Upload
marjorie-franklin
View
218
Download
0
Embed Size (px)
Citation preview
EncephalitiEncephalitiss
Dr.Ibrahim Khasraw Jaf
Department of Pediatrics
School of Medicine
Sulaymani University
Definition-:
It is inflammatory process of the brain parenchyma , mainly caused by special types of viruses , leading to mortality and morbidity among
children due to cerebral dysfunction.
Classification-:
According to the onset;
Acute: abrupt onset with rapidly developing clinical features , e.g.: enteroviruse , herpes
simplex virus encephalitis.
Subacute: slower developing symptoms within days to few weeks , e.g.: measles ,
HIV.
Chronic: develop over long period(months),
e.g.: S.S.P.E. , T.B . .
Classification (continue..)-:
According to anatomical site of involvement;
Focal: when one or more points of the brain lobes involved like , temporal , parietal
lobes of the brain , limbic system.
Diffuse: (generalized) when whole brain tissues involved .
Classification (continue..)-:
According to pathological process;
Direct: when the infective agent itself invade the brain and induce inflammation.
Indirect (post infectious) : when the infectious agent , after cure induce immune mediated inflammatory reaction in the brain due to antibody-antigen reaction , e.g.: post ,
chickenpox crebellitis .
Etiology-:
Viral : includes these viruses according to the incidence.
Enteroviruses : about 50% of cases due to these groups of viruses , e.g.: coxachi &
echo viruses (non polio viruses).
Herpes virus group : about 10-20% of cases (herpes simplex virus , Epstein-Barr virus , cytomegalovirus , varicella zoster virus ,
human herpes viruse 6,7 ).
Etiology (continue..)-:
Other viruses : may be caused by viruses which cause systemic diseases rarely as a part of complication they cause encephalitis like influenza virus , measles , mumps ,
rubella (german measles) , rabies , HIV.
Nonviral causes : (mainly bacteria) : like mycoplasma , rickettsia , fungi , parasites , mychobacterium(T.B.) , collagen tissue ,
e.g.: S.L.E. .
1/3rd of cases still no cause could be found.
Clinical features-:
-The onset is sudden or insidious (gradual). -Prodromal phase usually starts with flue-like
illness with cough , sore throat , fever. -Headache , nausea , vomiting , blurring of
vision , papillodema (due to increase intra cranial pressure) .
-Disturbance of consciousness , from lethargy to deep coma ,covulsion.
-Focal neurological signs : according to area involved.
-Skin rash & conjunctivitis in special types.
Diagnosis-:
- -C.S.F. : show lymphocytic pleocytosis , slight increase in protein with normal sugar (only decreased in mumps encephalitis) occasionally may be normal . Very high protein with very low sugar suggestive of tuberculus
infection (e.g.: tuberculoma ).
-E.E.G. : show diffuse slow wave , focal changes e.g.: temporal lobe abnormal finding
highly suggestive of herpes simplex virus.
Diagnosis (continue..)-:
-Neuro imaging : C.T. scan , M.R.I. may be normal but may show focal lesion according
to the site involved or may show diffuse brain swelling . Temporal lobe lesion suggestive of
herpes simplex virus(H.S.V.).
-Serology : antibody-antigen reaction test rising of titer against special virus like H.S.V.
4 fold or Igm type significant .
Diagnosis (continue..)-:
-Viral culture of C.S.F. , urine , stool , nasopharyngeal swab commonly reveal the
virus.
-P.C.R. : it is identify the virus through its DNA , it is highly specific and sensitive for C.S.F. ,
nowadays replaced the brain biopsy.
-Brain biopsy : the last and invasive procedure rarely done for special types like T.B. & non infectious causes
Differential diagnosis-:
-Reye syndrome(aform of hepatic encephalopathy).
-Hypoglycemia.
-Collagen vascular disease (C.V.A.).
-Drugs & toxins.
-Hypertensive encephalopathy.
Treatment-:
Non specific : measures to be taken like admission to I.C.U. then A,B,C,D.
Control convulsions by phenobarbiton.
Decrease intra cranial pressure by dexametasone
and or mannitol.
Pay attention to fluid & electrolytes.
Treatment (continue..)-:
Specific : intra venous acyclovir for H.S.V , V.Z.V. they are only viruses susceptible to drug therapy , otherwise there is no specific
treatment for other viral encephalitis.
Antibiotics for bacterial causes , e.g.: mycoplasma (erythromycin) , T.B. (anti T.B.).
Others according to the cause , e.g. steroid for S.L.E. .
Complication -:
Happen when there was no recovery within 2-3 weeks and they are common in spite of
proper treatment like;
-Death : generally occur in about 5% of cases.
-Paresis , spasticity , ataxia.
-Cognitive impairment.
-Epilepsy due to recurrent seizures.
Prevention-:
Only two viral forms of encephalitis could be prevented by vaccination against them , they are influenza virus and rabies virus vaccines done for
whom they are liable to get them.
Figure: EBV encephalitis. a Axial FLAIR image demonstrates abnormal T2-W signal in the bilateral frontal cortex and subcortical white matter. This is a typical pattern for viral encephalitis. The multiple vascular territories involved make ischemia unlikely. Additionally, a child presenting with multifocal strokes of this magnitude would have a profound clinical presentation with fixed neurologic deficits. b, c Axial (b) and coronal (c) FLAIR images demonstrate increased signal in the bilateral basal ganglia reflecting the unique tropism of EBV for this area
Meningitis :Definition:
It’s inflammation of leptomeninges caused by pathogenic microorganisms:
Bacteria:-strept.pneumoniae ,H.infleunzae ,meningococus
Viruses:- H.S.V,H.I.V,C.M.V,Mumps,enterovirus, HLCM.
Fungi:-coccidiomycosis,Histoplasmosis,
Uncommon:-Lyme disease ,catscratch dis. ,T.B. ,Toxoplasmosis,
Entameba: Acanthomeba
:Acute bacterial(septic)meningitis-:Bacteriology:
-Strept.pn.,nowadays commonest one -H.infleunzae,about 5% of cases(b.of vaccination.)
-Meningococcus (Niserea meningitidis) .rare but most serious and Weakest bacterium.
-Staph.aureas, common in post-surgical cases&penetrated wounds.
-Pneunococcus:in fracture base of skull &C.S.F leak
Clinical features:
*It’s variable according to the age of the patient:
-Neonates and infants:
*Fever or hypothermia, drowsiness' or irritability
*Tense anterior fontanel, convulsion, unexplained
*Repeated vomitting,lethargy, relactant to feed.
-Older aged children:
, meningisim *headache ,repeated vomiting ,toxicity (neck stiffness ,kerning&brudzinesky signs.)
C.F.continue:Skin rash in form of purpura ,called purpura
Fulminance(in meningococcemia)
Adrenal hemorrhag:shock state called (water -house fridrichsen syndrom)
-Signs of increase intracranial pressure (hypertention,bradycardia ,irregular respiration).
-Focal nearological signs: ptosis , 6th N.pulsy, anisocoria
Usually there's no papilodema.
Diagnosis:
-C.B.P. :Shows neutrophil leukocytosis,with picture ofacute bacterial inf.
-Positive acute phase reactants: high E.S.R.,+Ve C.R.P
-Blood culture &sensitivity may be +ve in about 90%
of cases.
-L.P for C.S.F. examination: us .show increase preasure, cell count,(majority are neutrophils),protein ,
&decrease sugar,coloure may be turbid.
-Signs of consumptive coageolopathy.or D.I.C.in
meningococcemia .
Contraindications of L.P:.
*Cardiopulmonary instability
*Infection in the site of L.P.
*Bleeding tendency.
*Papillodema.( absolute C.I.)
Normal C.S.F. parameter:
*Colure : clear
*pressure: <160mmH2O
*Cell count: 0-5Lymphocytes, No Neutrophils
*Protein: 15-35mg/dl
*Sugar: 50-80mg/dl(or 2/3rd of blood sugar)
*Culture: -ve .
But normal C.S.F. doesn't exclude meningitis.
D.Dx-:
*Encephalitis
*Intracranial hemorrhage.
*Encephalopathy.
*Posterior fossa tumore.
Treatment:
-Its one of ped. Top medical emergensy.
-Admission to hospital &in special isolated word.
-Control convulsion.
-Give I.V. fluid 2/3red of the daily requirement(to pre
-vent S.I.A.D.H.(
-Anti-biotics :Empirical choice is combination of vancomycine +one of third genration cephalosporins
-)cefotaxime or ceftriaxon (double of the simple dose.
-Steroid:Dexamethasone twice daily for two days.
Comlications:
*Early :Sub-dural effusion, Hydrocephalus,c.v.a .
Cerebral herniaition ,D.I.C, Adrenl hemorrhage
)water-house fridrichsen syndrome(
*Late :cerebral abscess ,cerebral pulsy,mental retardation, epilepsy, deafness,blindness .
Prevention: *Meningococcal vaccine for overcrowded areas
* Pneumococal vaccine: for Immune compromised children .
* Chemoprophylaxis.:Rifampicin10mg/kg/dos
12hourly for 2 days for contacts with meningoco- Ccemia .
& 10mg/kg/day single dose for 4days in H.infl.
- single inj. Of ceftriaxon ,oral ciprofloxacine are
Ulternatives.
THE END THANKS