Encephalitis literally means an inflammation of the brain, but it usually refers to brain inflammation caused by a virus. It's a rare disease that only occurs in approximately 0.5 per 100,000 individuals - most commonly in children, the elderly, and people with weakened immune systems (i.e., those with HIV/AIDS or cancer).

Although several thousand cases of encephalitis (also called acute viral encephalitis or aseptic encephalitis) are reported to the Centers for Disease Control and Prevention (CDC) every year, experts suspect that many more may go unreported because the symptoms are so mild.

Signs and Symptoms

Symptoms in milder cases of encephalitis usually include:

• fever
• headache
• poor appetite
• loss of energy
• just a general sick feeling

In more severe cases of encephalitis, a person is more likely to experience high fever and any of a number of symptoms that relate to the central nervous system including:

• severe headache
• nausea and vomiting
• stiff neck
• confusion
• disorientation
• personality changes
• convulsions (seizures)
• problems with speech or hearing
• hallucinations
• memory loss
• drowsiness
• coma

It's harder to detect some of these symptoms in infants, but there are still some important signs to look for including:

• vomiting
• a full or bulging soft spot (fontanel)
• crying that doesn't stop or that seems worse when an infant is picked up or handled in some way
• body stiffness

Because encephalitis can follow or accompany common viral illnesses, there are sometimes characteristic signs and symptoms of these illnesses beforehand. But often, the encephalitis appears without warning.

Causes

Because encephalitis can be caused by many types of germs, the infection can be spread in several different ways.

Of the many different kinds of viruses that can cause encephalitis, one of the most dangerous and the most common cause of encephalitis is the herpes simplex virus (HSV). HSV is the same virus that causes cold sores around the mouth, but when it attacks the brain it may be fatal in as many as half of newborns who become infected and up to 28% of individuals after the newborn period. Fortunately, HSV encephalitis is very rare.

Encephalitis can be a complication of Lyme disease transmitted by ticks, or of rabies spread by rabid animals.

Mosquitoes can also transmit the viruses for several types of encephalitis, including West Nile encephalitis, St. Louis encephalitis, and Western Equine encephalitis. Over the last several years in the United States, there's been concern about the spread of West Nile virus, which is transmitted to humans by mosquitoes that pick up the virus by biting infected birds.

Milder forms of encephalitis can follow or accompany common childhood illnesses, including measles, mumps, chickenpox, rubella (German measles), and mononucleosis. Viruses like chickenpox spread mostly via the fluids of the nose and throat, usually during a cough or sneeze.

Less commonly, encephalitis can result from a bacterial infection, such as bacterial meningitis, or it may be a complication of other infectious diseases like syphilis. Certain parasites, like toxoplasmosis, can also cause encephalitis in people with weakened immune systems.

Contagiousness

Brain inflammation itself is not contagious, but any of the various viruses that cause encephalitis can be. Of course, just because a child gets a certain virus does not mean that he or she will develop encephalitis. Still, to be safe, children should avoid contact with anyone who has encephalitis.

Prevention

Encephalitis cannot be prevented except to try to prevent the illnesses that may lead to it. Encephalitis that may be seen with common childhood illnesses like measles, mumps, and chickenpox can be largely prevented through proper immunization. Have your child immunized according to the immunization schedule recommended by your child's doctor. Children should also avoid contact with anyone who already has encephalitis.

In areas where encephalitis can be transmitted by insect bites, especially mosquitoes, children should:

• Avoid being outside at dawn and dusk (when mosquitoes are most active).
• Wear protective clothing like long sleeves and long pants.
• Use insect repellent.

Also, all standing water around your home should be drained, including buckets, birdbaths, and flowerpots, because these are breeding grounds for mosquitoes.

Some things you can do to avoid tick bites:

• Limit your child's contact with soil, leaves, and vegetation.
• Have your child wear long-sleeved, light-colored shirts and long pants.
• Check your child and your pets frequently for ticks.

Duration

For most forms of encephalitis, the acute phase of the illness (when symptoms are the most severe) usually lasts up to a week. Full recovery can take much longer, often several weeks or months.

Diagnosis

Doctors use several tests to diagnose encephalitis, including:

• imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), to check the brain for swelling, bleeding, or other abnormalities
• electroencephalogram (EEG), which records the electrical signals in the brain, to check for abnormal brain waves
• blood tests to confirm the presence of bacteria or viruses in the blood, and whether a person is producing antibodies (specific proteins that fight infection) in response to a germ
• lumbar puncture, also known as a spinal tap, in which cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) is checked for signs of infection

Treatment

Some children with very mild encephalitis can be monitored at home, but most will need care in a hospital, usually in an intensive care unit. Doctors will carefully monitor their blood pressure, heart rate, and breathing, as well as their body fluids, to prevent further swelling of the brain.

Because antibiotics aren't effective against viruses, they aren't used to treat encephalitis. However, antiviral drugs can be used to treat some forms of encephalitis, especially the type caused by the herpes simplex virus. Corticosteroids may also be used in some cases to reduce brain swelling. If a child is having seizures, anticonvulsants may also be given.

Over-the-counter (OTC) medications, like acetaminophen, can be used to treat fever and headaches.

Most people with encephalitis make a full recovery. In a small percentage of cases, swelling of the brain can lead to permanent brain damage and lasting complications like learning disabilities, speech problems, memory loss, or lack of muscle control. Speech, physical, or occupational therapy may be necessary in these cases.

Rarely, if the brain damage is severe, encephalitis can lead to death. Infants younger than 1 year and adults older than 55 are at greatest risk of death from encephalitis.

Hadi told the Post that the woman was unconscious when admitted to the hospital but that doctors could find no evidence that her loss of consciousness was related to acute respiratory distress or pneumonia, as was true of other avian flu patients treated at the hospital.

The woman’s cerebrospinal fluid was tested repeatedly after an initial result was negative, Hadi said.  He said he had not received results from the health ministry’s lab. If the tests are positive, the woman would be Indonesia’s first avian flu patient to have brain inflammation caused by the infection, Hadi told the Post.

Neurologic complications of H5N1 infection have been reported before, though rarely. A Vietnamese boy who died of encephalitis in 2004 was later found to have had H5N1 infection, according to a research report published last year. Encephalitis is also known to be a rare complication of ordinary influenza.

The sole survivor of the avian flu case cluster in North Sumatra last May, Jones Ginting, had brain abscesses after he was hospitalized in May. An Associated Press article, published after he was released from the hospital, said that after he experienced a stiff neck and headaches, tests showed multiple brain abscesses caused by parasites.

With the three newest avian influenza cases, Indonesia’s case-fatality rate is 76%, which is second only to that of Cambodia, where all six avian influenza patients died.

The latest cases bring the WHO's global avian flu count to 256 cases with 151 deaths, for a case-fatality rate of 59%.

Rhode Island Department of Health

Health Alert
12/30/06
Mycoplasma Related Illnesses Cluster at Greenwood Elementary, Warwick

The Department of Health (HEALTH) has been investigating a cluster of illness at the Greenwood Elementary School. The following epidemiological information is available. In mid November a 7 year old second grader had onset of respiratory symptoms, and an admission on Nov 30 th with encephalitis to which he succumbed on December 21st. Despite extensive post-mortem testing at CDC a pathogen has not been found. A 7-year-old classmate was admitted on December 13 th with an admitting diagnosis of aseptic/partially treated meningitis, which then took an encephalitic course with gradual recovery. Serology on this child is positive for Mycoplasma pneumoniae. This makes the case of encephalitis an epidemiologically linked case to a case of Mycoplasma associated disease. A third child, a fifth grader from the same school developed X-Ray confirmed pneumonia and was prescribed antibiotics and then developed Stevens Johnson syndrome resulting in a hospital admission. This child also had strong titers positive for Mycoplasma pneumoniae. Through active surveillance we have knowledge of at least 5 other children with X-Ray confirmed pneumonias. Serology and nasopharyngeal swabs on these children have been done and results are pending. No new cases have been reported in the last 2 weeks.

In response to the unusual presentations and the small size of the school and exerting an abundance of caution the Department of Health with consultation and support from the CDC is proposing the following actions which are being implemented by the City of Warwick .

1. Beginning Sunday, December 31 – Tuesday, January 2, 2007 antibiotic prophylaxis will be offered to all students, staff and their household members. A mass dispensing operation will be set up at the school and announced through the media and school communications channels. Zithromax suspension is the antibiotic of choice for children and adults (5 day course), and Doxycycline (10 day course) for those with contraindications.
2. School will remain closed from January 2 through the 5 th and re-open on the 8 th.
3. A pharyngeal carriage study and sero-prevalence study is planned to determine carriage rates and effectiveness of prophylaxis. Information to the parents about this will be integrated into the dispensing operation. HEALTH will conduct all aspects of the study.

There will be continued surveillance and support offered to the school as long as is necessary.

Physicians are advised to maintain a high index of suspicion and report cases of any febrile illness from Greenwood Elementary to HEALTH at 222 2577 (272 5952 after hours). Lab testing should be ordered after discussion with HEALTH for all Greenwood linked patients. Other patients not connected to Greenwood may be tested for serology (swabs should not be done) at commercial laboratories.

Health officials meet with W. Warwick parents to discuss encephalitis

By Kate Bramson and Cynthia Needham
projo.com and Journal staff writers

WEST WARWICK -- Forty to 50 parents met with Health Department officials this morning to discuss a string of bacterial illnesses that has left one elementary school student dead and sickened others.

The press was barred from the meeting today in West Warwick, but state Health Director Dr. David R. Gifford met with members of the news media after the session to discuss the meeting.

The Journal reported today that new test results show that a student at West Warwick’s John F. Deering Middle School probably suffered from encephalitis, a brain infection, brought about by the mycoplasma bacteria that caused illnesses in seven students at Warwick’s Greenwood Elementary School, including second grader Dylan Gleavey, who died of encephalitis on Dec. 21.

Gifford said this morning that the West Warwick student was hospitalized in either late November or early December. He said he believes the child is "home recovering," but the student may also be back in school.

Health officials do not believe there is any additional evidence of an outbreak at that school. But they are now exploring the possibility that the illnesses are connected.

With the help of five staffers from the U.S. Centers for Disease Control and Prevention, health officials have been working day and night to determine if an active strain of the bacteria still exists in the area, Gifford said. The bacteria is "extremely difficult to culture," and tests could take a week or more, Gifford said.

Meanwhile, the best advice health officials say they can offer parents and families is simple preventive hygiene. To prevent the spread of this bacterial infection and other illnesses, people should wash hands thoroughly -- using alcohol gels -- and cover their mouths and noses when coughing and sneezing. Children in schools are no longer told to cover their mouths with their hands, but rather the common advice now is to sneeze and cough into the crook of one's elbow.

Mycoplasma pneumoniae is a common bacteria that spreads much like a cold and usually manifests itself as bronchitis, or as walking pneumonia. In what health officials say are “very, very rare” cases, people who contract the bacteria can develop meningitis, an inflammation around the brain, or encephalitis.

Anyone with symptoms of walking pneumonia should seek treatment, health officials say. Symptoms include fever, cough and shortness of breath. Any symptoms of meningitis or encephalitis should prompt urgent medical evaluation, according to the Health Department. Such symptoms include moderate to severe headaches, disorientation or confusion, fever and neck stiffness.

Warwick’s Greenwood Elementary School -- Dylan Gleavey's school -- did not reopen today after the December school vacation and will remain closed until next Monday. Instead, the school is hosting three sessions a day to distribute free antibiotics to the families of Greenwood students to prevent against the bacteria spreading. Sessions today have been set for 10 a.m., noon and 2 p.m.

The state is also investigating higher-than-normal rates of absenteeism in two Coventry schools, Blackrock and Oak Haven elementary schools, with reports that the absences may be due to walking pneumonia, according to Gifford.

After this morning's meeting on the campus of Deering and the West Warwick High School, Gifford characterized the level of concern among parents at the meeting as "appropriate."

Also today, health officials continue to distribute written questions to parents to monitor whether their children have been sick recently. In West Warwick, the questionnaires ask if children have been to the doctor for sickness since Oct. 1. If yes, parents are asked to list their symptoms and whether the children had chest X-rays, were given antibiotics and were diagnosed with pneumonia.

A second meeting in West Warwick will take place today at 5:30 p.m. at the high school auditorium.

Also, state health officials have established a toll-free information line at (800) 942-7434 for parents of children in Warwick, West Warwick and Coventry schools. People can also visit the Health Department's Web s

Medical mystery around student infections deepens

Health investigators concluded today that a third child, a West Warwick middle schooler, had suffered from encephalitis probably brought on by a common infection that usually causes pneumonia, deepening a medical mystery that has drawn the attention of federal medical authorities.

The bacteria that seems to have caused the infection, mycoplasma pneumoniae, very rarely causes encephalitis, and encephalitis itself is extremely rare, so the cluster of three cases -- which included one death -- has prompted an intensive investigation by the U.S. Centers for Disease Control and Prevention. The surviving children have recovered.

Five doctors from the federal agency are in Rhode Island talking with school nurses and the families of children who have been out of school, trying to identify any additional cases. One possibility under consideration is that a new, more virulent strain of the bacteria may have developed, according to Dr. David R. Gifford, Rhode Island director of health.

But so far health officials do not know of any children who are currently ill with mycoplasma or with encephalitis. All the eight known mycoplasma cases -- which include five children who had pneumonia without encephalitis -- occurred in November and December.

Seven of the eight infections were in children who attended the Greenwood Elementary School in Warwick. The Health Department has closed the school for this week, and has offered antibiotics to the families every student. Nearly all agreed to take the drugs.

The Health Department distributed 1,182 doses of antibiotics on Sunday, yesterday and today. The department ordered the drugs from a distributor at a cost of $57,000, charged to a Health Department credit card. Several children had upset stomachs, a common reaction to the medication, but no allergic reactions were reported.

The Health Department has been holding meetings with parents in West Warwick yesterday and today to talk about the illnesses.

-- Journal medical writer Felice J. Freyer

Posted by Andrea Panciera  at 6:33 PM | Permalink | Comments (0)

January 04, 2007

Meningitis case closes schools in 3 communities

PROVIDENCE -- Schools in three Rhode Island communities are shutting down for the rest of the week after a Coventry elementary school student is admitted to the hospital with a probable case of meningitis.

State health officials say schools in Coventry, Warwick and West Warwick will close starting today.

The probable meningitis case in the Hopkins Hill School student reported last night is similar to previous cases in the area that have been reported.

Doctor David Gifford, director of the state health department, says there has been an unusually high incidence of pneumonia in the three communities.

Gifford said during a 6 a.m. press conference today that the schools are being closed out of an "abundance of caution."

He said health officials are awaiting tests to see if the probable case of meningitis is related to the mycoplasma bacteria that sickened students in other communities.

The decision on whether to reopen the schools will be made over the weekend.

A second-grader from West Warwick died of encephalitis last month. Two other students in the area were also diagnosed with the disease but have since recovered.

-- The Associated Press

_

The cause of encephalitis lethargica is not yet known for certain, but on the basis of research by British doctors Russell Dale and Andrew Church, the disease is now thought to be due to a massive immune reaction to an infection by the streptococcus-like bacterium, diplococcus. There is also some evidence of an autoimmune origin with antibodies (IgG) from patients with EL binding to neurones in the basal ganglia and mid-brain. It had been hypothesised that encephalitis lethargica, Sydenham's chorea and PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) are mediated by the same post-streptococcal immune response...

A BBC Horizon television programme on the potential for a world-wide outbreak of H5N1 Bird Flu broadcast on November 7, 2006 postulated that the 1920s outbreak of encephalitis lethargica might have been as a direct, delayed pathological result of the Spanish Flu pandemic.