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Encephalitis

Key sources
The following summarized guidelines for the evaluation and management of encephalitis are prepared by our editorial team based on guidelines from the Association of British Neurologists (ABN/BIA 2012), the Association of British Neurologists (ABN/BPAIIG 2012), and the Infectious Diseases Society of America (IDSA 2008).
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Guidelines

1.Screening and diagnosis

Clinical presentation: suspect encephalitis or another CNS infection in patients with current or recent febrile illness with altered behavior, cognition, personality or consciousness, or new seizures or focal neurological signs.
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2.Diagnostic investigations

Clinical assessment: assess for epidemiologic clues and risk factors to identify potential etiologic agents in patients with encephalitis.
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  • Evaluation for infectious etiology

  • Neuroimaging

  • Electroencephalography

3.Diagnostic procedures

Lumbar puncture: perform lumbar puncture as soon as possible after hospital admission in all patients with suspected encephalitis, unless there is a clinical contraindication.
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consider performing an immediate lumbar puncture after CT on a case-by-case basis, unless the imaging reveals significant brain shift or tight basal cisterns due to or causing raised ICP or an alternative diagnosis or the patient's clinical condition changes.
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  • Brain biopsy

4.Medical management

Setting of care: obtain immediate neurological specialist consultation in patients with suspected acute encephalitis and manage them in a setting where a clinical neurological review can be obtained as soon as possible and definitely within 24 hours of referral.
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  • Empirical therapy

  • Specific therapy (viruses)

  • Specific therapy (bacteria)

  • Specific therapy (mycobacteria)

  • Specific therapy (rickettsiae and ehrlichiae)

  • Specific therapy (spirochetes)

  • Specific therapy (fungi)

  • Specific therapy (protozoa)

  • Specific therapy (helminths)

  • Specific therapy (acute disseminated encephalomyelitis)

5.Specific circumstances

Patients with autoimmune encephalitis: include antibody-mediated encephalitis in the differential diagnosis of all patients with suspected encephalitis because of the poor outcomes if left untreated.
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6.Follow-up and surveillance

Follow-up
Do not discharge patients from the hospital without either a definite or suspected diagnosis. Formulate an arrangement for the outpatient follow-up (to include at least one follow-up appointment) and plans for ongoing therapy and rehabilitation at a discharge meeting.
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Ensure that all patients have access to assessment for rehabilitation, irrespective of age.
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