Viral encephalitis medical therapy

Template:Encephalitis Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]; João André Alves Silva, M.D. [3]

Overview

Encephalitis is an acute inflammation of the brain, commonly caused by a viral infection. Sometimes, encephalitis can result from a bacterial infection, such as bacterial meningitis, or it may be a complication of other infectious diseases like rabies (viral) or syphilis (bacterial). Certain parasitic or protozoal infestations, such as toxoplasmosis, malaria, or primary amoebic meningoencephalitis, can also cause encephalitis in people with compromised immune systems. Treatment with acyclovir with or without steroids and antibiotics should be initiated as soon as possible. Antiviral agent like acyclovir has been useful in treatment of encephalitis due to herpes simplex virus and varicella zoster. Treatment for other causative agents of encephalitis is mostly supportive.

Medical Therapy

General Considerations

• Reliably tested specific antiviral agents are available only for a few viral agents (e.g. acyclovir or ganciclovir for herpes simplex virus and varicella-zoster encephalitis). Administer the first dose of acyclovir as soon as possible (in the emergency department itself). Acyclovir can be initiated with or without antibiotics or steroids.The advantages of an early antiviral drug administration are:
  • Decreases disease duration
  • Decreases development of latency
  • Decreases development of complications
  • Decreases recurrence
  • Decreases transmission from infected person
• Treatment for Toxoplasma gondii and cytomegalovirus encephalitis are available but are used with limited success
• Treatment is usually symptomatic. In patients who are very sick, supportive treatment, such as mechanical ventilation, is equally important.
• Systemic complications like hypotension, shock, hypoxemia, electrolyte imbalances (hyponatremia, SIADH should be treated promptly.
• Neuroimaging with MRI or CT scan should be done before lumbar puncture especially if raised intracranial pressure is suspected.
• Lab tests like blood samples should be taken before initiation of therapy.
• Bed rest, plenty of fluids and anti-inflammatory drugs to relieve headache and fever should be used.

Empirical Treatment Regimen

• Adult & Pediatrics - Acyclovir, 10 mg/kg body weight, 8hourly, intravenous, for 2-3 weeks.
• Neonatal HSV - Acyclovir 10-15 mg/kg 8hourly, intravenous, for neonatal HSV
• HIV Positive - Foscarnet is generally the treatment of choice given the high incidence of acyclovir resistance in these group of patients.

Treatment for Increased Intracranial Pressure

General

• Elevation of head end of the bed
• Hyperventilation may be used to decrease intra-cranial pressure on emergency basis
• Constant monitoring of neurological status
• Avoid increase in intra cranial pressure i.e. control of straining and coughing
• Antipyretics and analgesic for fever and pain.
• Monitoring and preventing seizures and hypotension.

Drug Therapy

• Furosemide 20 mg iv and mannitol 1 gm/kg intravenously for diuresis (blood pressure and CVP should be monitored while administrating these drugs)
• Dexamethasone 10mg intravenously 6 hourly to decrease cerebral edema.

Encephalitis Drug Summary

Acyclovir

• It is effective for HSV1, HSV2 and varicella zoster.
• It is selectively taken up by the body cells infected with HSV and varicella zoster
• Prompt treatment with acyclovir is useful in decreasing complications, latency and communicability
• Side effects may include nausea, vomiting, diarrhea, loss of appetite, and muscle or joint pain. Rarely, serious adverse effects may include renal and liver functions abnormalities or suppression of bone marrow activity.

Foscarnet

• It is effective against HSV 1, HSV 2 and CMV
• It is useful in patients who have developed resistance or are non-responders against acyclovir for e.g. HIV positive patients
• Drug dosage depends on the renal function of the patient as Foscarnet is excreted through kidneys.

Dexamethasone

• It is used in post-infectious and disseminated encephalitis.
• It may be used as an adjunct with the antiviral agents

Furosemide

• It is used to in encephalitis associated with increased intracranial pressure. The mechanism of action is;
  • It decreases the production of CSF by inhibiting carbonic anhydrase enzymes.
  • Decreases cerebral sodium uptake
  • Inhibits cellular membrane chloride pumps.
• The dose should be individualized for patients

Mannitol

• Used only on short term basis.
• The doses should be individualized based on renal function

Lorazepam

• It is used for treatment of seizures associated with encephalitis.

Empiric Therapy

▸ Click on the following categories to expand treatment regimens.

Empiric Therapy   ▸  Suspected encephalitis   ▸  Antimicrobials based on epidemiology/clinic   ▸  Rickettsial/ Ehrlichial infection   ▸  Acute Disseminated Encephalomyelitis

Suspected encephalitis Preferred Regimen ▸ Acyclovir 10 mg/kg IV q8h in children and adults with normal renal function ▸ Acyclovir 20 mg/kg IV q8h in neonates Antimicrobials based on epidemiology/clinic Preferred Regimen ▸ Please refer to Pathogen-based therapy according to epidemiology and clinical evaluation Rickettsial/ Ehrlichial infection Preferred Regimen ▸ Acyclovir 10 mg/kg IV q8h in children and adults with normal renal function ▸ Acyclovir 20 mg/kg IV q8h in neonates PLUS ▸ Doxycycline 200 mg/d in two divided doses Alternative Regimen ▸ Tetracycline 25-50 mg/kg per day in four divided doses Oral Acute Disseminated Encephalomyelitis Preferred Regimen ▸ Acyclovir 10 mg/kg IV q8h in children and adults with normal renal function ▸ Acyclovir 20 mg/kg IV q8h in neonates PLUS ▸ Corticosteroids

Pathogen-Based Therapy — Viruses

▸ Click on the following categories to expand treatment regimens.

Viruses   ▸  Herpes simplex   ▸  Varicella-zoster virus   ▸  Cytomegalovirus   ▸  Epstein-Barr virus   ▸  Human herpesvirus 6   ▸  B virus   ▸  Influenza virus   ▸  Measles virus   ▸  Nipah virus   ▸  West Nile virus   ▸  Japanese encephalitis virus   ▸  St. Louis encephalitis virus   ▸  HIV   ▸  JC virus Pathogen-Based Therapy — Bacteria ▸ Click on the following categories to expand treatment regimens. Bacteria   ▸  Bartonella bacilliformis   ▸  Bartonella henselae   ▸  Listeria monocytogenes   ▸  Mycoplasma pneumoniae   ▸  Tropheryma whipplei Mycobacteria   ▸  Mycobacterium tuberculosis Rickettsioses and ehrlichioses   ▸  Anaplasma phagocytophilum   ▸  Ehrlichia chaffeensis   ▸  Rickettsia rickettsii   ▸  Coxiella burnetii Spirochetes   ▸  Borrelia burgdorferi   ▸  Treponema pallidum Pathogen-Based Therapy — Fungi, Protozoa and Helminths ▸ Click on the following categories to expand treatment regimens. Fungi   ▸  Coccidioides species   ▸  Cryptococcus neoformans   ▸  Histoplasma capsulatum Bacteria   ▸  Bartonella bacilliformis   ▸  Bartonella henselae   ▸  Listeria monocytogenes   ▸  Mycoplasma pneumoniae   ▸  Tropheryma whipplei Mycobacteria   ▸  Mycobacterium tuberculosis Rickettsioses and ehrlichioses   ▸  Anaplasma phagocytophilum   ▸  Ehrlichia chaffeensis   ▸  Rickettsia rickettsii   ▸  Coxiella burnetii Spirochetes   ▸  Borrelia burgdorferi   ▸  Treponema pallidum Fungi   ▸  Coccidioides species   ▸  Cryptococcus neoformans   ▸  Histoplasma capsulatum style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 305px; background: #A1BCDD; text-align: center;"> Protozoa   ▸  Acanthamoeba   ▸  Balamuthia mandrillaris   ▸  Naegleria fowleri   ▸  Plasmodium falciparum   ▸  Toxoplasma gondii   ▸  Trypanosoma brucei gambiense   ▸  Trypanosoma brucei rhodesiense Helminths   ▸  Baylisascaris procyonis   ▸  Gnathostoma species   ▸  Taenia solium Pathogen-Based Therapy — Postinfectious or Postvaccination status ▸ Click on the following categories to expand treatment regimens. Postinfectious/postvaccination status   ▸  Acute disseminated encephalomyelitis

Herpes simplex Preferred Regimen ▸ Acyclovir 10 mg/kg IV q8h in children and adults with normal renal function ▸ Acyclovir 20 mg/kg IV q8h in neonates

Follow Up Therapy

• Physiotherapy
• Occupational therapy
• Speech therapy
• Psychotherapy