**5. Treatment**

**Steps Procedure** 1 Obtain consent

12 Encephalitis

2 Position the patient in the lateral decubitus position1 3 Locate landmarks: between spinous processes at L4-51

when the Dura is punctured.4

should be 20 cm or less. 5

with 1-2 ml of CSF each5

1-2 hours before getting up1

Ochoa :Pediatrics Vol. 91 No. 2 February 1, 1993 pp. 379 -382

New England Journal Med 2006; 355:e12September 28, 2006

**Table 5.** A step by step method of performing a lumbar puncture.

MB BCh, FRCA : Neurology July 1, 1996 vol. 47 no. 1 33-37

Issue: 17, Pages: 789

**4.4. Serology**

reserved for any specifics tests.

possible viral causes of encephalitis.

4 Prep and drape the area after identifying landmarks. Use lidocaine 1% with or without epinephrine2 <sup>5</sup> Assemble needle either an A-traumatic or Quincke and manometer. A-traumatic can reduce a post

<sup>6</sup> Insert needle through the skin and advance through the deeper tissues. A slight pop or give is felt

<sup>7</sup> When CSF flows, attach the 3-way stopcock and manometer. Measure the intracranial pressure which

8 If CSF does not flow, or you hit bone, withdraw needle partially, recheck landmarks, and re-advance1 <sup>9</sup> Once the ICP has been recorded, remove the 3-way stopcock, and begin filling collection tubes 1-4

<sup>10</sup> Remove needle, and place a bandage over the puncture site. Instruct patient to remain lying down for

1. Lumbar puncture: Anatomical review of a clinical skill : J.M. Boon1,\*, P.H. Abrahams2, J.H. Meiring1, T. Welch3 Article first published online: 16 SEP 2004 : Clinical Anatomy : Volume 17, Issue 7, pages 544–553, 2004 2. Role of Local Anesthesia During Lumbar Puncture in Neonates : Joaquim M.B. Pinheiro, Sue Furdon, Luis F.

3. Choosing the best needle for diagnostic lumbar puncture : Damien Carson, MB BCh, FRCA and Michael Serpell,

4. Lumbar Puncture : Miles S. Ellenby, M.D., Ken Tegtmeyer, M.D., Susanna Lai, M.P.H., and Dana A.V. Braner, M.D.

5. Lumbar Puncture Technique: Thomas A. McLennan Canadian Medical Association Journal (1962) Volume: 86,

Once CSF is obtained test tube one sample is usually used for detecting protein and glucose levels. Test tube 2 is used to establish a possible etiological agent so can be used for serology and bacterial cultures. Test-tube 3 is used to establish cell count and finally test-tube 4 is

Once you have a CSF sample it can be used to preform serology tests in order to identify any

As the most common causes of encephalitis are viral, serology is a useful tool for diagnosis the aetiological agents of encephalitis. Routine PCR diagnosis of HSE type 1 and 2 is a highly sensitive and specific method for diagnosing encephalitis[57]. The identification of West Nile virus immunoglobulin M in cerebrospinal fluid is the recommended test to document central nervous system infection, but this test may not be positive in spinal fluid collected less than 8 days after the onset of symptoms[58].For the diagnosis of JE virus (JEV) infection an immu‐ noglobulin M capture dot enzyme immunoassay can distinguish JEV from dengue infec‐

lumbar puncture headache. Attach the 3-way stopcock to manometer3

The treatment is mainly focused on medical treatment as surgery is rarely required. Medical treatments rely on the assessment of the patients' needs. Prioritising clinical care is crucial as encephalitis can be life threatening so focusing treatment on jus the aetiological agent is a flaw in the clinician's judgement. Ensuring the patient's vital signs stay within a physiological range and if an aetiological agent is discovered then treatment specified for that agent should be deployed.

#### **5.1. Medical treatment**

Encephalitis is a medical emergency. Initially as we discussed the ABCD guidelines should be followed. Then after the diagnostic steps are undertaken the patient should be isolated until the aetiology is determined as most viral causes are airborne (table 6).


1. Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's.

2. Antiviral Therapy of Herpes simplex and Varicella-zoster Virus Infections Peter Wutzler Institute for Antiviral Chemotherapy, Clinicum of the University of Jena, Erfurt, Germany

3. Cytomegalovirus infection of the central nervous system. Griffiths P. Source Department of Virology, Royal Free and University College Medical School, London, UK

4. Diagnosis and treatment of viral encephalitis : A Chaudhuri, P G E Kennedy

5. Treatment of measles encephalitis with adrenal steroids : John E. Allen

6. Interferon-α protects mice against lethal infection with StLouisencephalitis virus delivered by the aerosol and subcutaneous routes : T.J.G Brooks, R.J Phillpotts

**Table 6.** The treatment modalities for viral aetiological agents of encephalitis.

The next most common aetiological cause of encephalitis is bacterial. Neurosyphillis treatment is based on administering Penicillin at the same levels of treponemicidal levels found in CSF[61]. Mycoplasma pneumonia encephalitis therapy most frequently deployed is erythro‐ mycin or minocycline. A high cerebrospinal fluid cell count, cerebrospinal fluid protein elevation, and higher age were associated with an unfavourable outcome[62].

[2] Internal Jugular Venous Pressure In Man : Its Relationship To Cerebrospinal Fluid And Carotid Arterial Pressures : A. Myerson, M.D.; J. Loman, M.D. : Jama Vol. 27

The Clinical Management of the Patient with Encephalitis

http://dx.doi.org/10.5772/55171

15

[3] Homans J. Diseases of the veins. New England Journal of Medicine 1944:231:51–60.

[4] Innervation of brain intraparenchymal vessels in subhuman primates: ultrastructural observations : L Briggs, JH Garcia, KA Conger, H Pinto de Moraes, JC Geer and W Hollander: journal of American Heart association: Stroke Volume 16, No 2, 1985

[5] The textbook of pychosomatic medicine: James L Levenson :page 624: American psy‐

[6] Seizures in encephalitis Usha Kant Misra DM, C T Tan MD, Jayantee Kalita DM :

[7] Seizures in encephalitis Usha Kant Misra DM, C T Tan MD, Jayantee Kalita DM, San‐

[8] Viral Etiology of Acute Childhood Encephalitis in Beijing Diagnosed by Analysis of Single Samples : Xu, Yunhe Md; Zhaori, Getu Md; Vene, Sirkka Msc; Shen, Kunling Md, Phd; Zhou, Yongtao Md; Magnius, Lars O. Md, Phd; Wahren, Britta Md, Phd; Linde, Annika Md, Phd : Pediatric Infectious Disease Journal: November 1996 - Vol‐

[9] Viral Encephalitis Richard J. Whitley, M.D. : New England Journel OF Medicine

[10] Enteroviral Infections in Primary Immunodeficiency (PID): A Survey of Morbidity and Mortality : E. Halliday, J. Winkelstein, A.D.B. Webster: science direct: Journal of

[11] Herpes Simplex Encephalitis Clinical AssessmentRichard J. Whitley, MD; Seng-Jaw Soong, PhD; Calvin Linneman Jr, MD; Chien Liu, MD; George Pazin, MD; Charles A. Alford, MD Journal of American medical association (JAMA 1982;247:317-320)

[12] Epstein-Barr Virus Infection : William A. Durbin, John L. Sullivan : Peadiatrics re‐

[13] West Nile Virus: Epidemiology and Clinical Features of an Emerging Epidemic in the United States\* Annual Review of Medicine Vol. 57: 181-194 (Volume publication date February 2006) First published online as a Review in Advance on September 1, 2005

[14] Relman DA, Loutit JS, Schmidt TM, Falkow S, Tompkins LS.The agent of bacillary angiomatosis. An approach to the identification of uncultured pathogens. New Eng‐

view volume 15 number 2, February 1, 1994, pages 63-68

DOI: 10.1146/annurev.med.57.121304.131418

land Journal of Medicine. 1990 Dec 6;323(23):1573-80.

No. 4, April 1932

chiatric publishing incorporated.

Neurology Asia 2008; 13 : pages 2-4

ume 15 - Issue 11 - pp 1018-1024

1990; 323: pages 242-250 : July 26, 1990

Infection, Volume 46, Issue 1, Page 1

jay Gandhi PGIMS, Neurology Asia 2008; 13 : 1 – 13

We have to consider systemic complications as well as CNS complications. Monitoring vital signs continuously is essential in ensuring no sequelae develop and if they do they are swiftly treated. In patients with elevated intracranial pressure (ICP), management with corticosteroids and mannitol should be considered[63]. Corticosteroids are thought to decrease cerebral oedema. Now we should consider treatment targeted to specific symptoms. For example seizures are treated by anticonvulsive therapy. Analgesics may be needed to relieve headaches. Antipyretics may be needed for temperature control. Sedatives may be prescribes for irrita‐ bility or restlessness.

Rare forms of encephalitis include acute disseminated encephalitis and paraneoplastic encephalitis. Acute disseminated encephalomyelitis is treated with high-dose corticosteroids. Plasma exchange can be considered when corticosteroids have not shown any benefit. We can also use treated with high-dose intravenous immunoglobulin (IVIG) [ 64]. Paraneoplastic encephalitis responds to immunotherapy with IVIG or plasma exchange.

#### **5.2. Surgical treatment**

In patients who have failed to respond to therapy to control elevated intracranial pressure or are inevitable at risk of uncal herniation a decompressive craniectomy is indicated. Surgical decompression may reduce changes of serious morbidity and mortality[65].

#### **5.3. Prognosis**

Cerebral inflammation is an indicator of mortality initial leucocytosis and development of se‐ vere hyponatremia is an indicator or increased morbidity and risk of mortality. In Japanese ence‐ phalitis a virus-specific immunoglobulin response is a marker for low risk of mortality[66]. Even though acyclovir reduces risk of mortality a high rate of patients still have morbidities[67].
