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Paediatr Child Health. 1998 Jan-Feb; 3(1): 45–46.
PMCID: PMC2851263

Acute childhood encephalitis and meningoencephalitis

Encephalopathy, the clinical finding of an altered state of consciousness with some or all of headache, neurological signs and fever, presents a difficult diagnostic challenge for physicians. The number of infectious and noninfectious conditions that can present with encephalopathy, with or without cerebrospinal fluid (CSF) pleocytosis, is long and complex. A systematic approach to these patients is required in order to optimize the probability of accurately determining the etiological cause of the illness and to ensure that early specific therapy is initiated. The background paper written by Ford-Jones and colleagues and reviewed by the Canadian Paediatric Society (CPS) Infectious Diseases and Immunization Committee (pages 33–41) reviews the differential diagnosis, course of investigation and current understanding of acute demyelinating encephalomyelitis, and presents the crucial therapeutic alternatives in the management of childhood encephalitis.

The Infectious Diseases and Immunization Committee of the CPS recommends the following.

  1. Clinical evaluation of all children should include questioning to identify patients with encephalopathy. Symptoms of encephalopathy include alterations in the level of consciousness such as lethargy, and behaviour and speech disturbances including dysphasia/aphasia and memory loss. The presence or absence of meningeal irritation as a major or insignificant clinical finding needs to be determined. When encephalopathy is found, careful and thorough questioning for contact risk factors such as antecedent illness, travel and insect bites, must be done.
  2. Children with encephalopathy need to be promptly transferred to a major medical centre if they do not improve within 24 to 48 h to ensure that necessary diagnostic testing (specialized imaging and microbiological assessments) and optimization of the management of seizures and increased intracranial pressure can be carried out. Uncomplicated viral meningoenephalitis or exanthem-related diseases can be managed expectantly, and transfer is not required. Any transfer of the patient should include the provision of supplying a serum sample (and CSF if available) collected early in the hospital admission.
  3. Timely investigation of all children is necessary to identify central nervous system infections that respond to specific therapies, such as acyclovir for acute encephalitis caused by herpes simplex virus and corticosteroid therapy for acute demyelinating encephalomyelitis, and to identify other treatable causes of encephalopathy, such as sepsis, metabolic derangements or vasculitis.
  4. Early consultations with colleagues in neurology, diagnostic imaging and infectious disease may be helpful to delineate the need for empiric anticonvulsant, specific antiviral and corticosteroid therapy.
  5. The clinical course of each child with encephalopathy should be monitored closely and documented on a daily basis. Particular attention should be paid to the changing levels of consciousness, fever, orientation, seizures, autonomic nervous system dysfunction, increased intracranial pressure, and speech and motor disturbances. Attention should be paid to areas outside the nervous system, particularly for evidence of nosocomial infection.
  6. Because children, following encephalopathy, may recall upon recovery discussions that took place around them during their illness, it is prudent to keep such discussions away from the bedside.
  7. Follow-up of all children with encephalopathy for identification of learning or behavioural problems, as well as neurological complications that did not arise until after discharge is recommended. In the case of herpes simplex virus infection, the possibility of relapse or recurrent infection should be considered.

Footnotes

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE

Members: Drs Gilles Delage, Directeur scientifique, Laboratoire de santé publique du Québec, Ste-Anne-de-Bellevue, Québec (chair); François Boucher, Département de pédiatrie, Centre Hospitalier Universitaire de Québec, Québec, Québec; Joanne Embree, Winnipeg, Manitoba; Elizabeth Ford-Jones, Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario (principal author); David Speert, Division of Infectious and Immunological Diseases, University of British Columbia, Vancouver, British Columbia; Ben Tan, Division of Infectious Diseases, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan

Consultants: Drs Noni MacDonald, Division of Infectious Diseases, Children’s Hopsital of Eastern Ontario, Ottawa, Ontario; Victor Marchessault, Cumberland, Ontario

Liaisons: Drs Neal Halsey, Johns Hopkins University, Baltimore Maryland (American Academy of Pediatrics); Susan King, Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario (Canadian Paediatric AIDS Research Group); David Scheifele, Division of Infectious Diseases, BC’s Children’s Hospital, Vancouver, British Columbia (Centre for Vaccine Evaluation); Ms Susan Tamblyn, Perth District Health Unit, Stratford, Ontario (Public Health); Dr John Waters, Provincial Health Officer, Alberta Health, Edmonton, Alberta (Epidemiology)

The recommendations in this Practice Guideline do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.


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