Overview

"Encephalitis" describes conditions in which the brain becomes irritated and

inflamed. As the Mayo Clinic explains, one of the more common causes of
encephalitis is an infection from a virus. These viruses can directly damage the
brain, but the immune response they generate can also be dangerous. Viral
encephalitis can be difficult to treat because viruses cannot be treated with
antibiotics.
Types
As the National Institute of Neurological Diseases and Stroke (NINDS) explains,
there are two types of viral encephalitis. Primary viral encephalitis is caused by a
virus directly infecting the brain. Secondary viral encephalitis is caused by a virus
infecting other tissues in the body and then eventually traveling to the brain.
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Viruses
The Mayo Clinic explains that there are several different viruses that account for the
majority of cases of primary encephalitis. The herpes simplex virus (especially the
HSV 1 strain) is the most common cause of viral encephalitis. Arboviruses, a class of
viruses transmitted by mosquitoes and other insects and include the West Nile
virus, can also lead to encephalitis. Rabies, varicella-zoster (the virus that causes
chickenpox and shingles) and the Epstein-Barr virus can also cause viral
encephalitis.
Pathophysiology
The Merck Manual explains that viral encephalitis can damage neurons via a couple
of different mechanisms. The viral infection itself can damage the neurons. The
infection can cause cells to develop small bits of cellular tissue--called "inclusion
bodies"--which are characteristic of viral damage. Viral infection of the neurons also
can lead to inflammation, which can lead to swelling around the brain and small
hemorrhages to develop, which can also cause permanent brain damage.
Symptoms and Diagnosis
The most common symptoms of viral encephalitis include a severe headache, a
fever and alterations in the patient's mental status. The Merck Manual explains that
patients often will develop seizures. Olfactory seizures (which are manifested by the
patient detecting foul odors, such as rotten eggs, that are not actually present) are
indicative of herpes encephalitis. Viral encephalitis is usually diagnosed using an
MRI of the brain as well as a testing of the patient's cerebrospinal fluid.
Treatment
Many cases of viral encephalitis, according to the Mayo Clinic, are difficult to treat
because some viruses are resistant to antiviral medications. Susceptible viruses can
be treated with antiviral medications (such as acyclovir). Otherwise, most patients
are given supportive care (which includes electrolytes and fluids) and are told to
rest. Severe cases of viral encephalitis can be treated with corticosteroids (to
reduce inflammation) and anti-convulsants (to prevent seizures).

Read more: http://www.livestrong.com/article/102791-pathophysiology-viral-

encephalitis/#ixzz1DNUUnqoX
Encephalitis is inflammation of the parenchyma of the brain, resulting from direct viral invasion.
Acute disseminated encephalomyelitis is brain and spinal cord inflammation caused by a
hypersensitivity reaction to a virus or another foreign protein. Both disorders can be caused by
many viruses. Symptoms include fever, headache, and altered mental status, often
accompanied by seizures or focal neurologic deficits. Diagnosis requires CSF analysis and
neuroimaging. Treatment is supportive and, for certain causes, includes antiviral drugs.

Etiology
Encephalitis may be a primary manifestation or a secondary (postinfectious) immunologic
complication of viral infection.

Primary viral infection: Viruses causing primary encephalitis directly invade the brain. These
infections may be

• Epidemic (eg, due to arbovirus, poliovirus, echovirus, or coxsackievirus)

• Sporadic (eg, due to herpes simplex, rabies, varicella-zoster, or mumps virus)
Mosquito-borne arboviral encephalitides infect people during the spring, summer, and early fall
when the weather is warm. Incidence in the US varies from 150 to > 4000 cases yearly, mostly
in children. Most cases occur during epidemics. Among arboviruses, La Crosse virus (California
virus) is identified as a cause primarily in the north central US. However, the virus is
geographically widespread, and La Crosse encephalitis is probably underrecognized and
accounts for most cases of arbovirus encephalitis in children. Mortality rate is probably < 1%.
Until 1975, St. Louis encephalitis occurred every 10 yr, mostly in the central and eastern US; it
is now rare. As of 2009, West Nile encephalitis has spread from the East Coast, where it first
appeared in 1999, to all of the western states. Mortality rate is about 9%. Small epidemics of
eastern equine encephalitis occur every 10 to 20 yr in the eastern US, mainly among young
children and people > 55. Mortality rate is about 50 to 70%. For unknown reasons, western
equine encephalitis has largely disappeared from the US since 1988.

In the US, the most common sporadic encephalitis is caused by herpes simplex virus (HSV);
hundreds to several thousand cases occur yearly. Most are due to HSV-1, but HSV-2 may be
more common among immunocompromised patients. HSV encephalitis occurs at any time of
the year, tends to affect patients < 20 or > 40 yr, and is often fatal if untreated.
Primary encephalitis can occur as a late consequence of a viral infection. The best known types
are HIV encephalopathy (which causes dementia—see Delirium and Dementia: HIV-Associated
Dementia), subacute sclerosing panencephalitis (which occurs years after a measles infection
and is thought to represent reactivation of the original infection—seeOther Viruses: Subacute
Sclerosing Panencephalitis (SSPE)), and progressive multifocal leukoencephalopathy (which is
caused by reactivation of JC virus—see Other Viruses: Subacute Sclerosing Panencephalitis
(SSPE)).

Immunologic reaction: Encephalitis can occur as a secondary immunologic complication of

certain viral infections or vaccinations. Inflammatory demyelination of the brain and spinal cord
can occur 1 to 3 wk later (as acute disseminated encephalomyelitis); the immune system
attacks one or more CNS antigens that resemble proteins of the infectious agent. The most
common causes used to be measles, rubella, chickenpox, and mumps (all now uncommon
because childhood vaccination is widespread); smallpox vaccine; and live-virus vaccines (eg,
the older rabies vaccines prepared from sheep or goat brain). In the US, most cases now result
from influenza A or B virus, enteroviruses, Epstein-Barr virus, hepatitis A or B virus, or HIV.

Pathophysiology
In acute encephalitis, cerebral edema and petechial hemorrhages occur throughout the
hemispheres, brain stem, cerebellum, and, occasionally, spinal cord. Direct viral invasion of the
brain usually damages neurons, sometimes producing visible inclusion bodies. Severe infection,
particularly untreated HSV encephalitis, can cause brain hemorrhagic necrosis.

Acute disseminated encephalomyelitis is characterized by perivenous demyelination and

absence of virus in the brain.

Symptoms and Signs

Symptoms include fever, headache, and altered mental status, often accompanied by seizures
and focal neurologic deficits. A GI or respiratory prodrome may precede these symptoms.
Meningeal signs are typically mild and less prominent than other manifestations. Status
epilepticus, particularly convulsive status epilepticus, or coma suggests severe brain
inflammation and a poor prognosis. Olfactory seizures, manifested as an aura of foul smells
(rotten eggs, burnt meat), indicate temporal lobe involvement and suggest herpes simplex
encephalitis.

Diagnosis
• MRI
• CSF testing
Encephalitis is suspected in patients with unexplained alterations in mental status. Clinical
presentation and differential diagnoses may suggest certain diagnostic tests, but MRI and CSF
analysis (including PCR for HSV) are usually done, sometimes with other tests to identify the
causative virus. Despite extensive testing, the cause of most cases of encephalitis remains
unknown.

MRI: MRI is sensitive for early HSV encephalitis, showing edema in the orbitofrontal and
temporal areas, which HSV typically infects. MRI shows demyelination in progressive multifocal
leukoencephalopathy and may show basal ganglia and thalamic abnormalities in West Nile and
eastern equine encephalitis. MRI can also exclude lesions that mimic viral encephalitis (eg,
brain abscess, sagittal sinus thrombosis). CT is much less sensitive than MRI for HSV but can
help because it is rapidly available and can exclude disorders that make lumbar puncture risky
(eg, mass lesions, hydrocephalus, cerebral edema).

CSF testing: If encephalitis is present, CSF is characterized by lymphocytic pleocytosis, normal

glucose, mildly elevated protein, and an absence of pathogens using Gram stain and culture
(similar to CSF in aseptic meningitis). CSF abnormalities may not develop until 8 to 24 h after
onset of symptoms. Hemorrhagic necrosis can introduce many RBCs and some neutrophils into
CSF, elevate protein, and modestly lower glucose.

PCR testing of CSF for many viruses (eg, HSV-1, HSV-2, varicella-zoster virus,
cytomegalovirus, West Nile virus, enteroviruses, JC virus) is becoming increasingly available.
PCR for HSV in CSF is sensitive and specific. However, results may not be available rapidly
and, despite advances in technology, false-negative and false-positive results may still occur
due to a variety of causes, not all being technical failures (eg, the blood in a mildly traumatic
CSF tap may inhibit the PCR amplification step).

CSF viral cultures grow enteroviruses but not most other viruses.

CSF viral IgM titers are often useful for diagnosing acute infection, especially West Nile
encephalitis, for which they are more reliable than PCR. Paired acute and convalescent
serologic tests of CSF and blood must be drawn several weeks apart; they can detect an
increase in viral titers specific for certain viral infections.

Brain biopsy: Brain biopsy may be indicated for patients who are worsening, who are
responding poorly to treatment with acyclovir

or another antimicrobial, or who have a lesion that is still undiagnosed.

Prognosis
Mortality rate varies with cause, but severity of epidemics due to the same virus varies during
different years. Permanent neurologic deficits are more likely to occur in infants.

Treatment
• Supportive care
• Acyclovir

for HSV encephalitis

Supportive therapy includes treatment of fever, dehydration, electrolyte disorders, and seizures.
Euvolemia should be maintained.

If HSV encephalitis is suspected, acyclovir

10 mg/kg IV q 8 h is started promptly and continued usually for 14 days. Acyclovir

is relatively nontoxic but can cause liver function abnormalities, bone marrow suppression, and
transient renal failure. Givingacyclovir

IV slowly over 1 h helps prevent nephrotoxicity.

Viral encephalitis
Introduction:
Encephalitis is an inflammation of the brain. Most often, it is caused by a
viral infection. Several different viruses can cause encephalitis. The most
common are the herpes viruses, childhood viruses such as measles, and
viruses transmitted by mosquito bite. There are two types of encephalitis --
primary and secondary. In primary encephalitis, a virus attacks the brain
and spinal cord directly. In secondary encephalitis, the virus invades another
part of your body and travels to your brain. The virus causes inflammation of
the nerve cells (encephalitis) or the surrounding membranes (meningitis).
Encephalitis is different from meningitis, but these two brain infections often
occur together. Most cases of encephalitis are mild and don't last long.
However, in some cases encephalitis can be life threatening. About 10,000 -
20,000 cases of encephalitis are reported annually in the United States.

Signs and Symptoms:

• Ninety percent of people with encephalitis have flu-like symptoms, such as

fever, sore throat, cough, and malaise.
• If meningitis accompanies encephalitis, the person may experience
headache, stiff neck, intolerance to light, and vomiting.
• People with severe encephalitis usually have some change in consciousness,
ranging from mild confusion to coma, often including disorientation and delusion
with possible hallucinations, agitation, and personality changes.
• Up to 50% of people with encephalitis may have seizures.
• Other signs and symptoms of encephalitis depend on which area of the brain
is most affected. These may include an impaired ability to use or comprehend
words or coordinate voluntary muscle movements, muscle weakness or partial
paralysis on one side of the body, uncontrollable tremors or involuntary
movements, and an inability to regulate body temperature.
• Infants may have bulging in the fontanels (soft spots) on the skull.

Causes:

Arboviruses, or viruses carried by insects, are among the most common

causes of viral encephalitis. Some of the major arboviruses that are
transmitted by mosquito include:

• Eastern equine encephalitis -- This infection is relatively rare, with only a few
cases reported each year. However, about half the people who develop severe
symptoms die or suffer permanent brain damage.
 • La Crosse encephalitis -- usually affects children under 16 years of age in the
upper Midwestern United States. It is rarely fatal.
• St. Louis encephalitis -- People in rural Midwestern and southern United
States are primarily affected. Many people have mild symptoms, although
symptoms can be severe in people over age 60. Up to 30% of infected seniors
die of the condition.
• West Nile encephalitis -- Primarily affects people in Africa and the Middle
East, but outbreaks have spread across the United States. Most cases are mild.
Symptoms are most severe in older adults and people with weakened immune
systems, and it can be fatal among those populations.
• Western equine encephalitis -- People in the western United States and
Canada are most at risk. It usually causes a mild infection, except in children
under 1 year of age, who can suffer permanent brain damage.

Other viruses that commonly cause viral encephalitis include:

• Herpes simplex virus type 1 (HSV-1), which is responsible for cold sores
• HSV-2, which is responsible for genital herpes
• Varicella zoster virus, which causes chicken pox and shingles
• Epstein-Barr virus, which causes mononucleosis

Childhood viruses that can cause encephalitis include:

• Measles (rubeola)
• German measles (rubella)
• Mumps

Not all cases of encephalitis are caused by viruses. Some nonviral causes of
encephalitis include:

• Bacterial infection
• Fungal infection
• Parasitic infection
• Noninfectious causes, such as allergic reactions or toxins

Risk Factors:

The following factors may increase your risk of becoming infected with viral
encephalitis:
 • Being very young or an older adult
• Being exposed to mosquitoes or ticks
• Having a weakened immune system
• Not being immunized against measles, mumps, and rubella
• Traveling to areas where viral encephalitis is prevalent

Diagnosis:

Encephalitis is a serious condition, so you should see a doctor if you or your

child starts having symptoms of encephalitis. Diagnosis and initial treatment
usually take place in a hospital. After performing a physical exam, a doctor
may take the following steps to diagnose the condition:

• Blood test -- detects viruses in the blood

• Spinal tap (lumbar puncture) -- detects viruses in the cerebrospinal fluid that
surrounds the brain and spinal cord
• Brain imaging -- magnetic resonance imaging (MRI) and computerized
tomography (CT) scan determine whether swelling is present in the brain
• Electroencephalogram (EEG) -- detects abnormal brain waves

Preventive Care:

The most effective way to prevent encephalitis is to avoid contracting viruses

that lead to encephalitis:

• Protect yourself from mosquitoes. Use insect repellent and wear long pants
and long sleeves. The most effective insect repellents use DEET, picaridin, or oil
of lemon eucalyptus. Do not apply insect repellent to children under 2 years of
age.
• Make sure your child is vaccinated against childhood diseases such as the
measles, mumps, and rubella (MMR).
• Maintain a balanced diet to keep your immune system healthy.

Treatment Approach:

Viral encephalitis is a serious medical condition. Although there are no

specific medications to treat encephalitis, often people with symptoms are
given the antiviral medication acyclovir (Zovirax), which is effective against
herpes simplex and varicella-zoster viruses. Although complementary and
alternative therapies have not been extensively studied for the treatment of
encephalitis, some studies indicate that scalp acupuncture, combined with
proper medication, may aid the healing process. Careful observation and
supportive care, including rest, proper nutrition, and fluids, are a mainstay
of treatment for encephalitis and allow the body to fight the infection. You
should always see your doctor if you have symptoms of encephalitis; don't
try to treat yourself.

Always tell your health care provider about the herbs and supplements you
are using or considering using, as some supplements may interfere with
conventional treatments.

Medications
Medications used to treat viral encephalitis include:

• Acyclovir (Zovirax) -- treats encephalitis caused by HSV, VZV, and EBV

• Ganciclovir (Cytovene) -- treats encephalitis caused by cytomegalovirus and
HSV1
• Anticonvulsant medications -- prevent and treat seizures associated with
encephalitis

Nutrition and Dietary Supplements

Although no specific vitamins or supplements have been shown to reduce
symptoms of encephalitis, following these nutritional tips may help improve
general health and well-being:

• Eat antioxidant foods, including fruits (such as blueberries, cherries, and

tomatoes), and vegetables (such as squash and bell peppers).
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no
allergy), or beans for protein.
• Use healthy oils in foods, such as olive oil or vegetable oil.
• Avoid caffeine, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

These supplements may also improve health:

 • A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-
complex vitamins, and trace minerals, such as magnesium, calcium, zinc and
selenium.
• Omega-3 fatty acids, such as fish oil, one to three times daily, to help
decrease inflammation and help with immunity.
• Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant and for
immune support.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and
muscular support.
• Acetyl-L-carnitine, 500 mg daily, for antioxidant and antiviral activity.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion
CFUs (colony forming units) a day, for maintenance of gastrointestinal and
immune health. You should refrigerate your probiotic supplements for best
results.
• L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal
health and immunity.

Herbs
Herbs are generally a safe way to strengthen and tone the body's systems.
As with any therapy, you should work with your health care provider to get
your problem diagnosed before starting any treatment. You may use herbs
as dried extracts (capsules, powders, teas), glycerites (glycerine extracts),
or tinctures (alcohol extracts). Unless otherwise indicated, you should make
teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for
leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day.

No herbs have been shown to help treat encephalitis. These herbs may help
support general health:

• Green tea (Camellia sinensis) standardized extract, 250 - 500 mg daily, for
antioxidant, anti-inflammatory, and immune effects. Use caffeine-free products.
You may also prepare teas from the leaf of this herb.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a
day, for inflammation and antiviral activity.
• Garlic (Allium sativum), standardized extract, 400 mg two to three times
daily, for immune activity.
• Astragalus (Astragalus membranaceus) standardized extract, 250 - 500 mg
four times daily for immune support and antiviral activity.
 • Elderberry (Sambucus nigra), one to two teaspoonfuls of standardized liquid
extract two to four times daily, for immune support and antiviral activity.

Acupuncture
A study of a small number of people with complications from encephalitis
suggests that acupuncture delivered to the scalp may lessen severe
complications and reduce symptoms. Some practitioners believe that scalp
acupuncture is effective for people with encephalitis because all meridians
converge at the head, and the method can stimulate and
regulate qi (energy) throughout the entire body. More research is needed.

Other Considerations:

Pregnancy
The most common cause of encephalitis in newborns is vaginal delivery by a
mother who is infected with herpes simplex virus 2 (HSV-2). This infection in
newborns is often severe and fatal. For this reason, pregnant women with a
history of HSV-2 infection may be advised to have a cesarean section, even
if there is no sign of an active infection.

Prognosis and Complications

Full recovery from encephalitis can take weeks or months. People recovering
from serious cases may have complications ranging from fatigue and
difficulty concentrating to tremors and personality changes. The most severe
problems associated with encephalitis result from the destruction of nerve
cells in the brain. How severe the complications are depends on the person's
immune system (whether it is healthy or weak) and what infection caused
the encephalitis. For example, many of those infected with Eastern equine
encephalitis and St. Louis encephalitis have permanent brain damage (such
as problems with memory, speech, vision, hearing, muscle control, and
sensation) and a low survival rate. Those infected with Epstein-Barr or
varicella zoster rarely experience any serious complications.

Most cases of encephalitis are mild and people make a full recovery.