Diagnosis Of Encephalitis Research Articles

The Leading Causes of Recurrent Hospitalization of Neurologically Impaired & Disabled Pediatric Patients in King Abdulaziz Medical City- Jeddah from 2013 to 2017

Background: Disabilities are a major issue, affecting 15% of the world’s population. They are mostly caused by NI such as GDD, CP, hydrocephalus, and HIE. Patients of such conditions, especially children, are more likely to require admission and healthcare. Therefore, it is necessary to investigate the causes that may lead these children to have multiple admissions Methods: A cross-sectional study was conducted by reviewing medical records of patients who were admitted to the pediatric ward of King Khalid National Guard Hospital, Jeddah, Saudi Arabia from 2013-2017 with any underlying NI. These impairments included any previous diagnosis of GD, CP, HIE, encephalitis, hydrocephalus, or corpus callosum agenesis. A non-probability convenience sampling technique was used to recruit patients who were under 15 years of age with the mentioned diagnoses, and all of the identified 265 patients were included in this study. Results: Analysis of a total of 635 admissions reports that the most common causes of admission in of patients with the mentioned included underlying conditions are other neurological conditions with (n=222, 35%) admissions, mainly due to seizures (n= 64, 10%), hydrocephalus (n=39, 6.1%), and delayed milestones (n=29, 4.6%). The second top category was respiratory conditions and infections (n=164, 25%). Aspiration pneumonia was documented (n=66, 10.4%), making it the top diagnosis in all admission, followed by seizures. The second top documented infection was pneumonia (n=40, 6.3%). The third top category was gastrointestinal infections and conditions. Leading that category is gastroenteritis (n=22, 3.4%) and GER (n=15, 2.4%). There was no There was a statistically significant relationship between NI and the gender of patients (p = 0.170). There was, however, a statistically significant relationship with the age group, feeding rout, home oxygen, documented disability, admission cause, and patient management (p < 0.001). Conclusion: Specific NI are more associated with certain conditions that are more likely to lead to hospitalization. Recognition of these conditions can be of future help in early detection and prevention of serious complications and morbidity.

Anti-NMDAR Encephalitis Presenting as Stroke-like Episodes in Children: A Case Series from a Tertiary Care Referral Centre from Southern India.

ABSTRACTBackground:Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is one of the common causes of treatable encephalitis in children characterized by severe memory deficit, speech disturbances, seizures, autonomic dysfunction, and movement disorders. Hemiparesis/stroke-like episode is not a usual presenting complaint of NMDAR encephalitis. The objective of this study was to report confirmed cases of seropositive anti-NMDAR encephalitis in children who presented with hemiparesis/stroke-like episodes.Materials and Methods:Retrospective review of charts of patients with a diagnosis of NMDAR encephalitis was performed at the pediatric neurology department attached to a tertiary care hospital for 6 years from March 2014 to February 2020. Only those case records with NMDAR seropositivity in the cerebrospinal fluid were collected and those who presented with stroke-like episode/hemiparesis were retrieved separately and the data were extracted in a predesigned proforma and analyzed.Results:Six children of 24 seropositive anti-NMDAR encephalitis presented with hemiparesis/stroke-like episode. All the six patients presented with hemiparesis, behavioral changes, and regression of speech. Three children had seizures and one child had Epilepsia partialis continua. Two children had dystonia and choreoathetosis. Methylprednisolone followed by oral steroids were administered in all patients. Cases 1, 2, and 4 made a full recovery within 7 days, but cases 3, 5, and 6 showed improvement after 20 days following additional IVIG. Four children have cognitive decline and behavioral problems. Case 6 had relapse and recovered with rituximab.Conclusion:Anti-NMDA receptor encephalitis which is a potentially treatable disease should be considered in the differential diagnosis when a child presents with hemiparesis/stroke-like episode.

Clinical Features and Long-Term Outcomes of Anti-Leucine-Rich Glioma-Inactivated 1 Encephalitis: A Multi-Center Study.

PurposeTo describe the clinical manifestation, immunotherapy, and long-term outcomes of anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis.Patients and MethodsThis study was a retrospective analysis of 117 patients with a diagnosis of anti-LGI1 encephalitis identified from the databases of multiple clinical centers between September 2014 and December 2019. The clinical features, ancillary test results, and details of long-term outcomes were evaluated.ResultsAmong the 117 patients with anti-LGI1 encephalitis, 69.2% (81/117) were male and 30.8% (36/117) were female. The median age of all patients at the onset of the disease was 57 years (interquartile range [IQR], 52–67). The median time from symptom onset to diagnosis was 8.7 weeks (IQR, 4.2–25). The main clinical features identified were seizures, cognitive impairment, and mental and behavioral abnormalities. Of the 117 patients, 109 were treated with immunotherapy. Symptoms including memory, mental ability, and behavior improved in all 109 patients after 3–5 days of treatment. The median time of follow-up for the treated patients was 33 months (IQR, 17–42). Of the treated patients, 16.2% (19/117) experienced a relapse, with a median delay of 5 months (IQR, 2.1–17) between onset and the first relapse. There were no mortalities over the follow-up period.ConclusionThe long-term outcome of patients with anti-LGI1 encephalitis was mostly favorable, although some patients continued to experience cognitive dysfunction. Early recognition is important for prompt initiation of immunotherapy that can improve clinical symptoms of anti-LGI1 encephalitis.

Meningitis and encephalitis in Poland in 2018.

Infectious diseases of the nervous system are most often manifested in the form of meningitis. We distinguish meningitis and/or encephalitis according to their etiology, i.e. bacterial and viral. The study discusses meningitis and encephalitis caused by: N. meningitidis, S. pneumoniae, H. influenzae and tick-borne encephalitis virus. This is due to the epidemiological surveillance of these diseases and the available prevention in the form of vaccinations against these diseases. The aim of the study is to assess the epidemiological situation of meningitis and encephalitis in Poland in 2018. The epidemiological situation of meningitis and encephalitis in Poland was assessed on data from the annual bulletin "Infectious diseases and poisoning in Poland in 2018" and "Vaccinations in Poland in 2018". In 2018, a total of 2406 cases of meningitis and/or encephalitis were registered in Poland. It is a 14.7% increase in incidence compared to 2017. An increase was recorded in the viral infections from 1212 to 1533 cases. In contrast, the number of infections with bacterial etiology decreased from 886 to 873 cases. Meningitis and/or encephalitis caused by pathogens specified in epidemiological surveillance have noticed a decreased incidence. The only exception is the increase in cases caused by S. pneumoniae, compared to 2017, from 177 to 212. This is an increase of 19.8% compared to the previous year. However, the number of cases of N. meningitidis showed a decrease of 16.4% during this period. Viral infections constituted 63.7% of all cases. Compared to 2017, it means an increase in the percentage of viral infections by 5.9 percentage points. Among laboratory confirmed cases of meningitis and/or encephalitis of known etiology, cases caused by Neisseria meningitidis (102 cases), Streptococcus pneumoniae (212 cases) and tick-borne encephalitis (197 cases) were predominant. There is a general increasing trend in the number of cases of viral meningitis and/or encephalitis. On the other hand, thanks to vaccinations, no significant increase was noted in H. influenzae, meningococcal and TBE infections. There is a chance to minimize the incidence of bacterial meningitis and/or encephalitis as in the H. influenzae infections. On the other hand, it should be seen that the problem of diagnosing cases of viral etiology should be considered. This is more related to the determination of the etiological factor than the diagnosis of viral meningitis and/or encephalitis. Difficulties in determining the etiological factor indicate that, meningitis and/or encephalitis remain a challenge for healthcare and epidemiological surveillance institutions.

West nile virus infection: One-Year postkidney transplant

West Nile virus (WNV) infections are a mosquito-borne virus of the Flaviviridae family. The clinical feature of the virus varies between individuals from being asymptomatic in most of the cases to severe central nervous system disease manifested as meningitis, encephalitis, and paralysis. Diabetic nephropathy patient with microvascular and macrovascular complications, who received a kidney transplant a year ago on immunosuppressive therapy, presented with a three-day history of upper respiratory tract infection and fever. He lived in an endemic area of brucella infection. He underwent a thorough and full evaluation with various laboratory and radiological evaluations. The patient was started empirically on ceftriaxone and acyclovir for a presumptive diagnosis of herpes encephalitis and covering also Listeria with ampicillin. The patient did not improve with the initial management, so a T2-weighted magnetic resonance imaging of the brain executed that showed nonspecific hyper-intensity in the left frontal area suggestive of microangiopathic changes. WNV-neutralizing antibodies were positive with a high titer >1:640, whereas WNV RNA was not detected in the plasma sample. In the serum sample, WNV IgM and IgG were both positive. WNV IgM antibodies were detected with 6.55 and 5.97 antibody index and were done by a semiquantitative ELISA. Furthermore, WNV-neutralizing antibodies were positive as well as with a titer of 1:80. As there is no specific antiviral treatment available, the patient management was supportive; reduction in immunosuppressive agents and the use of IV IgG. This is the first reported case of one-year post renal transplant who developed WNV encephalitis and neuropathy with significant response to immunoglobulin after 18 days of infections.

A rare cause of ophtalmoplegia: about a case

AbstractPurposeWernicke's encephalopathy (WE) is an acute neurological disorder induced by a thiamine (vitamin b1) deficiency, secondary to undernutrition or malabsorption. It is a rare but serious complication requiring urgent treatment. Characterized by: mental confusion, ophthalmoplegia and ataxia. In the absence of treatment, the progression is towards Korsakov syndrome where the lesions become irreversible. The objective of our work is to alert clinicians to the seriousness of this pathology, which in our case, the revelation was ophthalmological.MethodsWe report the case of a patient who consults in ophthalmological emergencies for bilateral ophthalmoplegia sudden installation and whose etiological diagnosis was in favor of Wernicke encephalitisResultsFifty‐year‐old patient who presented to the ophthalmic emergency department for reduced visual acuity with eye pain. The general examination finds a patient confused, disoriented in time and space with an unbalanced gait.The ophthalmological examination finds: ODG total ophthalmoplegia Lazy direct and consensual photomotor reflex. Bilateral stage I papillary edema.The rest of the ophthalmological examination is unremarkable. An MRI was requested which objectified a hyper signal of the thalamus in flair and T2 sequence. In front of this clinical and radiological picture, the diagnosis of gayet Wernicke's encephalitis was evoked and confirmed by the dosage of vitamin B1 which was lowered. She benefited from an injectable vitamin B1 treatment at a dose of 400 mg/day as soon as the diagnosis was suspected, followed by an oral relay (250 mg, twice a day). The evolution was favorable with improvement of consciousness after the 5th day, regression of visual disturbances and resumption of walking. The 6‐month follow‐up showed a normal fundus and a normal brain MRI.ConclusionsGayet Wernicke's encephalitis is a rare condition, which remains under diagnosed to this day. It is a diagnostic emergency requiring early treatment to prevent complications.

Clinical and laboratory characteristics of viral encephalitis in children in Menoufia governorate, Egypt

ObjectiveThis study was designed to highlight clinicoepidemiological profile investigation findings of acute viral encephalitis in children.BackgroundOwing to the high morbidity and mortality associated with viral encephalitis, it is important to establish a diagnosis and initiate therapy as soon as possible.Patients and methodsThis study was conducted on 50 cases that met the diagnostic criteria of encephalitis. Most of these patients were admitted at either General Department or Pediatric ICUs of Menoufia University Hospital and Shebin El-Kom Fever Hospital. All were subjected to complete history and examination, cerebrospinal fluid examination, electroencephalogram, computed tomography brain, and MRI brain.ResultsOf the 50 patients included in the study, there were 30 (60%) male 20 (40%) female patients, with mean ± SD age of 5.56 ± 4.90 (0.42–15.0) years. A total of 35 (70%) patients were from the rural area, 25 (50%) patients had low socioeconomic status, and 20% had positive consanguinity. Delayed development was observed only in 14% of patients. Pus cells ranged from 5 to 500 cell in 74% of patients, with mean lymphocyte percentage of 53.33 ± 35.98. Protein was elevated more than or equal to 50 in 82% of patients, and 20% of the patients showed background slowing and focal sharp wave in temporal lobe by electroencephalogram. Brain edema was detected in 15% patients. MRI abnormalities were detected in 24 patients.ConclusionClinical data, laboratory results, and neuroimaging findings support the diagnosis of encephalitis.

Clinical-etiological and MRI parallels of encephalitis in children

Improving the diagnosis of encephalitis (EF) in children by establishing clinical, etiological and MRI parallels. 364 children aged from 1 month to 17 years with EF were examined. MRI of the brain and spinal cord, blood and CSF examination for herpes viruses type 1-6 (HHV), enteroviruses (EV), tick-borne encephalitis viruses (TBEV), Borrelia burgdorferi (BB), varicella zoster (VVZ), herpes simplex (HSV1) and Epstein-Barr (EBV) were performed. The etiological structure was dominated by HHV types 1-6, tick-borne infections (19%), EV (14.6%), and other agents (6%). Clinical and topical variants of EF: leukoencephalitis (leukoePH) - 68.4%, polyoencephalitis (polioePH) - 22.8% and panencephalitis (panePH) - 8.8%. LEUKOEPH was more often caused by VVZ, EBV and BB, foci in the white matter of the large hemispheres, sensitive, cerebellar and pyramidal symptoms, acute course followed by complete recovery (65.8%), the risk of exacerbations and progression with the development of multiple sclerosis in 6% were observed in 80.7%. POLIO in 71.1% were caused by TBEV or EV, lesions were located in the thalamus, basal ganglia, cortex, manifested by deep depression of consciousness, epilepsy, central paralysis and speech disorders, in 83.1% there was a chronic course with the development of brain atrophy. PanEF was caused by cytomegalovirus in more than 1/2 of cases, with subtotal-total white matter damage, in 1/3 of cases - with the involvement of other structures, there was a chronic course with polymorphism of neurological symptoms, rare complete recovery (15.6%). The cerebellar form of EF in 88.7% was associated with VZV, subcortical and stem - with TBEV and EV, cortical and limbic - with HSV-1 and 2 and HHV-6. The outcomes of EF depend both on the timeliness of etiological and neuroimaging diagnostics, and on the adequacy of early therapy already with EF, including the use of acyclovir in combination with recombinant interferons alpha-2-β with antioxidants, and the immediate appointment of Cytoflavin infusions upon admission to the hospital. Clinical and topical variants and forms of EF in children are associated with etiology, have different rates of complications, the nature of the course and outcomes, the knowledge of which makes it possible to optimize the diagnostic process.

Encefalopatia/Encefalite Ligeira com Lesão Reversível do Corpo Caloso: Entidade Benigna Rara com Diagnósticos Diferenciais Menos Benignos

A encefalopatia/encefalite ligeira com lesão reversível do corpo caloso é uma entidade clínico-radiológica benigna rara, caracterizada por sintomas neurológicos inespecíficos associados a achados imagiológicos, em ressonância magnética, e lesão do corpo caloso. De etiopatogénese desconhecida, têm sido sugeridos vários desencadeadores (infeções, alterações metabólicas, fármacos, entre outros). Apresenta-se o caso de um homem de 44 anos, previamente saudável, admitido na urgência com quadro súbito de cefaleias, ataxia, mioclonias da face e disartria, em contexto de síndrome gripal. Após diagnóstico presuntivo de encefalite vírica iniciou aciclovir empiricamente, suspenso após ressonância magnética revelando lesões no corpo caloso. O doente evoluiu favoravelmente sem terapêutica dirigida, com resolução clínica em menos de uma semana e controlo imagiológico, aos dois meses, normal. Esta entidade, que exige diagnóstico diferencial entre condições benignas e outras, de pior prognóstico, é habitualmente diagnosticada por exclusão, não exige terapêutica dirigida e apresenta, quase universalmente, um desfecho favorável.

Variability in the Use of Novel Diagnostic Technology in Children With Suspected Encephalitis and in the Management of Emerging Encephalitides by Pediatric Infectious Disease Providers.

We surveyed pediatric infectious disease physicians through the Infectious Disease Society of America's Emerging Infections Network regarding the diagnosis and management of encephalitis. We identified practice variations, particularly with the use of new diagnostic modalities and management of autoimmune encephalitides. These findings may inform the creation of updated management guidelines.

Diagnosis of pediatric anti-NMDAR encephalitis at the onset: A clinical challenge.

To investigate the clinical and instrumental features at the onset addressing to the diagnosis of anti-NMDAR encephalitis. Twenty children (age: 15 months-17 years; 7 males, 13 females) with initial suspected diagnosis of autoimmune encephalitis, observed between January 2008 and March 2018, were included. The final diagnosis was anti-NMDAR encephalitis in 7 children, other/probable autoimmune encephalitis in 7 children, and primary psychosis in the remaining 6 children. At the clinical onset, anxiety disorder was the main symptom that helped in distinguishing the group of psychotic children from children with non-infectious encephalitis (P=0.05 OR=0.001), while epileptic seizures strongly predicted anti-NMDAR encephalitis (P=0.04 OR=28.6). At the onset, anti-NMDAR encephalitis could be distinguished from other/probable autoimmune encephalitis for the presence of sleep/wake rhythm alteration (P=0.05 OR=15). Among the symptoms occurring during the hospitalization, movement disorders (P=0.031 OR=12) were predictive of non-infectious encephalitis rather than primary psychosis. More specifically, the occurrence of language impairment (P=0.03 OR=33), epileptic seizures (P=0.04 OR=28.6) and catatonia (P=0.03, OR=33), were predictive of anti-NMDAR encephalitis. Also at this stage, anxiety disorder (P=0.03 OR=0.033) was predictive of primary psychosis. Our findings suggest that at the clinical onset epileptic seizures and sleep/wake rhythm alteration represent the main features addressing to the diagnosis of anti-NMDAR encephalitis rather than primary psychosis and other/probable autoimmune encephalitis, while anxiety disorder could be a solid predictor of primary psychosis.

Autoimmune N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: An important differential diagnosis for viral encephalitis

Autoimmune N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: An important differential diagnosis for viral encephalitis

Childhood Infectious Encephalitis: An Overview of Clinical Features, Investigations, Treatment, and Recent Patents.

Infectious encephalitis is a serious and challenging condition to manage. This overview summarizes the current literature regarding the etiology, clinical manifestations, diagnosis, management, and recent patents of acute childhood infectious encephalitis. We used PubMed Clinical Queries as a search engine and used keywords of "encephalitis" AND "childhood" Patents were searched using the key term "encephalitis" in google.patents.- com and patentsonline.com. Viral encephalitis is the most common cause of acute infectious encephalitis in children. In young children, the clinical manifestations can be non-specific. Provision of empiric antimicrobial therapy until a specific infectious organism has been identified, which in most cases includes acyclovir, is the cornerstone of therapy. Advanced investigation tools, including nucleic acid-based test panel and metagenomic next-generation sequencing, improve the diagnostic yield of identifying an infectious organism. Supportive therapy includes adequate airway and oxygenation, fluid and electrolyte balance, cerebral perfusion pressure support, and seizure control. Recent patents are related to the diagnosis, treatment, and prevention of acute infectious encephalitis. Viral encephalitis is the most common cause of acute infectious encephalitis in children and is associated with significant morbidity. Recent advances in understanding the genetic basis and immunological correlation of infectious encephalitis may improve treatment. Third-tier diagnostic tests may be incorporated into clinical practice. Treatment is targeted at the infectious process but remains mostly supportive. However, specific antimicrobial agents and vaccines development is ongoing.

Acute radiological features facilitate diagnosis and prognosis of anti-N-methyl-d-aspartate receptor (NMDAR) and anti-voltage-gated potassium channel (VGKC) encephalitis in adults

BackgroundAnti-N-methyl-d-aspartate receptor (NMDAR) and anti-voltage-gated potassium channel (VGKC) encephalitis are the commonest antibody-associated autoimmune encephalitides (AIE). Acute clinical features have been well-described, but data on the role of radiological findings in diagnosis and prognosis of AIE are limited. MethodsAnti-NMDAR and anti-VGKC encephalitis patients from the National Neuroscience Institute were identified. We compared clinical and paraclinical features, at acute presentation and on follow-up between and within groups. ResultsTwenty-six anti-NMDAR and 11 anti-VGKC encephalitis patients were reviewed. At acute presentation, dysautonomia (57.7%) and impairment of consciousness (84.6%) occurred exclusively in anti-NMDAR encephalitis. Cerebrospinal fluid pleocytosis was more common in anti-NMDAR encephalitis (88.5% vs 20.0%, p = 0.003), while ictal electroencephalography abnormalities were more frequent in anti-VGKC encephalitis (11.5% vs 45.5%, p = 0.022). On acute imaging, leptomeningeal enhancement was seen only in anti-NMDAR encephalitis (37.5%), while hippocampal T2 hyperintensities supported the diagnosis of anti-VGKC encephalitis (63.6% vs 12.5%, p = 0.002). At follow-up (median 53.0 months, range 13.0–119.0), anti-NMDAR encephalitis patients had better modified Rankin scale scores (median 0.0 vs 3.0, p = 0.023). Relapses occurred equally in both groups. Anti-VGKC encephalitis patients with abnormal acute MRI were more likely to have poor outcomes compared to those with normal imaging (100% vs 25%, p = 0.008), whereas acute imaging features in anti-NMDAR encephalitis did not predict long-term outcomes. ConclusionsAcute MRI findings can aid in early diagnosis and prognostication in suspected AIE. Leptomeningeal enhancement in anti-NMDAR encephalitis and hippocampal lesions in anti-VGKC encephalitis, together with typical clinical features, may allow distinction between these antibody subtypes, and specific abnormal imaging features in anti-VGKC encephalitis may be used as a prognostic marker.

Electroencephalographic Findings in Pediatric Patients with Anti-N-Methyl-D-Aspartate Receptor Encephalitis: The San Diego Experience

AbstractDiagnosing anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis clinically can be challenging. There is a growing interest in identifying specific electroencephalographic features to help guide early management. A retrospective chart review was conducted of pediatric patients admitted to Rady Children's Hospital between January 1, 2010 and April 1, 2017. We included patients with the diagnosis of encephalitis who underwent continuous video electroencephalogram (VEEG) for at least 12 hours, and presented with less than 14 days of symptoms. We compared the electroencephalographic features of non-rapid eye movement (NREM) sleep between patients with antibody confirmed anti-NMDAR encephalitis and patients with encephalitis from other etiologies. We identified seven patients who met our inclusion criteria, five of whom were diagnosed with anti-NMDAR encephalitis. Four of the five patients had a significant reduction in NREM sleep, while one patient had increased NREM sleep associated with clinical catatonia and hypersomnolence. Sleep was preserved in the two cases of nonimmune mediated encephalitis. Our results suggest that a prolonged VEEG to capture sleep coupled with clinical features can aid in early diagnosis and treatment of anti-NMDAR encephalitis, often before confirmatory antibody testing is available.

The Clinical Features and Prognosis of Anti-NMDAR Encephalitis Depends on Blood Brain Barrier Integrity

BackgroundAnti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune nervous system disease that has become increasingly recognized. This retrospective study is aimed to analyze the relations between clinical manifestations and blood brain barrier (BBB) integrity in anti-NMDAR encephalitis patients. MethodsAnti-NMDAR encephalitis patients were admitted to the First Affiliated Hospital of Guangxi Medical University from April 2014 to April 2020. Patients were grouped by the normal BBB and damaged BBB groups according to the cerebrospinal fluid (CSF) albumin/serum albumin (QAlb). Neutrophil-to-lymphocyte ratio (NLR) in peripheral blood was used for estimating the inflammatory status. The modified Rankin Scale (mRS) was used to assess prognosis. ResultsSeventy-three anti-NMDAR encephalitis patients were diagnosed based on the autoimmune encephalitis diagnosis criteria of 2016. Fifty-three (72.6%) patients were in the normal BBB group and twenty (27.4%) were in the BBB damaged group. There were no significant differences in gender, age, psychiatric disturbances, epilepsy, speech disorder, motor dysfunction, memory dysfunction, and autonomic dysfunction between the two groups (p>0.05). Nevertheless, the proportions of decreased consciousness, ICU admission, NLR, CSF protein and intrathecal IgG synthesis (IgGIF, IgGLoc) in the damaged BBB group were higher than that in the normal BBB group (p<0.05). Patients (79.2%) with normal BBB had good prognosis compared to patients with damaged BBB (50%) after 2 months follow-up. The median mRS before and after immunotherapy in the damaged BBB group were significantly higher than that in the normal BBB group (p<0.01, p<0.05, respectively). Additionally, QAlb increased was positively correlated with the quantitative intrathecal IgG synthesis (IgGLoc: r=0.66; IgGIF: r=0.433, all p<0.001). ConclusionThe dysfunction of BBB can be helpful in evaluating its prognosis since QAlb showed associations with ICU admission, NLR, a higher CSF protein, intrathecal IgG synthesis (IgGLoc, IgGIF) and mRS score after 2 months follow-up.

ANTI-NMDA RECEPTOR ENCEPHALITIS: A DIAGNOSTIC CHALLENGE FOR THE INTERNIST

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis is an autoimmune disease with a multifaceted presentation that involves memory deficits, psychiatric symptoms and autonomic instability. CASE PRESENTATION: We report a case of a 42 years old female who presented in the Emergency Room with a constellation of behavioral symptoms, delirium, body stiffness and fever for 1 week. Her past history was significant for seizures two years back, managed with valproic acid 500 mg BID and levetiracetam 500 mg BID. Glasgow Coma Scale (GCS) at the time of presentation was 9/15, which rapidly dropped to 3/15 without clinically observed seizures. The patient was intubated and admitted to the intensive care unit. Physical and neurological examination showed generalized dystonia, neck stiffness, 3/5 power in upper limbs and 2/5 in lower limbs. Cerebrospinal fluid (CSF) analysis was significant for lymphocytic pleocytosis which given the clinical presentation was consistent with the diagnosis of viral encephalitis. Initial treatment with ceftriaxone, acyclovir and dexamethasone was started. Computed tomography (CT) scan of the brain was normal. An electroencephalogram (EEG) revealed moderate to severe diffuse encephalopathy. During the hospital stay, she developed worsening orofacial rhythmic dyskinetic movements and autonomic dysfunction. GCS remained low even after initial management for viral encephalitis. Given the predominant symptoms of psychiatric, autonomic and dyskinetic features, further evaluation for an underlying autoimmune etiology was done. As a result, NMDA-R antibodies were positive. Steroids were administered and GCS improved after four sessions of plasmapheresis. Referral to an outside facility was made where she died after 4 days. The cause of her terminal events could not be established. DISCUSSION: Anti NMDA-R presents with combination of motor symptoms, speech disorder, seizures, decreased level of consciousness, behavioral and cognitive problems that usually prevail in earlier stages of disease. These symptoms steer patients to receive psychiatric evaluation first, often leading to late diagnosis and therapy. Anti NMDA-R encephalitis is a potentially treatable disease if diagnosed earlier and treated alone or combination therapy of plasmapheresis, intravenous immunoglobulins, pulsed steroids and immunosupressives. The internist should consider immediate screening for NMDA-R antibodies in a patient with new onset psychosis, evidence of encephalitis, neurological symptoms and abnormal or non-specific EEG, CSF or MRI manifestations. CONCLUSIONS: Early diagnosis and prompt initiation of treatment can potentially limit the worsening of psychiatric and neurological symptoms over the course of the disease and in our patient may have led to a better outcome. Reference #1: Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J: Frequency andcharacteristics of isolated psychiatric episodes in anti-N-methyl-D-aspartate receptor encephalitis. JAMA Neurol. 2013 DISCLOSURES: No relevant relationships by Fariha Ilyas, source=Web Response No relevant relationships by Maheen Ilyas, source=Web Response No relevant relationships by Mahnoor Khalid, source=Web Response No relevant relationships by Abdul Mannan Khan Minhas, source=Web Response No relevant relationships by Ahmed Qavi, source=Web Response

Next-generation sequencing in the diagnosis of viral encephalitis: sensitivity and clinical limitations

Identification of pathogens causing viral encephalitis remains challenging, and in over 50% of cases the etiologic factor remains undetermined. Next-generation sequencing (NGS) based metagenomics has been successfully used to detect novel and rare infections, but its value for routine diagnosis of encephalitis remains unclear. The aim of the present study was to determine the sensitivity of shotgun metagenomic sequencing protocols, which include preamplification, and testing it against cerebrospinal fluid (CSF) samples from encephalitis patients. For sensitivity testing HIV and HBV positive sera were serially diluted in CSF from an uninfected patient. NGS repeatedly detected HIV and HBV sequences present at concentrations from 105 to 102 and from 105 to 10 viral copies/reaction, respectively. However, when the same protocols were applied to RT-PCR/PCR positive CSF samples from 6 patients with enteroviral encephalitis (median viral load 47 copies/ml) and 15 patients with HSV, CMV or VZV encephalitis (median viral load 148 copies/ml), only 7 (28.6%) were identified as positive. In conclusions, while NGS has the advantage of being able to identify a wide range of potential pathogens it seems to be less sensitive compared to the standard amplification-based assays in the diagnosis of encephalitis, where low viral loads are common.

Shuni virus-induced meningoencephalitis after experimental infection of cattle.

Shuni virus (SHUV), an insect-transmitted orthobunyavirus of the Simbu serogroup within the family Peribunyaviridae, may induce severe congenital malformations when naïve ruminants are infected during gestation. Only recently, another clinical presentation in cattle, namely neurological disease after postnatal infection, was reported. To characterize the course of the disease under experimental conditions and to confirm a causal relationship between the virus and the neurological disorders observed in the field, six calves each were experimentally inoculated (subcutaneously) with two different SHUV strains from both clinical presentations, that is encephalitis and congenital malformation, respectively. Subsequently, the animals were monitored clinically, virologically and serologically for three weeks. All animals inoculated with the 'encephalitis strain' SHUV 2162/16 developed viremia for three to four consecutive days, seroconverted, and five out of six animals showed elevated body temperature for up to three days. No further clinical signs such as neurological symptoms were observed in any of these animals. However, four out of six animals developed a non-suppurative meningoencephalitis, characterized by perivascular cuffing and glial nodule formation. Moreover, SHUV genome could be visualized in brain tissues of the infected animals by in situ hybridization. In contrast to the 'encephalitis SHUV strain', in animals subcutaneously inoculated with the strain isolated from a malformed newborn (SHUV 2504/3/14), which expressed a truncated non-structural protein NSs, a major virulence factor, no viremia or seroconversion, was observed, demonstrating an expected severe replication defect of this strain in vivo. The lack of viremia further indicates that virus variants evolving in malformed foetuses may represent attenuated artefacts as has been described for closely related viruses. As the neuropathogenicity of SHUV could be demonstrated under experimental conditions, this virus should be included in differential diagnosis for encephalitis in ruminants, and cattle represent a suitable animal model to study the pathogenesis of SHUV.

Brainstem Encephalitis Caused by Listeria monocytogenes.

International outbreaks of listerial infections have become more frequent in recent years. Listeria monocytogenes, which usually contaminates food, can cause potentially fatal infections. Listerial cerebritis is a rare disease that is encountered mostly in immunocompromised or elderly patients. However, listerial brainstem encephalitis (mesenrhombencephalitis or rhombencephalitis) is found in persons who were formerly in good health, and recognizing this disease, particularly at its early stages, is challenging. Listerial brainstem encephalitis has high mortality, and serious sequelae are frequently reported in survivors. Early recognition and correct diagnosis, as well as the timely use of appropriate antibiotics, can reduce the severity of listerial infections. The trigeminal nerve is proposed as a pathway through which L. monocytogenes reaches the brainstem after entering damaged oropharyngeal mucosa or periodontal tissues. This review introduces the clinical manifestations, pathology, magnetic resonance imaging (MRI) findings, diagnosis, and treatment of listerial brainstem encephalitis. Moreover, it proposes that L. monocytogenes may also invade the brainstem along the vagus nerve after it infects enteric neurons in the walls of the gastrointestinal tract.