Acute Febrile Encephalopathy Research Articles

The Optimal Management of Acute Febrile Encephalopathy in the Aged Patient: A Systematic Review.

The elderly comprise less than 13 percent of world population. Nonetheless, they represent nearly half of all hospitalized adults. Acute change in mental status from baseline is commonly seen among the elderly even when the main process does not involve the central nervous system. The term “geriatric syndrome” is used to capture those clinical conditions in older people that do not fit into discrete disease categories, including delirium, falls, frailty, dizziness, syncope, and urinary incontinence. Despite the growing number of elderly population, especially those who require hospitalization and the high burden of common infections accompanied by encephalopathy among them, there are several unresolved questions regarding the optimal management they deserve. The questions posed in this systematic review concern the need to rule out CNS infection in all elderly patients presented with fever and altered mental status in the routine management of febrile encephalopathy. In doing so, we sought to identify all potentially relevant articles using searches of web-based databases with no language restriction. Finally, we reviewed 93 research articles that were relevant to each part of our study. No prospective study was found to address how should AFE in the aged be optimally managed.

Clinical profile and prognostic markers of acute febrile encephalopathy (AFE) in adult patients presenting to a North Indian tertiary care hospital

Background: Acute febrile encephalopathy (AFE) is a clinical term used to an altered mental state that either accompanies or follows a short febrile illness and is characterized by a diffuse and nonspecific brain insult manifested by a combination of coma, seizures, and decerebration. Objective: To identify the clinical and etiological profile of acute febrile encephalopathy in adult patients presenting to JNMCH, Aligarh from January-December, 2014. Patients and Methods: 238 adults (>14 yrs.) presenting to the emergency with complains of fever (>38΀C) of less than 2 weeks duration with altered sensorium with/or without seizure were prospectively investigated for etiological cause. The investigations included routine blood investigations, chest X-rays, cerebrospinal fluid (CSF) microscopy, bacterial and fungal cultures, CSF serology, peripheral smear and serology for malarial parasite. Other investigations included were CT or MRI wherever indicated. Non-infectious causes were ruled out by various investigations mentioned above. Outcome was evaluated by the report of investigations and response to treatment over during the period of inpatient treatment. Results: Out of all the patients admitted, acute pyogenic meningitis was the most common cause accounting for 34.5% of cases followed by cerebral malaria 20.2%, sepsis associated encephalopathy 14.3%, acute meningoencephalitis 9.2%, tubercular meningitis 6.7%, enteric encephalopathy 2.5% and fungal meningitis in 1.3% cases. Conclusion: Acute pyogenic meningitis is the most common cause of AFE in the patients who reported to JNMCH in the past one year. Prompt and specific treatment can mimimise morbidity and mortality in many cases presenting with AFE.

Acute febrile encephalopathy in children and predictors of mortality.

Incidence of acute febrile encephalopathy (AFE) is high in children and associated with high mortality and sequela. Limited data is available about predictors of mortality in children of AFE from central India. To study the predictors of mortality in children of AFE. This is observational, prospective study, carried out in a tertiary care hospital of central India. Duration of the study was two years (2010 to 2012). One hundred and seventy six children in the age group of one month to 12 years, presented with fever ≤ 2wks duration and altered mental status lasting for more than 4h were enrolled in the study. Outcome was evaluated in the study subjects. Data was analysed by use of Chi-square test, Fisher's exact test and multivariate regression. P-value ≤ 0.05 was considered statistically significant. Maximum enrolled children were of viral encephalitis (46.59%) and rest, were of pyogenic meningitis, tuberculosis meningitis and cerebral malaria. Among independently significant variables, shock, severe anaemia, bradycardia, Glasgow coma scale (GCS) of less than eight and refractory seizures were found to be significant and other variables like respiratory failure, multiorgan dysfunction syndrome and abnormal coagulation profile were found insignificant on full model of multivariate regression analysis. Refractory seizures, GCS <8, bradycardia, shock and severe anaemia were independent predictors for mortality in children of AFE.

L-2-Hydroxyglutaric Aciduria: Report of Two Indian Families

L-2-Hydroxyglutaric aciduria (L-2-HGA) is a rare type of organic acidemia that has characteristic neurological manifestations including macrocephaly, developmental delay, epilepsy and cerebellar ataxia. Worldwide, few hundred cases of L-2-HGA are reported till date. The authors report the first three cases of L-2-HGA from two Indian families. Pertinent clinical aspects of this rare neurometabolic disorder namely, lack of acute exacerbations, and predisposition to brain tumors, are highlighted. In the present series, all cases had infantile onset of symptoms in the form of global developmental delay, seizures and cerebellar ataxia without extra-pyramidal signs or macrocephaly. One child presented as acute febrile encephalopathy which has not been described as a presenting feature.

Spontaneous central vein thrombosis in a patient with activated protein C resistance and dengue infection: An association or causation?

Spontaneous central vein thrombosis is a rare and potentially fatal condition in critical care setting. Activated protein C resistance due to homozygous factor V Leiden mutation is an exceptional cause of central venous thrombosis. We recently treated a healthy female student who presented with acute febrile illness, septic shock, and encephalopathy. Neck ultrasonography (USG) prior to an attempt of right internal jugular vein (IJV) cannulation revealed non compressibility of the vein along with absence of venous blood flow. Right IJV and subclavian vein thrombus was confirmed subsequently in USG Doppler by radiologist. Radiological evidence of distal pulmonary artery embolism in pulmonary angiography was also evident. Further investigations demonstrated homozygous Factor V Leiden mutation and activated factor C resistance and Dengue IgM positivity in our patient. Intravenous heparin followed by oral vitamin K anticoagulants (OVKA) aided in her recovery. Spontaneous intravascular thrombosis with activated protein C resistance and the relationship of acute Dengue infection were explored in our report.

Late-onset epilepsy in children with acute febrile encephalopathy with prolonged convulsions: A clinical and encephalographic study

The aim of this study is to analyze the characteristics of epilepsies as the sequelae of acute febrile encephalopathy with prolonged convulsions during childhood. Sixteen patients (M:F=9:7) aged 2–13years (mean 6.1years) with history of febrile acute encephalopathy were retrospectively reviewed. These patients experienced febrile encephalopathy at the age of 11months to 4years, with 11 individuals presenting with findings of a biphasic clinical course (n=5), frontal predominant (n=8) lesions, and/or reduced diffusivity in the cerebral white matter on magnetic resonance imaging (MRI; n=3). The remaining 5 patients had unilateral lesions that manifested the phenotype of hemiconvulsion–hemiplegia–epilepsy syndrome (HHES). Epilepsy emerged with a latent period of 2months to 2years after the acute phase of febrile encephalopathy. Head nodding or spasm with subsequent motion arrest and brief tonic seizures were the main seizure phenotypes. Ictal records of epileptic seizures were available in 9 patients. Epileptiform discharges with a focal or uneven distribution appeared at the seizure onset and lasted less than 1s in all patients; these were followed by either generalized attenuation or fast activity in 8 patients with head nodding, spasm, or brief tonic seizures, and by localized fast activity in 1 patient with versive tonic seizures. Notably, the seizure onset area was often located outside the severe lesions on MRI, i.e., in the parietal areas in patients with frontal predominant lesions, and in the spared hemisphere of HHES. Although phenobarbital, zonisamide, carbamazepine, clobazam, clonazepam, and clorazepate were partially effective in some patients, daily seizures persisted in 11 patients. Callosotomy was performed in 2 patients, and beneficial effects were observed in both. These characteristics suggested a broad distribution of augmented excitability in these patients, resulting in the rapid propagation of epileptic activity in the initial phase of ictal phenomena. Thus, this study investigates the most severe subgroup of epilepsy following febrile acute encephalopathy and provides the basis for further exploration of the pathogenesis and treatment of characteristic seizures in this population.

Imaging in adult patients with acute febrile encephalopathy: What is better, computerized tomography (CT) or magnetic resonance imaging (MRI)?

ObjectiveTo compare the efficacy of cranial imaging techniques in adult patients with acute febrile encephalopathy. MethodsWe enrolled one hundred and two patients presenting to the emergency with fever of shorter than 15-day duration and altered sensorium. All the patients were subjected to routine investigations, detailed cerebrospinal fluid analysis, computerized tomograms (Non contrast followed by contrast enhanced) and Magnetic resonance imaging of the brain. Final diagnosis was reached after considering the clinical, biochemical findings, imaging results and response to therapy. The positive yield of radiological investigations was compared against the final diagnosis. ResultsThe patients were divided into three groups. Of these patients, 48 had evidence of meningoencephalitis, 22 patients had pyogenic meningitis, and 20 were combined together in others group. In other 12 patients, a definitive diagnosis could not be made. Only 37% patients were detected to have abnormal computerized tomograms and the commonest abnormality was diffuse edema, which failed to point to an etiological diagnosis. Magnetic resonance imaging was abnormal in 62.75% cases and was able to suggest an etiological diagnosis in 100% cases of cerebral venous thrombosis, tubercular meningitis, 95% cases of meningoencephalitis and 45% with meningitis. ConclusionsMagnetic resonance imaging provides better information than computerized tomography in adult patients with acute febrile encephalopathy.

The etiological diagnosis and outcome in patients of acute febrile encephalopathy: A prospective observational study at tertiary care center

Acute febrile encephalopathy (AFE) is a clinical term used to an altered mental state that either accompanies or follows a short febrile illness and is characterized by a diffuse and nonspecific brain insult manifested by a combination of coma, seizures, and decerebration. To identify the etiological diagnosis and outcome in adult patients with AFE. A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care center in northwest India. The non-infectious causes of unconsciousness were excluded and then only a diagnosis of AFE was considered. Cerebrospinal fluid (CSF) analysis and imaging of brain was done to determine the possible etiology. Outcome was assessed at 1 month of follow-up after discharge by using modified Rankin Scale (mRS). Data were analyzed and presented as mean, median, and percentages. A P value of <0.05 was considered significant. Of the total 120 patients studied, pyogenic meningitis was the most common cause accounting for 36.7%, followed by acute viral encephalitis (AVE) in 28.33% of the patients (Japanese B encephalitis in 12.5%, herpes simplex virus encephalitis in 3.33%, and other undetermined viral etiology in 12.5%). Cerebral malaria, sepsis associated encephalopathy (SAE), and tuberculous meningitis were diagnosed in 21.7%, 9.17%, and 4.2% of cases, respectively. Of the total, 16 patients died, 6 with AVE, 3 with pyogenic meningitis, 3 with cerebral malaria, and 4 with SAE. mRS at discharge was >3 in 14 patients with AVE (P < 0.001), and in the remaining it was <3. After 1 month, mRS was >3 in six patients with AVE and in the rest it was ≤1 (P < 0.001). In this study, pyogenic meningitis was the leading cause of AFE, followed by AVE and cerebral malaria. The outcome in cases with AVE can be fatal or more disabling than other etiologies.

Acute Infantile Encephalopathy Predominantly Affecting the Frontal Lobes (AIEF)

Acute Infantile Encephalopathy Predominantly Affecting the Frontal Lobes (AIEF) is a relatively recent described entity. This article includes case reports of two patients who had bifrontal involvement during acute febrile encephalopathy. Case 1 describes a 1-y-old boy who presented with hyperpyrexia and dialeptic seizures. Imaging revealed significant bilateral frontal lobe involvement while serology proved presence of Influenza B infection. Over a period of onewk, he recovered with significant cognitive decline and perseveratory behavior. Another 6-y-old boy presented with language and behavioral problems suggestive of frontal dysfunction after recovering from prolonged impairment of consciousness following a convulsive status epilepticus. Bilateral superior frontal lesions with gyral swelling was evident on neuroimaging. These cases are among the very few cases of AIEF described in recent literature and the article also reviews this unique subtype of acute encephalopathy.

Childhood refractory focal epilepsy following acute febrile encephalopathy with anti-amphiphysin antibody

European Journal of NeurologyVolume 18, Issue 6 p. e70-e70 LETTER TO THE EDITOR Childhood refractory focal epilepsy following acute febrile encephalopathy with anti-amphiphysin antibody J.-J. Lin, J.-J. Lin Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorI.-J. Chou, I.-J. Chou Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorK.-L. Lin, K.-L. Lin Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorH.-S. Wang, H.-S. Wang Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this author J.-J. Lin, J.-J. Lin Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorI.-J. Chou, I.-J. Chou Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorK.-L. Lin, K.-L. Lin Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this authorH.-S. Wang, H.-S. Wang Division of Pediatric Neurology, Chang Gung Children’s Hospital, Chang Gung University College of Medicine, Taoyuan, TaiwanSearch for more papers by this author First published: 25 January 2011 https://doi.org/10.1111/j.1468-1331.2010.03342.xCitations: 2 Dr Huei-Shyong Wang, MD, Division of Pediatric Neurology, Chang Gung Children’s Hospital, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan (tel.: 886 3 3281200 ext. 8200; fax: 886 3 3288957; e-mail: wanghs444@cgmh.org.tw). Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume18, Issue6June 2011Pages e70-e70 RelatedInformation

Imaging in adult patients with acute febrile encephalopathy: What is better computerized tomography or magnetic resonance imaging

Imaging techniques are commonly used by emergency physicians in a febrile comatose patient. Their utility requires judicious use of the available resources. In this study, we have compared the efficacy of cranial imaging techniques in adult patients with acute febrile encephalopathy. This prospective observational study enrolled 101 patients presenting to the emergency with fever of less than 15 days duration and altered sensorium. All the patients were subjected to routine investigations, detailed cerebrospinal fluid analysis, computerized tomograms (noncontrast followed by contrast enhanced), and magnetic resonance imaging of the brain. Final diagnosis was reached after considering the clinical, biochemical findings, imaging results, and response to therapy. The positive yield of radiological investigations was compared against the final diagnosis. The patients were divided into three groups. Forty-eight had evidence of meningoencephalitis, 22 patients had pyogenic meningitis, and 20 were combined together in other group. In 12 patients, a definitive diagnosis could not be made. Only 37% patients were detected to have abnormal computerized tomograms and the most common abnormality was diffuse edema, which failed to point to an etiological diagnosis. Magnetic resonance imaging was abnormal in 62.75% cases and was able to suggest an etiological diagnosis in 100% cases of cerebral venous thrombosis, tubercular meningitis, 95% cases of meningoencephalitis, and 45% patients with meningitis. We can conclude that magnetic resonance imaging provides better information than computerized tomography in adult patients with acute febrile encephalopathy.

Acute febrile encephalopathy in adults from Northwest India

Background:Acute onset fever with altered mentation is a common problem encountered by the physician practicing in tropical countries. Central nervous system (CNS) infections are the most common cause resulting in fever with altered mentation in children.Aim:In this study, we have tried to analyze the cause of encephalopathy following short febrile illness in adults presenting to a tertiary care center in Northwestern part of India.Setting and Design:A prospective observational study carried out in a tertiary care center in the Northwestern India over a period of 1 year.Material and MethodsA total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months. The demographic variables were recorded in detail. In addition to routine investigations, cerebrospinal fluid analysis, noncontrast- and contrast-enhanced computed tomography, along with magnetic resonance imaging were performed in all the subjects.Statistical AnalysisThe results were analyzed using SPSS statistical software. The values were expressed as mean with standard deviation for contiguous variable as percentage for the others.Results and ConclusionOut of these, 70% had primary CNS infection as the etiology. A total of 33% patients had meningitis, 29.9% had evidence of meningoencephalitis, and 12.7% were diagnosed as sepsis-associated encephalopathy. These were followed by cerebral malaria, leptospirosis, and brain abscess as the cause of febrile encephalopathy in adults. Among the noninfectious causes, acute disseminated encephalomyelitis, cortical venous thrombosis, and neuroleptic malignant syndrome were documented in 2.36% each. In 11% of the patients, the final diagnosis could not be made in spite of the extensive investigations. Our study demonstrates that acute febrile encephalopathy in adults is a heterogeneous syndrome with primary CNS infections being the commonest etiology.

Novel Influenza A (H1N1) Presenting as an Acute Febrile Encephalopathy in a Mother and Daughter

Novel Influenza A (H1N1) Presenting as an Acute Febrile Encephalopathy in a Mother and Daughter

Clinical and etiological profile of acute febrile encephalopathy in Eastern Nepal

To investigate the clinical and etiological profile of acute febrile encephalopathy in children presenting to a tertiary care referral center of Eastern Nepal. 107 children (aged 1 month to 14 yrs) presenting to the emergency with fever (> 38 C) of less than 2 weeks duration with altered sensorium with/or without seizure were prospectively investigated for etiological cause. The investigations included blood and CSF counts, blood and CSF cultures, peripheral smear and serology for malarial parasite, and serology for Japanese encephalitis (JE) virus. Other investigations included EEG and CT or MRI wherever indicated. The most common presenting complaints apart from fever and altered sensorium were headache and vomiting. Convulsions, neck rigidity, hypertonia, brisk deep tendon reflexes, extensor plantar response and focal neurological deficits were seen in 50%, 57%, 22.4%, 28%, 39.3% and 9.3% of the subjects, respectively. The diagnoses based on clinical presentation and laboratory findings were pyogenic meningitis in 45 (42%), non JE viral encephalitis in 26 (25%), JE in 19 (18%), cerebral malaria in 8 (7%), herpes encephalitis and tubercular meningitis in 4 (4%) each, and typhoid encephalopathy in 1 case. Pyogenic meningitis and viral encephalitis including JE are the most common causes of acute presentation with fever and encephalopathy. Preventive strategies must be directed keeping these causes in mind.

Randomized, Controlled Trial of Oral Ribavirin for Japanese Encephalitis in Children in Uttar Pradesh, India

Japanese encephalitis is associated with high rates of mortality and disabling sequelae. To date, no specific antiviral has proven to be of benefit for this condition. We attempted to determine the efficacy of oral ribavirin treatment for reducing early mortality among children with Japanese encephalitis in Uttar Pradesh, India. Children (age, 6 months to 15 years) who had been hospitalized with acute febrile encephalopathy (a < or =2-week history of fever plus altered sensorium) were tested for the presence of immunoglobulin M antibodies to Japanese encephalitis virus with commercial immunoglobulin M capture enzyme-linked immunosorbent assay. Children with positive results were randomized to receive either ribavirin (10 mg/kg per day in 4 divided doses for 7 days) or placebo syrup through nasogastric tube or by mouth. The primary outcome was early mortality; secondary outcome measures were early (at hospital discharge; normal or nearly normal, independent functioning, dependent, vegetative state, or death) outcome, time to resolution of fever, time to resumption of oral feeding, duration of hospitalization, and late outcome (> or =3 months after hospital discharge). The study was double-blind, and analysis was by intention to treat. A total of 153 patients were enrolled during a 3-year period; 70 patients received ribavirin, and 83 received placebo. There was no statistically significant difference between the 2 groups in the early mortality rate: 19 (27.1%) of 70 ribavirin recipients and 21 (25.3%) of 83 placebo recipients died (odds ratio, 1.10; 95% confidence interval, 0.5-2.4). No statistically significant differences in secondary outcome measures were found. For the dosage schedule used in our study, oral ribavirin has no effect in reducing early mortality associated with Japanese encephalitis. ClinicalTrials.gov identifier: NCT00216268 .

A study of acute febrile encephalopathy with special reference to viral etiology

To study the etiological profile of patients with acute febrile encephalopathy syndrome focusing chiefly on the viral etiology, and to correlate clinical and radiological features of patients with viral encephalitis. A prospective hospital based study conducted on the consecutive patients admitted in a pediatric unit during the period of 1(st) February 2004 to 31st January 2005 based on the following inclusion criteria: (1) Age more than 1 month and less than 18 years and (2) A diagnoses of acute febrile encephalopathy, based on the following criteria: (i) fever (ii) acute depression of consciousness or mental deterioration for more than 12 hours with or without motor or sensory deficit and (iii) Total duration of illness at the time of admission 1 week or less. The final study group comprised of 151 patients with mean age of 3.21 +/- 2.9 (range of mth-13 years) and male: female ratio of 1.71: 1. A diagnosis other than viral encephalitis was reached in 94 patients (62.3 %). Pyogenic meningitis was the most frequent diagnosis 51(33.8 %) followed by tubercular meningitis 12 (7.9 %), and cerebral malaria 8 (5.2 %) in the patient group of non-viral causes. Fifty-seven cases (37.3%) were suspected as viral encephalitis and mean age of the cases suspected as viral encephalitis was 2.8 +/- 2.9 (Range 1 mth-10 yrs) with male: female ratio of 1.28: 1. Etiological diagnosis was reached or considered probable in 41 (72%) cases out of the suspected patients. The most common etiological agent identified was enterovirus 71 in 20 patients (35.1 %). The other viruses identified were mumps in 6 (10.5%), Japanese encephalitis in 5 (8.7%), and measles in 4 (7%) cases. MRI brain was done in 39 patients and was abnormal in 14 patients. Out of 57 cases of suspected viral encephalitis 10 patients expired within 48 hours, 2 > 48 hours and 19 atients had significant neurological sequels at discharge. The etiology of acute febrile encephalopathy varies from infectious etiologies to noninfectious metabolic disorders. There are no distinguishing clinical or radiological features to differentiate the various causes of viral encephalitis. The clinical and the radiological findings in encephalitis should be interpreted in the geographical and other epidemiological background.

Dengue encephalopathy in children in Northern India: Clinical features and comparison with non dengue

Acute febrile encephalopathy (AFE) is a common cause of childhood hospital admissions in Lucknow. In recent years, many patients have been hospitalized with AFE and hemorrhagic manifestations, some of whom were proven to have dengue viral infection. To (i) define the role of dengue encephalopathy (DE) as a cause of AFE in children in Lucknow, (ii) document features of dengue hemorrhagic fever (DHF) in them and (iii)compare clinical features of definite dengue and non dengue AFE. Prospective study at a teaching hospital in northern India. Children between 1-12 years of age hospitalized with fever and altered consciousness of 2 weeks or less duration were enrolled after excluding bacterial and tuberculous meningitis and frank hepatic encephalopathy. Clinical and laboratory details were charted. Haemagglutination inhibition (HI) test for dengue and Japanese encephalitis viruses in paired sera and IgM antibody capture ELISA for dengue were done. Real time PCR was done in those samples testing positive for dengue IgM. Those with either positive HI test or positive dengue PCR in CSF or serum were considered definite dengue infection and features of DHF were charted in them. Those negative for IgM antibodies after 5 days of illness or whenever done, HI test, were considered definite non dengue. Clinical and laboratory features were compared between definite dengue and non dengue groups. A total of 265 patients of AFE were enrolled over a 2 year period. HI test was positive in 15/49 (30.6%) and IgM in 52/238 (21.8%) patients thus tested. A total of 62 patients were positive for dengue antibodies by either test. Real time PCR assay for dengue virus genome was positive in 28/42 (69%) tested -- 21/29 (72.4%) in CSF and 9/15 (60%) in serum. A total of 39 patients met the criteria for definite dengue infection of which only 2 fulfilled the WHO criteria for DHF. Comparing DE and non DE, rash, bleeding, swelling over body, and hepatomegaly were significantly more common and meningeal signs less frequent in DE. Mean platelet counts and serum albumen were lower and liver enzymes and INR were significantly higher in DE. Dengue viral infection is a cause of AFE in children in this region. Majority of DE here appears to be due to viral invasion of brain as suggested by high PCR positivity in CSF and lack of WHO criteria for DHF. Differentiating features of DE include swelling and hepatic dysfunction.

Clinical Features in Children Hospitalized during the 2005 Epidemic of Japanese Encephalitis in Uttar Pradesh, India

Japanese encephalitis is a disease that affects the rural poor in Asia. In August-September 2005, a severe epidemic of Japanese encephalitis occurred in Uttar Pradesh, one of India's poorest states. Children admitted to the King George Medical University hospital (Lucknow, Uttar Pradesh, India) with acute febrile encephalopathy (defined as fever plus encephalopathy of <or=2 weeks' duration) from July to October 2005 underwent ELISA for Japanese encephalitis virus immunoglobulin M in cerebrospinal fluid or serum on hospital admission. Clinicolaboratory features of patients with positive test results were recorded.Results. Of the 223 children tested, 77 had positive results for Japanese encephalitis immunoglobulin M. Patients were from 18 districts of Uttar Pradesh. All but 1 were from rural areas, and none were <2 years of age. The prodromal period was very short (mean+/-standard deviation, 2.61+/-2.23 days). Convulsions were present in 76 patients (98.7%). The mean (+/- standard deviation) Glasgow Coma Scale score was 7.4+/-2.7. Generalized hypertonia was found in 39 patients (50.6%), and focal deficits were found in 35 patients (45.4%), including 19 cases of monoparesis and 16 cases of hemiparesis. Gastric hemorrhage was found in 42 patients (54.5%). Extrapyramidal features were found in 24 (31.1%), a hyperepneic breathing pattern was found in 20 (26%), and thrombocytopenia was found in 5 (15.6%) of 32 patients. The mean cerebrospinal fluid cell count was 48.3 cells/mm(3). The serum bilirubin level was normal in all patients, but the aspartate aminotransferase level was elevated in all 21 patients (100%) tested and the alanine aminotranferase level was elevated in 25 (47.2%) of 53 patients. In-hospital mortality was 34%. Clinical features of Japanese encephalitis were severe. Derangements in liver function and thrombocytopenia were found in a significant proportion of patients. These findings were not highlighted during earlier epidemics of the illness and could suggest a possible mutation of the virus towards other flaviviruses.

Emergency cranial computed tomography in the management of acute febrile encephalopathy in children.

OBJECTIVE: Evaluation of the influence of emergency cranial computed tomography on the management of acute febrile encephalopathy in children. METHODS: A retrospective study in children with acute febrile encephalopathy who...

Persistent Intrathecal Immune Activation in Patients with Herpes Simplex Encephalitis

Neopterin and beta 2-microglobulin (beta 2M) levels were analyzed in sequential cerebrospinal fluid (CSF) and serum samples from 20 patients with herpes simplex encephalitis (HSE) and 30 patients with acute febrile encephalopathy of other cause (non-HSE). Markedly elevated acute phase CSF levels of neopterin and beta 2M were found in 19 HSE patients, but the levels were only moderately increased in most of those with non-HSE. Neopterin levels were analyzed in an additional 15 HSE patients who died within a month of the onset of neurologic symptoms and correlated with the clinical severity of the HSE. After HSE, but not after non-HSE, increased levels of neopterin and beta 2M persisted for a long time (> or = 13 years). Specific intrathecal IgG activity persisted in all but 2 HSE patients. These findings indicate that there is a vigorous acute inflammatory response and a long-term persistence of intrathecal cellular and humoral immune activity in HSE.