Encephalitis: Supportive Management

00:00 unless the hospital is rampant with mosquitoes, which is unusual. and certainly you don't have to isolate them if it's been caused by a mosquito So, how do you manage patients with encephalitis? Well, if they are very sick, obviously, they have to be monitored in the intensive care unit.

00:13 Now, do you have to isolate them? We certainly don't have to isolate them for herpes virus.

00:19 They're not contagious if they have herpes encephalitis We certainly don't have to isolate them for herpes virus.

00:19 They're not contagious if they have herpes encephalitis unless they have some sort of active lesion on their mouth, genitalia or some kind of rash consistent.

00:31 So, generally, you don't have to isolate patients with herpes virus and certainly you don't have to isolate them if it's been caused by a mosquito unless the hospital is rampant with mosquitoes, which is unusual.

00:45 But if it's just encephalitis of unknown cause, then respiratory or contact isolation would be prudent.

00:53 If they have seizures, you’re going to manage those seizures with benzodiazepines acutely, and you would maintain them on fosphenytoin IV.

01:05 And the certainly increased intracranial pressure can occur and is dangerous, so the neurosurgeons will often put a continuously monitoring lead for increased intracranial pressure.

01:22 Corticosteroids may also be required; and if it's very severe, hyperventilation and IV mannitol.

01:34 Lumbar punctures need to be avoided in patients with increased intracranial pressure due to the scare of herniating.

01:46 As far as empirical therapy goes, sometimes you can't tell what's causing the encephalitis.

01:53 So, what you’ve got to do is treat everybody as if they had herpes simplex encephalitis and give IV acyclovir.

02:02 And that's the goal.

02:04 There's no proven benefit in other forms of encephalitis.

02:09 Now, if you know the patient also has influenza, if the viral studies indicate influenza, we would give oseltamivir, which is a neuraminidase inhibitor.

02:20 But looking at the mechanism of action, it doesn't honestly make a lot of sense that it would work well in the central nervous system, and so we need more data on whether it works.

02:33 So, in somebody with influenza encephalitis, we would give it.

02:37 Alternatively, peramivir is an IV antiviral that may be used for patients who cannot tolerate oral therapy, which may be an issue in patients with encephalitis.

02:46 Rabies is essentially untreatable, although there are one or two patients who have survived this.

02:54 And this was accomplished with inducing a coma and giving IV ribavirin.

03:05 In other words, we essentially induced coma in the patient with proven rabies and gave the patient enteral amantadine.

03:14 And this was done on a 15-year-old girl.

03:18 Her survival was reported in The New England Journal of Medicine.

03:22 So, using that model, we are treating patients with that kind of a model.

03:30 But there have been patients treated that way that have not survived.

03:34 And that brings us to the end of our discussion about encephalitis.