From the Guidelines
Acute encephalitis syndrome (AES) in pediatric patients should be managed with immediate empiric antimicrobial therapy, typically with acyclovir 10-15 mg/kg IV every 8 hours for 14-21 days, along with broad-spectrum antibiotics such as ceftriaxone 100 mg/kg/day divided every 12 hours and vancomycin 60 mg/kg/day divided every 6 hours, as recommended by the Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines 1.
The causes of AES in pediatric patients can be diverse, including viruses (enteroviruses, arboviruses, herpes viruses), bacteria, fungi, parasites, or autoimmune conditions. The management approach should be tailored to the suspected cause, with a focus on supportive care, including management of increased intracranial pressure, maintenance of normoglycemia, and prevention of complications.
Some key points to consider in the management of AES in pediatric patients include:
- Early recognition of the clinical syndrome and prompt initiation of empiric antimicrobial therapy
- Diagnostic workup, including lumbar puncture for CSF analysis, blood cultures, complete blood count, metabolic panel, neuroimaging (preferably MRI), and EEG
- Specific treatment depends on the identified cause, which may include antiviral medications, antibiotics, or immunomodulatory therapies
- Supportive care, including management of increased intracranial pressure, maintenance of normoglycemia, and prevention of complications
- Early rehabilitation to improve outcomes, as AES can result in significant neurological sequelae in children
It is essential to note that the clinical presentation of AES in pediatric patients can be vague, and differentiating infection-associated encephalitis from other causes of encephalopathy poses a significant diagnostic challenge. Therefore, a broad and comprehensive approach to both assessment and rehabilitation is necessary, with neuropsychology and child and adolescent mental health teams as central components, and access to speech and language therapists, neuro-physiotherapists, and occupational therapists.
The most recent and highest quality study, which is the 2012 guidelines from the Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group 1, provides the most up-to-date recommendations for the management of suspected viral encephalitis in children. These guidelines emphasize the importance of prompt recognition, investigation, and management of AES in pediatric patients to improve outcomes and reduce the risk of long-term neurological sequelae.
From the Research
Causes of Acute Encephalitis Syndrome (AES) in Pediatric Patients
- The disease is caused by a diverse group of pathogens including viruses, bacteria, fungi, and protozoans 2
- Viral (30.4%) and rickettsial infections (22%) were the common etiologies identified in one study 3
- Herpes simplex virus 1 encephalitis was the most frequently identified etiology in another study 4
- Scrub typhus (11.2%) and dengue (9%) were the two most common underlying illnesses in a study from South India 3
- Autoimmune encephalitis, such as anti-NMDA receptor encephalitis, is also a cause of AES in pediatric patients 5, 4
Management of Acute Encephalitis Syndrome (AES) in Pediatric Patients
- Early recognition, appropriate testing and empiric treatment, and management of the expected complications of acute encephalitis are crucial 6
- Third-generation cephalosporin drugs (85.7%) and acyclovir (77.7%) were the most commonly used empiric antimicrobial drugs in one study 3
- Immunomodulatory treatment was associated with a better functional outcome in patients with autoimmune encephalitis 4
- The need for prolonged hospitalization is related to more severe disabilities 2
- GCS ≤ 8 at presentation and requirement for invasive ventilation were found to be significant predictors of poor outcome 3
Outcome of Acute Encephalitis Syndrome (AES) in Pediatric Patients
- A considerable proportion of AES survivors are left with disabilities 2
- About one-third of children had a poor outcome, defined as death, discharge against medical advice with neurological deficits, or Glasgow Outcome Score Extended (GOS-E) ≤ 5 at the time of discharge 3
- Unfavorable outcome was associated with need for intubation, receiving immunomodulatory treatment, prolonged hospitalization, and high erythrocyte sedimentation rate at admission 5
- Early identification of disabilities through the Liverpool scoring system and clinical examination can aid in implementing appropriate intervention strategies 2