Viral Encephalitis - DOC

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					                        Viral Encephalitis

                                By

                   Prof Dr Amr Abd El Fatah

  A 23 year old female patient medically free by history —
 presented to E.R with disturbed conscious level with no
                   history of trauma.

G.C.S 10/15: E4 V1 M5 with marked weakness on the left       —
side.

the patient was intubated for suspicion of aspiration (bulbar
palsy) and was transeferred to the ICU.

-Examination

Pupils: bilateral equal and reactive.   —

Marked left hemiparesis.    —

Vital data: pulse 90 bpm , Bp 110/60, RR 28 breath/min.      —

Neck rigidity was noticed So CSF sampling was ordered.

Investigations

C.T brain with contrast was done that revealed hypodense         —
area at the right tempro-parietal region

Full labs ordered with no abnormality was detected.    —

Day 1:

Medications:

Rocephin 2 gm /24 hrs.      —
Unasyn 3 gm/12 hrs.      Mannitol 100 ml / 8 hrs.                    —


Decadrone amp. /8 hrs.        —

The next day the patient showed marked respiratory distress,

                                  ABG :

                  PH 7.49              HCo3:         —

                  P02 :60                 So2:   —

                             Pco2:59      —

        So mechanical ventilation started SIMV mode

The following labs were also ordered

AntiDNA antiRNA CRP ESR           —

CSF sample results showed :

— Culture and sensitivity: no growth

Cytology: no pus cells   —

Chemistry :

Glucose 9 , protein : 715

So Zoferax was added

Patient motor power was gradually improved especially            —
on the right side.

Fever subsided with the new Antibiotic regimen.          —

Physiotherapy stuff members were consulted and               —
sessions of physiotherapy were orded.
Patient is now ready for discharge
Commentary:
D.D.

              Viral ( Herpetic ) Encephalitis
              Viral meningo-encephalitis
              Bacterial meningo-encephalitis
              Auto-immune vasculopathic encephalitis ( SLE, R.A., Scleroderma
               ..etc)
              Brain Abscess
              Epidural and Subdural Infections
              Neoplasms, Brain
              Stroke, Hemorrhagic
              Stroke, Ischemic




Most properly Things in favor of Viral ( Herpetic ) Encephalitis

   CSF report
   Radiology Findings


CSF sample results showed:
Culture and sensitivity: no growth
—Cytology: no pus cells      —
—Chemistry :
 Glucose 9 , protein : 715
( in viral enchpalitis Protein levels are elevated to the range 60-700 mg/dL (average,
100 mg/dL).
Glucose values may be normal or mildly decreased (30-40 mg/dL).
http://emedicine.medscape.com/article/792486-workup#a0719
Radiology findings:

In adults, CT scans classically reveal hypodensity in the temporal lobes either
unilaterally or bilaterally. with or without frontal lobe involvement. Hemorrhage is
usually not observed. A gyral or patchy parenchymal pattern of enhancement is
observed. Contrast enhancement generally occurs later in the disease process.
analyses in a case of biopsy-proven herpes simplex encephalitis. Eur Neurol.
1991;31(6):372-5. [Medline].

                                              -weighted MRI in herpes simplex
encephalitis: a report of three cases. Neuroradiology. Feb 2004;46(2):122-5.
[Medline].

              Bryant KK, Puri V. West Nile virus encephalitis in a child with left-
side weakness. Clin Infect Dis. Sep 15 2003;37(6):e91-4. [Medline].

                                    EJ, Leeds NE. CT in the early diagnosis of herpes simplex encephalitis. AJR
Am J Roentgenol. Jan 1980;134(1):61-6


Some questions:
         o What was her CXR on admission any consolidation , pneumonic patches
           indicating aspiration.
         o Since she was intubated early why not commenced on mechanical
           ventilation to :
                       control PaCO2
                       provide proper sedation to minimize exhaustion coughing and
                        bucking on ETT
         o Adding low level PEEP which is lost by ETT to prevent atelectasis in
           patient with suspected aspiration.

o If you suspected bacterial meningo-encepahilits the antibiotic regimen is
  ceftriaxone (Rocephin 2gm /12hrs) or Cefotaxime 2gm /4-6hrs +
  Dexamethasone0.15mg/kg prior to rocephin to inhibit the TNF formation +
  Vancomycin. 1 gm/12 hrs

o In viral encephalitis Acyclovir 10-15 mg/kg / 8hrs for 14-21 days +
  dexamethasone as before.

o Why the Rt side improved while the pathology is Rt temporal lobe in the left limb
  did she had a Rt. weakness as well?

				
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posted:6/9/2012
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