Primary Care Conference May 25, 2005 Becky Byers MD Guest patient Charlie Byers PhD

ENCEPHALITIS: An Inside Account Physician/Spouse Professor/Patient

Clinical Case Patient is now a 58 year old professor. He had had a viral syndrome for approximately one week, then on 3/6/03 felt feverish and chilled; helped kids with homework, then went to bed early. Awoke 3/7/03 with mental status changes including confusion and inability to answer questions appropriately.

Past Medical History Asthma, chronic; well-controlled on Advair 100/50 BID, albuterol prn (seldom needed). Dyslipidemia (baseline HDL 18); on statin and Niaspan. Non-smoker. No hypertension, DM.

ER and Stroke Team Normal enhanced head CT without acute bleed. IV Heparin. Normal head MRI without evidence of acute stroke or perfusion abnormality. Normal MRA of the neck without evidence of focal stenosis. EEG - abnormal, but non-diagnostic.

Lumbar Puncture Nucleated cells 7, 82% lymphocytes, 18% macrophages. No RBCs. Protein 70 (15-45) Glucose 68 (40-80) Gram stain - negative. Admitted to Neuro ICU with probable viral encephalitis.

Neuro ICU Empiric IV ceftriaxone and ampicillin. Empiric IV acyclovir. ID Consult - recommended stopping antibiotics; continue acyclovir 10 mg/kg Q 8 hours. Send CSF for viral culture, HSV PCR, Enteroviruses, LCM, Mycoplasma, AFB/ fungal culture and smear.

Serology for coccidioidomycosis, HIV ELISA, serum cryptococcal antigen, Mycoplasma serology, Enterovirus, and LCM serology. CXR. Consider repeat CSF if not improving over next 24 hours.

Objectives Brief review of causes of encephalitis. Patient perspective of the illness and the recovery process. Living with uncertainty; the power/anxiety of knowing/not knowing “the cause”.

Encephalitis Infection involving brain parenchyma, characterized by cognitive deficits. 20,000 annual viral cases in U.S. Primary vs postinfectious (viral invasion vs immune-mediated disease). Often few, if any, CSF abnormalities with a pure encephalitis (small increase in WBC/ lymphocytes and protein concentration, normal glucose, absence of RBCs).

Viral Infections of the CNS Enteroviruses - Coxsackie A and B Echoviruses Polioviruses Arthropod-borne viruses West Nile virus St. Louis encephalitis virus California encephalitis virus Eastern/Western e.v.

Herpesviruses- Herpes simplex 1 Herpes simplex 2 Cytomegalovirus Varicella zoster virus Epstein Barr virus Simian herpes B virus

Other Viruses HIV Rabies virus Lymphocytic choriomeningitis virus Influenza virus Mumps virus Measles

Diseases Mimicking Viral CNS Infections - Infectious Causes Tuberculosis Partially treated bacterial meningitis Listeria meningitis Spirochetal infection (syphilis, Lyme disease, leptospirosis) Rocky Mountain spotted fever Fungal (cryptococcosis, coccidioidomycosis, histoplasmosis)

Mycoplasma pneumoniae Parameningeal infection (brain abscess, epidural or subdural abscess) Amebic infection Trypanosomiasis Toxoplasmosis Cerebral malaria

Disseminated cat-scratch disease Whipple’s Disease Legionellosis

Noninfectious Causes Tumor Dural venous sinus thrombosis Sarcoidosis Cerebral vasculitis Behcet’s disease Drug-induced meningitis (NSAIDs, sulfa) Migrainous syndromes with pleocytosis

Patient Perspective Anomaly between patient’s ability to understand vs communicate verbally. Comprehension vs emotional response by the patient; associated difficulty for family and doctor to understand patient’s mental state.

Patient Perspective 2 Prolonged nature of rehabilitation; difference between test results and patient perspective. Effect on the patient of the expectation of family and friends to be told definitive etiology.