Type Of Encephalitis Research Articles

Hyponatremia Is Predictive of HSV-1 Encephalitis among Patients with Viral Encephalitis.

Encephalitis is an inflammatory process involving the brain parenchyma associated with neurologic dysfunction. The main causes of infectious encephalitis are viruses, including Herpes simplex virus type 1 (HSV-1). As the mortality rate of HSV-1 encephalitis could be reduced with early acyclovir treatment, it is imperative to distinguish HSV-1 encephalitis from other type of viral encephalitis as early as possible. However, sophisticated methods for definitive diagnosis of HSV-1 encephalitis are not readily available. We aimed to explore distinctive clinical and laboratory features of HSV-1 encephalitis. All of the adult patients with viral encephalitis hospitalized between 2011-2017 were enrolled, including 16 patients with HSV-1 encephalitis and 51 patients non-HSV-1 viral encephalitis. Determination of viruses in cerebrospinal fluid was performed by PCR tests. Female sex, hyponatremia, and abnormalities in MRI were independently associated with HSV-1 encephalitis (p < 0.05 for each). In particular, hyponatremia (< 135 mEq/L) was found in nine patients with HSV-1 encephalitis (56.3%) and 10 patients with non-HSV-1 viral encephalitis (19.6%) (p = 0.005). As serum sodium is determined easily and quickly in clinical practice, the presence of hyponatremia among patients with viral encephalitis could be helpful for the early diagnosis of HSV-1 encephalitis before cerebrospinal fluid PCR results were available. Moreover, the presence of positive finding in MRI could further support the diagnosis. This is the first study that compared the serum sodium levels among patients between HSV-1 and non-HSV-1 viral encephalitis. We thus propose the diagnostic value of hyponatremia for HSV-1 encephalitis.

An evolving redefinition of autoimmune encephalitis.

Autoimmune encephalitis encompasses a wide variety of protean pathologic processes associated with the presence of antibodies against neuronal intracellular proteins, synaptic receptors, ion channels and/or neuronal surface proteins. This type of encephalitis can also involve children with complex patterns of seizures and unexpected behavioural changes, which jeopardize their prompt recognition and treatment. Many epidemiological studies have shown that numerous immune-based forms of encephalitis can be encountered, almost surpassing the rate of postinfectious encephalitides. However, the overall exact prevalence of autoimmune encephalopathies remains underestimated, and the definition of diagnostic algorithms results muddled. The spectrum of neuropsychiatric manifestations in the pediatric population with autoimmune encephalitis is less clear than in adults, but the integration of clinical, immunological, electrophysiological and neuroradiological data is essential for a general approach to patients. In this review we report the most relevant data about both immunologic and clinical characteristics of the main autoimmune encephalitides recognized so far, with the aim of assisting clinicians in the differential diagnosis and favouring an early effective treatment. Correlations between phenotype and autoantibodies involved in the neurological damage of autoimmune encephalitis are largely unknown in the first years of life, because of the relatively small number of pediatric patients adequately studied. Future multicenter collaborative studies are needed to improve the diagnostic approach and tailor personalized therapies in the long-term.

Encephalitis Associated to Metabotropic Glutamate Receptor 5 (mGluR5) Antibodies in Cerebrospinal Fluid

A 68-years-old Hispanic man, complained of night sweats, low grade fewer, unexplained weight loss, and memory problems over 3 months. Abdominal tomography showed multiple intra-abdominal adenopathy and biopsy confirmed classic Hodgkin's lymphoma. He commenced treatment with chemotherapy. Three months later, he had acute onset of inattention, auditory hallucinations and alterations of anterograde memory. The patient developed psychomotor agitation, unresponsive to a combination of neuroleptics and benzodiazepines. Brain MRI showed a small established cerebellar infarction. Electroencephalogram was normal. Tests for toxic metabolic encephalopathy were negative. One oligoclonal IgG bands was found in the Cerebrospinal fluid (CSF), which was not observed in corresponding serum, but cell count and protein were normal. Extensive testing for infectious encephalitis was unremarkable. CSF testing for commercially available neural and non-neural autoantibodies was negative. The patient fulfilled the Gultekin diagnostic criteria for paraneoplastic limbic encephalitis and methylprednisolone IV 1g/d for 5 days was given. He recovered rapidly, with progressive improvement in memory and psychomotor agitation. After treatment commenced, results for antibodies to mGluR5 in CSF taken prior to treatment were returned as positive. mGluR5 is found on post-synaptic terminals of neurons and microglia and is expressed primarily in the hippocampus and amygdala. This case highlights the difficulties in diagnosing this type of encephalitis: the CSF did not show pleocytosis, the MRI showed only chronic change and the electroencephalogram was normal. The dramatic recovery after methylprednisolone help to better characterized the clinical spectrum of auto-immune encephalitis. Diagnosing anti mGlutR5 encephalitis may lead to potentially highly effective treatment option and may anticipate the diagnostic of a cancer. A high index of suspicion is needed to avoid missed diagnosis. In patients with unexplained encephalitis, testing for antibodies to mGluR5 in CSF and serum should be considered. When there is a reasonable index of suspicion of auto-immune encephalitis, treatment should not be delayed for the antibody results.

Magnetic Resonance Imaging Findings in Viral Encephalitis: A Pictorial Essay.

Viral encephalitis by definition is the result of human virus affecting the brain and sparing the meninges. The other nervous system manifestations are meningitis, meningoencephalitis, encephalomyelitis, and encephalomyeloradiculitis. Encephalitis can involve any age group from children to old people. The severity of the disease depends on the viral agent and the host immune system. The patient can present with fever, headache, seizure, neurological deficit, or altered sensorium. Laboratory investigations, imaging, and cerebrospinal fluid analysis are crucial in the diagnosis of encephalitis. Magnetic resonance imaging (MRI) findings may be nonspecific or specific and plays a major role in the diagnosis of encephalitis and predicting the possible cause. This pictorial essay reviews the MRI findings of common types of viral encephalitis.

Eastern Equine Encephalitis and YouTube videos: A content analysis.

Eastern Equine Encephalitis virus (EEEV) infections among humans are rare, but can result in severe consequences. YouTube can serve as a platform for EEEV health education. This study aims to assess the characteristics of the top EEEV-related YouTube videos, and whether their informational contents vary by uploading source. On August 15, 2016, we searched YouTube.com for the top 100 videos by number of views featuring "Eastern Equine Encephalitis". We manually coded and statistically analyzed the contents, source of uploads and meta-data of 100 most viewed EEEV-related YouTube videos. Univariate logistic regression was applied to identify if videos of different sources (consumer, professional, and news) differed in their contents. Excluding one video, 21 Consumer, 9 Professional, and 69 News videos were analyzed (N=99). Compared with news-videos, consumer-videos are less likely to mention the geography of EEEV transmission (OR=0.21, p<0.01); professional-videos are more likely to mention other types of encephalitis (OR=27.50, p<0.01), and to mention horses only (OR=8.5, p<0.01). Professional videos provided the most comprehensive information. However, few videos from professionals made it to the top 100 list. The untapped potential of YouTube as a unique platform to disseminate EEEV information deserves the attention of public health professionals.

Autoantibodies Associated with Autoimmune Basal Ganglia Disorders

Autoimmune basal ganglia disorders (ABGDs) are presumed autoimmune encephalitides characterized by movement disorders and basal ganglia lesions on neuroimaging. The most common type of autoimmune encephalitis manifesting as movement disorders is anti-N-methyl-D-aspartate (NMDA) receptor encephalitis. Anti-phospholipid antibody syndrome and neuropsychiatric lupus may present with chorea or other involuntary movements. In childhood, Sydenham's chorea is an important differential diagnosis. Although autoantibodies directed against the surface antigens on basal ganglia neurons are assumed to cause ABGDs, few autoantibodies have been demonstrated to be relevant to certain clinical syndromes except for anti-NMDA receptor antibodies. However, recent studies have identified autoantibodies to the dopamine D2 receptor and collapsin response mediator proteins in patients with ABGDs. It remains to be elucidated, however, whether these autoantibodies to basal ganglia antigens play pathogenic roles in ABGDs.

Paraneoplastic movement disorders.

Paraneoplastic movement disorders are rare, autoimmune-mediated, nonmetastatic complications of malignant neoplasms. Common paraneoplastic movement disorders include paraneoplastic chorea, dystonia, cerebellar degeneration, different types of encephalitis, opsoclonus-myoclonus syndrome, stiff person syndrome, and neuromyotonia. Syndromes usually develop before tumor diagnosis, have subacute onset, and are associated with serum or cerebrospinal fluid antibodies. Two types of antibodies can be distinguished: antibodies against nuclear and cytoplasmic neuronal antigens (anti-Hu, anti-Ri, anti-Yo, anti-Ma, anti-CV2/CRMP5, anti-Gephrin, and anti-GABATRAP) and antibodies recently identified against cell surface and synaptic proteins (anti-NMDAR, anti-LGI1, and anti-Caspr2). These two types differ from each other in a few important aspects. Antibodies against cell surface and synaptic protein disrupt cell-surface antigens. Clinical symptoms are related to the disruption of antigens and potentially can be reversed by immunotherapy. The association between these antibodies and malignancy is much less consistent. On the other hand, antibodies against nuclear and cytoplasmic neuronal antigens seem to be not pathogenic; however, they most likely indicate a T-cell-mediated immune response against neurons. Due to T-cell-mediated neuronal loss, response to immunotherapy is generally disappointing. Early recognition of all these diseases is crucial because it may lead to the disclosure of occult cancer. This review is focused on paraneoplastic movement disorders with emphasis on clinical presentations, investigational findings, and therapeutic results.

A new extremely hazardous viral disease in southeast Asia which affects both swine and humans

Since the end of 1998, incidents of a serious viral encephalitis have been reported in Malaysia and recently in Singapore, a 50% of which led to death. According to the updated information on this new disease, its transmission is related to swine. At first, it was believed that cause of the encephalitis was the virus of the Japanese encephalitis type B. However, after the proper laboratory examinations, it was proved that a new, unknown virus was related to the etiology of the incidents. This virus belongs to the Paramyxoviridae family and has many common characteristics with the Hendra virus, without being the actual one. The first name attributed to the virus was Hendra like virus, but recently the name Nipah virus prevails.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis in a Young Woman with Ovarian Teratoma

Background: Anti-N-Methyl-D-Aspartate (NMDA) Receptor encephalitis is a common cause of autoimmune encephalitis, usually associated with ovarian teratoma, especially in young women. It’s important to recognize quickly this type of encephalitis in order to give the patient the better chance to recover. Case: We report a typical case of anti-NMDA encephalitis associated to ovarian dermoid in a young woman. Neurological assessment revealed the presence of anti- NMDA autoantibodies in cerebrospinal fluid and TC abdomen revealed the presence of an ovarian dermoid. Surgery to remove the mass was performed and immunotherapy was started. Now she’s doing well, and she only has a little memory deficit. Conclusion: Ovarian dermoid is common, instead enchephatis is a rare entity, so further investigations is needed to know more about this specific type of ovarian dermoid.

Brain magnetic resonance-imaging findings of anti-N-methyl-d-aspartate receptor encephalitis: a cohort follow-up study in Chinese patients

The aim of this report was to assess routine clinical brain magnetic resonance imaging (MRI) and its relation to clinical characteristics and disease prognosis. Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients were consecutively recruited from West China Hospital between October 1, 2011 and April 1, 2016. Brain MRI findings of 106 patients were analysed, and outcomes were assessed at 4, 8, and 12months after discharge from the hospital using the modified Rankin scale (mRS). An MRI of the brain was normal in 52/106 (49.1%) patients and abnormal or atypical in 54/106 (50.9%) patients. The initial MRI was abnormal with T2 or fluid-attenuated inversion recovery (FLAIR) hyper-intensity signals in 20/106 (18.9%) patients. There were no statistically significant differences between the MRI findings and clinical presentations (seizure, hypoventilation, loss of consciousness, and tumour) (P>0.05). Patients with normal MRIs were younger than patients with abnormal MRIs (P<0.05). The mean mRS score at the 4-month follow-up was significantly higher in patients with abnormal MRIs than in patients with normal MRIs (P<0.05). Brain MRI abnormalities are typically mild or unrelated to clinical symptoms, which is a clinico-radiological paradox of this type of immune encephalitis. Abnormal MRIs did not affect prognosis evaluated by mRS.

P 82 Case presentation – haemorrhagic encephalitis by HSV with organic psychosyndrome with slowing, personality change, memory disturbance/word-finding disturbance and moderate neurological abnormalities [severe headache, hyperaesthesia in the face, pathological reflexes

The 16-year-old patient J.P. was ill for five days with fever (maximum 38.9 °C, 38.2 °C on the day before), bipolar headache, nausea, and vomiting twice. No further signs of infection, pretreatment with paracetamol and ibuprofen. J.P. had hardly eaten, but still drunken enough. On admission, J.P. cmplained of bifrontal headache and nausea, but was well-oriented. Motor movement and sensitivity normal, muscles normoton. No meningitic signs, no ataxia, proper reflexes of the muscles triggerable identically on both sides. Temp. 36.4 °C, RR 112/67 mmHg, Hf 69 beats/min, oxygen saturation 96%. Laboratory chemistry: no relevant increased inflammation parameters. No meningism in multiple examination by pediatric consultants in the following one and a half days. An increase in headaches, an unclear change in the personality of the patient, retarded reactions (“always very reserved and sparing of words”), an MRI of the head was performed, showing a typical encephalitis picture with haemorrhagic temporal lobe encephalitis, as is often observed in HSV encephalitis. After lumbar puncture, we immediately began acyclovir therapy. At times very severe headaches were treated parenterally with metamizole and piritramide. The personality changes increased in the first few days. The patient was initially only limited oriented (knew, for example, that we had the first day of the week, but not that this is the Monday, knew that his sisters had visited him on the previous day and could distinguish them by telling the place of their residence, but did not know their names) and was significantly slowed down. The symptoms slowly decreased somewhat from the 6th day of treatment onwards. After 11 days there was still pronounced memory and word-finding disorder, slight disorientation and attention deficits. An inpatient early rehabilitation was organized, but by J.P. rejected it after extensive discussions. With the consent of his parents he wished a long-term outpatient rehabilitation, which was organized in co-operation with the health insurance, the parents and the therapists working in the county. In addition to pediatric support, this included physiotherapy on a neurophysiological basis, speech therapy and occupational therapy. In the further course the general condition improved, the personality disorder regressed and the word-finding disturbances also improved. The thorough neuropsychological assessment before dismissal showed disturbances in the area of memory, attention, visual perception and executive functions, in spite of the overall improvement. After 3 1/2 weeks, J.P. In good general condition and subjectively free of complaints in the further outpatient rehabilitation. Parallel to this J.P. attended his previous school class, and after a few months in the following summer he passed the final exams of the school (Fachoberschulreife/Realschulabschluss). The diagnostic measures are presented in the clinical context: MRI at the beginning, after 4 weeks, after 3 and 7 months EEG Neuropsychological testing before rehabilitation and after 6 months.

Seizures and risk of epilepsy in autoimmune and other inflammatory encephalitis.

The aim of this study was to assess the seizure manifestations and risk of epilepsy in encephalitis associated with antibodies against neuronal cell-surface (autoimmune encephalitis) or myelin-associated antigens, and to review several chronic epileptic disorders, including Rasmussen's encephalitis, fever-induced refractory epileptic syndromes (FIRES) and new-onset refractory status epilepticus (NORSE). Seizures are a frequent manifestation of autoimmune encephalitis. Some autoimmune encephalitis may associate with characteristic features: faciobrachial dystonic seizures (anti-LGI1 encephalitis), electroencephalogram extreme delta brush (anti-NMDAR) or multifocal FLAIR-MRI abnormalities (anti-GABAAR). In anti-LGI1 encephalitis, cortical, limbic and basal ganglia dysfunction results in different types of seizures. Autoimmune encephalitis or myelin-antibody associated syndromes are often immunotherapy-responsive and appear to have a low risk for chronic epilepsy. In contrast patients with seizures related to GAD65-antibodies (an intracellular antigen) frequently develop epilepsy and have suboptimal response to treatment (including surgery). Rasmussen's encephalitis or FIRES may occur with autoantibodies of unclear significance and rarely respond to immunotherapy. A study of patients with NORSE showed that 30% developed chronic epilepsy. Although seizures are frequent in all types of autoimmune encephalitis, the risk for chronic epilepsy is dependent on the antigen: lower if located on the cell-surface, and higher if intracellular. For other disorders (Rasmussen's encephalitis, FIRES, NORSE), the prognosis remains poor.

Post-marketing safety surveillance for inactivated and live-attenuated Japanese encephalitis vaccines in China, 2008–2013

IntroductionTwo types of Japanese encephalitis (JE) vaccines, inactivated JE vaccine (JE-I) and live-attenuated JE vaccine (JE-L), are available and used in China. In particular, one JE-L, produced by a domestic manufacturer in China, was prequalified by WHO in 2013. We assessed the safety of JE vaccines in China during 2008–2013 using the Chinese National Adverse Events Following Immunization Information System (CNAEFIS) data. MethodsWe retrieved AEFI reporting data about JE vaccines from CNAEFIS, 2008–2013, examined demographic characteristics of AEFI cases, and used administrative data on vaccine doses as denominator to calculate and compare crude reporting rates. We also used disproportionality reporting analysis between JE-I and JE-L to assess potential safety signals. ResultsA total of 34,879 AEFIs related with JE-I and JE-L were reported, with a ratio of male to female as 1.3:1; 361 (1.0%) cases were classified as serious. JE vaccines were administered concurrently with one or more other vaccines in 13,592 (39.0%) of cases. The overall AEFI reporting rates were 214.4 per million vaccination doses for JE-L and 176.9 for JE-I (rate ratio [RR]: 1.2, 95% confidence interval [CI]: 1.1–1.3) in 2010–2013. Febrile convulsions (FC) following JE-I was found as a signal of disproportionate reporting (SDR). However, there was no significant difference between the reporting rates of FC of JE-I and JE-L (0.3 per million vaccination doses for JE-L, 0.4 for JE-I, p=0.05). ConclusionsWhile our analysis did not find apparent safety concern of JE vaccines in China, further study should consider JE-I vaccines and febrile convulsion, and taking more sensitive methods to detect signals.

Serial 18F-FDG PET/CT Findings in a Patient With IgLON5 Encephalopathy

We presented the serial FDG PET/CT brain scans of a 64-year-old woman with IgLON5 encephalopathy, which is a novel syndrome in association with antibodies to a neuronal cell adhesion protein named IgLON5, and FDG PET findings have not been characterized previously. For our case, the relatively hypermetabolism in primary sensorimotor cortices, basal ganglia, and cerebrum comparing to other cortical regions on the pretreatment FDG PET/CT was partially recovered on the follow-up FDG PET/CT scan after immunotherapy, corresponding with the alleviation of clinical syndromes. The metabolic change pattern was not similar as other types of autoimmune encephalitis.

Anti-N-methyl-D-aspartate receptor encephalitis: a common cause of encephalitis in the intensive care unit.

Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR encephalitis) is the most common type of immune-mediated encephalitis. This study aimed to assess the incidence and mortality of anti-NMDAR encephalitis in intensive care unit (ICU) to evaluate the clinical manifestations, laboratory findings, managements and outcomes, and to compare these characteristics with patients with non-anti-NMDAR encephalitis admitted to ICU. Patients admitted to the neurological ICU with suspected encephalitis were included between January 1, 2012 and July 31, 2015. Cerebrospinal fluid (CSF) of enrolled patients was screened for anti-NMDAR antibodies using a cell-based assay. 72 critically ill patients with encephalitis of uncertain etiology were investigated, and 16 patients were positive for anti-NMDAR antibodies in CSF. Compared to patients with non-anti-NMDAR encephalitis, patients with anti-NMDAR encephalitis were younger, more likely to present with the psychiatric symptoms, dyskinesia, and autonomic dysfunction, and had longer ICU stays. The abnormal movements were so difficult to control that complicated the management. The outcome was favorable in ten patients 1year after the disease onset, and the mortality was as high as 25% overall. The incidence of anti-NMDAR encephalitis is high among critically ill patients with encephalitis of uncertain etiology. Controlling dyskinesia proved to be a challenge. Persistent dysautonomias were additional difficult to manage confounders. Same points being highlighted in this study may aid clinicians in the management of patients with anti-NMDAR encephalitis in intensive care practice.

Clinical, imaging, and follow-up observations of patients with anti-GABAB receptor encephalitis

Purpose: Anti-gamma-aminobutyric acid B (anti-GABAB) receptor encephalitis is a newly described type of autoimmune encephalitis. We report a case series of patients diagnosed with anti-GABAB receptor encephalitis in China, focusing on their presentations, laboratory and imaging results, and outcomes, as well as the treatment strategies which were employed. Methods: Data from patients diagnosed with anti-GABAB receptor encephalitis in the Second Affiliated Hospital, School of Medicine, Zhejiang University, from January 2014 to June 2015 were retrospectively collected and analyzed. Based on specific diagnostic criteria, seven cases were included. Results: Six of the seven patients were males, and a median age at presentation of 56 years (range: 4–71 years). Seizures were the most common initial symptom, and all patients developed symptoms of typical limbic encephalitis during their disease course. Additional types of autoantibodies were identified in four patients. After presentation, three patients were found to have small cell lung cancer and one patient was eventually diagnosed with thymoma. All patients accepted first-line immune therapy, but only one chose tumor treatment. The three tumor-free patients had a good outcome, whereas those with tumors had a poor one. Finally, there were no relapses during follow-up. Conclusion: Anti-GABAB receptor encephalitis is a rare, unique autoimmune disease, and is often associated with tumors. It should be considered in the differential diagnosis for middle and senior-aged patients who present with predominantly limbic encephalitis symptoms. Importantly, earlier recognition of this potentially treatable condition could improve its overall prognosis.

MRI findings and differential diagnosis in children with cerebral paragonimiasis

ObjectiveTo analyze the clinical characteristics and MRI features of cerebral paragonimiasis in children. MethodsTwenty-four patients (17 males and 7 females, ages: 5–14 years; mean age: 9.67 years) with cerebral paragonimiasis were recruited from June 2012 to December 2015. The diagnosis was confirmed by IgG enzyme-linked immunosorbent assays or pathologic examination. The clinical and MRI findings of all patients were analyzed retrospectively. Pre- and post-contrast MR imaging of the brain were performed using a GE Signa HDxt 3.0T scanner in all patients, and diffusion and susceptibility weighted imaging were obtained in 3 patients. ResultsConsumption of raw or undercooked fresh water crabs or crayfish within one year prior to the presentation was confirmed in 18 cases. The most common presenting symptom was headache, followed by vomiting, seizures, hemiparesis, hypesthesia and blurred vision. Twenty-two cases had high eosinophil counts (≥0.5 × 109/L), and the paragonimus serum antibody were positive in 23 cases. The lesions were surgically removed in 2 cases and the diagnoses were confirmed by pathologic examination. Of 24 cases, 17 cases manifested with cerebral hemorrhage, showing short T1 and long T2 signal intensities, most of which were located in cerebral cortex and subcortical areas. Of 17 cases with cerebral hemorrhage, 2 cases showed nodular and ring-like enhancement, while the other 15 patients revealed no enhancement. Seven cases of encephalitis type showed multiple conglomerate, and ring-like enhancements. The “tunnel” sign was found in 3 cases. Most patients showed small lesions surrounded by extensive vasogenic edema that was isointense on diffusion weighted imaging. ConclusionsThe clinical manifestations of cerebral paragonimiasis are nonspecific in children while the MRI findings of cerebral paragonimiasis are characteristic, including irregular hemorrhage, ring-like enhancement and disproportionately large areas of surrounding edema. Brain MRI plays an important role in the diagnosis of cerebral paragonimiasis in children.

The Etiological Diagnosis and Outcome in Patients of Acute Viral Encephalitis: A Prospective Observational Study at Tertiary Care Centre of North India

Background: Encephalitis, despite being an uncommon entity, is of public health importance worldwide because of its high morbidity and mortality. Around 70% of the disease burden is in Uttar Pradesh itself. Purpose of study: To study the etiological prevalence and outcome of different viruses as causative agent of acute viral encephalitis in patients reporting to a tertiary health care center in North India. Methods: All the patients presenting with febrile encephalopathy attending the medicine outdoor patient department or emergency of medicine department were enrolled in the study, of these a total of 92 patients fulfilling the inclusion criteria were included in the study. An informed consent from the patients/their attendants was obtained. Results: Minimum age of patients was found to be 14 years while maximum age was 61 years. Around 65.22% were males and majority of the patients were from Barabanki (22.83%). Magnetic Resonance Imaging findings were found to be positive in 85.87%. Most common etiology was Japanese encephalitis (38.04%) with human immunodeficiency Virus encephalitis (3.26%) being least common. After a follow up at 1 month, neurological sequelae were found to be highest in Japanese encephalitis while 100% mortality in human immunodeficiency virus encephalitis and recovery was highest in Dengue encephalitis (85.00%). Difference in outcome of different types of encephalitis was found to be statistically significant. Recovery was highest in age group up to 20 years (57.69%). Difference in outcome and age of patients was found to be statistically significant. Conclusion: Early Reporting, appropriate workup and stabilization of the suspected acute viral encephalitis patients are important so as to reduce the morbidity and mortality.

Fever, Myositis, and Paralysis: Is This Inflammatory Myopathy or Neuroinvasive Disease?

West Nile virus (WNV) is a mosquito-borne RNA Flavivirus which emerged in North America in 1999. Most patients present with a febrile illness but a few develop WNV neuroinvasive disease. Myopathy is an uncommon manifestation. We describe a case of a 42-year-old male from Los Angeles who presented with 8 days of fever and muscle pain. Initial physical exam was normal except for 4/5 muscle strength testing in his extremity proximal muscles. Laboratory revealed a creatine kinase of 45,000 and a urinalysis with large blood but no red blood cells, suggesting rhabdomyolysis. The patient's condition declined despite aggressive supportive care and hydration, and on hospital day #6 he developed severe altered mental status and progressed to complete right arm paralysis and 2/5 muscle strength in bilateral legs. EMG/NCS showed sensorimotor axonal polyneuropathy and the cerebrospinal fluid was positive for IgM and IgG WNV antibodies. The patient was diagnosed with WNV neuroinvasive disease, poliomyelitis (and encephalitis) type with myopathy/muscle involvement. He was treated supportively and his muscle and neurologic disease gradually improved. At 12-month follow-up his muscle enzymes had normalized and his weakness had improved to 5/5 strength in bilateral legs and 3/5 strength in the right arm.

Heterogeneity of clinical features and corresponding antibodies in seven patients with anti-NMDA receptor encephalitis

Anti-N-methyl D-aspartate (NMDA) receptor encephalitis is the most common type of encephalitis in the spectrum of autoimmune encephalitis defined by antibodies targeting neuronal surface antigens. In the present study, the clinical spectrum of this disease is presented using instructive cases in correlation with the anti-NMDA receptor antibody titers in the cerebrospinal fluid (CSF) and serum. A total of 7 female patients admitted to the hospital of Hannover Medical School (Hannover, Germany) between 2008 and 2014 were diagnosed with anti-NMDA receptor encephalitis. Among these patients, 3 cases were selected to illustrate the range of similar and distinct clinical features across the spectrum of the disease and to compare anti-NMDA antibody levels throughout the disease course. All patients received immunosuppressive treatment with methylprednisolone, intravenous immunoglobulin and/or plasmapheresis, followed in the majority of patients by second-line therapy with rituximab and cyclophosphamide. The disease course correlated with NMDA receptor antibody titers, and to a greater extent with the ratio between antibody titer and protein concentration. A favorable clinical outcome with a modified Rankin Scale (mRS) score of ≤1 was achieved in 4 patients, 1 patient had an mRS score of 2 after 3 months of observation only, whereas 2 patients remained severely impaired (mRS score 4). Early and aggressive immunosuppressive treatment appears to support a good clinical outcome; however, the clinical signs and symptoms differ distinctively and treatment decisions have to be made on an individual basis.