PRESENTER Dr JeevanMODERATOR Dr Jayakumar

Acute febrile encephalopathy (AFE) is a clinical term used to describe patients presenting with short febrile illnesses with altered mental state

Central nervous system (CNS) infections are the most common causes of altered mental status in patients with nontraumatic coma The various etiologies are virus bacterium or a parasite

In India Cerebral Malaria JE and bacterial meningitis are the common causes of AFE while TBM can present with subacute or chronic history

Most acutely ill febrile patients with encephalopathy can make complete neurological recovery once the underlying cause is identified and treated promptly and appropriately

This study was carried out to evaluate the patients presenting with AFE in a tertiary care center in northern India to understand the etiology and their outcomes over a period of 1 year

Inclusion Criteria

All patients between 14 and 60 years of age with fever of less than 2 weeks duration with altered mentation either at onset or following fever and lasting at least 24 h were enrolled into the study

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Acute febrile encephalopathy (AFE) is a clinical term used to describe patients presenting with short febrile illnesses with altered mental state

Central nervous system (CNS) infections are the most common causes of altered mental status in patients with nontraumatic coma The various etiologies are virus bacterium or a parasite

In India Cerebral Malaria JE and bacterial meningitis are the common causes of AFE while TBM can present with subacute or chronic history

Most acutely ill febrile patients with encephalopathy can make complete neurological recovery once the underlying cause is identified and treated promptly and appropriately

This study was carried out to evaluate the patients presenting with AFE in a tertiary care center in northern India to understand the etiology and their outcomes over a period of 1 year

Inclusion Criteria

All patients between 14 and 60 years of age with fever of less than 2 weeks duration with altered mentation either at onset or following fever and lasting at least 24 h were enrolled into the study

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

In India Cerebral Malaria JE and bacterial meningitis are the common causes of AFE while TBM can present with subacute or chronic history

Most acutely ill febrile patients with encephalopathy can make complete neurological recovery once the underlying cause is identified and treated promptly and appropriately

This study was carried out to evaluate the patients presenting with AFE in a tertiary care center in northern India to understand the etiology and their outcomes over a period of 1 year

Inclusion Criteria

All patients between 14 and 60 years of age with fever of less than 2 weeks duration with altered mentation either at onset or following fever and lasting at least 24 h were enrolled into the study

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

This study was carried out to evaluate the patients presenting with AFE in a tertiary care center in northern India to understand the etiology and their outcomes over a period of 1 year

Inclusion Criteria

All patients between 14 and 60 years of age with fever of less than 2 weeks duration with altered mentation either at onset or following fever and lasting at least 24 h were enrolled into the study

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Inclusion Criteria

All patients between 14 and 60 years of age with fever of less than 2 weeks duration with altered mentation either at onset or following fever and lasting at least 24 h were enrolled into the study

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

patients in whom persistent altered mental state could be attributed to one or more deranged metabolic parameters such as

hypoglycemia (lt50 mgdL) hypoxia (PaO 2 lt 60 mm Hg) hypercarbia (PaCO 2 gt 50 mm Hg) hyponatremia (lt120 mgdL)

hypernatremia (gt150 mgdL) azotemia (serum creatinine gt3 mgdL) ICSOL or endocrinopathies Patients having cerebrovascular diseases

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

A prospective observational study was done in patients aged 14 years or above who were admitted with AFE at a tertiary care centre in northwest India

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Investigations done included hemogram metabolic profile chest radiography and ECG

Peripheral smear for malarial parasite was examined in all the patients A histidine-rich protein-based immunochromatographic card test for falciparum malaria was performed in patients with negative peripheral smears where clinical suspicion for complicated malaria was high

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Samples for blood cultures and urine cultures were collected and any clinically obvious site of sepsis was investigated LP was carried out in all the patients at admission and CSF was analyzed for cytology protein levels glucose gram stain culture sensitivity for microbes and adenosine deaminase levels

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

All patients underwent non-contrast- and CECT of the brain This was followed by a MRI scan of the brain using contrast if required

Tests for detecting IgM antibodies against JE and herpes simplex virus (HSV) in CSF were done in suspected cases of viral encephalitis

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Serological tests for other viral etiologieswere not available in our institute Patients were classified into broad groups of pyogenicmeningitis (PM) viral encephalitis (meningoencephalitis) and other clinical syndromes on the basis of predesigned diagnostic criteria

Modified Rankin Scale (mRS) at the time of discharge and after 1 month follow-up was used to assess the outcome

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Of the total 120 patients studied pyogenicmeningitis was the most common cause accounting for 367 followed by acute viral encephalitis (AVE) in 2833 of the patients (Japanese B encephalitis in 125 herpes simplex virus encephalitis in 333 and other undetermined viral etiology in 125)

Cerebral malaria sepsis associated encephalopathy (SAE) and TBM were diagnosed in 217 917 and 42 of cases respectively

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Of the total 16 patients died 6 with AVE 3 with pyogenic meningitis 3 with cerebral malaria and 4 with SAE

mRS at discharge was gt3 in 14 patients with AVE (P lt 0001) and in the remaining it was lt3 After 1 month mRS was gt3 in six patients with AVE and in the rest it was le1 (P lt 0001)

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Fever with altered mental state is a common symptom complex leading to hospital admissions in both adults and children in our country and is also known as AFE

It is postulated that alteration in sensorium in a patient with CNS infection indicates an element of parenchymal involvement

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

This can explain the altered mental state in patients with meningoencephalitis In CM and leptospirosis primary parenchymalinvolvement may be responsible for encephalopathy

Altered mentation in primary meningealinvolvement is difficult to explain Raised ICP may contribute to altered mentation to some extent Another postulate is the spillage of inflammatory cells to the adjacent brain parenchyma and the resultant parenchymalinvolvement

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

In SAE metabolic alterations and inflammatory cytokines may play an important role in the pathogenesis of encephalopathy rather than direct parenchymal involvement

CT scan brain was performed as baseline imaging in all the patients with AFE firstly to rule out contraindications for lumbar puncture

Enhancement of the meninges was seen on contrast-enhanced CT scan in cases of bacterial meningitis However meningeal enhancement is a nonspecific sign and may also be caused by other different etiologies like carcinomatous meningitis reactive meningitis and inflammatory vascular diseases of CNS

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

MRI brain in patients with HSV encephalitis and JE may have characteristic findings

Bilateral T2 thalamic hyperintensities in particular hemorrhage were the most common finding seen in patients with JE out of seven patients in whom MRI brain was done

MRI brain in patients with HSV encephalitis showed characteristic T2-weighted hyperintensities in the temporal lobes

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

Many acutely ill febrile patients with encephalopathy can make complete recovery once the underlying cause is treated but considerable skill is required to correctly diagnose the underlying etiology

The majority of patients in the study made a complete recovery however a significant number of patients died and a small number of patients were also left with neurologic sequelae

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

To conclude PM is the most common etiology identified followed by acute meningoencephalitis and CM in patients with AFE The outcome in cases with AVE can be fatal or more disabling than other etiologies Higher prevalence of JE is related to geographic and seasonal variations

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

J Emerg Trauma Shock 2010 Jul3(3)220-4

Acute febrile encephalopathy in adults from Northwest India

Bhalla A Suri V Varma S Sharma

Department of Internal Medicine PGIMER

A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months

A total of 33 patients had pyogenicmeningitis 299 had evidence of meningoencephalitis and 127 were diagnosed as sepsis-associated encephalopathy These were followed by cerebral malaria leptospirosis and brain abscess as the cause of febrile encephalopathy in adults

Indian J Pediatr 2009 Nov76(11)1109-11

Clinical and etiological profile of acute febrile encephalopathy in eastern Nepal

Singh RR Chaudhary SK Bhatta NK KhanalB Shah D

Source

Department of Pediatrics and Adolescent Medicine and 1Microbiology BP KoiralaInstitute of Health Sciences Dharan Nepal

Indian J Pediatr 2009 Nov76(11)1109-11

Clinical and etiological profile of acute febrile encephalopathy in eastern Nepal

Singh RR Chaudhary SK Bhatta NK KhanalB Shah D

Source

Department of Pediatrics and Adolescent Medicine and 1Microbiology BP KoiralaInstitute of Health Sciences Dharan Nepal

107 children (aged 1 month to 14 yrs) presenting to the emergency with fever (gt 38 C) of less than 2 weeks duration with altered sensorium withor without seizure were prospectively investigated for etiological cause

Conclusion Pyogenic meningitis and viral encephalitis including JE are the most common causes of acute presentation with fever and encephalopathy