Several studies have documented the potential mimics of HSV encephalitis in adults and children.
12- Bell D.J.
- Suckling R.
- Rothburn M.M.
- Blanchard T.
- Stoeter D.
- Michael B.D.
- et al.
Management of suspected herpes simplex virus encephalitis in adults in a UK teaching hospital.
, 13- Michael B.D.
- Sidhu M.
- Stoeter D.
- Roberts M.
- Beeching N.J.
- Wilkins E.
- et al.
The epidemiology and management of adult suspected central nervous system infections – a retrospective cohort study in the NHS northwest region.
, 14- Kneen R.
- Jakka S.
- Mithyantha R.
- Riordan A.
- Solomon T.
The management of infants and children treated with aciclovir for suspected viral encephalitis.
, 32- Chataway J.
- Davies N.W.
- Farmer S.
- Howard R.S.
- Thompson E.J.
- Ward K.N.
Herpes simplex encephalitis: an audit of the use of laboratory diagnostic tests.
, 33- Whitley R.J.
- Cobbs C.G.
- Alford Jr., C.A.
- Soong S.J.
- Hirsch M.S.
- Connor J.D.
- et al.
Diseases that mimic herpes simplex encephalitis. Diagnosis, presentation, and outcome. NIAD Collaborative Antiviral Study Group.
Whitley et al. demonstrated that of 432 (168 < 18 years old) patients undergoing brain biopsy for presumed HSV encephalitis: 195 (45%) had the diagnosis proven histologically and in a further 95 patients (22%) an alternative, often treatable, diagnosis was established.
33- Whitley R.J.
- Cobbs C.G.
- Alford Jr., C.A.
- Soong S.J.
- Hirsch M.S.
- Connor J.D.
- et al.
Diseases that mimic herpes simplex encephalitis. Diagnosis, presentation, and outcome. NIAD Collaborative Antiviral Study Group.
However, the clinical presenting features of these two groups were very similar. Chataway et al. found that, of those patients initially considered to have HSV encephalitis, inflammatory aetiologies such as ADEM or multiple sclerosis were the most frequent mimics.
32- Chataway J.
- Davies N.W.
- Farmer S.
- Howard R.S.
- Thompson E.J.
- Ward K.N.
Herpes simplex encephalitis: an audit of the use of laboratory diagnostic tests.
Some of the rarer paediatric diagnoses included epileptic encephalopathies such as Rasmussen's encephalitis and Alper's syndrome. Kneen et al. showed the broad range of final diagnoses in children initially treated with aciclovir for possible HSV encephalitis in children and Bell et al. and Michael et al. demonstrated that this was also similar in adult practice.
12- Bell D.J.
- Suckling R.
- Rothburn M.M.
- Blanchard T.
- Stoeter D.
- Michael B.D.
- et al.
Management of suspected herpes simplex virus encephalitis in adults in a UK teaching hospital.
, 13- Michael B.D.
- Sidhu M.
- Stoeter D.
- Roberts M.
- Beeching N.J.
- Wilkins E.
- et al.
The epidemiology and management of adult suspected central nervous system infections – a retrospective cohort study in the NHS northwest region.
, 14- Kneen R.
- Jakka S.
- Mithyantha R.
- Riordan A.
- Solomon T.
The management of infants and children treated with aciclovir for suspected viral encephalitis.
The clinical picture clearly varies with disease severity but can also vary with aetiological agent; of the many viruses that cause acute encephalitis in children, some have a predilection for localised parts of the brain which can determine the initial clinical picture and the subsequent clinical course.
34Neuroimaging of herpesvirus infections in children.
Although, De Tiege et al.
35- De Tiege X.
- Rozenburg F.
- Heron B.
The spectrum of herpes simplex encephalitis in children.
endorse the view that the concept of a ‘‘classical’’ picture of HSV encephalitis in children is now out-dated and remind clinicians that the most common reason for failure to diagnose HSV encephalitis is non-specific initial clinical presenting symptoms and signs.
7- McGrath N.
- Anderson N.E.
- Croxson M.C.
- Powell K.F.
Herpes simplex encephalitis treated with acyclovir: diagnosis and long term outcome.
Seizures are more frequently found in patients presenting with encephalitic processes affecting the cortex, which are more often infectious in aetiology, as opposed to encephalitic processes predominantly affecting subcortical white matter that more frequently have an immune-mediated pathogenesis (e.g. ADEM). However, seizures and movement disorders are also often seen in children with encephalitis due to autoimmune antibody-mediated disease (see ‘Special circumstances’ section). Seizures can also be subtle and include subtle motor status: a syndrome of subtle continuous motor seizure activity. This often follows overt convulsive seizures or status epilepticus or non-convulsive status epilepticus (NCSE): a syndrome of encephalopathy with no overt motor seizure activity but an electrical seizure correlate on the EEG. A study of 144 (134 children) patients with encephalitis due to Japanese encephalitis virus found that 40 had witnessed seizures in hospital. Of these, 25 had one or more episodes of status epilepticus including 15 who went onto develop subtle motor status. Patients with witnessed convulsive or subtle motor status epilepticus were more likely to die (
p = 0.0003).
36- Solomon T.
- Dung N.M.
- Kneen R.
- Thao L.T.T.
- Gainsborough M.
- Nisalak A.
- et al.
Seizures and raised intracranial pressure in Vietnamese patients with Japanese encephalitis.
However, it is very unusual for patients with encephalitis or other CNS infections and encephalopathy to present with de novo NCSE. A study of 236 consecutive intensive care unit patients (11% < 16 years) during the first 3 days of an illness with coma (and no witnessed overt or subtle seizures) identified that 19 (8%) were in NCSE. Of these, 2 were children. Only one adult had a CNS infection (diagnosis unspecified).
37- Towne A.R.
- Waterhouse E.J.
- Boggs J.G.
- Garnett L.K.
- Brown A.J.
- Smith Jr., J.R.
- et al.
Prevalence of nonconvulsive status epilepticus in comatose patients.
In another study of 45 consecutive adults diagnosed with NCSE, 20 had no previous diagnosis of epilepsy. Twenty-eight of the 45 patients had a remote risk factor for developing epilepsy including previous CNS infections in some (number not specified).
38- Haffey S.
- McKernan A.
- Pang K.
Non-convulsive status epilepticus: a profile of patients diagnosed within a tertiary referral centre.
Despite its relative rarity, NCSE can only be diagnosed with an EEG and as there are specific treatments available, an EEG should be considered in all patients with undiagnosed encephalopathy.
39- Cinque P.
- Cleator G.M.
- Weber T.
- Monteyne P.
- Sindic C.J.
- van Loon A.M.
The role of laboratory investigation in the diagnosis and management of patients with suspected herpes simplex encephalitis: a consensus report. The EU Concerted Action on Virus Meningitis and Encephalitis.
Diagnostic features for specific aetiologies
The history is important in defining the spectrum of agents potentially responsible for encephalitis as this is influenced by age, immunocompetence, geography and exposure. Geographical restrictions are laid out in the
Table 2. These are particularly significant for arthropod-borne infections.
As indicated above the features for HSV are non-specific: many patients with suspected HSV encephalitis ultimately prove to have a different diagnosis. In adults, the finding of labial herpes (cold sores) has no diagnostic specificity for HSV encephalitis and is merely a marker of critical illness. However, in children who are more likely to develop encephalitis with a primary HSV infection, labial herpes may be noted.
43- Lahat E.
- Barr J.
- Barkai G.
- Paret G.
- Brand N.
- Barzilai A.
Long term neurological outcome of herpes encephalitis.
, 44- Elbers J.
- Bitnun A.
- Richardson S.E.
- Ford-Jones E.L.
- Tellier R.
- Wald R.M.
- et al.
A 12-year prospective study of childhood herpes simplex encephalitis: is there a broader spectrum of disease?.
Lahat reported 2 children with recent labial herpes in a series of 28 children aged from 3 months to 16 years with proven HSV encephalitis due to a primary infection
43- Lahat E.
- Barr J.
- Barkai G.
- Paret G.
- Brand N.
- Barzilai A.
Long term neurological outcome of herpes encephalitis.
and Elbers reported active or a recent history of labial herpes in 4 out of 16 children with proven HSV encephalitis.
44- Elbers J.
- Bitnun A.
- Richardson S.E.
- Ford-Jones E.L.
- Tellier R.
- Wald R.M.
- et al.
A 12-year prospective study of childhood herpes simplex encephalitis: is there a broader spectrum of disease?.
Elbers also reported that 3 further children with positive CSF PCR for HSV-1 were excluded from his series because of an atypical presentation. These children all had a milder illness (all had fever, one had multiple seizures, one had a single seizure and ataxia and one had lethargy and headache) and normal cranial imaging. Elbers concluded that the CSF PCR results may be false positives or due to reactivation of the virus but it is also conceivable that HSV can cause a mild encephalitis and for this reason it should be considered in the differential diagnosis of children with less severe symptoms. A mild HSV encephalitis has also been reported in 2 previous children aged 3.5 and 15 years who recovered without treatment with aciclovir.
31- Marton R.
- Gotlieb-Stematsky T.
- Klein C.
- Lahat E.
- Arlazoroff A.
Mild form of acute herpes simplex encephalitis in childhood.
Children with HSV encephalitis may also present with an acute opercular syndrome (disturbance of voluntary control of the facio-linguo-glosso-pharyngeal muscles leading to oro-facial palsy, dysarthria and dysphagia).
45- van der Poel J.C.
- Haenggeli C.A.
- Overweg-Plandsoen W.C.
Operculum syndrome: unusual feature of herpes simplex encephalitis.
, 46- Garcia-Ribes A.
- Martinez-Gonzalez M.J.
- Prats-Vinas J.M.
Suspected herpes encephalitis and opercular syndrome in childhood.
CNS disease caused by HSV-2 is rare outside the neonatal period. The most common manifestation in adults is aseptic meningitis which may be recurrent.
47Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's.
, 48- Meylan S.
- Robert D.
- Estrade C.
- Grimbuehler V.
- Peter O.
- Meylan P.R.
- et al.
Real-time PCR for type-specific identification of herpes simplex in clinical samples: evaluation of type- specific results in the context of CNS diseases.
This has also been reported in children and the possibility of sexual abuse may need to be considered.
49- Kumar S.
- Kumar S.
- Kohlhoff S.A.
Recurrent HSV-2 meningitis in a 9-year-old girl.
Varicella zoster virus (VZV) can cause central nervous system manifestations through a post-infective immune-mediated cerebellitis, an acute infective viral encephalitis or a vasculopathy; the neurological presentation may be preceded by the vesicular rash of by days or weeks, though it occasionally occurs before the rash or even in patients with no rash.
50- Dangond F.
- Engle E.
- Yessayan L.
- Sawyer M.H.
Pre-eruptive varicella cerebellitis confirmed by PCR.
, 51Varicella-zoster virus: atypical presentations and unusual complications.
, 52- Wagner H.J.
- Seidel A.
- Grande-Nagel I.
- Kruse K.
- Sperner J.
Pre-eruptive varicella encephalitis: case report and review of literature.
Encephalitis is more common in adults, especially those with cranial dermatome involvement or a disseminated rash or the immunocompromised. The presentation may be acute or sub-acute with fever, headache, altered consciousness, ataxia and seizures. A more common neurological presentation associated with VZV infection in children is post-infectious cerebellitis particularly in young children. This is usually a relatively mild and self limiting disorder but children can become unwell due to hydrocephalus secondary to swelling of the cerebellum in more severe cases.
53CNS diseases associated with varicella zoster virus and herpes simplex virus infection. Pathogenesis and current therapy.
, 54- Shkalim V.
- Amir J.
- Kornreich L.
- Scheuerman O.
- Straussberg R.
Acute cerebellitis presenting as tonsillar herniation and hydrocephalus.
Children usually present with a short history of unsteadiness or limb ataxia and nystagmus. The other relatively common association in childhood is between VZV infection and arterial ischaemic stroke, and is thought to account for up to one third of cases of arterial stokes in paediatric practice. The majority present with acute but permanent hemiparesis, acute chorea or facial weakness which is commonly transient;
55- Miravet E.
- Danchaivijitr N.
- Basu H.
- Saunders D.E.
- Ganesan V.
Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection.
seizures and visual or speech disturbances also occur. Patients usually present after the rash has cleared and the time period can be very delayed with a mean of 3 months (range 1 week to 48 months) reported in a recent London study.
55- Miravet E.
- Danchaivijitr N.
- Basu H.
- Saunders D.E.
- Ganesan V.
Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection.
However, early manifestations can occur within days of exposure,
50- Dangond F.
- Engle E.
- Yessayan L.
- Sawyer M.H.
Pre-eruptive varicella cerebellitis confirmed by PCR.
well before the vesicular eruption, which may be uncharacteristically mild,
52- Wagner H.J.
- Seidel A.
- Grande-Nagel I.
- Kruse K.
- Sperner J.
Pre-eruptive varicella encephalitis: case report and review of literature.
making diagnosis more challenging, especially as onset of encephalitic features can be abrupt or gradual.
51Varicella-zoster virus: atypical presentations and unusual complications.
PCR for VZV DNA in the CSF is positive in around a third of patients. A more sensitive test (positive in over 90% patients) is measuring VZV specific IgG antibodies in CSF. The levels can be compared to a concomitant serum sample as a reduced serum/CSF ratio of VZV IgG confirms intrathecal synthesis.
56- Nagal M.A.
- Cohrs R.J.
- Mahalingham R.
- Wellish M.C.
- Forghani B.
- Schiller A.
- et al.
The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features.
Epstein–Barr virus (EBV) encephalitis most commonly affects teenagers (median age 13 years; but generally presents in the absence of signs of the typical mononucleosis clinical picture.
57- Doja A.
- Bitnun A.
- Ford Jones E.L.
- Richardson S.
- Tellier R.
- Petric M.
- et al.
Pediatric Epstein-Barr virus—associated encephalitis: 10-year review.
In Doja's series of 21 patients, 17 had a non-specific prodrome of fever and 14 had headache. Manifestations of EBV encephalitis and encephalomyelitis may also include an altered level of consciousness, seizures and visual hallucinations.
57- Doja A.
- Bitnun A.
- Ford Jones E.L.
- Richardson S.
- Tellier R.
- Petric M.
- et al.
Pediatric Epstein-Barr virus—associated encephalitis: 10-year review.
, 58Epstein Barr-virus encephalitis and encephalomyelitis: MRI findings.
, 59- Cecil K.M.
- Jones B.V.
- Williams S.
- Hedlund G.L.
CT, MRI, and MRS of Epstein-Barr virus infection: case report.
However, the temporal relationship between symptoms is highly variable, including CNS disease as the presenting manifestation, making aetiological diagnosis difficult on clinical grounds and highlighting the need to consider EBV in all cases of childhood encephalitis irrespective of symptoms.
57- Doja A.
- Bitnun A.
- Ford Jones E.L.
- Richardson S.
- Tellier R.
- Petric M.
- et al.
Pediatric Epstein-Barr virus—associated encephalitis: 10-year review.
Encephalitis may be associated with respiratory illnesses in children: most common pathogens include the influenza viruses, paramyxoviruses and the bacterium
M. pneumoniae. There may be no preceding respiratory symptoms prior to the development of encephalitis in a significant proportion of patients.
60- Christie L.J.
- Honarmand S.
- Talkington D.F.
- Gavali S.S.
- Preas C.Y.
- Yagi S.
- et al.
Pediatric encephalitis: what is the role of mycoplasma pneumoniae?.
, 61- Bitnun A.
- Ford-Jones E.
- Petric M.
- MacGregor D.
- Heuter H.
- Nelson S.
- et al.
Acute childhood encephalitis and Mycoplasma pneumoniae.
In a recent study of patients with
M. pneumonia encephalitis, the affected children were an older cohort (median age 11 years old), presenting with a short prodrome of fever (70%), lethargy (68%), and altered consciousness (58%), while gastrointestinal (45%) and respiratory (44%) symptoms were less common.
60- Christie L.J.
- Honarmand S.
- Talkington D.F.
- Gavali S.S.
- Preas C.Y.
- Yagi S.
- et al.
Pediatric encephalitis: what is the role of mycoplasma pneumoniae?.
Their clinical course progressed rapidly (median 2 days from onset to hospitalization), and commonly required intensive care (55%). Seizures were less common in the clinical picture. Symptoms of progressive symmetrical external opthalmoplegia typify Bickerstaff brainstem encephalitis in association with
M. pneumonia and can serve as a clue to diagnosis especially when accompanied by ataxia.
62- Steer A.C.
- Starr M.
- Kornberg A.J.
Bickerstaff brainstem encephalitis associated with Mycoplasma pneumoniae infection.
Influenza has been reported to be associated with a spectrum of neurological disorders in adults and children ranging through a mild encephalopathy with seizures, encephalitis, ADEM, encephalopathy with posterior reversible encephalopathy syndrome, malignant brain oedema syndrome and acute necrotising encephalopathy (ANE).
65Acute encephalopathy and encephalitis caused by influenza virus infection.
, 66- Akins P.A.
- Belko J.
- Uyeki T.M.
- Axelrod Y.
- Lee K.K.
- Silverthorn J.
H1N1 encephalitis with malignant edema and review of neurologic complications from influenza.
Patients with influenza (particularly influenza B) can also have associated severe myositis.
63- Wang Y.H.
- Huang Y.C.
- Chang L.Y.
- Kao H.T.
- Lin P.Y.
- Huang C.G.
- et al.
Clinical characteristics of children with influenza A virus infection requiring hospitalization.
, 64- Lin C.H.
- Huang Y.C.
- Chiu C.H.
- Huang C.G.
- Tsao K.C.
- Lin T.Y.
Neurologic manifestations in children with influenza B virus infection.
Patients with influenza encephalopathy/encephalitis rarely have viral antigens or viral nucleic acid in CSF or neural tissue and the mechanisms for causing neurological illness are still unclear. Influenza A in particular, has been reported in association with ANE, a severe encephalopathy often associated with fever and in which typical MRI abnormalities have been reported in the thalami, brainstem and cerebral white matter.
65Acute encephalopathy and encephalitis caused by influenza virus infection.
, 66- Akins P.A.
- Belko J.
- Uyeki T.M.
- Axelrod Y.
- Lee K.K.
- Silverthorn J.
H1N1 encephalitis with malignant edema and review of neurologic complications from influenza.
, 67The puzzling picture of acute necrotising encephalopathy after influenza A and B infection in young children.
ANE has most frequently been reported in young children in small outbreaks in Japan and other Southeast Asian countries. This disorder has been found to have an autosomal dominant inheritance pattern in some families with genetic mutations identified.
68- Neilson D.E.
- Adams M.D.
- Orr C.M.
- Schelling D.K.
- Eiben R.M.
- Kerr D.S.
- et al.
Infection-triggered familial or recurrent cases of acute necrotizing encephalopathy caused by mutations in a component of the nuclear pore RANBP2.
There is some very recent evidence that the H1N1 strain of Influenza A that emerged in 2009 may cause more neurological manifestations than seasonal flu. Ekstrand reported 18 children with H1N1and compared them to 16 with seasonal flu. Children with the H1N1 strain were more likely to have encephalopathy, focal neurological signs, aphasia and an abnormal EEG.
69- Ekstrand J.J.
- Herbener A.
- Rawlings J.
- Turney B.
- Ampofo K.
- Korgenski E.K.
- et al.
Heightened neurologic complications in children with pandemic H1N1 influenza.
Encephalitis associated with gastrointestinal symptoms includes infection with enteroviruses, rotavirus and human parechoviuses. Enteroviral encephalitis can be associated with a brainstem syndrome. Large outbreaks of encephalitis have been reported with enterovirus 71 in Bulgaria 1975, Hungary 1997, Malaysia 1997 and Taiwan 1997. Children under 5 are more commonly affected
70- Chen C.Y.
- Yao Y.C.
- Huang C.C.
- Lui C.C.
- Lee K.W.
- Huang S.C.
Acute flaccid paralysis in infants and young children with enterovirus 71 infection: MR imaging findings and clinical correlates.
and the highest mortality is in those aged 6–12 months.
71- Lin T.Y.
- Chang L.
- Huang Y.C.
- Hsu K.H.
- Chiu C.H.
- Yang K.D.
Different proinflammatroy reactions in fatal and non-fatal enterovirus 71 infections: implications for early recognition and therapy.
, 72Enterovirus 71: the virus, its infections and outbreaks.
Clues to infection with this virus include the typical papular lesions on the hands, feet and in the mouth but those with encephalitis often develop neurogenic pulmonary oedema
73- Prager P.
- Nolan M.
- Andrews I.P.
- Williams G.D.
Neurogenic pulmonary edema in enterovirus 71 encephalitis is not uniformaly fatal but causes severe morbidty in survivors.
on day 2–3 of illness which can rapidly progress to fatal cardiorespiratory collapse despite intervention.
71- Lin T.Y.
- Chang L.
- Huang Y.C.
- Hsu K.H.
- Chiu C.H.
- Yang K.D.
Different proinflammatroy reactions in fatal and non-fatal enterovirus 71 infections: implications for early recognition and therapy.
Rotavirus encephalopathy has been reported to cause convulsions and cerebellar signs in some children.
74- Liu B.
- Fujita Y.
- Arakawa C.
- Kohira R.
- Fuchigami T.
- Mugishima H.
- et al.
Detection of rotavirus RNA and antigens in serum and cerebrospinal fluid samples from diarrheic children with seizures.
, 75- Kobayashi S.
- Negishi Y.
- Ando N.
- Ito T.
- Nakano M.
- Togari H.
- et al.
Two patients with acute rotavirus encephalitis associated with cerebellar signs and symptoms.
Rashes may be seen in other encephalitides; for example a maculopapular or vesicular rash is seen in Rickettsial infections or the highly typical rash of measles virus infection. Measles can cause three separate encephalitic illnesses and is of particular concern given the recent rise in cases reported in children and young adults across Europe. The first is either an acute encephalitis or acute disseminated encephalomyelitis associated with the acute infection, although patients may present without the typical rash.
76- Wairagkar N.S.
- Shaikh N.J.
- Ratho R.K.
- Ghosh D.
- Mahajan R.C.
- Singhi S.
- et al.
Isolation of measles virus from cerebrospinal fluid of children with acute encephalopathy without rash.
The second is a sub-acute encephalopathy around six months after the primary infection in the immunocompromised with measles inclusion bodies in the brain often without a rash. The third is sub-acute sclerosing panencephalitis (SSPE) in the immunologically normal which can occur several years after the primary infection. Patients with the sub-acute forms usually present with a dementia, visual problems and later with seizures.
77- Gutierrez J.
- Issacson R.S.
- Koppel B.S.
Subacute sclerosing panencephalitis: an update.
HHV6 (and possibly HHV7) is a cause of encephalitis causing severe disease and long-term sequelae far beyond self-resolving febrile convulsions.
78- Ward K.N.
- Leong H.N.
- Thiruchelvam A.D.
- Aykinson C.E.
- Clark D.A.
Human Herpesvirus 6 DNA levels in CSF due to primary infection differ from those due to chromosomal viral intergration and have implications for diagnosis of encephalitis.
Typical below age 2 years
79- Mannonen L.
- Herrgard E.
- Valmari P.
- Rautiainen P.
- Uotila K.
- Aine M.R.
- et al.
Primary human herpesvirus 6 infection in the central nervous system can cause severe disease.
ataxia and prolonged convulsions are the major neurological manifestations and gastrointestinal symptoms can accompany the high fever and rash systemically, thus can be indistinguishable from the viral encephalitides typified by gastroenteritis.
Sometimes the pattern of neurological deficit can be a clue as to the possible aetiology. Thus autonomic dysfunction, myoclonus and cranial neuropathies can indicate brainstem encephalitis, which is seen in listeriosis, brucellosis, some viral infections or rarely tuberculosis (
Table 8. Brainstem encephalitis); there may be tremors and other movement disorders if the thalamus and other basal ganglia are involved, as seen in flaviviruses, such as West Nile virus and Japanese encephalitis, and alphaviruses such as Eastern equine encephalitis virus.
, 81- Harvala H.
- Bremner J.
- Kealey S.
- Weller B.
- McLellan S.
- Lloyd G.
- et al.
Case report: eastern equine encephalitis virus imported to the UK.
An encephalitis with an acute flaccid paralysis is characteristic of polio, and other enterovirsues, such as enterovirus 71, as well as flaviviruses.
82- Ooi M.H.
- Wong S.C.
- Lewthwaite P.
- Cardosa M.J.
- Solomon T.
Clinical features, diagnosis and management of enterovirus 71.
Table 8Brainstem encephalitis (rhombencephalitis) - clues and causes, from (Solomon, Hart et al., 2007).110- Solomon T.
- Hart I.
- Beeching N.J.
Viral Encephalitis: a clinician's guide.
Table 9Additional investigations to consider in the differential diagnosis of encephalitis.
Abbreviations: MRI magnetic resonance imaging; ASO antistreptolysin; PCR polymerase chain reaction; CSF cerebrospinal fluid; FBC full blood count; ESR erythrocyte sedimentation rate; CRP C-reactive protein; ANA antinuclear antibodies; ENA extraneuclear antibodies; dsDNA double stranded deoxyribonucleic acid antibodies; C3/4 complement; ACE angiotensin converting enzyme; CT computed tomography; LDH lactate dehydrogenase; IgG/M/A immunoglobulin; PET positron emission tomography; CNS central nervous system.