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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
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Initial evaluation and management of suspected encephalitis in children older than one month of age

Initial evaluation and management of suspected encephalitis in children older than one month of age
History
Symptoms – Fever, decreased level of consciousness, irritability or personality/behavior change, seizures, focal neurologic abnormalities
Travel
Exposure (animals, insects, freshwater swimming, toxins)
Immunizations and immune status
Physical findings

Vital signs and general examination
Neurologic examination, particularly for GCS and focal findings
Laboratory studies

Blood tests:

  • CBC
  • Glucose, electrolytes, BUN, creatinine
  • LFTs, ammonia
  • Coagulation studies
  • Blood cultures
  • Serologies for EBV, HIV, and Mycoplasma pneumoniae (IgM and IgG)
  • EBV PCR
  • Acute serum sample (to hold for subsequent serologic testing if necessary)

Urine tests:

  • Urine drug screen
  • Urinalysis

CSF studies (perform lumbar puncture after neuroimaging if a mass lesion has not been ruled out):

  • Opening pressure (if feasible)
  • CSF cell count/differential
  • CSF glucose and protein
  • CSF Gram stain and bacterial culture
  • CSF PCR testing*
  • If possible, save a sample of CSF (to hold for subsequent testing)

Other laboratory tests to consider:

  • Testing for influenza and other respiratory viruses (ie, respiratory panel/PCR, viral culture)
  • Throat swab for HSV, enterovirus, M. pneumoniae PCRs
  • Stool or rectal swab for enterovirus PCR and viral culture
  • Tests for toxic metabolic encephalopathy and inborn errors of metabolism
  • Testing for autoimmune encephalitis (NMDAR and VGKC antibodies), if clinically indicated
  • CSF acid fast stain and Mycobacterium tuberculosis culture, if clinically indicated
Ancillary studies
Neuroimaging – MRI preferred, but perform CT if MRI not promptly available, impractical, or cannot be performed
EEG – As soon as is feasible
Presumptive diagnosis

Based upon ALL of the following:

  • Altered mental status, focal neurologic deficits, and/or seizures, plus 
  • CSF pleocytosis, plus
  • Abnormal neuroimaging or EEG, plus
  • No other etiology identified
Treatment
Stabilization
Support airway, breathing, and circulation
Endotracheal intubation for GCS ≤8 or compromised airway
Fluid resuscitation with normal saline (20 mL/kg, initial bolus) for signs of hypovolemia or shock
Treat seizures with lorazepam (0.1 mg/kg IV)
Empiric antimicrobial therapy

Empiric acyclovirΔ (for all patients with suspected acute infectious encephalitis):

  • Age >28 days to <3 months – 20 mg/kg IV every 8 hours◊
  • Age ≥3 months to <12 years – 10 to 15 mg/kg IV every 8 hours◊
  • Age ≥12 years – 10 mg/kg IV every 8 hours◊

Empiric antibiotics (give until bacterial meningitis has been excluded):

  • Vancomycin 15 mg/kg IV every 6 hours (maximum 4 g/day)◊, plus
  • Either ceftriaxone 50 mg/kg IV every 12 hours (maximum 4 g/day) or cefotaxime (if available) 100 mg/kg IV every 8 hours (maximum 4 g/day)
Consider empiric treatment for other causes (eg, Mycoplasma pneumoniae, influenza, Rocky Mountain spotted fever, cat scratch disease, Q fever, ehrlichiosis) as indicated based upon clinical findings, season, exposure history, and other risk factors§

BUN: blood urea nitrogen; CBC: complete blood count; CMV: cytomegalovirus; CNS: central nervous system; CSF: cerebrospinal fluid; CT: computed tomography; EBV: Epstein-Barr virus; EEG: electroencephalography; GCS: Glasgow coma scale; HHV-6: human herpesvirus 6; HIV: human immunodeficiency virus; HSV: herpes simplex virus; IV: intravenous; LFT: liver function test; NMDAR: anti-N-methyl-D-aspartate receptor; MRI: magnetic resonance imaging; PCR: polymerase chain reaction; VZV: varicella zoster virus; VGKC: voltage-gated potassium channel; WNV: West Nile virus.

* PCR testing may consist of multiplex testing for multiple viral and bacterial pathogens simultaneously in a single CSF sample (eg, FilmArray meningitis/encephalitis panel [BioFire]) or individual PCR tests for specific pathogens. Testing for HSV, enterovirus, and parechovirus should be performed in all patients; testing for additional pathogens may be warranted based upon history and epidemiology (eg, Mycoplasma pneumoniae, influenza, CMV, EBV, HHV-6, VZV, WNV).
¶ Refer to separate UpToDate topics for details regarding the approach to diagnostic testing in children with suspected toxic metabolic encephalopathy, inborn errors of metabolism, or autoimmune encephalitis.
Δ Empiric acyclovir therapy is provided to all patients with suspected encephalitis until HSV infection has been excluded (ie, by negative CSF PCR). Refer to UpToDate topics on HSV for additional details.
◊ The doses of acyclovir and vancomycin listed in this table are for patients with normal kidney function. Dosing adjustment is required in patients with renal insufficiency. Refer to drug monographs for details.
§ Empiric therapy for M. pneumoniae typically consists of a macrolide antibiotic (eg, azithromycin). Several agents are available for treatment of influenza in children (oseltamivir, peramivir, baloxavir, and zanamivir); refer to UpToDate's topics on seasonal influenza in children for details. Empiric therapy for cat scratch disease, Rocky Mountain spotted fever, Q fever, or ehrlichiosis typically consists of doxycycline (rifampin is added in the case of cat scratch disease). Risk factors for these infections include exposure to or bites/scratches from cats or kittens (cat scratch disease), exposure to ticks in endemic regions (Rocky Mountain spotted fever and ehrlichiosis) and exposure to farm animals (Q fever). Refer to separate UpToDate content on these infections for additional details.

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