order to improve patient outcomes, physicians should be more vigilant for HSE, and begin acyclovir therapy expeditiously on the basis of clinical suspicion rather than waiting for confirmatory tests.
Collapse
|
38
|
Sermer DJ, Woodley JL, Thomas CA, Hedlund JA. Herpes simplex encephalitis as a complication of whole-brain radiotherapy: a case report and review of the literature. Case Rep Oncol 2014; 7:774-9. [PMID: 25722668 PMCID: PMC4322695 DOI: 10.1159/000369527] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 55-year-old male recently diagnosed with stage IV lung adenocarcinoma presented with altered mental status approximately 1 week after the completion of 14 fractions of whole-brain radiotherapy (WBRT) for brain metastases. On admission, he was somnolent but oriented and without focal neurological deficits. Brain imaging revealed marked regression of his brain metastases. Laboratory values were only significant for hyponatremia with urine hyperosmolality consistent with syndrome of inappropriate antidiuretic hormone secretion. The patient developed seizures 3 days after admission, at which time cerebrospinal fluid was significant for positive herpes simplex virus (HSV)-1 PCR but with a negative cell count, and acyclovir was started for HSV encephalitis (HSE). After 3 weeks of acyclovir 10 mg/dl i.v. 3 times per day, he had significant neurological recovery and was discharged. Although HSE is a relatively rare condition, it is the most common cause of sporadic encephalitis in Western countries. Since the pathogenesis is believed to be due to the reactivation of latent HSV, it is possible that patients who are immunosuppressed are at higher risk for HSE. In addition, patients who are immunosuppressed or immunocompromised often present atypically, which may delay time to diagnosis and treatment, thus significantly worsening prognosis. This case report intends to raise awareness of this severe condition in the context of patients who have received WBRT and immunosuppressive therapy. In addition, important considerations of diagnosis and treatment of HSE in this patient population are discussed.
Collapse
Affiliation(s)
- David J Sermer
- Duke University Medical Center, Durham, N.C., USA ; Tufts University School of Medicine, Boston, Mass., USA
| | - Jamie L Woodley
- College of Osteopathic Medicine, University of New England, Biddeford, Me., USA
| | | | | |
Collapse
|
39
|
Herpes simplex virus encephalitis: Clinical manifestations, diagnosis and outcome in 106 adult patients. J Clin Virol 2014; 60:112-8. [DOI: 10.1016/j.jcv.2014.03.010] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/24/2014] [Accepted: 03/15/2014] [Indexed: 11/22/2022]
|
40
|
Encefaliti infettive. Neurologia 2014. [DOI: 10.1016/s1634-7072(14)66664-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
41
|
Gibani MMM, Brown RL, Davies NWS. Demystifying encephalitis: guidelines for an emergency not to miss. Br J Hosp Med (Lond) 2014; 75:12-5. [PMID: 24401965 DOI: 10.12968/hmed.2014.75.1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Malick M M Gibani
- Core Medical Trainee in the Department of Infectious Diseases and Tropical Medicine, Northwick Park Hospital, London
| | - Rachel L Brown
- Core Medical Trainee, National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Nicholas W S Davies
- Consultant in the Department of Neurology, Chelsea and Westminster Hospital and Imperial College Healthcare NHS Trust, London
| |
Collapse
|
42
|
Abstract
Viral encephalitis causes an altered level of consciousness, which may be associated with fever, seizures, focal deficits, CSF pleocytosis, and abnormal neuroimaging. Potential pathogens include HSV, VZV, enterovirus, and in some regions, arboviruses. Autoimmune (eg, anti-NMDA receptor) and paraneoplastic encephalitis are responsible for some cases where no pathogen is identified. Indications for ICU admission include coma, status epilepticus and respiratory failure. Timely initiation of anti-viral therapy is crucial while relevant molecular and serological test results are being performed. Supportive care should be directed at the prevention and treatment of cerebral edema and other physiological derangements which may contribute to secondary neurological injury.
Collapse
Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine and Clinical Neurosciences, Foothills Medical Center, McCaig Tower, 3134 Hospital Drive NW, Calgary, AB T2N 2T9, Canada.
| |
Collapse
|
43
|
Kennedy PGE, Steiner I. Recent issues in herpes simplex encephalitis. J Neurovirol 2013; 19:346-50. [PMID: 23775137 DOI: 10.1007/s13365-013-0178-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/01/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
Herpes simplex encephalitis (HSE) remains the most important cause of fatal sporadic encephalitis in man. Caused by herpes simplex virus type 1 (HSV-1), and more rarely by HSV-2, it can have devastating clinical consequences for the patient, especially when the instigation of acyclovir therapy has been delayed by more than 2 days or more. Even with acyclovir treatment, nearly a third of patients may die or suffer significant morbidity. Both host and viral factors may interact to affect the clinical phenotype. Here we consider some of the recently published management guidelines for HSE and comment on various current issues of contention. The latter includes the timing and frequency of cerebrospinal fluid examinations for the polymerase chain reaction detection of HSV, decisions regarding acyclovir therapy including the consequences of delay in its initiation, and the use of corticosteroids in the disease.
Collapse
Affiliation(s)
- Peter G E Kennedy
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, University of Glasgow, Scotland, UK.
| | | |
Collapse
|
44
|
Abstract
Herpes simplex or herpes zoster reactivation after spinal surgery is rarely reported. This case report and review of the literature describes patients in whom this reactivation occurs to clarify the diagnosis and management. In addition to reporting their case, the authors reviewed case reports and series published between 1980 and 2012 found through a PubMed search. Herpes reactivation is generally confined to a vesicular rash that can be treated with acyclovir. However, occasional dissemination has occurred and has led to myelitis or encephalitis. Atypical presentations led to delays in diagnosis, delayed treatment, and poor neurological outcome. While rare, herpes simplex or herpes zoster reactivation is a complication of spine surgery that must be considered in the face of new-onset focal neurological symptoms in a dermatome pattern without a structural cause, even without a rash.
Collapse
|
45
|
Yansouni CP, Bottieau E, Lutumba P, Winkler AS, Lynen L, Büscher P, Jacobs J, Gillet P, Lejon V, Alirol E, Polman K, Utzinger J, Miles MA, Peeling RW, Muyembe JJ, Chappuis F, Boelaert M. Rapid diagnostic tests for neurological infections in central Africa. THE LANCET. INFECTIOUS DISEASES 2013; 13:546-58. [PMID: 23623369 DOI: 10.1016/s1473-3099(13)70004-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Infections are a leading cause of life-threatening neuropathology worldwide. In central African countries affected by endemic diseases such as human African trypanosomiasis, tuberculosis, HIV/AIDS, and schistosomiasis, delayed diagnosis and treatment often lead to avoidable death or severe sequelae. Confirmatory microbiological and parasitological tests are essential because clinical features of most neurological infections are not specific, brain imaging is seldom feasible, and treatment regimens are often prolonged or toxic. Recognition of this diagnostic bottleneck has yielded major investment in application of advances in biotechnology to clinical microbiology in the past decade. We review the neurological pathogens for which rapid diagnostic tests are most urgently needed in central Africa, detail the state of development of putative rapid diagnostic tests for each, and describe key technical and operational challenges to their development and implementation. Promising field-suitable rapid diagnostic tests exist for the diagnosis of human African trypanosomiasis and cryptococcal meningoencephalitis. For other infections-eg, syphilis and schistosomiasis-highly accurate field-validated rapid diagnostic tests are available, but their role in diagnosis of disease with neurological involvement is still unclear. For others-eg, tuberculosis-advances in research have not yet yielded validated tests for diagnosis of neurological disease.
Collapse
Affiliation(s)
- Cedric P Yansouni
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Eikeland R, Mygland Å, Herlofson K, Ljøstad U. Risk factors for a non-favorable outcome after treated European neuroborreliosis. Acta Neurol Scand 2013; 127:154-60. [PMID: 22690926 DOI: 10.1111/j.1600-0404.2012.01690.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2012] [Indexed: 11/27/2022]
Abstract
AIM To identify possible risk factors for reduced health-related quality of life (HRQoL) and fatigue after treated Lyme neuroborreliosis (LNB). METHODS We included 50 patients with LNB and analyzed associations between their demographic, clinical, and laboratory characteristics at baseline and outcome at 30 months assessed by the self-report questionnaires Short Form-36 (SF-36) and Fatigue Severity Scale (FSS). RESULTS Lower scores in the SF-36 domain Physical Component Summary were associated with pretreatment symptom duration >6 weeks (B = -11.0, P = 0.001) and non-complete recovery at 4 months (B = -5.5, P = 0.037) (R(2) = 0.35). Lower scores in the SF-36 domain Mental Component Summary were associated with non-complete recovery at 4 months (B = -8.9, P = 0.01 (R(2) = 0.14). Higher FSS scores were associated with pretreatment symptom duration >6 weeks (B = 1.4, P = 0.006), high scores on the composite clinical score pretreatment (B = 0.1, P = 0.003), and non-complete recovery at 4 months (B = 1.6, P = 0.005) (R(2) = 0.46). No laboratory test results were associated with these predefined outcomes. CONCLUSIONS Delayed treatment start, more symptoms and findings before treatment, and non-complete recovery at 4 months after treatment are possible predictors of a poorer HRQoL and more fatigue 30 months after treated LNB. We did not find age, gender, educational level, involvement of the central nervous system, coexisting diseases, or cerebrospinal fluid findings to be associated with reduced HRQoL or fatigue. Our findings should be replicated in future studies before any conclusions can be drawn.
Collapse
Affiliation(s)
- R. Eikeland
- Department of Neurology; Sørlandet Hospital; Arendal; Norway
| | | | - K. Herlofson
- Department of Neurology; Sørlandet Hospital; Arendal; Norway
| | - U. Ljøstad
- Department of Neurology; Sørlandet Hospital; Kristiansand; Norway
| |
Collapse
|
47
|
Affiliation(s)
- Dennis W Simon
- Department of Critical Care Medicine, The Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | | | | | | |
Collapse
|
48
|
Poissy J, Champenois K, Dewilde A, Melliez H, Georges H, Senneville E, Yazdanpanah Y. Impact of Herpes simplex virus load and red blood cells in cerebrospinal fluid upon herpes simplex meningo-encephalitis outcome. BMC Infect Dis 2012; 12:356. [PMID: 23245564 PMCID: PMC3560250 DOI: 10.1186/1471-2334-12-356] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 12/14/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Herpes simplex encephalitis (HSE) often leads to severe disability or death. Factors usually associated with outcome include Simplified Acute Physiology Score, age and delay of initiation of acyclovir treatment.Our aim was to determine the impact of Herpes simplex virus (HSV) load in cerebrospinal fluid (CSF) upon HSE outcome. METHODS We retrospectively determined HSV load in the CSF of 43 patients with confirmed HSE, hospitalized in northern France from 1998 to 2005, using CSF samples collected the day of hospital admission and stored at -20°C. We analyzed the association between HSV load and mortality/morbidity by the Glasgow Outcome Scale. Fisher's exact test and Wilcoxon's test were used for statistical analysis. RESULTS The M/F sex ratio was 1.7 and median patient age was 61 years. Median HSV load in CSF was 2.0 log copies/μL (IQR 25-75=1.2-2.6). The mortality rate was 32.6% six months after HSE diagnosis. Higher age was associated with mortality (p=0.03). Longer delay in acyclovir initiation tended to be associated with higher mortality but did not reach statistical significance (p=0.08). Severe disability and death due to HSV were associated with a higher Knaus score (p=0.004), later acyclovir initiation (p=0.006), older age (p=0.04) and presence of red blood cells in CSF (p=0.05). HSV load in CSF was neither associated with mortality (p=1.00) nor with morbidity (p=0.90). CONCLUSION In this study, HSV load in CSF was not found to be associated with poor outcome in patients with HSE. These data do not support measurement of HSV load at admission in patients with HSE.
Collapse
Affiliation(s)
- Julien Poissy
- Service universitaire de Maladies infectieuses et du Voyageur, Centre hospitalier de Tourcoing, France
| | - Karen Champenois
- Equipe ATIP/Avenir INSERM U995, Université Lille Nord de France, Lille, France
| | | | - Hugues Melliez
- Service universitaire de Maladies infectieuses et du Voyageur, Centre hospitalier de Tourcoing, France
| | - Hugues Georges
- Service de Réanimation polyvalente et des Maladies infectieuses, Centre hospitalier de Tourcoing, France
| | - Eric Senneville
- Service universitaire de Maladies infectieuses et du Voyageur, Centre hospitalier de Tourcoing, France
| | - Yazdan Yazdanpanah
- Service universitaire de Maladies infectieuses et du Voyageur, Centre hospitalier de Tourcoing, France
- Equipe ATIP/Avenir INSERM U995, Université Lille Nord de France, Lille, France
| |
Collapse
|
49
|
Solomon T, Michael BD, Smith PE, Sanderson F, Davies NWS, Hart IJ, Holland M, Easton A, Buckley C, Kneen R, Beeching NJ. Management of suspected viral encephalitis in adults--Association of British Neurologists and British Infection Association National Guidelines. J Infect 2012; 64:347-73. [PMID: 22120595 DOI: 10.1016/j.jinf.2011.11.014] [Citation(s) in RCA: 224] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/13/2011] [Indexed: 12/25/2022]
Abstract
In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.
Collapse
Affiliation(s)
- T Solomon
- Institute of Infection and Global Health, University of Liverpool, The Apex Building, West Derby Street, Liverpool, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Abstract
Infections in the central nervous system (CNS) are caused by a wide range of microorganisms resulting in distinct clinical syndromes including meningitis, encephalitis, and pyogenic infections, such as empyema and brain abscess. Bacterial and viral infections in the CNS can be rapidly fatal and can result in severe disability in survivors. Appropriate identification and acute management of these infections often occurs in a critical care setting and is vital to improving outcomes in this group of patients. This review of diagnosis and management of acute bacterial and viral infections in the CNS provides a general approach to patients with a suspected CNS infection and also provides a more detailed review of the diagnosis and management of patients with suspected bacterial meningitis, viral encephalitis, brain abscess, and subdural empyema.
Collapse
Affiliation(s)
- J David Beckham
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | | |
Collapse
|