Diagnosis Of Viral Encephalitis Research Articles

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.

Super Refractory Status Epilepticus in a Case of Post Mumps Autoimmune Encephalitis: A Rare Case Report


 
 
 
 Seizure is a common problem in many paediatric patients. When seizures persist even after 24 hrs of anaesthetic treatment it is known as Super Refractory Status Epilepticus (SRSE). We report a 10 years old girl admitted with fever, altered sensorium and GTCS with a provisional diagnosis of viral encephalitis. In the line of SRSE infusion thiopental was also started after giving first line antiepileptic as per guidelines. Seizures persisted despite six anti-epileptic drugs, steroids and infusion anaesthetic. MRI brain was suggestive of T2W Flair hyperintensity in B/L hippocampal and Para-hippocampal gyrus and CSF and blood positive for Mumps IgM. This was suggestive of Mesial temporal sclerosis (MTS) which is the scarring and loss of neurons in the deepest portion of the temporal lobe due to oxygen starvation to the brain, head trauma, brain infection or without any apparent cause. Dramatic response was seen after 36-48 hours of IVIG administration.
 
 
 

A Clinico-Demographic Profile of Acute Encephalitis Syndrome and its Outcome Among Children

Introduction: Acute Encephalitis Syndrome (AES) is defined as acute onset of fever and a change in mental status and/or new onset of seizures in a person of any age, in any geographical region, at any time of year. It may be due to viral or bacterial etiology. Dysfunction of motor system and mental retardation are common complications.
 Methods: A prospective cross-sectional hospital based study was done among children from 1 month to 15 years of age admitted with diagnosis of AES from October 2014 to October 2015. The clinical details and reports of CSF analysis were recorded and analyzed.
 Results: Out of 70 patients of AES admitted, 40 (57.10%) were male and 30 (42.90%) were female. The highest number of cases were in age group of 6-10 years i.e. 26(37.2%); whereas 20 (28.5%) were 11-15 years, 17(24.30%) were among 2-5 years and 7(10%) were below 2 years. The patients were predominantly from Far- Western and Mid-Western region of Nepal. The maximum AES cases were of farmers of lower education level from rural area with low socio economic group and were reported during monsoon. The clinical profiles of AES were fever, altered sensorium and convulsion followed by irritability, headache, vomiting, lethargy, photophobia and ear discharge. 50 patients had AES with viral origin including nine were Japanese Encephalitis and 41 were Viral with unknown etiology whereas 20 were of Bacterial origin which includes 15 were Bacterial (septic) meningitis and five of Tubercular meningitis. Three children (4.3%) died with diagnosis of viral encephalitis. 29 (41.4%) had complete recovery and 15 (21.4%) had partial recovery, nine (12.9%) went LAMA (left against medical advice) and 14 (20%) were DOPR (discharge on patient request). The partially recovered patients had sequelae of motor system dysfunction and mental retardation.
 Conclusion: Acute encephalitis syndrome is a medical emergency in which early detection and treatment is very essential and remains a serious threat to global health, especially in the developing countries.

Japanese encephalitis: the vectors, ecology and potential for expansion.

Japanese encephalitis (JE) is a viral disease predominantly located in South East Asia and commonly associated with transmission between amplifying hosts, such as pigs, and the mosquito Culex tritaeniorhynchus, where human infection represents a dead end in the life cycle of the virus. The expansion of JE beyond an Asiatic confine is dependent on a multitude of complex factors that stem back to genetic subtype variation. A complex interplay of the genetic variation and vector competencies combine with variables such as geography, climate change and urbanization. Our understanding of JE is still at an early stage with long-term longitudinal vector surveillance necessary to better understand the dynamics of JE transmission and to characterize the role of potential secondary vectors such as Cx. pipiens and Cx. bitaeniorhynchus. The authors review the vectors indicated in transmission and the ecological, genetic and anthropological factors that affect the disease's range and epidemiology. Monitoring for the presence of JE virus in mosquitoes in general can be used to estimate levels of potential JE exposure, intensity of viral activity and genetic variation of JEV throughout surveyed areas. Increased surveillance and diagnosis of viral encephalitis caused by genotype 5 JE virus is required in particular, with the expansion in epidemiology and disease prevalence in new geographic areas an issue of great concern. Additional studies that measure the impact of vectors (e.g. bionomics and vector competence) in the transmission of JEV and that incorporate environmental factors (e.g. weekly rainfall) are needed to define the roles of Culex species in the viral pathogenesis during outbreak and non-outbreak years.

PROPER DIFFUSION-WEIGHTED WINDOW LEVEL IN MR IMAGING IN ACUTE VIRAL ENCEPHALITIS AND HYPOXIC ISCHAEMIC ENCEPHALOPATHY

Introduction: Diffusion-weighted magnetic resonance (MR) imaging provides image contrast that is different from that provided by conventional MR techniques. Improper Paper Submission DateDiffusion weighted (DW) window level obscures the diffuse cortical abnormality on DW image, hence proper windowed Diffusion weighted images are must for evaluation of cortical and deep grey matter nuclei abnormality. The increased sensitivity of DWI sequences with regard to viral encephalitis/hypoxic ischaemic encephalopathy (HIE) has been shown in several studies This study was performed to evaluate the role of proper DWI window level (250/150) in the diagnosis of viral encephalitis and HIE vs improperly windowed (500-850/250-Paper Publication Date 400) DW images for evaluation of cortical and deep grey matter nuclei. Material and Methods: We performed conventional MRI including T1, T2-Weighted and DOI fluid attenuated inversion recovery (FLAIR) sequences and DWI in 16 patients with viral encephalitis and 02 patients of hypoxic ischaemic encephalopathy diagnosed on the basis of laboratory, clinical and radiologic findings. Gradient B value of diffusion was 0, 400 and 800. Properly windowed (250/150) DW image versus an improperly windowed (500-850/250-400) DW image were evaluated for evaluation of cortical and deep grey matter nuclei signal intensity. Results: Axial DW images were reviewed at a consistent window level of 250/150. DW image with proper window level of 250/150 shows that the cortical/ deep gray matter nuclei abnormality is more evident. Apparent diffusion coefficient (ADC) map further illustrates the cortical restricted diffusion. Although with improperly windowed DWI (500-850/250-400), there is accentuated greywhite matter differentiation, but improper window level obscures the diffuse cortical abnormality on DW image. With proper window level of DW images, diffusion restriction was picked up in all the 16 cases of acute viral encephalitis and 02 patients of HIE. Conclusion: Proper window level of DWI (250/150) is helpful in early diagnosis of acute viral encephalitis and hypoxic ischaemic encephalopathy.

PROPER DIFFUSION-WEIGHTED WINDOW LEVEL IN MR IMAGING IN ACUTE VIRAL ENCEPHALITIS AND HYPOXIC ISCHAEMIC ENCEPHALOPATHY

Introduction: Diffusion-weighted magnetic resonance (MR) imaging provides image contrast that is different from that provided by conventional MR techniques. Improper Paper Submission DateDiffusion weighted (DW) window level obscures the diffuse cortical abnormality on DW image, hence proper windowed Diffusion weighted images are must for evaluation of cortical & deep grey matter nuclei abnormality. The increased sensitivity of DWI sequences with regard to viral encephalitis/hypoxic ischaemic encephalopathy (HIE) has been shown in several studies This study was performed to evaluate the role of proper DWI window level (250/150) in the diagnosis of viral encephalitis & HIE vs improperly windowed (500-850/250-Paper Publication Date 400) DW images for evaluation of cortical & deep grey matter nuclei. Material and Methods: We performed conventional MRI including T1, T2-Weighted and DOI fluid attenuated inversion recovery (FLAIR) sequences and DWI in 16 patients with viral encephalitis & 02 patients of hypoxic ischaemic encephalopathy diagnosed on the basis of laboratory, clinical and radiologic findings. Gradient B value of diffusion was 0, 400 & 800. Properly windowed (250/150) DW image versus an improperly windowed (500-850/250-400) DW image were evaluated for evaluation of cortical & deep grey matter nuclei signal intensity. Results: Axial DW images were reviewed at a consistent window level of 250/150. DW image with proper window level of 250/150 shows that the cortical/ deep gray matter nuclei abnormality is more evident. Apparent diffusion coefficient (ADC) map further illustrates the cortical restricted diffusion. Although with improperly windowed DWI (500-850/250-400), there is accentuated grey–white matter differentiation, but improper window level obscures the diffuse cortical abnormality on DW image. With proper window level of DW images, diffusion restriction was picked up in all the 16 cases of acute viral encephalitis and 02 patients of HIE. Conclusion: Proper window level of DWI (250/150) is helpful in early diagnosis of acute viral encephalitis & hypoxic ischaemic encephalopathy.

Epidemiological features of viral encephalitis in Cangzhou of China with use of multiplex RT-PCR for five RNA viruses

ObjectiveWith use of multiplex RT-PCR testing the five RNA viruses associated with viral encephalitis, the aim of research is to find out the epidemiological features of viral encephalitis in Cangzhou of China. MethodsPatients hospitalized in Cangzhou central hospital with the diagnosis of viral encephalitis from January 2010 to December 2012 were retrospectively analyzed. The sensitivity and specificity of multiplex RT-PCR was compared with ELISA through testing CSF samples of enterovirus (EVs), Japanese encephalitis virus (JEV), mumps virus (MUV), measles virus (MV) and rubella virus (RV). ResultsDisease incidence of viral encephalitis in Cangzhou of China was 18.6 per 100 thousand, and the main pathogen focused on EVs, MUV, JEV, MV and RV, which positive rate were 27.8%, 14.4%, 12.2%, 6.7% and 3.3% respectively. The sensitivity and specificity were all higher than ELISA. ConclusionThe most common pathogens responsible for viral encephalitis in Cangzhou, Hebei province, China, were EVs, and the multiplex RT-PCR was a rapid, sensitive, accurate method of testing the viruses responsible for causing these illnesses.

Viral Encephalitis

Viral encephalitis refers to acute inflammatory process of brain parenchyma caused by viral agents. Viruses are known to be the most common infectious agents associated with acute encephalitis. Acute neurologic manifestations in viral encephalitis are diverse, including fever, headache, abnormal behaviors, altered consciousness, seizure, and focal or multifocal neurological deficits. A diagnosis of viral encephalitis can be challenging. Real-time polymerase chain reaction test of cerebrospinal fluid is useful in establishing immediate diagnosis and prognosis of the disease. Prognosis differs from the type of viral agent. Prompt diagnosis and management include antiviral treatment and control of elevated intracranial pressure. Key Words: Encephalitis; Viral; Intensive care units

Viral Encephalitis

Viral encephalitis refers to acute inflammatory process of brain parenchyma caused by viral agents. Viruses are known to be the most common infectious agents associated with acute encephalitis. Acute neurologic manifestations in viral encephalitis are diverse, including fever, headache, abnormal behaviors, altered consciousness, seizure, and focal or multifocal neurological deficits. A diagnosis of viral encephalitis can be challenging. Real-time polymerase chain reaction test of cerebrospinal fluid is useful in establishing immediate diagnosis and prognosis of the disease. Prognosis differs from the type of viral agent. Prompt diagnosis and management include antiviral treatment and control of elevated intracranial pressure. Key Words: Encephalitis; Viral; Intensive care units

К вопросу дифференциации вирусных энцефалитов

Вирусные энцефалиты являются одной из актуальных проблем современной неврологии. У практикующих врачей возникают диагностические затруднения, требующие дифференциации с опухолевым процессом, острыми церебральными сосудистыми синдромами, токсическими энцефалопатиями, психозами. В связи с этим представляют клинический интерес собственные наблюдения сложности дифференциации вирусных энцефалитов и опухолей головного мозга. Представлены 2 наблюдения с диагнозом «вирусный энцефалит». Были проанализированы неврологический статус, КТ головного мозга, ЭЭГ, ЭхоЭГ, исследования глазного дна, клинико-лабораторные исследования, исследования спинномозговой жидкости, данные объективного анамнеза. Приведенные наблюдения отображают разные клинические манифестации герпетических энцефалитов, необходимость глубокого анализа симптомов заболевания, их динамики, результатов параклинического исследования и обязательной дифференциации, прежде всего с процессами сосудистого и опухолевого характера.

Application of DWI combined MRI for the diagnosis of viral encephalitis in children

Objective To investigate the value of diffusion weighed imaging (DWI) for the diagnosis of viral encephalitis in children.Methods The magnetic resonance (MR) findings of 36 children with viral encephalitis were retrospectively analysed.The location,size,signal intensity,as well as the time from the onset of neurologic symptoms to MR examination were studied.Results The lesions showed long T1 and long T2 signal intensities.Cerebral cortex,basal ganglia,thalamus were most frequently involved.Among the 36 cases,the lesions in 18 cases were shown clearer and more distinct on DWI than on conventional T2WI,the average time from the onset of neurologic symptoms to MR examination was 8.2 days.14 cases were shown clearer on conventional T2WI than on DWI,the average time from the onset of neurologic symptoms to MR examination was 12.6 days.4 cases were shown similarly on DWI and T2WI,the average time from the onset of neurologic symptoms to MR examination was 7.8 days.Conclusion DWI and conventional MRI have different advantages to show differrent pathological changes in different clinical stages.DWI combined with MRI has potential value in the early and precise diagnosis of viral encephalitis. Key words: Viral encephalitis; Children; Diffusion weighed imaging (DWI); Magnetic resonance imaging (MRI)

Viral encephalitis

While systemic viral infections are exceptionally common, symptomatic viral infections of the brain parenchyma itself are very rare, but a serious neurologic condition. It is estimated that viral encephalitis occurs at a rate of 1.4 cases per 100.000 inhabitants. Geography is a major determinant of encephalitis caused by vector-borne pathogens. A diagnosis of viral encephalitis could be a challenge to the clinician, since almost 70% of viral encephalitis cases are left without an etiologic agent identified. In this review, the most common viral encephalitis will be discussed, with focus on ecology, diagnosis, and clinical management.

Using Real Time PCR For The Etiological Diagnosis Of Viral Encephalitis

Viral infections of the central nervous system (CNS) represent a challenge for early diagnosis and proper treatment of the disease. Different studies should be performed on the patient in order to arrive at an accurate diagnosis. The electroencephalogram, magnetic resonance imaging, viral culture, serological and cytochemical analysis are important tools to diagnose this disease. However, the polymerase chain reaction (PCR) or conventional PCR has become the gold standard for the diagnosis of viral encephalitis. Indeed, Real Time PCR (RT-PCR) equipments are replacing the conventional PCR ones. Faster results may be an explanation of this fact. Information obtained from dissociation curve analysis of the RT-PCR technique represents a highly sensitive and specific tool for the Herpes simplex (HSV), Varicela (VZV), Cytomegalovirus (CMV) and Enterovirus (EV) detection.

Study on the significance of MRI and cerebrospinal fluid cytology in the diagnosis of viral encephalitis (meningitis)

Objective To explore the significance of magnetic resonance imaging (MRI) and cerebrospinal fluid cytology in the diagnosis and treatment of viral encephalitis (meningitis). Methods The head MRI and cerebrospinal fluid data of 189 patients with viral encephalitis (meningitis) were reviewed, and early changes of cerebrospinal fluid cyotology of patients with normal or abnormal MRI findings were analysed retrospectively. Results Among 189 viral encephalitis (meningitis) patients, 96 (50.79%) patients presented abnormal MRI, and 129 (68.25%) patients presented abnormal cerebrospinal fluid cytological findings. In patients with abnormal MRI the abnormality rate of cerebrospinal fluid cytological findings was 72.92% (70/96), while in patients with normal MRI it was 63.44% (59/93), the difference was significant (P = 0.000). Conclusion In the early stage of viral encephalitis (meningitis) MRI changes appear later than abnormal cerebrospinal fluid cytological findings, but both of them are important for clinical diagnosis and treatment of this disease. DOI：10.3969/j.issn.1672-6731.2011.05.013

A Case of Neonatal Coxsackie B2 Meningo-Encephalitis in which Serial Magnetic Resonance Imaging Findings Reveal the Development of Lesions

We report a patient with neonatal Coxsackie B2 meningo-encephalitis in whom magnetic resonance imaging (MRI) could be performed serially from the early stage of the disease. The patient was a 12-day-old girl born at a gestational age of 37 weeks. She was hospitalized due to poor suckling. During her hospital stay, she developed clonic seizures in the right upper and lower limbs. Coxsackie B2 virus was detected, and a diagnosis of viral encephalitis was made. The first diffusion-weighted images (DWI) showed an abnormal high-intensity area restricted to the corpus callosum and posterior limb of the internal capsule 8 h after onset of seizures. Repeated MRI revealed damage to the white matter, which finally changed into diffuse excessive necrosis followed by cystic leukomalacia. Early DWI is valuable for the early detection and diagnosis of neonatal meningo-encephalitis. This is the first report of the detailed neuroradiological course of neonatal Coxsackie B2 meningo-encephalitis.

Genotype V Japanese Encephalitis Virus Is Emerging

Japanese encephalitis (JE) is a global public health issue that has spread widely to more than 20 countries in Asia and has extended its geographic range to the south Pacific region including Australia. JE has become the most important cause of viral encephalitis in the world. Japanese encephalitis viruses (JEV) are divided into five genotypes, based on the nucleotide sequence of the envelope (E) gene. The Muar strain, isolated from patient in Malaya in 1952, is the sole example of genotype V JEV. Here, the XZ0934 strain of JEV was isolated from Culex tritaeniorhynchus, collected in China. The complete nucleotide and amino acid sequence of XZ0934 strain have been determined. The nucleotide divergence ranged from 20.3% to 21.4% and amino acid divergence ranged from 8.4% to 10.0% when compared with the 62 known JEV isolates that belong to genotype I–IV. It reveals low similarity between XZ0934 and genotype I–IV JEVs. Phylogenetic analysis using both complete genome and structural gene nucleotide sequences demonstrates that XZ0934 belongs to genotype V. This, in turn, suggests that genotype V JEV is emerging in JEV endemic areas. Thus, increased surveillance and diagnosis of viral encephalitis caused by genotype V JEV is an issue of great concern to nations in which JEV is endemic.

Usefulness of various MRI sequences in the diagnosis of viral encephalitis

There is paucity of studies regarding the utility of various conventional MRI sequences in the diagnosis of viral encephalitis. The present study evaluates the usefulness of various MRI sequences in acute viral encephalitis. 88 consecutive viral encephalitis patients, aged 2–72 years were subjected to clinical evaluation. Consciousness was assessed by Glasgow Coma Scale (GCS). Serum or cerebrospinal fluid (CSF) was analyzed for dengue, Japanese encephalitis (JE), herpes, measles, echo, coxsackie and polio viruses using ELISA or PCR. Cranial MRI was done and T1, T2, FLAIR and DW images were obtained. The MRI changes were correlated with type of encephalitis and duration of illness. All the patients had altered sensorium and 37 had seizures. 22 patients had JE, 9 had dengue, 8 had herpes simplex encephalitis (HSE), 2 had Epstein-Barr virus encephalitis (EBVE) and 47 had non-specific encephalitis. The median duration of MRI study from onset was 10 days. In JE (20/22), HSE (8/8), and EBVE (2/2), MRI abnormalities were more common compared to dengue (2/9) and non-specific (20/47) encephalitis. The MRI abnormalities were more common in FLAIR (57.1%) compared to T2 (52.9%), DWI (38.1%) and T1 (19.3%) sequences. The mean ADC value in JE patients was lower (974.0 ± 110.85 ×10 −6 mm 2/s) than HSE (1024.33 ± 485.76 × 10 −6 mm 2/s). Additional MRI lesions were seen in 12.6% cases on FLAIR sequence. FLAIR and T2 sequences were more sensitive in revealing abnormalities in viral encephalitis.

Clinical and economic importance of applying the guidelines for the diagnosis of viral encephalitis

Viral encephalitis are diseases with complex diagnostic problems, because symptoms are similar to those of flu syndrome and they will resolve in about a week. Brain involvement and prognosis depend on pathogen and patient immunity. In 2008, the American Society of Infectious Diseases has approved guidelines to guide clinician to an appropriate diagnostic evaluation: clinician should ask specific tests, without resorting to a general request (eg. neurotropic viruses), reducing time and costs of etiologic diagnosis. The guidelines set out methods and the proper timing to execute tests for each virus, indicating when to integrate molecular research with antibody research to avoid false negative results, and how to interpret results. During the period September 2007 - August 2009, microbiology laboratory of San Martino hospital in Genoa has analyzed 300 cerebrospinalis liquor from Liguria with a clinical diagnosis of suspected viral encephalitis.The search for viruses HSV1, HSV2,VZV, EBV,CMV, HHV6,Adenovirus, Enterovirus and JCV was performed by real time PCR. Only 51 liquor were positive (16 HSV1, 5 HSV2, 4 VZV, 17 EBV, 2 CMV, 2 HHV6, 1 Adenovirus, 4 Enterovirus and 4 JCV with 4 coinfection). This study confirms that the percentage of encephalitis with a recognized etiologic agent remains very low, despite the increase in positivity in the last two years.This confirms the importance of applying the guidelines to improve the diagnosis of viral encephalitis.

Ethics roundtable: 'Open-ended ICU care: Can we afford it?'

The patient is a 27-year-old previously healthy male with a diagnosis of viral encephalitis with a lymphocytic pleocytosis on cerebrospinal fluid examination. For 3 months, he has been in status epilepticus (SE) on high doses of barbiturates, benzodiazepines, and ketamine and a ketogenic feeding-tube formula. He remains in burst suppression on continuous electroencephalography (EEG). He is trached and has a percutaneous endoscopic gastrostomy (PEG) feeding tube. He has been treated several times for pneumonia, and he is on a warming blanket and is on vasopressors to maintain his blood pressure. His vitals are stable and his lab work is within limits. The sedation is decreased under EEG guidance every 72 hours, after which he goes back into SE and heavy sedation is resumed. The latest magnetic resonance imaging (MRI) shows edema but otherwise no obvious permanent cortical damage. The family wants a realistic assessment of the likely outcome. The neurologist tells them the literature suggests the outlook is poor but not 100% fatal. As long as all of his other organs are functioning on life support, there is always a chance the seizures will stop at some time in the future, and so the neurologist recommends an open-ended intensive care unit (ICU) plan and hopes for that outcome.