Encephalitis: Understanding the Causes, Pathophysiology, Symptoms, and Management

What Encephalitis

Encephalitis is inflammation of the brain parenchyma. When the meninges get involved it's referred to as Meningoencephalitis. Myelitis refers to inflammation of the spinal cord. When both the brain and the spinal cord are involved, the condition is called encephalomyelitis. Encephalitis strikes 10-15 people per 100,000 each year globally. This condition can affect anyone, but more commonly in younger people.

Causes of Encephalitis

The cause of encephalitis is well not understood. However, amongst the commonest understood causes, viruses tends to be the most cause. Non infectious disease and infections may also lead to encephalitis.

The cause of encephalitis is classified into two namely infectious and non-infectious encephalitis according to the organism causing

Infectious Encephalitis

Infectious encephalitis is typically caused by a viral infection. Vaccines for measles, mumps, rubella and chickenpox have reduced the rate of encephalitis from these diseases, but other viruses can cause encephalitis. The most common causes of viral encephalitis are herpes simplex virus types 1 and 2, varicella zoster virus, Epstein-Barr virus, enteroviruses, tick-borne viruses, rabies virus, and mosquito-borne viruses, and other insects or animals such a West Nile virus, Japanese encephalitis virus, La Crosse virus, St. Louis virus, Equine viruses.

Autoimmune encephalitis

Autoimmune encephalitis refers to a group of conditions that occur when the body's immune system mistakenly attacks healthy brain cells, leading to inflammation of the brain. This involves an abnormal immune response targeting specific components within neurons. Autoantibodies produced by the immune system attack these neuronal components and trigger inflammation in the brain. Examples include anti-NMDA receptor encephalitis and autoimmune limbic encephalitis. Other autoimmune diseases include; Systemic lupus erythematosus, Behçet's disease, Hashimoto's encephalopathy, Sydenham's chorea and tumors. Autoimmune encephalitis usually happens after the disease.

Other microorganisms such as bacteria, fungi and parasites can also cause encephalitis, though rarely. For some individuals, recent travel, or an immunocompromised state (such as HIV, diabetes, steroids, chemotherapy treatment) are important risk factors for infectious encephalitis.

Pathophysiology of Encephalitis

Encephalitis refers to the inflammation of the brain parenchyma, and its pathophysiology involves a complex interplay between various factors. The underlying mechanisms can differ based on the cause of encephalitis, which may be infectious (viral, bacterial, fungal) or non-infectious (autoimmune). In infectious encephalitis, viral infections are the most common etiological agents. The pathophysiology begins with viral entry into the central nervous system (CNS), either through hematogenous spread or direct invasion from adjacent sites such as respiratory tract or peripheral nerves.
Once inside the CNS, viruses primarily target neurons and glial cells. They often gain access by crossing endothelial barriers using specific receptors present on these cells' surfaces. Viruses then replicate within infected cells, leading to cell damage and death. The immune response plays a critical role in encephalitis pathogenesis. Microglia—the resident immune cells in the CNS—become activated upon encountering pathogens or their products. This activation triggers an inflammatory cascade involving cytokines and chemokines that recruit other immune cells like macrophages and lymphocytes to combat infection. While this immune response aims to control viral replication and eliminate infected cells, it can also contribute to neuronal damage due to excessive inflammation. Inflammatory mediators released during this process disrupt normal neuronal function and integrity through oxidative stress, excitotoxicity (excessive stimulation leading to cellular damage), and blood-brain barrier disruption.
Furthermore, viral replication within neurons may lead to cytopathic effects directly impacting cellular viability. Viruses often interfere with intracellular processes necessary for cell survival or induce apoptotic pathways that result in programmed cell death.
In bacterial encephalitis—which is less common but typically more severe than viral forms—pathogens enter the CNS via bloodstream dissemination or direct extension from nearby structures such as sinuses or middle ear infections. Bacterial toxins released during infection contribute to brain tissue damage and trigger an inflammatory response similar to viral encephalitis.
Non-infectious causes of encephalitis include autoimmune conditions where the body's immune system mistakenly targets components of brain tissue, leading to inflammation. Autoantibodies directed against specific proteins within neurons disrupt normal neural function and contribute to the pathophysiology of encephalitis in these cases. It is important to note that while this overview provides a general understanding of encephalitis' pathophysiology, variations can occur depending on specific pathogens involved, host factors, and other variables. This knowledge helps guide diagnostic strategies and treatment approaches for managing this condition effectively.

Signs & Symptoms of Encephalitis

Symptoms of encephalitis vary depending on the affected area of the brain, but individuals often shows flu-like symptoms. In more severe cases, individuals may experience;

• Myalgia
• Headache
• Confusion
• Fever
• Drowsiness
• Fatigue
• Seizures or convulsions
• Tremors
• Stroke
• Hallucinations
• Partial paralysis in the arms and legs
• Impaired judgment
• Memory loss
• Problems with speech or hearing
• Double vision
• Hallucinations
• Personality changes
• Loss of consciousness
• Partial paralysis in the arms and legs
• Decline in mental status, such as confusion, agitation, or hallucinations

diagnosis & Test

• Magnetic Resonance Imaging (MRI) to detect the inflammation
• Electroencephalography (EEG) to monitor the electrical activity of the brain (seizures)
• Lumbar puncture (spinal tap) to take a small sample of spinal fluid to look for infections, like bacteria and viruses
• Urine analysis
• Blood test
• Brain biopsy

Medical Management of Encephalitis

• Antivirals for viral encephalitis such as Acyclovir (Zovirax), Ganciclovir (Cytovene), and Foscarnet (Foscavir).
• Mild encephalitis is usually treated with fluid hydration, bed rest, anti-inflammatory medications such as ibuprofen or acetaminophen, and close monitoring.
• Anticonvulsants to treat seizures, such as phenytoin (Dilantin)
• Rehabilitation therapy, psychotherapy, occupational and physiotherapy or speech therapy may require to maintain an optimal quality of life
• Anti-inflammatory drugs — such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) — to relieve headaches and fevers

Nursing Management of Encephalitis

The following are the measures to put in place in the care of a hospitalized person diagnosed of encephalitis;

• Maintain adequate fluid intake to prevent dehydration, but avoid fluid overload, which may increase cerebral edema.
• Maintain adequate nutrition. Give small, frequent meals, or supplement meals with nasogastric tube or parenteral feedings.
• To prevent constipation and minimize the risk of increased ICP resulting from straining at stool, provide a mild laxative or stool softener.
• Carefully positioned the patient to prevent joint stiffness and neck pain, and turn the patient often.
• Provide thorough mouth care.
• If the patient has seizures, take precautions to protect him from injury.
• Measure and record intake and output.
• Regularly reorient the patient becomes if delirious or confused
• Maintain a serene and comfortable atmosphere
• Assess the patient neurological status every 1-2 hours and when necessary until a steady condition.
• Assess the patient`s vital signs at least every 4 hours
• Observe the patient for any signs and symptoms of increased ICP, such as sudden headache, vomiting, and decreased alertness.
• Evaluate the patient`s level of consciousness utilizing the Glasgow Coma scale.
• Raise the head of the bed between 30 to 45 ° while maintaining the patient`s head in neutral placement to allow appropriate venous blood flow from the brain and to decrease ICP
• Place the patient on seizure precautions chart and monitor and render care during seizure activities.
• Take note and record the quality of seizure episodes, focusing on the frequency and type and inform the doctors of every seizure episode.
• Evaluate the patient`s ability to comply with simple or complex instructions.
• Motivate the significant other to be involved in the therapeutic management and decision-making regarding the rendered care to the patient.