Encephalitis (Brain Fever)

Definition Encephalitis is an acute inflammatory condition or infection of the brain usually occurring as a complication or sequel to some viral diseases characterized by various degrees and manifestations of cerebral dysfunction. Etiologic Agent The causative factor generally remains unknown or maybe caused by a variety of pathologic agents including bacteria, viruses, fungi, rikettsia, toxins, chemical substances or trauma.

Rikettsia - Rickettsia are bacteria, which are obligate intracellular parasites

many disease-causing, that live in vertebrates and are transmitted by bloodsucking parasitic arthropods such as fleas , lice and ticks. Rickettsias unlike other bacteria, but like viruses, they require a living host (a living cell) to survive 1. Virus Virus encephalitis can be due to the direct effects of an acute infection, or as one of the sequelae of a latent infection. A common cause of encephalitis in human is herpes (HSE). It causes inflammation of the brain. Herpes (HSE) - Herpes of the brain is called herpes simplex encelpalitis and is a very serious health disorder. HSE is caused by HSV-2 and is asscoiated with repeated outbreaks of genital herpes. HSE causes inflammation of the brain and can affect people of any age although typically it will appear in the person who already has genital herpes and who has had repeated outbreaks. 2. Bacteria It can be caused by a bacterial infection such as bacterial meningitis spreading directly to the brain (primary encephalitis), or may be a complication of a current infectious syphilis (secondary encephalitis).

3. Certain parasitic or protozoal infestations, such as toxoplasmosis, malaria or primary amoebic meningoencephalitis, can also cause encephalitis in people with compromised immune systems. Lyme disease and/or Bartonella henselae may also cause encephalitis. The virus of Arthropod-borne viral encephalitis belongs to the group of arboviruses. The natural habitat of these viruses appears to be many species of wild birds and some domestic birds that live in a symbiotic relationship with several known species of mosquitoes, many of which belong to the culex group. Toxoplasmosis - disease caused by the sporozoan Toxoplasma gondii, especially: a. A congenital disease characterized by lesions of the central nervous system that can cause blindness and brain damage. b. An acquired disease characterized by fever, swollen lymph nodes, and lesions in the liver, heart, lungs, and brain. Arbovirus Arbovirus is short for arthropod-borne virus. Arboviruses are a large group of viruses that are spread by certain invertebrate animals (arthropods), most commonly blood-sucking insects. Culex group subgroup of mosquito Incubation period The incubation period is 5 - 15 days, with a range from 4 21 days.

Mode of Transmission It is transmitted to human by a bite of an infected mosquito. The mosquito becomes infected by biting an infected bird and after incubating the virus in its own body for five to seven days, the mosquitoes carry the virus to healthy birds, horses, pigs and humans. Infection of man is the end of the cycle, since the infection is not transmitted from man to man and mosquitoes do not carry the virus from humans.

Classification

1. Primary Encephalitis an infection caused by direct invasion of the CNS by the virus resulting to an inflammatory reaction. These arthropod-borne viruses as follows: a. Eastern Equine Encephalitis (EEE)  Considered as a serious epidemic diseases of the horses  Principally affecting children under 5 years of age.  The virus can multiply in the Aedes sullicitans mosquito b. Western Equine Encephalitis (WEE)  Milder and usually affecting adults c. St. Louis Encephalitis  The organism believed to gain entrance through the olfactory tract  Caused by bite of an infected mosquito Culex tarsalis d. Japanese Encephalitis  A potentially severe viral disease that is spread by bite of an infected mosquito, Culex triteaniorhyncus, that live in rural rice growing and pig farming regions. The mosquito breeds in flooded rice field and standing water around planted fields. Once the mosquito is infected, it will carry the virus and capable of transmitting the disease for life. There is no evidence of human to human transmission.  Affecting children 5 10 years old; more in male than in female with the ration of 3:1  Case fatality rate is 30 35%  Peak season for JE is March April; September October where rice fields are flooded to hasten growth of the plants that also favor the breeding place for the mosquitoes.

2. Secondary Encephalitis a. Post Infection Encephalitis usually a complication or a sequelae to some viral diseases like measles, chicken pox and mumps. b. Post Vaccinal Encephalitis most common is anti-rabies vaccine

Clinincal Manifestations A. Japanese Encephalitis  Flu-like symptoms (fever, chills, headache, nausea, vomiting)  Stiff neck, confusion, neurologic manifestations occur within 72 hours (drowsiness, seizures, bizarre, coma)  Decreased IQ  Serious brain damage

B. General Manifestations  During the prodromal period (1 - 4 days), patient experience fever, headache, vomiting and apathy. Prodromal period: the time during which a disease process has begun but is not yet clinically manifest.  Chills, sore throat, conjunctivitis, arthralgia, myalgia and abdominal pain.

Athralgia joint pain Myalgia means "muscle pain" and is a symptom of many diseases and disorders. The most common causes are the overuse or over-stretching of a muscle or group of muscles. Nuchal rigidity - stiffness in the nape of the neck, often accompanied by pain and

spasm on attempts to move the head; the most common sign of meningitis.

Ataxia - is a neurological sign and symptom that consists of gross lack of coordination of muscle movements Stupor - is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain. Ptosis - is a (drooping) of the upper or lower eyelid. Occular palsy
Paralysis of 2/3 of face due to cavernous sinus thrombosis

Flaccid - lacking firmness, resilience, or muscle tone ; lacking vigor or energy Phonation voicelessness

 Later, the patient go through encephalitic signs, manifested by nuchal rigidity, ataxia, tremors, mental confusion, speech difficulties, stupor or hyperexcitability, convulsion, coma and death.  Ocular palsy, ptosis, and flaccid paralysis  Disturbances in swallowing, mastication, phonation, respiration and movements of the muscles of the eyes or face.  Uncontrollable contraction or twitching of the muscles of the different parts of the body.

Diagnostic Exams 1. CSF Analysis 2. Serologic Tests 90% confirmatory, usually done on the 7th day of illness 3. ELISA (IgM) 4. Polymarase Chain Reaction

Sequelae I. Motor Disturbances

 Persistent convulsions  Parkinsonian syndrome or paralysis agitans  Epylepsy-like manifestations

II.

Mental Disturbances

 Mental dullness  Mental retardation  Lethargy  Mental depression  Sleep disturbances

III.

Endocrine Disturbances

 Patient may grow fat or thin  Sexual interest or activity is lost

Nursing Management 1. Symptomatic and supportive 2. Control of convulsion (Diazepam and Barbiturates) as ordered 3. Sanitary disposal of nose and throat secretions

4. TSB or alcohol sponges maybe given if the temperature is exceedingly high 5. Unless is patient is comatose, oral fluid should be encouraged 6. Oral care should be strictly done 7. A mouth gag and protective devices, such as bedrails, should be available in case convulsion occurs. 8. Intake and output records are closely monitored 9. Patient should be observed for neurologic signs involving speech, swallowing difficulty, twitching, eye movements and indications of paralysis. 10. The beginning, duration and frequency of all convulsions should be carefully observed and recorded.

Prevention and Control 1. Preventive measures are directed toward the identification of mosquito vectors. 2. Elimination of breeding places, destruction of larvae, screening of homes, use of repellents 3. A broad public education program is an important phase of all preventive program.

Meningococcal Infections
There are two major types of meningococcal infections: meningitis and meningococcemia

I.

Meningitis (Cerebrospinal Fever)

Definition  The inflammation of the meninges of the brain and spinal cord as a result of viral and bacterial infection  Such inflammation may involve the three meningeal membranes, the dura matter, the arachnoid and the pia matter Etiologic Agent The disease can be caused by several kinds of organisms, which include the pneumococcus, staphylococcus, streptococcus and tubercle bacillus. The specie Neiserria meningitides (meningococcus) is the organism causing most epidemics of meningitis which also can cause primary pneumonia, purulent conjunctivitis, endocarditis, sinusitis and genital infections.

Incubation Period Incubation period is variable, the extreme limits being set from 1 10 days.

Mode of Transmission  Respiratory droplets through nasopharyngeal mucosa  By direct invasion through otitis media  May also follow skull fracture, a penetrating head wound, lumbar puncture or ventricular shunting procedures  Viral meningitis is usually a result of a complication of an existing viral infection.

Diagnostic Procedures 1. Lumbar Puncture (CSF) Purpose of Lumbar Puncture a. Diagnostic purpose  To obtain specimen, the CSF  To take x-ray of the spinal canal and cord b. Therapeutic purposes  To reduce intracranial pressure  To introduce serum and other medications  To inject an anesthetic agent 2. Gram Stain 3. Smear and blood culture 4. Smear from petechiae 5. Urine culture

Types of Meningitis 1. Aseptic Meningitis  A benign syndrome characterized by headache, fever, vomiting and meningeal symptoms  Begins suddenly with fever up to 40C, alterations in consciousness (drowsiness, confusion, stupor), neck and spine stiffness, which is slight at first.

 Characteristic sign of meningeal irritation a. Stiff neck or nuchal rigidity b. Opisthotonus is a state of a severe hyperextension and spasticity in which an individual's head, neck and spinal column enter into a complete "bridging" or "arching" position.[1] This abnormal posturing is an extrapyramidal effect and is caused by spasm of the axial muscles along the spinal column.

c. (+) Brudzinskis sign  Flexion of the hips when the neck is flexed from a supine position.

d. (+) Kernig sign  A sign of meningeal irritation evidenced by reflex contraction and pain in the hamstring muscles, when attempting to extend the leg after flexing the hip.

e. Exaggerated and symmetrical deep tendon reflexes

 Sinus arrhythmia, irritability, photophobia, diplopia and other visual problems  Delirium, deep stupor and coma Arrhythmia - An irregularity in the force or rhythm of the heartbeat. Irritability is a state of extreme sensitivity to stimulation of any kind. Photophobia is a symptom of abnormal intolerance to visual perception of light, sometimes additionally defined by abnormal or irrational fear of light Diplopia double vision Delirium - temporary state of mental confusion and fluctuating consciousness resulting from high fever, intoxication, shock, or other causes. It is characterized by anxiety, disorientation, hallucinations, delusions, and incoherent speech.

 Signs of intra-cranial pressure a. Bulging fontanel in infants b. Nausea and vomiting (projectile) c. Severe fontanel headache

d. Blurring of vision e. Alteration in sensorium

Sensorium: The totality of those parts of the brain that receive, process and interpret sensory stimuli. The sensorium is the supposed seat of sensation, the place to which impressions from the external world are conveyed and perceived. The sensorium also refers to the entire sensory apparatus of the body. In medicine, "sensorium" is sometimes used as a generic term for the intellectual and cognitive functions.

Complications 1. Subdural effusion 2. Hydrocephalus 3. Deaf-mutism 4. Blindness of either one or both eyes 5. Otitis media and mastoiditis 6. Pneumonia or bronchitis Subdural effusion is a collection of fluid beneath the outer lining of the brain. If this fluid becomes infected, the condition is called a subdural empyema. Causes, incidence, and risk factors: A subdural effusion is a rare complication of bacterial meningitis. Subdural effusion is more common in infants and in persons who have meningitis caused by Haemophilus influenzae. Hydrocephalus, also known as "water on the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles,

or cavities, of the brain. Deaf-mutism - congenital deafness that results in inability to speak Mastoiditis is an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces.[1][2] It is usually caused by untreated acute otitis media (middle ear infection) and used to be a leading cause of child mortality.

Modalities of Treatment  If meningitis is left untreated it has a mortality rate of 70% - 100%  Treatment includes management appropriate antibiotic therapy and supportive care

 Usually IV antibiotics are given for two weeks and are followed by oral antibiotics such as: y Ampicillin y y Cephalosporin (Ceftriaxone) Aminoglycosides

 Digitalis glycosides ( digoxin) to control arrhythmias  Manitol to decrease cerebral edema  Anticonvulsant or sedative to reduce restlessness and convulsion  Acetaminophen to relieve headache and fever

II.

Acute Meningococcemia

 Most common among children, ages 6 months to five years old  Following an incubation period of 3 4 days meningococci invade the bloodstream, the joints, the skin, the adrenal glands, the lungs, without invading the mininges.

 Usually it starts with nasopharyngitis followed by sudden onset of spiking grade fever with chills, nausea, vomiting, malaise and headache  Petechial, purpuric or ecchymotic hemorrhages scattered over the entire body and mucous membrane, which could be due to acute vasculitis followed by suppurative necrosis and hemorrhage into the dermal connective tissues.

Purpura is purple-colored spots and patches that occur on the skin, organs, and in mucus membranes, including the lining of the mouth. Purpura occurs when small blood vessels under the skin leak. When purpura spots are very small, they are called petechiae. A petechia is a small (1-2mm) red or purple spot on the body, caused by a minor hemorrhage Large purpura are called ecchymoses. Vasculitis is a term for inflammation of the blood vessels. The inflammation can affect any of the vessels including capillaries, venules, arterioles and lymphatics.

 The adrenal lesions start to bleed into the medulla which extends to the cortex.  The combination of the dermal manifestations and adrenal medullary hemorrhage, is known as Waterhouse-friderichsen syndrome  Waterhouse-friderichsen syndrome is the rapid development of petechiae to purpuric and ecchymotic spots in association with shock  The condition runs short course and is usually fatal. This frequently occurs in fulminant type of meningococcemia.

Nursing Management for Aseptic Meningitis 1. Asses neurologic condition of the patient  Observe the patients level of consciousness and check for signs of increased intracranial pressure (ICP) manifested by:

y y y

Plucking at bedcovers Projectile vomiting Seizures, changes in motor functions and vital signs

 Watch for deterioration of patients condition, which may be a signal for an impending crisis  Monitor fluid balance. y y y Maintain adequate fluid to avoid dehydration, but avoid fluid overload because of danger of cerebral edema. Measure central venous pressure and intake and output

 Watch for adverse reaction of antibiotics and other drugs. Avoid IV infiltration and phlebitis. Infiltration, or tissuing, describes leakage of fluids or blood from damaged blood vessels as a result of medical interventions. Phlebitis, also called superficial venous thrombosis or superficial thrombophlebitis, is a blood clot that develops in a vein close to the surface of the skin  Position the patient carefully to prevent joint stiffness and neck pain. y Turn him often complications to avoid pressure sores and respiratory

y y y y

Assist with ROM, passive or active. Maintain adequate nutrition and elimination Ensure patients comfort Provide reassurance and support to the patient and the family.

Follow strict aseptic technique when treating patients with head wounds or skull fractures Isolation is necessary especially if nasal culture is positive.

y Prevention

 Several vaccines are available to protect against certain types of meningitis.  Teach clients with chronic sinusitis or other chronic infections about the importance of proper and prompt medical treatment and diagnosis.

MCV4 should be used in people ages 2 through 55 years in these risk groups, but MPSV4 can be used if someone has a permanent contraindication or precaution to the use of MCV4. MPSV4 is the only licensed meningococcal vaccine product that can be used in adults 56 years or older.

Portals of entry resulting in meningitis, meningoencephalitis, and intracranial mass lesions.

CULEX TARSALIS

Bruzinskis Sign
 Flexion of the hips when the neck is flexed from a supine position.

Kernig Sign
 A sign of meningeal irritation evidenced by reflex contraction and pain in the hamstring muscles, when attempting to extend the leg after flexing the hip.