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Mini Dragon Group (ages 6-7)

공개·회원 14명
Valentine Ponomarev
Valentine Ponomarev

Download Intensive Care Management Patients With Viral Encephalitis Pdf ##HOT##

Although rare (i.e.,

Download Intensive care management patients with viral encephalitis pdf


While viral relapse is possible and some cases have had at least transient HSV PCR positivity during the relapse episode [165], many have no evidence of HSV activity, as demonstrated by negative HSV PCR from the CSF and poor clinical response to antiviral medications. An immune-mediated process has long been suspected in this setting. In one study, 32 consecutive adults with CSF PCR- or serology-proven HSVE who were treated with aciclovir or vidarabine were prospectively followed for relapse, which occurred in 4 patients [168]. However, none of these had HSV PCR positivity in the CSF during the apparent relapse, and markers of neural and glial cell damage (including neuron-specific enolase, S-100, and glial fibrillary acidic protein) were markedly lower in the CSF during relapse than on initial presentation. The authors concluded that direct viral cytotoxicity was not the mechanism of relapse, but rather suggested an immune-mediated process.

Patients with post-HSVE immune-mediated encephalitis are likely to respond favorably to immunotherapy but may be left with neurological deficits attributable to the HSVE. First-line treatment with steroids and/or IVIg or plasma exchange resulted in substantial improvement in all patients in the series by Armangue et al. [153]. One patient who had SE transiently improved with plasma exchange but developed further seizures and required second-line treatment with rituximab and IVIg.

Neurologists must be aware of the numerous conditions that may mimic encephalitis. Some examples include vascular disease, systemic infection (with no direct CNS infection) or inflammation, toxic exposures, or metabolic derangements (table e-1 at Such conditions need to be aggressively investigated in all patients with suspected encephalitis. Given the range of conditions that cause and mimic encephalitis, obtaining a thorough history is crucial. Important historical points include the presence of recent illness, ill contacts, unusual exposures (including occupational, vector, and animal), outdoor activities, and ingestions. It is critical to elicit travel history, both recent and remote, since agents such as rabies or malaria can become symptomatic long after initial exposure.

In the 1980s the outcome of patients with herpes simplex virus (HSV) encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 hours after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited.

In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

The scope of the guideline is to cover the initial management of all patients with suspected encephalitis, up to the point of diagnosis, in an acute care setting such as acute medical unit or emergency department. They are thus intended as a ready reference for clinicians encountering the more common causes of encephalitis, rather than specialists managing rarer causes. The guidelines also cover the specific treatments and further management of patients for whom a diagnosis of viral encephalitis is made, particularly that due to HSV, varicella zoster virus (VZV) and enteroviruses.

Many patients with suspected viral encephalitis ultimately prove to have another infectious or non-infectious cause for their illness. The further management and treatment of such patients is beyond the scope of this guideline, but the authors have included a section on follow-up and support for encephalitis patients in both the healthcare and voluntary sectors after discharge from hospital.

Encephalitis is a serious neurological condition and unfortunately, despite improvements in specific and more supportive treatments such as excellent intensive care management, encephalitis still has a high mortality (death) rate.

Central nervous system (CNS) infections continue to affect populations worldwide with high morbidity, mortality and risk of long-term sequelae and are also associated with a range of emerging and re-emerging viral threats to Europe, such as West Nile virus, Toscana virus, measles and enteroviruses [1, 2]. The epidemiology of community-acquired CNS infections is neither fixed nor homogeneous, with changes over time and between locations. The introduction of vaccines has reduced the burden of the two most common etiological agents for bacterial meningitis in adults and older children, Streptococcus pneumoniae and Neisseria meningitidis [3, 4]. Haemophilus influenzae type B (Hib) is also becoming a rare cause of meningitis in Europe [5]. However, reports of serotype replacement and an increased rate of reduced sensitivity to antimicrobial agents of S. pneumoniae, with varying rates across the region, are a cause of concern, which requires antibiotic regimes to be tailored to regions and travel [3, 5]. Neonatal meningitis is associated with high morbidity and higher incidence compared to older age groups [6]. In neonates, common pathophysiology are primary bloodstream infections with secondary haematogenous distribution to the CNS [6] most commonly caused by Streptococcus agalactiae (group B streptococcus; GBS) or Escherichia coli [3]. Encephalitis, an inflammation of the brain parenchyma associated with high morbidity and risk of long-term sequelae, is commonly caused by viruses [7]. It is estimated that 40 to 60% of cases remain without an aetiological diagnosis [8, 9]. This may partly be due to a lack of consensus on clinical case definitions and standardised diagnostic approaches [10]. The most commonly diagnosed causes of viral CNS infections in Europe are Herpes simplex virus (HSVs), enteroviruses, Varicella-zoster virus (VZV) and arthropod-borne viruses (arboviruses) [11]. The epidemiology of encephalitis is constantly evolving [11], and emerging infectious diseases may present as undifferentiated CNS infections [12]. This is ilustrated by the re-emergence of West Nile virus (WNV) in south-eastern Europe and the emergence of Toscana virus as a leading cause of aseptic meningitis in regions in southern Europe during the summer [13, 14]. Another cause of concern are recent outbreaks of enterovirus-associated severe neurological disease which cause a strain on paediatric intensive care units [15].

Two reviewers screened the title, abstract and full-text guidelines for inclusion. CMGs covering diagnostics and/or clinical management of suspected community-acquired bacterial or viral CNS infections which were aimed at or used by clinicians in Europe and published from 2004 onwards were included. The CMG produced by Médicins Sans Frontières (MSF) aimed at field settings globally was included, as it could be used in Europe in emergency situations. There were no language limitations. Guidelines published in non-English languages were translated using Google Translate and reviewed by a reviewer with good to excellent knowledge of the language. Guidelines that were not aimed at European populations were excluded, unless a clinician responding to the survey reported using them. General antibiotic and local standard operating policies were excluded. Guidelines focused only on patients with specific risk factors, such as HIV, were excluded.

Encephalitis is an inflammation of the brain parenchyma associated with neurological dysfunction [7, 10], which is reflected in the syndromic presentation. Meningoencephalitis affects both the brain parenchyma and meninges [25]. Four of the 12 CMGs covering viral aetiologies described symptoms at presentation in adults [7, 10, 22, 26], four in paediatric populations [7, 10, 27, 28] and six in unspecified populations [25, 29,30,31,32,33] (Table 2). Most of the guidelines cited focal neurological signs, seizures, fever, altered levels of consciousness (ALOC) and changes to personality or behaviour as signs and symptoms of encephalitis in both children and adults. It was noted that objective fever might be lacking at the time of assessment [10, 26] particularly in immunosuppressed patients [10].

This review highlights variations in the quality and recommendations of CMGs for community-acquired CNS infections in use across Europe. A harmonised European framework-CMG with adaptation to local epidemiology and risks may improve access to up-to-date CMGs and the early identification and management of (re-) emerging CNS infections with epidemic potential. The review particularly highlights the need for an updated European CMG for infectious encephalitis, which covers all risk groups, including paediatric and elderly populations. Further research into risk groups for infections and effective treatment strategies to target these populations is required.

The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit. 041b061a72


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