1. Prognosis and Therapy of Viral Encephalitis in Adults
Wang Yiming
PUMC 2001
Excerpt from NIAID-CASG (National Institute of Allergy and Infectious Diseases-Collaborative Antiviral Study group) recommendations and European consensus 2005

2. Prognosis Pathogen Immunological state Environmental factors
Correct diagnosis and appropriate treatment

3. Pathogen Herpes simplex virus (HSV) Varicella-zoster virus (VZV)
Epstein-Barr virus (EBV)
Mumps
Measles
Enterovirus

4. Clues from Trails Of NIAID-CASG
Major determinants of Prognosis: Age, duration of disease, level of consciousness
< 30y with a normal level of consciousness
GCS<6 (Whiley et al., 1986)
Late death: severely impaired patients (not the persistent or reactivated HSV infection)

5. Age: Occurrence and Severity
HSE %
<20
20-50
>50
Age

6. PCR detection of viral DNA
Diagnostic golden standard
Sensitivity: 94%; Specificity: 98% (NIAID-CASG)
HSV-DNA persists 1 week or more

7. Detection of HSV DNA

9. PCR detection of viral DNA
Virus load in the CSF appears to correlate directly with outcome
Quantity of virus (copies of viral DNA/mL) correlate statistically with: 1. Decreased level of consciousness, 2. Presence of a lesion detected by either CT or MRI, 3. Poor neurological outcome.
Domingues et al., 1997,1998

11. Therapy
Anti-viral therapy
Corticosteroid
Surgical intervention

12. Anti-viral therapy Acyclovir: 38% return to normal function.
Ganciclovir
Valciclovir (Biran and Steiner, 2002)
Pleconaril: “broad spectrum” (Pevear et al., 1999)

13. Corticosteroid
Large dose of corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective and their use is controversial.

14. Surgical Intervention
Surgical decompression
Improve outcome in HSE in individual cases (Yan, 2002)

15. PCR Monitoring of Therapy
PCR of the CSF should be considered at completion of therapy for HSE to monitor treatment (category 2 recommendation)

16. PCR Monitoring of Therapy
Aciclovir treatment of HSE mostly leads to a sharp decline of DNA copies.
CSF-PCR should be performed upon completion of days aciclovir therapy. Patients with detectable HSV DNA should receive an additional course of therapy. (Cinque P. et al., 1996)