Diagnosis and Management of Acute Encephalitis in Children

Pediatric non-congenital central nervous system infections: role of imaging in the emergency department

Neurological emergencies in pediatric patients, including central nervous system infections like meningitis and encephalitis, account for significant morbidity and mortality. Neuroimaging plays an important role in the management of these infections, especially when children present with non-specific symptoms such as fever, seizures, or altered consciousness. While computed tomography scans are typically the initial imaging step, magnetic resonance imaging is preferred for its superior detail and lack of ionizing radiation. Radiologists play a crucial role in guiding clinicians to select the appropriate imaging modality based on clinical presentation, patient age, and available technology. Optimizing techniques for these studies may help to give an overview of imaging protocols and an optimal diagnostic algorithm for these patients. In this article, we delineate the prevalent radiological manifestations associated with the primary etiological agents of central nervous system infections, encompassing bacteria, fungi, viruses, and parasites. Furthermore, we share our clinical experience with particular radiologic findings in select pathologies, underscoring the critical importance of evaluating these non-congenital infections within the context of emergency medical care.

The role of immunoglobulin in cerebrospinal fluid on the differential diagnosis of autoimmune encephalitis and viral encephalitis in children

BACKGROUND

A case-control study was conducted to analyze the role of cerebrospinal fluid immunoglobulin in the differential diagnosis of autoimmune encephalitis and viral encephalitis in children.

METHODS

One hundred and twenty patients with autoimmune encephalitis (AE) treated in our hospital from February 2021 to February 2022 were included as the observation group (AE group). 100 patients with viral encephalitis (VE group) were selected as the control group. The clinical data of all patients were collected and analyzed retrospectively. Immunoglobulin G (IgG) and immunoglobulin A (IgA)in cerebrospinal fluid of the two patients were measured by immune turbidimetry. Immunoglobulin M (IgM), and the diagnostic value of immunoglobulin in cerebrospinal fluid (CSF) in patients with AE was analyzed by receiver working curve (ROC).

RESULTS

The level of IgG in the cerebrospinal fluid of the AE group was higher than that of the VE group, and the level of IgM was lower than that of the VE group, and the difference was statistically significant (P < 0.05). There was no significant difference in IgA levels between the two groups (P > 0.05). In terms of Magnetic Resonance (MR) features, the paraventricular, hippocampal, occipital and parietal lobes were more involved in AE patients, frontal and temporal lobes were more involved in VE patients, and paraventricular and occipital lobes were involved in MS. The proportion of bilateral extensive lesions in both groups was significantly higher than 50%. The proportions of patients in the AE group involving the lateral ventricle, insula, and parietal lobes were significantly higher than those in the VE group, and the proportions involving the basal ganglia, temporal lobes, and frontal lobes were significantly lower than those in the VE group, and the differences were statistically significant (All P < 0.05). The Area Under Curve (AUC) of IgG, IgA and IgM alone in the diagnosis of AE were 0.795(0.587-0.762), 0.602(0.502-0.631) and 0.627(0.534-0.708), respectively with the sensitivity values of 81.24% and 65.608, respectively and the specificity values of 65.08%, 57.54% and 75.01% respectively. The AUC of IgA + IgM in the diagnosis of AE was 0.733(0.617-0.849), and the sensitivity and specificity are 62.58% and 75.07% respectively. The AUC of IgA + IgG in the diagnosis of AE was 0.823(0.730-0.917), and the sensitivity and specificity were 81.24% and 67.54% respectively. The AUC of IgG + IgM in the diagnosis of AE was 0.886(0.814 ~ 0.958), and the sensitivity and specificity were 84.48% and 77.59% respectively. The AUC of IgA + IgM + IgG in the diagnosis of AE was 0.924 (0.868-0.981) with the sensitivity of 93.82%, and the specificity of 77.56%.

CONCLUSION

The level of immunoglobulin in cerebrospinal fluid can be used as an effective reference index for the diagnosis of AE. The combined detection of IgA, IgM and IgG can improve the accuracy, sensitivity and specificity of AE.

Genetic causes of infection induced encephalitis

INTRODUCTION

Patients with encephalitis following a viral infection are often thought to have a para infectious, inflammatory, or autoimmune cause for their presentation. These diagnoses usually result in treatments with immunosuppressant therapies which can have side effects. However, there is an increasing body of evidence demonstrating that patients can have a direct genetic cause mediating viral infection triggered encephalitis, where inflammation is a secondary response. These patients may benefit not from immunosuppressive therapies, but from protection from infection through dedicated immunisation programs and early antiviral therapies at times of infection.

METHODS

A small case series of paediatric neurology patients (n = 2) from a single institution with infection induced encephalitis and an underlying genetic cause, is presented. Patients with a confirmed genetic cause of infection induced encephalitis were identified and consented by their treating neurologist for inclusion in this case series. Ethics approval was gained for this case series and review of the surrounding literature.

CONCLUSION

A case of both DBR1 and NUP214 genetic changes resulting in infection induced encephalitis is presented. This case series raises awareness of this rare group of disorders and provides clues to their identification. Features to prompt clinician consideration of such genetic conditions are also highlighted. Although rare, identification of these patients is important due to implications on treatment, prognosis, and family planning.

Role of physical therapy intervention in acute disseminated encephalomyelitis

We reported a case of a school-going child, diagnosed with acute disseminated encephalomyelitis (ADEM) who presented with symptoms such as high fever, acute hemiplegia and ataxia and was referred for physiotherapeutic intervention. This case report aims to document the assessment and management of ADEM from the intensive care unit to the home setting by physical therapy. Also, the child developed ventilator-associated pneumonia and a right lower motor neuron facial injury for which the child was referred to paediatric physical therapy. Since then, continuing for 8 months has helped the child to be independent in all aspects of mobility with no complaints. The child showed improvement in WeeFIM scores and Sunnybrook facial grading after 99 sessions of intensive physical therapy for approximately 83 hours along with the home programme. It has been proven an efficient treatment method along with other medical lines of treatment for neurological impairment associated with ADEM.

Effect of Pediatric Rehabilitation on Children With Viral Encephalitis: A Case Report

Viral encephalitis poses a significant threat to public health, particularly affecting children and the elderly. We present a case of a 1.5-year-old child with viral encephalitis, characterized by sudden convulsions following a bout of cold and fever. Comprehensive physiotherapy rehabilitation was initiated, focusing on improving mobility, strength, and functional abilities. The interventions included caregiver education, range of motion exercises, strengthening exercises, mobility training, and task-oriented activities. After treatment, there was a notable improvement in the child's clinical outcomes, as evidenced by a reduction in weakness, enhanced functional mobility, and improved scores on outcome measures such as the Pediatric Cerebral Performance Category and Functional Mobility Scale. This case highlights the importance of early physiotherapy intervention in pediatric viral encephalitis to mitigate long-term complications and optimize functional outcomes.

Prognostic model for aneurysmal subarachnoid hemorrhage patients requiring mechanical ventilation

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of death and disability worldwide and imposes serious burdens on society and individuals. However, predicting the long-term outcomes in aSAH patients requiring mechanical ventilation remains challenging. We sought to establish a model utilizing the Least Absolute Shrinkage and Selection Operator (LASSO)-penalized Cox regression to estimate the prognosis of aSAH patients requiring mechanical ventilation, based on regularly utilized and easily accessible clinical variables.

METHODS

Data were retrieved from the Dryad Digital Repository. Potentially relevant features were selected using LASSO regression analysis. Multiple Cox proportional hazards analyses were performed to develop a model using the training set. Receiver operating characteristics and calibration curves were used to assess its predictive accuracy and discriminative power. Kaplan-Meier and decision curve analyses (DCA) were used to evaluate the clinical utility of the model.

RESULTS

Independent prognostic factors, including the Simplified Acute Physiology Score 2, early brain injury, rebleeding, and length of intensive care unit stay, were identified and included in the nomogram. In the training set, the area under the curve values for 1-, 2-, and 4-year survival predictions were 0.82, 0.81, and 0.80, respectively. In the validation set, the nomogram exhibited excellent discrimination ability and good calibration. Moreover, DCA demonstrated that the nomogram was clinically beneficial. Finally, a web-based nomogram was constructed (https://rehablitation.shinyapps.io/aSAH).

INTERPRETATION

Our model is a useful tool for accurately predicting long-term outcomes in patients with aSAH who require mechanical ventilation and can assist in making individualized interventions by providing valuable information.

Early Prediction of Epilepsy after Encephalitis in Childhood Based on EEG and Clinical Features

Objective

The present study was designed to establish and evaluate an early prediction model of epilepsy after encephalitis in childhood based on electroencephalogram (ECG) and clinical features.

Methods

255 patients with encephalitis were randomly divided into training and verification sets and were divided into postencephalitic epilepsy (PE) and no postencephalitic epilepsy (no-PE) according to whether epilepsy occurred one year after discharge. Univariate and multivariate logistic regression analyses were used to screen the risk factors for PE. The identified risk factors were used to establish and verify a model.

Results

This study included 255 patients with encephalitis, including 209 in the non-PE group and 46 in the PE group. Univariate and multiple logistic regression analysis showed that hemoglobin (OR = 0.968, 95% CI = 0.951-0.958), epilepsy frequency (OR = 0.968, 95% CI = 0.951-0.958), and ECG slow wave/fast wave frequency (S/F) in the occipital region were independent influencing factors for PE (P < 0.05).The prediction model is based on the above factors: -0.031 × hemoglobin -2.113 × epilepsy frequency + 7.836 × occipital region S/F + 1.595. In the training set and the validation set, the area under the ROC curve (AUC) of the model for the diagnosis of PE was 0.835 and 0.712, respectively.

Conclusion

The peripheral blood hemoglobin, the number of epileptic seizures in the acute stage of encephalitis, and EEG slow wave/fast wave frequencies can be used as predictors of epilepsy after encephalitis.

Evaluation, Treatment, and Outcomes of Viral and Autoimmune Encephalitis in Children

Viral encephalitis and autoimmune encephalitis are currently the most common causes of encephalitis. Determining the causative agent is helpful in initiating medical treatment that may help reduce long-term sequelae. Cerebrospinal fluid, neuroimaging, serologic, and electroencephalogram in combination with clinical manifestations play a role in determining the cause of the encephalitis. Although motor dysfunction tends to improve, there is a significant risk of long-term neurologic and cognitive sequelae. These persistent deficits that occur in childhood indicate the importance for ongoing rehabilitative services to maximize functional skills, improve cognitive deficits, and assist with community integration.

Determination of Clinical, Electrophysiological, and Radiological Characteristics of Pediatric Autoimmune Encephalopathy

Autoimmune encephalopathy (AE) is a group of diseases with subacute onset, that represents a wide clinical spectrum, manifested by complex neuropsychiatric symptoms and signs. In this study, the data of 27 patients diagnosed and followed up in our clinic with the diagnosis of AE between 2011 and 2021 were evaluated retrospectively. Out of 27 patients, 6 were definite seropositive AE, 2 of them met the diagnostic criteria for limbic encephalitis, and the remaining 19 were probable AE. Nowadays, we see AEs with increasing frequency. While there is a generally established approach in the diagnosis and treatment of seropositive patients, there are still hesitations and diagnostic difficulties in seronegative AEs. In this study, clinical, radiological, and prognostic features of definite and probable AE patients diagnosed in a tertiary pediatric neurology clinic were documented. It is thought that pediatric neurologists have an important responsibility to increase awareness about AE in pediatricians. In the future, it is predicted that AE will be diagnosed more frequently with new antibodies and one has to differentiate it from viral encephalitis and neuropsychiatric syndromes and diseases.

Protecting the blossoming brain - Neurocritical care in children

This special issue of the Biomedical Journal is entirely dedicated to the latest updates regarding the medical efforts to preserve the fragile young brain after injury. Thereby, we learn about symptoms and diseases such as different forms of epilepsy, acute encephalopathy, increased intracranial pressure, and posthaemorrhagic hydrocephalus, as well as about their origins, such as infection, autoimmune diseases, preterm birth, or abusive head trauma. Moreover, diagnosis and surveillance techniques are discussed, including ultrasound of the optic nerve sheath diameter and multimodal monitoring. Finally, we discover various established and emerging therapeutic approaches, comprising target temperature management, ketogenic diet, and immunomodulation.

A reappraisal of the value of video-EEG recording in the emergency department

Introduction: Some neurologic conditions that can quickly and with low costs be recognized, classified and treated thanks to the availability of an EEG recording in an emergency setting. However, although considered a cheap, not invasive, highly accurate diagnostic investigation, still today, an EEG recording in emergency, in real time during the event paroxysmal ictal phase, is not yet been become a routine.Areas covered: This review will cover the role and utility of EEG recording in the emergency setting, both in emergency department and intensive care unit, in adult and pediatric age, in people admitted for status epilepticus (convulsive or non-convulsive), paroxysmal non-epileptic events, or other conditions/diseases presenting with mental status changes.Expert opinion: The prompt recognition of some specific EEG-patterns can permit an immediate and appropriate therapeutic choice with the resolution of dramatic clinical pictures, which, if not recognized, sometimes could result in severe prognostic events with high mortality or neuropsychiatric disability. It is important in the next future, to improve the availability of these EEG digital continuous monitoring, which should be widely used in emergency settings, developing moreover tools and techniques permitting also review, analysis and EEG-reporting by experts who can work away from the hospital.

Pediatric Anti-NMDA-R Encephalitis: Presentation, Diagnosis, and Management

Immune- mediated encephalitis is the most common cause of encephalitis after infection in children and adults. Although this disease process was identified nearly 20 years ago, the variety of clinical presentations and the lack of specific diagnostic criteria can make the identification of anti-N-methyl-D-aspartate receptors (NMDA-R) encephalitis challenging. Moreover, identifying NMDA-R antibodies in blood or cerebrospinal fluid can take days to weeks, and thus clinicians need to have a high index of suspicion to investigate for this disease in patients who may appear to have an overlap of neurologic and psychiatric symptomatology. In this article, the authors describe three illustrative cases of anti-NMDA-R encephalitis in children age 3 to 16 years. The discussion reviews our current understanding of the clinical presentation, diagnostic criteria, and inpatient therapeutic management of anti-NMDA-R encephalitis, as well as illuminates the unique and often perplexing presentations of this disease process versus other organic and psychiatric causes of altered mental status. [Pediatr Ann. 2019;48(10):e387-e390.].