Japanese B encephalitis

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  • 1. Meningoencephalitis
  • 2. Terms to understand • Encephalitis • Encephalopathy • Meningitis • Meningism • Myelitis • Radiculitis
  • 3. Meningoencephalitis • Acute inflammation of meninges & brain tissue • CSF – pleocytosis • Gram stain & culture negative • Changes in MRI brain • Mostly self limiting
  • 4. Etiology • Enterovirus; coxsackie, polio, echo • Arbovirus; JEV, WNV, Dengue • Herpes virus; HSV1&2, VZ, EBV, CMV. • Others; mumps, measles, rabies, adenoV. • Bacteria; TB, mycoplasma, rickettsiae • Protozoa; acanthameba, toxoplasma
  • 5. JEV
  • 6. JEV
  • 7. JEV • Flavivirus • Spread by culex • Single stranded RNAV • 1955 in pondicherry • 2005; 1400 deaths in UP & Bihar
  • 8. DYNAMICS OF JE TRANSMISSION Environment Vector Mosquito Host - Amplifying Host - Carrier Victim-Accidental Full Recovery DeathRecovery with residual complications
  • 9. Subcutaneous injection Regional lymph nodes Extra neural Tissues Connective tissue Striated muscle Pancreas Adrenal Smooth muscle Efferent lymphatics Thoracic duct Plasma ViremiaReticuloendothelial cell clearance Humoral antibody Olfactory epithelium Vascular endothelium Neural Parenchyma Neurons, Glia(?) CNS antibody lymphocytes, macrophage Cellular dysfunction Cellular lysis Inflammation ? ?
  • 10. Pathogenesis • Direct invasion & destruction by virus • Host reaction to viral antigens • Meningeal congestion • Mononuclear infiltration • Neuronal disruption • Neuronophagia, vasculitis • Demyelination [ADEM]
  • 11. Structures affected • HSV; temporal lobe • Arbovirus; entire brain • Rabies; basal parts • Varicella; cerebellum
  • 12. Clinical features • Depends on parenchymal involvement • Preceding mild febrile illness & exantheme • Acute onset of high fever, headache, irritability,lethargy,nausea,myalgia • Convulsions, stupor, coma • Fluctuating FND, emotional outburst • Ant.horn cell injuryflaccid paralysis [west nile,entero virus]
  • 13. DD • Meningitis of various organisms
  • 14. Clues in history • Travel • Vaccination • Rash • Oral ulcers • Parotitis, orchitis • Dogbite • Pets
  • 15. Clues in examination • Cranial N palsy; HSV, EBV, TB. • Ataxia; VZV, • AFP; polio, enteroV, tick borne. • Rash; VZV, typhus, mycoplasma • Parotitis; mumps, • LN; HIV, EBV, CMV, Rubella. • Dementia; HIV • Hydrophobia; rabies.
  • 16. Diagnosis • CSF: lymphocytic predominance  Protein: normal, high in HSV  Glucose: normal, low in mumps  Culture of organism [entero V]  Viral antigen by PCR  Culture from NPswab, vesicle, feces, urine  IgM, IgG titre
  • 17. PLED in HSV
  • 18. MRI brain (T2W image): right temporal lobe high signal in a patient with herpes encephalitis
  • 19. Bilateral asymmetric thalamic hyper intensity
  • 20. Substantia nigra involvement
  • 21. Management • Monitor GCS • ABC • Restrict IVF • Anticovulsants, antipyresis , • Treat ICT • Moitor; glucose, BUN, elect, ABG, LFT, • Acyclovir
  • 22. Infant < 1 yr Child 1-4 yrs > 4 years EYES 4 Open Open Open 3 To voice To voice To voice 2 To pain To pain To pain 1 No response No response No response VERBAL 5 Coos, babbles Oriented, speaks, interacts, social Oriented and Alert 4 Irritable cry, consolable Confused speech, disoriented, consolable Disoriented 3 Cries persistently to pain Inappropriate words, inconsolable Nonsensical speech 2 Moans to pain Incomprehensible, agitated Moans, unintelligible 1 No response No response No response MOTOR 6 Normal spontaneous movement Normal spontaneous movement Follows commands 5 Withdraws to touch Localizes pain Localizes pain 4 Withdraws to pain Withdraws to pain Withdraws to pain 3 Decorticate flexion Decorticate flexion Decorticate flexion 2 Decerebrate extension Decerebrate extension Decerebrate extension 1 No response No response No response
  • 23. Bad Prognosis • <3 yrs • GCS <6 for 4days • Hyponatremia • 50-60% sequalae
  • 24. Prevention • Vaccine for jEV – Inactivated mouse brain Vaccine – Live attenuated SA-14-14-2 vaccine • Mosquito control • Management of pigs