Encephalitis

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ENCEPHALITISPresentator : Pirhot L M Y Siahaan

Supervisor : Dr. Hj. Melda Deliana Sp. A (K)

PEDIATRIC DIVISONHAJI ADAM MALIK HOSPITAL

FACULTY OF MEDICINEUNIVERSITAS SUMATERA UTARA

Case Report

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Definition

enkephalos + -it is meaning brain inflammation

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Epidemiology

• In United States at 3.5-7.4 per 100,000 persons per year

• Japanese virus encephalitis (JE), occurring principally in Japan, Southeast Asia, China, and India, is the most common viral encephalitis outside the United States.

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Etiology• Here are some of the more common causes

of encephalitis:– Herpes viruses (HSV, VZV,EBV)– Childhood infections (Measless, mumps, rubella)– Arboviruses

• Eastern equine encephalitis• Western equine encephalitis• St. Louis encephalitis• La Crosse encephalitis• West Nile encephalitis

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Pathophysiology

Portals of entry are virus specific the virus replicates outside the CNS and gains entry either by HEMATOGENOUS SPREAD or by TRAVELING ALONG NEURAL (rabies, HSV, VZV) and olfactory (HSV) pathways across the blood-brain barrier, the virus enters neural cells, with resultant disruption in cell functioning, perivascular congestion, hemorrhage, and inflammatory response diffusely affecting gray matter disproportionately to white matter viruses that invade gray matter directly, acute disseminated encephalitis and postinfectious encephalomyelitis (PIE), secondary to measles (most common), Epstein-Barr virus (EBV), and CMV, are immune-mediated processes, which result in multifocal demyelination of perivenous white matter.

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Clinical Manifestation

• high fever (102° F to 105° F [38.9° C to 40.6° C]), severe headache, and vomiting

• drowsiness• disorientation• seizures• paralysis• delirium• coma.

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Examination• Laboratory Findings

– Complete blood count (CBC) with differential: Findings are usually within the reference range

Condition Pressure

(cmH2O)

Cell Count

(WBC/

mm3)

Cell TypeGlucose

(mg/dL)

Protein

(mg/dL)

Normal 9-18 0-5 Lymph 50-75 15-40

Bacterial

Meningitis

20-50 100-

100.000

>80%

PMN<40 /N 10-1000

Viral

meningitis/

encephalitis

9-20 10-500Lymph(early

PMN)

N50-100

TB

meningitis

18-30 <500 Lymph<50 /N

100-300

Cryptococc

al

meningitis

18-30 100-200 Lymph<40 /N

50-300

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• Imaging NORMAL (to dfferentiate

with SOL, intracranial haemorrhage)

• EEG characteristic paroxysmal

lateral epileptiform discharges

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Treatment

• Increased intracranial pressure should be managed in the ICU setting with head elevation, gentle diuresis, mannitol, and hyperventilation.

• Seizures Phenytoin and valproic acid can be administered intravenously. Phenytoin and carbamazepine can be administered when oral or intragastric drug administration is possible. Benzodiazepines are also important when used to abort status epilepticus.

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• Medication :– No specific treatment is available for the

arbovirus encephalitides – Pharmacotherapy for herpesvirus

encephalitis consists of acyclovir and vidarabine

– recombinant interferon alpha is currently being assessed in a trial for Japanese B encephalitis

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Prognosis

• If the therapy is timely, the prognosis is good patient suffers from some symptoms even after the treatment (sequelae)

• When treatment is delayed, permanent brain damage or death is more likely, especially in very young children and older people

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Prevention

• The most effective way to prevent viral encephalitis is to try to prevent the illnesses that can cause it.

• Keeping immunizations current for common childhood illnesses, such as measles, mumps, and chicken pox.

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Anamnesis

• Personal Anamnesis

– Name: Bendri Turnip – Sex : Male – Age : 1 month old– BW : 2,7 kg– BL : 50,3 cm – Address : Jl. – Date of hospitalized :

March 8th 2009

•History of immunization

– BCG : -– DPT : ? – POLIO : ?– CAMPAK : ?– HEPATITIS : ?– Interpretation :

unclear

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AnamnesisMain problem : Black fecesAnalize :

– It had been happened for three days ago , frequently 3x/ day, volume ± 10 - 15 cc/x. There are no blood that mix in feces, and no LENDIR

– Black vomiting has found about 3 days ago frequently 3x/ day, volume ± 5 cc/x, and there was a bloody vomitting right now

– Fever was founded since 2 weeks ago, high fever, sometimes the temperature increase and decrease, normally by giving antipyretic drugs.

– Jaudice (+) when her age was 2 weeks– Pale (+) in 3 days ago– Lazy to drink (+) 2 days ago– Low pitched cry (+) 2 days ago– Urinary abnormal, with tea appearance 1 weeks ago– History of birth : spontan, helped with midwife, low age (8 month), spontaneus

crying (-), blue baby?, shortness of breathing? Weight of the new born baby: 2500 gram

– History of food : formula milk: 0-1 weeks age. ASI: 1 weeks until nowHistory of disease : This patent was delivered from the doctor in Deli Serdang hospital

with the diagnose of anemia ec?.

History of drugs : O2 and RL

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Physical Examination

• Status present– Body weight : 2,7 kg, body length : 50,3

cm, axilla temperature : 37,9 oC– Consciousness : CM– Anemic (+), icteric (+), cyanotic (-),

edema (-), dyspnoe (-)

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•Status localisata

– Head : oppened scalp, with icteric faceEyes : Inferior palpebra conjunctiva was pale, sclera (+) icteric, light reflexes +/+, pupils were isochoricMouth : dry & pale muccouseEars & nose : within normal limit.

– Neck : There were no lymph node enlargement ,nuchal rigidity (-).– Chest : Fusiformic of simetrical, retraction was not seen, icteric (+)

• HR : 134 bpm, regulare, murmur (+) sistolik grade III/6 in LMCS ICR III-IV• RR : 52 bpm, regulare, ronchi was not found

– Abdomen : distention was found, normal peristaltis sound, icteric (+)Liver: palpated 6 cm bellow right arcus costa, smooth and sharp edgeSpleen: palpated S 1-2

– Extremities : pulse was 134 bpm, regulare, p/v was good, CTR < 3”, pale (+), icteric (+)

– Genital : male, within normal limit.– Refleks physiologic right left

• APR/KPR +/+ +/+– Refleks pathologic - -

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Laboratory finding at 3rd February 2009

• Hb : 9,6 gr/dL• Ht : 29,0%• Leu : 10.800/mm3• Tromb : 188.000/mm3 • Ureum/Cr : 21/0,7 GFR = 91,2• SGOT/SGPT : 17/7• KGD adrandom: 111• Na/K/Cl : 131/3,6/100

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• Differential Diagnosis :– Neonatal Sepsis– Neonatal Hepatitis

• Working Diagnosis :– Neonatal Sepsis

• Treatment :– O2 0,5-1 L/i– IVFD D5 % NaCl 0,225 % 4

gtt/i mikro– Inj. Gentamycin 12

mg/24hours/iv skin test– Inj. Ampicillin 125 mg/8

hours/iv skin test– Transfused PRC 10cc/12

hours– Diet ASI/NGT 50 cc/3 hours

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• Planning : – Complete Blood Count, urin and feces analize– Giemsa-stained thick or thin film of peripheral blood – LFT/RFT– Total/direct Billirubin– Albumin– CRP– Blood culture & sensitivity test– Screening hepatitis– Blood glucose test– Electrolit– HST

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Follow up 4 – 5th February 2009S Decreasing of consciousness (+), Fever (+)

O SP Temp : 38 - 39oC BW : 32 kg GCS : 11 : e : 4 m : 3 v : 4

Head Eyes : Pale of inferior palpebre conjunctiva (-), icteric (-), light reflexes +/+, isochoric pupils. Ears, nose, and mouth : within normal limit

Neck Lymph node enlargment (-), nuchal rigidity (+)

Thoraks SF, retraction (-) HR : 120 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-)

Abdomen

Soft and flexible, normal peristaltic sound

Extremitas

Pulse : 120 bpm,regular, p/v was good BP : 110/70 mmHg

A DD/ Encephalitis Meningoencephalitis Meningitis

P 02 3 L/iHead elevation 30o IVFD D 5% NaCl 0,45% 10 gtt/i makroInj. Cefotaxim 1gr/8 hours/ivInj. Ampicillin 1 gr/6 hours/ivPhenytoin drip 75 mg/12 hours /iv 20 gtt/i mikroManitol 20% 24 gr/8 hours/iv 240 gtt/i mikroParacetamol 3 x 500 mg (if needed)Diet SV 1750 Kkal with 60 gr protein

Consul to neurology 5th February 2009 Phenytoin : Loading dose : 20 mg/kgBB Maintenance : 5 mg/kgBBManitol 20 % 24 gr/8 hours/iv Water Balance Chek blood electrolyte everdayMantoux test : -LP : None (-), Pandy (-)

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Follow up 6 – 7th February 2009S Decreasing of consciousness (+), Fever (-)

O SP Temp : 36,8 - 37oC BW : 32 kg GCS : 10 : e : 4 m : 2 v : 4



Thoraks SF, retraction (-) HR : 94 - 100 bpm, reg, murmur (-) RR : 28 - 36 tpm, reg, crackle (-)

Abdomen


Extremitas

Pulse : 94 - 100 bpm,regular, p/v was good BP : 100/70 mmHg



Head CT Scan result : There was no SOL or intracranial haemorrhage Laboratory finding : WBC : 6,7 K/uL RBC : 3,70 M/uL Na : 136 HGB : 9,6 g/dL K : 4,2 HCT : 28,5% Ca : 7,8 MCV : 76,9 fL Cl : 103 MCH : 25,9 pg PLT : 282 K/uL

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Follow up 8 – 9th February 2009S Increasing of consciousness (+), Fever (-)




Thoraks SF, retraction (-) HR :88 - 92 bpm, reg, murmur (-) RR : 24 - 30 tpm, reg, crackle (-)

Abdomen


Extremitas

Pulse : 88 -92 bpm,regular, p/v was good BP : 100/70 mmHg



Laboratory finding :Na : 136K : 4,2Cl : 103

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Follow up 10 – 12th February 2009S Decreasing of consciousness (-), Fever (-)



Neck Lymph node enlargment (-), nuchal rigidity (-)

Thoraks SF, retraction (-) HR :88 - 92 bpm, reg, murmur (-) RR : 24 - 28 tpm, reg, crackle (-)

Abdomen


Extremitas



P Head elevation 30o IVFD D 5% NaCl 0,45% 10 gtt/i makro aff, using threewayInj. Cefotaxim 1gr/8 hours/ivInj. Ampicillin 1 gr/6 hours/ivPhenytoin drip 75 mg/12 hours /iv 20 gtt/i mikroManitol 20% 24 gr/8 hours/iv 240 gtt/i mikro affParacetamol 3 x 500 mg (if needed)Diet MII 1750 Kkal with 40 gr proteinPhysiotherapy

Consult to neurology : IVFD aff using threeway Manitol affCSF analize : Colour : clear LDH : 46 Glukosa : 51 Protein : 16 pH : 8,5Laboratory finding :Na : 140 Ca : 7,5K : 4,45Cl : 105

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Follow up 13 – 15th February 2009S Decreasing of consciousness (-), Fever (-), convulsion (-)




Thoraks Simetrical Fusiformis, retraction (-) HR :88 - 92 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-)

Abdomen


Extremitas


A Encephalitis

P Using threewayInj. Cefotaxim 1gr/8 hours/ivInj. Ampicillin 1 gr/6 hours/ivPhenytoin drip 75 mg/12 hours /iv 20 gtt/i mikroParacetamol 3 x 500 mg (if needed)Diet MII 1750 Kkal with 40 gr proteinPhysiotherapy

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Follow up 16 – 17th February 2009

S Decreasing of consciousness (-), Fever (-), convulsion (-)




Thoraks Simetrical Fusiformis, retraction (-) HR :88 - 92 bpm, regular, murmur (-) RR : 24 - 28 tpm, regular, crackle (-)

Abdomen


Extremitas


A Encephalitis

P Using threewayInj. Cefotaxim 1gr/8 hours/ivInj. Ampicillin 1 gr/6 hours/ivPhenytoin drip 75 mg/12 hours /iv 20 gtt/i mikro tappering offParacetamol 3 x 500 mg (if needed)Diet MII 1750 Kkal with 40 gr proteinPhysiotherapy

17th February 2009, the patient discharge (PAPS) from the hospital

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Documents

Encephalitis