This document discusses encephalitis and encephalopathies in children. It begins with important definitions such as encephalopathy, acute encephalitis syndrome, encephalitis, and meningoencephalitis. It then discusses the types and etiologies of encephalitis including infectious causes such as viral, bacterial, parasitic and immune related causes as well as non-infectious causes. Specific conditions discussed in more detail include Japanese encephalitis, herpes simplex virus encephalitis, and metabolic encephalopathies. The document concludes with sections on the clinical features, investigations, management steps including empirical treatment and supportive care, and preventive strategies for encephalitis.
Derived from Greek word “enkephalos”- meaning brain.
“Pathos” meaning is disease.
The term “encephalopathy” is defined as altered mental status as a result of a diffuse disturbance of brain function.
Acute meningoencephalitis Powerpoint presentation.
It comprises of acute meningitis and acute encephalitis, their clinical features, physical assesment, diagnosis and treatment.
Please find the power point on Meningoencephalitis. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Derived from Greek word “enkephalos”- meaning brain.
“Pathos” meaning is disease.
The term “encephalopathy” is defined as altered mental status as a result of a diffuse disturbance of brain function.
Acute meningoencephalitis Powerpoint presentation.
It comprises of acute meningitis and acute encephalitis, their clinical features, physical assesment, diagnosis and treatment.
Please find the power point on Meningoencephalitis. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Meningitis is a clinical syndrome characterized by inflammation of the meninges, the three layers of membranes that enclose the brain and spinal cord.
Infections of the central nervous system (CNS) can be divided into two broad categories:
Those primarily involving the meninges and those primarily confined to the parenchyma (encephalitis).
Meningitis is a clinical syndrome characterized by inflammation of the meninges, the three layers of membranes that enclose the brain and spinal cord.
Most cases of meningitis are caused by an infectious agent that has colonized or established a localized infection elsewhere in the host.
Classically described as the triad of fever, neck stiffness, and altered mental state; in reality, this picture is only seen in 44% of adults with bacterial meningitis and is even less specific in children
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
2. Encephalopathy
Encephalopathy describes a clinical
syndrome of altered mental status,
manifesting as reduced consciousness
or altered behavior
Acute Encephalitis Syndrome (AES)
Acute onset of fever and a change in
mental status (including symptoms such
as confusion, disorientation, coma, or
inability to talk) AND/ OR new onset of
seizures (excluding simple febrile
seizures)
Encephalitis
Encephalitis means
inflammation of the brain.
Meningoencephalitis
Acute inflammatory process
involving the meninges and,
to a variable degree, brain
tissue
0
1
0
2
0
4
0
3
IMPORTANT DEFINITIONS
6. Differences Between Encephalitis And
Encephalopathy
Parameter Encephalitis Encephalopathy
Headache Common Uncommon
Seizures Focal / Generalized Generalized
Focal signs Usually present Usually absent
Fluctuation Usual Steady
Liver dysfunction Common Uncommon
Leucocytosis Common Uncommon
CSF pleocytosis Common Absent
EEG Diffuse / focal Diffuse slowing
MRI Abnormal Usually normal
9. Japanese Encephalitis (JE)
• Single stranded neurotropic RNA virus of Flaviviridae family
• Vector: Cules tritaenirrhynchus – breeds on rice fields
• Infection zoonotic with pigs and Ardeid birds as chief hosts
• Man is incidental dead-end host
• 1/4th cases in India
• High incidence in W.Bengal, Bihar, Assam, Orissa,
Pondycherry, Goa and MP
• Incubation period 5-15 days
10. Japanese Encephalitis (JE)
• Clinical presentations:
1. Abortive
2. Aseptic meningitis
3. Severe encephalomyelitis: with
or without radiculitis
• Sudden onset with high fever,
vomiting, mental confusion,
irritability and loss of
consciousness
• Stages:
1. Prodromal
2. Encephalitic
• Acute (3-4 days)
• Subacute (7-10 days)
3. Convalescence (4-7 weeks)
11. Japanese Encephalitis (JE)
Prevention:
• Anti-mosquito measures: Insecticidal sprays, larvicides, bed nets, repellants
• Vaccination:
– Mouse brain killed vaccine
– Live attenuated SA-14-14-2 vaccine (China)
– IC 51 vaccine – Ixiaro: Inactivated Vero cell culture-derived JE vaccine
– Indian Strain vaccine (821564 XZ) Kolar (JENVAC)
– Chimeric vaccine Live attenuated YFV-17D/JEV: With Pre-membrane and
envelope genes of yellow fever 17 D infectious clone
12. Herpes Simplex Virus (HSV) Encephalitis
• Leading cause of sporadic encephalitis
• Nonspecific prodrome of headache, fever and vomiting followed by altered
consciousness, focal or generalize seizures
• Focal neurologic signs – characteristic
• Movement disorders, stroke, behavioural disorders, hallucinations and
memory loss
• CSF: Pleocytosis
• Neuroimaging: Characteristic temporal lobe signal changes with MRI
13. Management Steps
Detailed History and Examination [SAMPLE]Step02
InvestigationsStep03
Empirical TreatmentStep 04
Supportive CareStep05
Rapid Assessment and Stabilization [ABCDE]Step01
Prevention/treatment of complications & rehabilitationStep06
Management Steps
14. Step 1: Rapid Assessment and Stabilization
• Airway:
– Establish and maintain :
– Intubate if…
• GCS<8, impaired airway reflexes
• abnormal respiratory pattern,
• signs of raised ICP,
• oxygen saturation <92% despite high flow oxygen, and
• fluid refractory shock
A
15. Step 1: Rapid Assessment and Stabilization
• Breathing:
– Ventilation,
– Oxygenation
• Circulation:
– Establish IV access,
– take samples (CBC, Blood sugar, KFT, LFT, electrolytes, blood
gas, lactate, PS and RDT for malarial parasite, serology for
viruses),
– Fluid bolus if in circulatory failure (20 mL/kg NS),
– inotropes if required
B
C
16. Step 1: Rapid Assessment and Stabilization
• Disability: refers to a child's neurologic function in terms of the level of
consciousness and cortical function.
– Identify signs of cerebral herniation or raised ICP
• Exposure: Examine undressed; as feasible!
– Temperature: treat fever and hypothermia
• Treat ongoing seizures- Benzodiazepine, followed by phenytoin
loading
D
E
17. Step 2: Detailed History and Examination -
SAMPLE
• Signs & symptoms
– Fever, headache, vomiting, seizures, abnormal posturing
– Altered behavior, cognition, personality changes, altered consciousness
– Prodromal symptoms- flu-like illness, diarrhea
– Rash, vesicles, past history of chicken pox
• Allergies:
– for Drugs, foods, pets
• Medications:
– Drug or toxin exposure- enquire for presence of any drugs at home
– Cancer treatment, steroid/immunosuppressant treatment
S
A
M
18. Step 2: Detailed History and Examination -
SAMPLE
• Past pertinent medical history
– Diabetes, congenital heart disease, chronic kidney or liver disease
– Other concurrent systemic illness e.g. jaundice (hepatic failure), pneumonia
(hypoxic encephalopathy), diarrhea (dyselectrolytemia), dysentery (shigella
encephalopathy)
– Characteristics of some IEMs
– Residence of child: Rural/urban, endemic for cerebral malaria, any epidemic of
AES in neighborhood
– History of animal contact, insect bite, dog bite
– Personal or family history of seizure disorder
– Family history of previous infant/child deaths
P
19. Step 2: Detailed History and Examination -
SAMPLE
• Last oral intake (Last menstrual cycle)
– Drug or toxin exposure- enquire for presence of any drugs at home
• Events leading to present illness
– Recent history of travel / History of trauma
– Recent immunizations
L
E
20. Step 2: General Physical Examination
• Pallor - cerebral malaria, or intracranial bleed.
• Icterus - leptospirosis, hepatic encephalopathy, or cerebral malaria.
• Skin rashes - in meningococcemia, dengue, measles, varicella, rickettsial
diseases, arboviral diseases, and enteroviral encephalitis.
• Petechiae - in meningococcemia, dengue and viral hemorrhagic fevers.
• Parotid swelling and orchitis - mumps as etiology.
• Labial herpes in young children - herpes simplex virus encephalitis
21. Step 2: Neurological Examination
• A modified GCS should be used for infants and young children
• Pupillary size, shape, symmetry and response to light provide valuable clues to
brainstem and third nerve dysfunction.
• Unilateral pupillary dilatation in the comatose patient should be considered as
evidence of oculomotor nerve compression from ipsilateral uncal herniation
• Progressive symmetrical external ophthalmoplegia suggest Bickerstaff
brainstem encephalitis in association with M. pneumoniae, especially when
associated with ataxia
22. Step 2: Neurological Examination
• Personality changes, confusion and disorientation
– Herpes Simplex Encephalitis
• Presence of oculocephalic (doll’s eye), oculovestibular, corneal, cough and gag
reflexes:
– Brainstem dysfunction is an important feature in some causes of viral encephalitis such as
enterovirus 71, mumps, and rabies
• Associated acute flaccid paralysis
– enterovirus infections (anterior horn cell involvement),
– poliomyelitis (anterior horn cell involvement),
– acute disseminated encephalomyelitis (due to myelitis)
23. Step 2: Neurological Examination
• Myoclonic jerks
– seen frequently in enterovirus encephalitis
• Retinal hemorrhages
– an important clue for cerebral malaria in endemic setting
• Signs of meningeal irritation
– Meningitis
• Myocarditis
– an important complication of EV 71 encephalitis
24. Step 3: Investigations
• Basic investigations
– Complete blood count (including platelet count)
– Blood glucose, serum electrolytes
– Liver and kidney function tests
– Blood culture
– Arterial blood gas, and lactate
– A peripheral smear / rapid diagnostic test for malaria
– Chest x-ray should also be obtained
25. Step 3: Investigations
• Lumbar puncture: If the patient is hemodynamically stable, and no features
of raised intracranial pressure
• CSF should be examined for
– Cytology, biochemistry, Gram stain, Ziehl-Nielsen stain for acid fast bacilli, bacterial
culture, latex agglutination, PCR for HSV 1 and 2, and IgM antibodies for JE and for
Dengue virus (if suspected).
– Concurrent blood sugar must also be measured to look for the CSF to blood sugar ratio.
1-2 mL CSF should be stored for other virological studies,
27. Step 3: Investigations - Neuroimaging
• CT scan:
– presence of bleed, cerebral edema,
– temporal lobe hypodensities in herpes simplex encephalitis,
– thalamic abnormalities in JE, and
– basal exudates and hydrocephalus in tubercular meningitis
– may also show brain herniation,
– effacement of cisterns, and
– infective collections such as brain abscesses and subdural empyema
28. Step 3: Investigations
MRI FINDINGS IN VIRAL ENCEPHALITIS AND SOME MIMICKERS
Etiology MRI Finding
Herpes simplex
encephalitis
Abnormal signal intensity in medial temporal lobe, cingulate gyrus, and orbital
surface of frontal lobes
Japanese B
encephalitis
Abnormal signal intensity in thalami (87-94%), substantia nigra, and basal
ganglia
Nipah virus Focal subcortical and deep white matter and gray matter lesions; small
hyperintense lesions in the white matter, cortex, pons and cerebral peduncles
have also been seen
Varicella Multifocal abnormalities in cortex, associated cerebellitis, vasculitis and
vasculopathy
Acute disseminated
encephalomyelitis
Multifocal abnormalities in subcortical white matter; involvement of thalami,
basal ganglia, and brainstem also seen
29. Role of brain biopsy in Encephalitis
No place in the initial assessment in immunocompetant children
• Stereotactic brain biopsy is indicated when:
– no diagnosis after the 1st week
– focal abnormalities on imaging
– if the findings could change the child’s management
• An open biopsy
– if imaging shows nothing focal
– from the non-dominant frontal lobe, may be preferable
30. Step 4: Empirical Treatment
• A broad spectrum antibiotic ceftriaxone must be given,
– which can be stopped if no evidence of bacterial meningitis is
forthcoming.
• Empirical anti-malarial (artemisin-based combination therapy)
must be started if there is a suspicion of cerebral malaria.
– This should be stopped if the peripheral smear and rapid
diagnostic tests are negative.
31. Step 4: Empirical Treatment
• Acyclovir must be started in all cases of sporadic viral encephalitis. It should be stopped if an
alternative diagnosis has been made, or HSV PCR in the CSF is negative and MRI is normal.
– Dose: 10 mg / kg IV infusion in 1 hr 8 hrly for 2-3 wks.
– Acyclovir resistant cases Foscarnet is the only drug available.
– Corticosteroids should not be used routinely in patients with HSV Encephalitis
• Cerebral edema
– Mannitol 1-2 gm/ Kg infuse quickly
– Glycerol orally
– Diuretics
– Steroids
– Elective hyperventilation
32. Step 5: Supportive Care
(a) Maintenance intravenous fluids: hypotonic fluids (e.g.Isolyte P) must be
avoided, especially in the presence of raised intracranial pressure
(b) Management of raised intracranial pressure:
(c) Maintain euglycemia
(d)Treatment and prevention of seizures
(e) Other
– Acid-base and electrolyte abnormalities should be corrected.
– Nosocomial infections must be prevented and treated promptly
33. Step 6: Prevention / treatment of
complications and rehabilitation
• Nosocomial infections, aspiration pneumonia
• Coagulation disturbances
• Myocarditis in EV 71 - milrinone
• Early physiotherapy
34. Step 6: Preventive Strategies
(i) Surveillance for cases of AES;
(ii) Vector control;
(iii) Reduction in man-vector contact;
(iv) Vaccination.
35.
36. METABOLIC ENCEPHALOPATHIES
• Encephalopathy refers to altered mental status that includes “disorientation,
short-term memory impairment, inattentiveness and abnormal state of
arousal”
• Encephalopathy could result from lack of glucose, vitamin cofactors or
oxygen and end organ failure.
• Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J (eds). Harrisons Principles of
Internal Medicine. 19th Ed. New Delhi: Mc Graw Hill; 2015.
37. METABOLIC ENCEPHALOPATHIES
• ‘Metabolic encephalopathy refers to “clinical state of global cerebral
dysfunction induced by systemic stress varying in clinical presentation from
mild executive dysfunction to deep coma”
– Kinnier Wilson
• METABOLIC ENCEPHALOPATHIES #Sangeetha Yoganathan, Sayli Umakant *Bidkar Indian
Journal of Practical Pediatrics 2020;22(1) : 26-35
39. Dys-electrolytemia related Encephalopathy
• Sodium less than 125 mmol/L (hyponatremia), sodium more than 160 mmol/L
(hypernatremia),
• Ionized calcium less than 0.5 mmol/L (hypocalcemia), ionized calcium more
than 3 mmol/L (hypercalcemia),
• Phosphorus less than 0.5 mmol/L (hypophosphatemia),
• Magnesium less than 0.5 mmol/L (hypomagnesemia) and magnesium more
than 2 mmol/L (hypermagnesemia)
Osmotic demyelination syndrome: with rapid correction of hyponatremia, malnutrition, burn injuries,
cirrhosis, pituitary surgeries, prolonged use of diuretics, hypophosphatemia and folate deficiency.
40. Hypoglycemic encephalopathy
• Hypoglycemia:
– Blood sugar < 50 mg/dL in neonates less than 48 hr
< 60 mg/dL after 48 hours of life
– may occur due to low birth weight, sepsis, hyperinsulinism,
inborn errors of metabolism, growth hormone deficiency,
adrenal insufficiency and medications.
– Symptoms in these patients include lethargy, headache,
seizures and altered sensorium
41. Inborn Errors of Metabolism (IEM)
– Clinical Clues
• Neurological
– Lethargy, coma, poor sucking, apnea, myoclonic seizures,
hypotonia or hypertonia, involuntary movements, hiccups,
fast breathing
• Gastrointestinal
– Hepatosplenomegaly, Cholestatic jaundice
• Others
– Hypothermia,
– Sepsis-like presentation with no response to antibiotics,
– Abnormal urine odor, dysmorphic features,
– Hydrops fetalis
42. Wernicke encephalopathy
• Results from thiamine deficiency
• The classical triad described in Wernicke encephalopathy
1. memory disturbances,
2. ataxia and
3. ophthalmoplegia are not observed in majority of cases
44. Hepatic encephalopathy (HE)
West Haven grading
Grade Clinical features
1 • Lack of awareness
• Decreased attention span
• Impaired calculation
• Euphoria or anxiety
2 • Lethargy or apathy
• Disorientation of time or place
• Personality changes
• Inappropriate behavior
• Impaired calculation
3 • Hypersomnolence
• Disorientation
• Stupor
4 • Coma
45. Reye syndrome
Diagnostic criteria
• “Acute noninflammatory encephalopathy that is documented clinically by
a) an alteration in consciousness and
b) CSF containing less than or equal to 8 leukocytes/cu.mm or
c) a histologic specimen demonstrating cerebral edema without perivascular or
meningeal inflammation.
• Hepatopathy documented by either
a) a liver biopsy or an autopsy considered to be diagnostic of Reye syndrome
b) a threefold or greater increase in the levels of ALT / AST or serum ammonia.
c) No more reasonable explanation for the cerebral and hepatic abnormalities
46. Posterior Reversible Encephalopathy Syndrome
(PRES)
• In children and adults with uncontrolled hypertension of varied etiology,
– use of immunosuppressive drugs and antiretroviral drugs,
– blood transfusion,
– hypercalcemia,
– eclampsia,
– thrombotic thrombocytopenic purpura,
– hemolytic uremic syndrome,
– von Hippel Lindau disease and exposure to contrast media
47. Posterior Reversible Encephalopathy Syndrome
(PRES)
• Possible mechanisms
– impaired cerebrovascular autoregulation,
– endothelial damage and
– vasogenic edema
• Symptoms include headache, vomiting, seizures, lethargy,
somnolence, stupor, coma, visual disturbances and focal motor
deficits
48. MANAGEMENT
• 1. General measures:
– Maintain euglycemia, correct dyselectrolytemia if identified and supplement
thiamine or other vitamin cofactors
– Antiepileptic medications must be chosen appropriately
– Raised intracranial pressure if identified must be managed appropriately
– Strict control of hypertension and elimination of precipitating factors
49. MANAGEMENT
• 2. Specific measures and organ support
a) The management of hepatic encephalopathy involves
– maintenance of fluid and electrolyte balance and euglycemia.
– protein restricted diet to decrease the blood ammonia levels
– use of antibiotics such as ampicillin and metronidazole
b) Hemodialysis or peritoneal dialysis may be useful in selected cases.
c) With Reye syndrome
– maintain the cerebral perfusion pressure and
– supportive measures such as 10% dextrose infusion,
– raised ICP management and correction of hyperammonemia
50. MANAGEMENT
• 2. Specific measures and organ support
d) Adrenal crisis:
– Volume expansion with IV fluids and
– correction of hyponatremia and hypoglycemia.
– Hydrocortisone (100 mg/m2/day) as infusion or bolus in the first 24
hours and may be gradually tapered to oral maintenance doses.
– Treatment of infection.
e) Diabetic ketoacidosis:
– appropriate intravenous fluids,
– insulin infusion and correction of dyselectrolytemia
51. Points to Remember
• Metabolic encephalopathy should be suspected in any child with altered
consciousness after excluding CNS infection, structural disorders, toxin
ingestion and trauma.
• Organ or system failure like hepatic encephalopathy, hypoxia,
dyselectrolytemia and endocrine dysfunction are responsible for metabolic
encephalopathy.
• Underlying etiologies are diverse which can be narrowed down by
recognizing the clinical clues.
• Management includes acute stabilization and specific measures based on
etiology including organ support.