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Clinical and etiological profile of acute febrile encephalopathy in Eastern Nepal

Authors:
Rupa Rajbhandari Singh at B.P. Koirala Institute of Health Sciences
Rupa Rajbhandari Singh
S K Chaudhary
S K Chaudhary
S K Chaudhary
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Nisha Bhatta at B.P. Koirala Institute of Health Sciences
Nisha Bhatta
Basudha Khanal at B.P. Koirala Institute of Health Sciences
Basudha Khanal
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Abstract

To investigate the clinical and etiological profile of acute febrile encephalopathy in children presenting to a tertiary care referral center of Eastern Nepal. 107 children (aged 1 month to 14 yrs) presenting to the emergency with fever (> 38 C) of less than 2 weeks duration with altered sensorium with/or without seizure were prospectively investigated for etiological cause. The investigations included blood and CSF counts, blood and CSF cultures, peripheral smear and serology for malarial parasite, and serology for Japanese encephalitis (JE) virus. Other investigations included EEG and CT or MRI wherever indicated. The most common presenting complaints apart from fever and altered sensorium were headache and vomiting. Convulsions, neck rigidity, hypertonia, brisk deep tendon reflexes, extensor plantar response and focal neurological deficits were seen in 50%, 57%, 22.4%, 28%, 39.3% and 9.3% of the subjects, respectively. The diagnoses based on clinical presentation and laboratory findings were pyogenic meningitis in 45 (42%), non JE viral encephalitis in 26 (25%), JE in 19 (18%), cerebral malaria in 8 (7%), herpes encephalitis and tubercular meningitis in 4 (4%) each, and typhoid encephalopathy in 1 case. Pyogenic meningitis and viral encephalitis including JE are the most common causes of acute presentation with fever and encephalopathy. Preventive strategies must be directed keeping these causes in mind.
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Correspondence and Reprint requests : Dr. Dheeraj Shah,
Associate Professor, Department of Pediatrics and Adolescent
Medicine B. P. Koirala Institute of Health Sciences, Dharan,
Nepal.
[DOI--10.1007/s12098-009-0233-8]
[Received April 14, 2008; Accepted January 19, 2009]
Original Article
Clinical and Etiological Profile of Acute Febrile
Encephalopathy in Eastern Nepal
Rupa R. Singh, S. K. Chaudhary, Nisha K. Bhatta, B. Khanal1 and Dheeraj Shah
Department of Pediatrics and Adolescent Medicine and 1Microbiology, B.P. Koirala Institute of Health Sciences,
Dharan, Nepal
ABSTRACT
Objective. To investigate the clinical and etiological profile of acute febrile encephalopathy in children presenting to a tertiary
care referral center of Eastern Nepal.
Methods. 107 children (aged 1 month to 14 yr) presenting to the emergency with fever (> 380 C) of less than 2 wk duration
with altered sensorium with/ or without seizure were prospectively investigated for etiological cause. The investigations
included blood and CSF counts, blood and CSF cultures, peripheral smear and serology for malarial parasite, and serology
for Japanese encephalitis (JE) virus. Other investigations included EEG and CT or MRI wherever indicated.
Results. The most common presenting complaints apart from fever and altered sensorium were headache and vomiting.
Convulsions, neck rigidity, hypertonia, brisk deep tendon reflexes, extensor plantar response and focal neurological deficits
were seen in 50%, 57%, 22.4%, 28%, 39.3% and 9.3% of the subjects, respectively. The diagnoses based on clinical
presentation and laboratory findings were pyogenic meningitis in 45 (42%), non JE viral encephalitis in 26 (25%), JE in 19
(18%), cerebral malaria in 8 (7%), herpes encephalitis and tubercular meningitis in 4 (4%) each, and typhoid
encephalopathy in 1 case.
Conclusion. Pyogenic meningitis and viral encephalitis including JE are the most common causes of acute presentation
with fever and encephalopathy. Preventive strategies must be directed keeping these causes in mind. [Indian J Pediatr
2009; 76 (11) : 1109-1111]
E-mail: shahdheeraj@ hotmail.com
Key words: Key words:
Key words: Key words:
Key words: Encephalopathy; Japanese encephalitis; Viral encephalitis
Acute encephalopathy denotes a diffuse and
nonspecific brain insult manifested by a combination of
coma, seizures and decerebration, and is an important
cause of morbidity and mortality in young hospitalized
children. Various causes such as viral encephalitis,
cerebral malaria, bacterial meningitis, Reye’s syndrome
etc. have been implicated in etiology and the
proportionate contribution of each varies according to
the geographical area. Despite so many epidemiological
reports and investigations, the presentation with acute
onset fever and altered sensorium has often remained a
mystery especially in Indian states of Uttar Pradesh,
Bihar and West Bengal.1-3 The terai region of Nepal
borders these states and shares similar ecology. There
has not been any comprehensive, systemic study of the
etiology of childhood febrile encephalopathy in Nepal.
The present study was conducted at a tertiary care
referral center of Eastern Nepal to find out the
etiological pattern and clinical presentation of acute
febrile encephalopathy in children.
MATERIAL AND METHODS
All children (aged between 1 month and 14 yr)
presenting to the Department of Pediatrics and
Adolescent Medicine, B.P. Koirala Institute of Health
Sciences, Dharan, Nepal with fever (temperature >
380C) of less than 2 wk duration alongwith altered
sensorium with or without seizures were prospectively
enrolled in the study from January 2003 to January
2004. Children having history of head injury, febrile
seizures or past history of seizures were excluded from
the study.
Indian Journal of Pediatrics, Volume 76—November, 2009 1109
Rupa R Singh
et alet al
et alet al
et al
1110 Indian Journal of Pediatrics, Volume 76—November, 2009
A detailed history and clinical examination
including neurological examination were done in all
subjects. The investigations performed in every child
included blood counts, peripheral smear for malarial
parasite, quantitative buffy coat (QBC) for malaria,
optimal test, blood culture, cerebrospinal fluid (CSF)
examination for cytology, Gram stain, AFB stain,
biochemistry and culture. Samples for JE serology were
collected aseptically, placed in labelled container in a
CO2 jar, and were dispatched at the earliest possible
opportunity to the JE laboratory. Anti-JE IgM was done
by using the IgM antibody capture ELISA (MAC ELISA)
in serum and CSF samples of the patients. Chest X-ray,
Ultrasonography of the head, electroencephalogram
and CT scan were done as and when required.
Patients were diagnosed as confirmed cases of
Japanese encephalitis if anti JE IgM was found to be
positive in cerebrospinal fluid. Pyogenic meningitis
was diagnosed on the basis of polymorphonuclear
leucocytosis in CSF or/and positive Gram stain or
culture of CSF. Cerebral malaria was diagnosed in
patients having febrile encephalopathy alongwith
positive peripheral smear or serology for Plasmodium
falciparum.
RESULTS
One hundred and seventeen children were admitted
with a diagnosis of acute febrile encephalopathy
during the study period. 10 children could not be
included in the study as they left against medical advice
after admission before the detailed work up could be
completed. Two third of the cases were more than 5 yr
of age whereas the rest one-third were below the age of
5 yr. Only 9 (8.4%) cases of acute febrile encephalopathy
occurred in infants. Almost two-thirds (69 out of 107;
64.5%) of the subjects were male. Majority (78.5%) of the
cases belonged to terai (plains) region of Nepal.
The most common presenting complaints apart from
fever and altered sensorium were headache and
vomiting. In one-third (35.5%) of the cases, the duration
of the fever was less than 72 hr. The duration of central
nervous system (CNS) features was even shorter with
headache and altered sensorium being present for less
than 72 hr in 81.3% and 96.3% children, respectively.
The mean (+ SD) Glasgow coma score (GCS) was 9.6 (+
3.2). Convulsions were reported in 54 (50%) subjects.
Neck stiffness and Kernig’s sign were present in 61
(57%) and 47 (43.9%) cases, respectively. Hypertonia
was present in 24 (22.4%) patients whereas brisk
reflexes and extensor plantar response were present in
30 (28%) and 42 (39.3%) subjects, respectively. Focal
neurological deficits at presentation were present in
only 10 (9.3%) children. Leucocytosis (TLC > 14,000)
was seen in 48.6% children.
The most common illness presenting as fever with
altered sensorium was viral encephalitis seen in 49
(45.8%) cases. The cause of viral encephalitis was
established as Japanese encephalitis in 19 (17.7%)
patients and herpetic encephalitis in 4 (3.7%) patients.
Pyogenic meningitis was second most common
diagnosis responsible for 45 (42%) cases. Cerebral
malaria was documented in 8 (7.5%) children and
tubercular meningitis in 4 (3.7%) children presenting as
acute febrile encephalopathy. Typhoid fever was a
cause of encephalopathy in one subject. Blood culture
was positive only in 10 (22.2%) cases of pyogenic
meningitis and CSF culture positivity was even less (7
out of 45; 15.5%).
Among 19 cases of JE, 15 were older than 5 yr. Only
one case of JE occurred in infancy. The duration of the
symptoms of fever, headache and altered sensorium in
these cases were comparable to the non-JE cases.
Similarly, the proportion of cases having convulsions
(52.6% vs. 50%), hypertonia (36.8 % vs. 19.3%), extensor
plantar response (36.8% vs. 39.8%) and focal
neurological deficits (10.5% vs. 9.1%) in JE was
comparable to the other cases of acute febrile
encephalopathy. Neck rigidity, however, was more
commonly seen in JE (84.2% vs. 51.1%; P< 0.01).
DISCUSSION
In the present study, viral encephalitis was the most
common cause (46%) of acute febrile encephalopathy.
40% of cases (19 out of 49) of viral encephalitis could
be attributed to Japanese encephalitis. Overall, JE was
responsible for 18% of cases of acute febrile
encephalopathy in children from our region. Pyogenic
meningitis was the second most common diagnosis
after viral encephalitis in children presenting with
febrile encephalopathy. Earlier studies from several
regions of India have documented the pyogenic
meningitis to be the most common diagnosis in such
children. A study by Kumar et al. from Lucknow, India
in children with acute encephalopathy showed
pyogenic meningitis and JE to be responsible for 18%
and 12% of cases, respectively4. Mehrotra et al. found
pyogenic meningitis in 49.1% and viral causes in
11.4%5. In comparison to these studies, viral
encephalitis was more common in the present study.
This could be due to the fact that most patients in our
hospital were referred from other places. This raises the
possibility of enrolling more patients who did not
respond to the usual treatment thus increasing the
proportion of cases of viral encephalitis. This pattern
could also be related to the catchment area of our
hospital including nearby terai areas which border
portions of Bihar and Eastern U.P. where periodic
outbreaks of JE and other viral encephalitis are
Clinical and Etiological Profile of Acute Febrile Encephalopathy in Eastern Nepal
Indian Journal of Pediatrics, Volume 76—November, 2009 1111
common. In one-fourth of the cases included in the
present study, no specific etiology was found and these
were labeled as viral encephalitis due to other viruses. It
is possible that a more detailed diagnostic work up
such as serology and antigen detection by PCR for other
viruses could have picked more etiologies.
Cerebral malaria was the diagnosis in only 8 (7.5%)
children in the study. Thus, it was an uncommon cause
of fever presenting with encephalopathy in the present
study area. Kumar et al in their study on 740 children
with acute encephalopathy also found cerebral malaria
in only 4 (0.5%) cases.4 Empirical treatment with
quinine is very frequently used in children when they
present with fever and encephalopathy in malaria
endemic areas. However, the present study and similar
other studies from South-East Asia show that cerebral
malaria is a relatively uncommon cause of acute febrile
encephalopathy in children. The resistance to quinine
and other antimalarial drugs is slowly increasing in
these countries6,7. This could be related to the empirical
use of this drug in conditions where it is not warranted.
Thus, quininie should be offered to children with acute
febrile encephalopathy only if there is documentation of
infection with P. falciparum. All efforts however must be
made to diagnose cerebral malaria by examining
peripheral smear repeatedly and also by using
serological tests in cases where index of suspicion is
high.8
In the present study, Gram stain positivity was seen
in almost two-thirds of patients with pyogenic
meningitis whereas the blood and CSF culture positivity
were relatively low. This could be due to antibiotic being
given outside prior to admission in our hospital in
many patients.
Most clinical features of JE in the present study were
similar to those seen with other causes of acute febrile
encephalopathy. This suggests that serology should be
done in all cases of acute febrile encephalopathy to
make the diagnosis of JE as the clinical presentation
alone is not specific for this diagnosis. The proportion
of children having seizures and focal neurological
deficits in the present study was lower in comparison
to an earlier study from Lucknow, India9. This seems to
be related to more virulent mutant strains of viruses in
the Lucknow study.9
CONCLUSION
Viral encephalitis was the most common cause of acute
febrile encephalopathy in children from this region
followed closely by pyogenic meningitis. Amongst
children having viral encephalitis, JE was responsible
for one out of five cases. Cerebral malaria was relatively
uncommon cause of acute febrile encephalopathy. The
causes and risk factors for high prevalence of viral
encephalitis need to be urgently explored in order to
initiate preventive strategies. Vaccination against JE has
already been started in this part of Nepal based on
preliminary findings from the present study. Other
studies need to be conducted in different geographical
areas to find out usefulness of such a program.
Contributions: RRS and NKB conceptualized the study and
decided the methodology. SKC participated in collection of data.
BK conducted the microbiology workd up. DS wrote the
manuscript which was critically analysed by RRS. All authors
approved the manuscript.
Conflict of Interest : None
Role of Funding Source : None
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... Contrary a far less mean duration of fever was seen in a study by Mueller et al. from Cambodia and the possible explanation was that this study was conducted among outpatients in a community setting while ours was a in-patient study conducted at a tertiary care hospital. [9] Similar results were observed in a study among pediatric AES cases from Nepal by Singh et al. [10] The mean duration of altered sensorium in our study was 81.83 ± 59.78 h with most the 54.3% of cases admitted after 72 h of onset of altered sensorium. This is contrary to the study done by Reza and Sareh where the mean duration of altered sensorium was much less 46.8 ± 5 h, similarly Singh et al. from Eastern Nepal reported a <72 h duration of altered sensorium for 96.3% children they studied. ...
... This is contrary to the study done by Reza and Sareh where the mean duration of altered sensorium was much less 46.8 ± 5 h, similarly Singh et al. from Eastern Nepal reported a <72 h duration of altered sensorium for 96.3% children they studied. [10,11] The possible cause in our study as PGIMER, Chandigarh, India, being a tertiary care hospital and most of our patients were referred from other hospitals. 65.7% of cases were referred after being treated outside in our study. ...
... Similar findings were also seen from the study done in Iran by Reza and Sareh, Singh et al. from Uttarakhand. [6,10] The poor predictors of outcome in our study were female gender, presence of fever (more than 38°C) at presentation, positive MRI findings, GCS ≤7 and patients with no clear-cut diagnosis. The strongest predictors of outcome were poor GCS and the cases where the diagnosis was not established with a P = 0.001 and 0.002 respectively. ...
Changing Clinical Profile and Predictors of Mortality in Patients of Acute Febrile Encephalopathy from North India
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Introduction Acute encephalitis syndrome (AES) or acute febrile encephalopathy is a clinical condition characterized by altered mental status occurring after or along with a short febrile illness. In developing countries, infections are the predominant cause of AES. Prominent infections known to cause AES include viruses (such as herpes simplex virus [HSV], Japanese Encephalitis [JE] virus, dengue, enteroviruses [EVs]), bacteria, fungus, and parasites. In the present study, we aim to analyze the etiology, clinical features, and predictors of mortality in patients presenting with acute febrile encephalopathy or acute encephalitic syndrome. The present study was a prospective observational study conducted at Post Graduate Institute of Medical Education and Research a tertiary care center in Chandigarh, India. Methods A total of 105 patients with ≥18 years of age with fever (body temperature >101° F for duration ≤14 days) and altered sensorium (Glasgow coma scale [GCS] score ≤10) lasting for more than 24 h, either accompanying the fever or following it were enrolled. Demographic and clinical details were recorded on pro forma. Cerebrospinal fluid (CSF) analysis was performed for all the enrolled patients at admission for cytology, CSF glucose to blood glucose ratio, protein levels, gram stain and culture sensitivity, adenosine deaminase levels, polymerase chain reaction for HSV/EV/mycobacterium tuberculosis (TB) and immunoglobulin M Enzyme-linked immune assay for JE. Computed tomography of the brain was done in all patients while magnetic resonance imaging (MRI) of the brain was carried out in 75 patients. Results Among the 105 patients, tubercular meningitis was seen in 27 (25.7%) patients followed by acute pyogenic meningitis in 18 (17.1%) patients. Probable viral encephalitis was present in 12 (11.4%) cases. Septic encephalopathy ( n = 10) and scrub typhus encephalitis ( n = 8), HSV encephalitis ( n = 6), dengue encephalitis ( n = 4), leptospirosis ( n = 3) were the other infections causing acute febrile encephalitis in our study. In addition to fever and altered sensorium common symptoms observed were headache (52.4%), vomiting (35.2%), and seizures (29.5%). The factors predicting increased mortality were female gender, fever of more than 38°C at admission, GCS <7, MRI showing disease-related findings like altered signal intensity bilateral medial temporal and insular area in herpes simplex encephalitis, etc., changes, and the group of patients where a definite diagnosis could not be established during the hospital stay. Conclusions Tubercular meningitis/central nervous system TB is the predominant cause of acute febrile encephalopathy in developing countries. Scrub and dengue encephalitis are emerging as an important cause of acute febrile encephalopathy and occur predominantly in postmonsoon seasons. Acute febrile encephalopathy remains an important cause of mortality in patients presenting to Emergency Department (ER). The strongest predictors of mortality are low GCS and undiagnosed cases of AES.
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... In children, CNS infections are the commonest cause of altered mental condition with febrile non-traumatic coma in India as well as other developing countries but it can result from wide variety of aetiologies posing as a diagnostic challenge. [3][4][5][6][7][8][9] It can result from various CNS infections such as cerebral malaria (CM), Japanese B encephalitis (JE), bacterial meningitis. 10 The occurrence of encephalitis in India is not known as there is problem in establishing viral analysis and the fact that a wide variety of both infectious and non-infectious CNS disorders, may mimic the illness. ...
... In the study done by Biswas et al most common presenting complaints were convulsion and vomiting and in study by Singh et al, most common presenting complaints were headache and vomiting. 7,15 In our study, cerebral malaria was the commonest cause (31.1%) of AFE in children followed by suspected viral encephalitis (16.3%) and pyogenic meningitis (14.7%). ...
... Results were different in study done by Singh et al where pyogenic meningitis (42%) was commonest cause followed by viral encephalitis and cerebral malaria. 7 In this study, out of total 61 cases, 26.2% patients were expired and 73.8% patients were discharged after the treatment. In the study done by Karmarkar et al they found that 19.01% ...
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Background: Acute febrile encephalopathy (AFE) is a medical emergency as well as diagnostic and therapeutic challenge in children. Objective of this study was to assess clinico-aetiological profile and outcome in children with AFE.Methods: This prospective observational study was carried out at tertiary care hospital Udaipur, from January 2020 to July 2021. Total 61 children aged 1 month to 18 years who were admitted in PICU with fever ≤2 weeks duration and altered sensorium either at onset or following fever were enrolled. Patient’s detailed history and physical examination including detailed neurological examinations were recorded on pre-structured performa. The investigations included CBC with PBF, ESR, malarial parasite, dengue, scrub typhus, typhi-dot, blood sugar, KFT, electrolytes, LFT, calcium, CSF examination, urine examination, X-ray chest. ABG, serum ammonia, blood culture for bacteriological studies and CT/MRI brain were performed whenever required.Results: 61 patients were admitted with fever and loss of sensorium. The most common clinical sign was the pallor (63.9%) and vomiting (55.7%) was the most common clinical symptom. Cerebral malaria was the commonest cause (31.1%) of AFE followed by suspected viral encephalitis (14.7%) and pyogenic meningitis 9 (14.7%). Out of total 61 patients, 45 (73.8%) patients were discharged and 16 (26.2%) patients were expired. Maximum mortalities were seen in Reye’s syndrome (5 out of 6 cases) and was most in age group <5 years of age (26 cases).Conclusions: Cerebral malaria was the leading cause of AFE followed by suspected viral encephalitis and pyogenic meningitis. While determining the aetiology of AFE in a malarial endemic area, cerebral malaria should be considered in all patients. Reye’s syndrome should also be considered in patients of AFE should be evaluated to diagnose or rule out this entity.
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... 7 This difference may be accounted by the differences in presentation across the countries and the varying etiologies (bacterial meningitis, tuberculous meningitis and cerebral malaria seen by Anga G et al.; as against tubercular meningitis, viral encephalitis and bacterial meningitis seen in our study). 7 The spectrum of clinical profile of children presenting with acute febrile encephalopathy studied by Singh et al. (2009) revealed that fever (100%) and altered sensorium (100%) were the most common presenting complaints with mean GCS of 9.6 (similar to ours). 8 Another common feature in our study was presence of convulsion/s at presentation (84 patients; 70%). ...
... 7 The spectrum of clinical profile of children presenting with acute febrile encephalopathy studied by Singh et al. (2009) revealed that fever (100%) and altered sensorium (100%) were the most common presenting complaints with mean GCS of 9.6 (similar to ours). 8 Another common feature in our study was presence of convulsion/s at presentation (84 patients; 70%). This percentage was higher than that in studies by Kumar We had 20 deaths (mortality 16.7%) and 100 patients survived (83.3%). ...
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Background: Fever and altered sensorium constitute a medical emergency in children. Early recognition, accurate diagnosis and timely management may help in reducing the morbidity and mortality in acute febrile encephalopathy (AFE). AIM: To study etiology, clinical presentation and outcome in children presenting with acute febrile encephalopathy. Methods: This prospective observational cohort study was conducted in a tertiary care center over the duration of one year (2016 to 2017).consecutive patients (age group of one month to 12 years) presenting with fever of ≤ 2 weeks duration and altered mental status were enrolled. The clinical features were noted and patients were followed up through the duration of hospital stay (wards & intensive care unit). Etiology and clinical features were listed as percentage of total cases. Risk factors for mortality were determined using chi-square test. Results: 120 children were enrolled. Besides fever and altered sensorium, convulsions (70%) and meningeal signs (38.3%) were common clinical features. Tubercular meningitis (33.3%) was the most common cause followed by viral encephalitis (24.2%), bacterial meningitis (9.2%) and cerebral malaria (5.8%). Mortality was 16.7% with neuro-morbidity seen in 45% of the cases. Longer duration of hospital stay (≥ 28 days), longer duration of PICU stay (> 14 days), longer duration of mechanical ventilation (≥ 7 days) and low Glasgow coma score (GCS< 8) were risk factors associated with higher mortality. Conclusion: Infectious causes were the commonest cause of AFE. AFE has a high rate of neuro-morbidity. Early identification of high risk factors may help to reduce the mortality. Corresponding Author : Milind S. Tullu, Professor Additional, Department of Pediatrics, Seth Gordhandas Sunderdas Medical College & King Edward Memorial Hospital, Mumbai 400012, Maharashtra, India.
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... Singh et al., reported that almost two-thirds (64.5%) of the subjects with AFE were male. 8 Although no documented CNS infection has a male preponderance, this apparent male predominance can be attributable to the male-dominated social structure in which a sick male receives preferential medical attention. ...
... A lumbar puncture is a preferred method of obtaining CSF. 8 There is an increase in protein concentration in patients with TM and PM in the previous studies performing biochemical analysis. 11,12 Higher protein concentration is observed in TM than PM due to breaches in the bloodbrain barrier and increased local synthesis of gamma globulins. ...
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... Fever with altered mental state, also known as Acute Febrile Encephalopathy, is a constellation of symptom and signs that leads to hospitalizations in both adults and children in our country. Also, similar complaints apart from fever and altered sensorium, headache and vomiting were also observed in acute febrile encephalopathy in children presenting to a tertiary care referral center of Eastern Nepal by Singh et al. 4 Average duration of fever was 3.97±2.40 in days. The average duration of fever was comparable to the study done by Sharma et al who found mean duration of 4.4±3.57 ...
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... A large number of ( n = 5963) typhoid fever were recorded from Bharatpur during 2002 (population, 92,214); 25 132 strains of S. enterica typhi, isolated from 2,568 blood samples from the eastern part of Nepal with one case of acute febrile encephalopathy 26 and 82 cases of enteric fever in the western part of Nepal between 2000 and 2005. 27,28 The enteric fever was laboratory (serology and blood culture) confirmed in all five developmental regions. Since then, sporadic cases and/or outbreaks have continued validating the endemicity of enteric fever in the country (Fig. 1). ...
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... These findings were similar with the study done by Sharma et al. 5 JE virus was the most common virus we could isolate. In our study, JE encephalitis was found in 13.5% cases which was similar to study done by Kumar et al., 9 Singh et al., 10 ...
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Full-text available
  • Apr 2021
Background: Acute febrile encephalopathy (AFE) is defined as fever associated with acute alteration of consciousness, with or without seizure, motor and/ or sensory deficit and total duration of illness one week or less. It is associated with significant morbidity and mortality in children. Various etiologies have been implicated in its causation and differ as per geographical. Efforts to promptly identify the underlying etiology and institute appropriate treatment early and adequately should be our goal so as to avoid any long-term sequelae and death. Aims and Objectives: To evaluate the clinical profile and aetiology of children presenting with fever and altered sensorium and to assess the predictors of morbidity & mortality related to Acute Febrile Encephalopathy. Materials and Methods: In this prospective, hospital-based study, a total of 282 children, between 1month to 12 years, presenting to the department of Pediatric Medicine, Calcutta National Medical College, Kolkata, West Bengal, India with fever and altered sensorium were clinically evaluated and investigated. Each patient was examined for vital signs, detailed systemic examination with focus on neurological examination. The etiology of AFE was evaluated based on detailed history, a meticulous clinical examination and relevant investigations. Results: The incidence of AFE was 5% of the total hospital admissions. Demographic profile showed 166 (58.8%) males, 116 (41.2%) females and 48% of the study population less than 5 years of age. The most important presenting complaints apart from fever and altered sensorium, were convulsion and vomiting. Raised Intracranial tension (58%), low GCS (58%) and shock (48%) were commonest presenting signs. CNS infections were the most common cause of AFE encountered. Low GCS, refractory seizures, multi-organ failure respiratory failure were significantly associated with death (p
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... Most studies from the region have excluded the non-infectious causes. 1,[8][9][10][11][12][13] History of headache and presence of nuchal rigidity point to an infectious aetiology over a non-infectious cause. Tuberculosis (24%), scrub typhus (17.6%), viral meningoencephalitis (7.5%), pyogenic meningitis (6.4%) and sepsis associated (7.5%) were the specific infectious aetiologies in our study. ...
Clinical spectrum, aetiology and predictors of acute febrile encephalopathy at a tertiary hospital in south India – A prospective observational study
Article
Full-text available
  • Oct 2020
Acute febrile encephalopathy is a common syndrome in the tropics with high mortality encountered by emergency physicians. In order to study the aetiology of acute febrile encephalopathy and its mortality and functional outcome over one year, data on all patients >18 years of age with short duration of fever (<14 days) and altered mental status were collected and followed up until one month after discharge. Non-infectious aetiology, found in 29%, portends a poor outcome.
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... However, central nervous system (CNS) infections are the most common cause of fever associated encephalopathy in children in the tropics. [5][6][7][8] The infectious causes of acute febrile encephalopathy vary widely in different regions of the world and this can have a bearing on the empirical therapy as well. (Table 1) From a clinical perspectiveit is useful to combine and categorize the causes of febrile encephalopathy into: (Table 2) 1. Febrile encephalopathy with meningeal signs 2. Febrile encephalopathy without meningeal signs While the above is suggested, children especially infants and those severely ill may not have meningeal signs despite a meningeal infection or inflammation. ...
Febrile encephalopathy
Article
Full-text available
  • Nov 2018
Febrile encephalopathy can be due to various causes that vary according to the local epidemiology and season. The critical window for diagnosis and effective intervention is often short. The basic principles of management include; the initial assessment and stabilization, focussed clinical evaluation and neurological assessment. Management include general and specific measures. Raised intracranial pressure, seizures and hemodynamic instability must be managed urgently and appropriately, since the diagnosis or specific etiology is not immediately apparent, empiric therapy based on local disease prevalence is initiated. A more specific management can be followed after a diagnosis is established or is reasonably certain.
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Clinicoetiological profile and outcome of patients of acute febrile encephalopathy in a tertiary care hospital in New Delhi - A prospective observational study
Article
Full-text available
  • Jun 2024
Background: Acute febrile encephalopathy (AFE) in spite of being a common clinical condition is less known to the general population thereby resulting in delay in seeking medical attention with detrimental consequences. The causes can range from infectious central nervous system (CNS) and systemic diseases to non-infectious conditions such as neuroleptic malignant syndrome, poisoning, and drug overdose. Early diagnosis and prompt medical management can result in good clinical outcome in terms of morbidity and mortality. Aims and Objectives: The aims and objectives are to study the clinical profile, etiology, seasonal variation, and outcome in patients admitted as case of AFE in a tertiary care hospital. Materials and Methods: All patients of AFE fulfilling the inclusion and exclusion criteria admitted in the departments of neurology and general medicine in Batra Hospital and Medical Research Centre (BHMRC) New Delhi, a tertiary care hospital were subjected to study analysis. The patients underwent detailed history, examination, baseline, and special investigations such as cerebrospinal fluid and magnetic resonance imaging brain whenever needed. Patients of AFE were studied according to the prevalence, etiological diagnosis, and seasonal variations. The final outcome at discharge was based on modified Rankin scale (mRs). Results: About 122 serially admitted patients diagnosed with AFE were found eligible and included in the study. About 47 (45%) patients had acute pyogenic CNS infection while as 36 (35%) had non-pyogenic CNS infection followed by malarial, tubercular, and cryptococcal CNS infection. We found maximum number of cases (n=61, 50%) of AFE during monsoon followed by 36 patients (30%) in post-monsoon, 15 patients (12%) were in summer, and only 10 cases (8%) during winter. We found higher and statistically significant disability in CNS infection group, patients with delayed hospitalization (P=0.001), and lower Glasgow coma scale (0.00001). Conclusion: AFE being a condition with serious consequences, we conclude that clinical suspicion, sensitization, and swift response from the treating physicians are required to avoid worse outcomes associated with the delayed diagnosis and late hospitalization of these patients.
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Virological investigations of acute encephalopathy in India
Article
Full-text available
  • Dec 1990
  • Arch Dis Child
A total of 740 consecutive children aged between 6 months and 12 years who presented with acute encephalopathic illnesses during a three year period were assessed both clinically and by laboratory investigations. Cerebrospinal fluid was examined for the presence of cells or other abnormal substances, and any organisms were cultured. Blood examination included white cell count and estimations of haemoglobin, urea, glucose, and electrolyte concentrations and serum alanine aminotransferase and aspartate aminotransferase. A firm diagnosis was established in 278 patients (38%). Pyogenic meningitis (n = 134), measles encephalopathy (n = 38), and electrolyte imbalance (n = 23) were important causes in this group, cerebral malaria (n = 4) was uncommon and there were no cases of Reye's syndrome. The diagnoses of the remaining 462 were combined under the heading 'acute unexplained encephalopathy'. Altogether 394 of the 462 patients underwent virological investigations for arboviruses and 92 (23%) had one or more indicators of Japanese encephalitis. No other arboviruses could be isolated. Throat swabs from 187 patients with acute unexplained encephalopathy were studied on monkey kidney tissue cell lines of which 14 were positive (8%). These were identified as adenovirus, parainfluenza, influenza, poliomyelitis, Coxsackie, and echovirus; in two cases the virus was untypable. Japanese encephalitis is an important cause of acute childhood encephalopathy in this region. Clinical features of the illness may be mimicked by several disorders which require specific treatment. Thirty four of the 92 died (37%).
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JE virus encephalitis: 1988 epidemic at Gorakhpur
Article
Full-text available
  • Apr 1993
Gorakhpur region experienced the most serious outbreak of Japanese encephalitis (JE) in 1988 in which 875 children were admitted in the Department of Pediatrics, BRD Medical College, Gorakhpur. Children between 7-10 years age group constituted half (49.3%) of these cases, convulsions (83.8%), altered sensorium (78.2%), headache (68.8%) and hypertonia (77.0%) were the main presenting features. IgM against JE virus was demonstrated in 18/25 CSF and 27/53 sera collected from these children. Significant titres of HI antibodies against JE were present in 498/670 patients. Patients were managed symptomatically. Dexamethasone and dopamine were given to only 137 (15.7%) children admitted with shock and peripheral circulatory failure. Almost a third (31.8%) of the patients expired, 51.4% recovered completely and 10.7% recovered partially. Corticosteroids did not improve the outcome. Twenty four patients had recurrence of symptoms after excellent recovery from acute attack of whom two died and 5 developed neurological deficits.
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Clinical Features in Children Hospitalized during the 2005 Epidemic of Japanese Encephalitis in Uttar Pradesh, India
Article
Full-text available
  • Jul 2006
  • CLIN INFECT DIS
Japanese encephalitis is a disease that affects the rural poor in Asia. In August-September 2005, a severe epidemic of Japanese encephalitis occurred in Uttar Pradesh, one of India's poorest states. Children admitted to the King George Medical University hospital (Lucknow, Uttar Pradesh, India) with acute febrile encephalopathy (defined as fever plus encephalopathy of <or=2 weeks' duration) from July to October 2005 underwent ELISA for Japanese encephalitis virus immunoglobulin M in cerebrospinal fluid or serum on hospital admission. Clinicolaboratory features of patients with positive test results were recorded.Results. Of the 223 children tested, 77 had positive results for Japanese encephalitis immunoglobulin M. Patients were from 18 districts of Uttar Pradesh. All but 1 were from rural areas, and none were <2 years of age. The prodromal period was very short (mean+/-standard deviation, 2.61+/-2.23 days). Convulsions were present in 76 patients (98.7%). The mean (+/- standard deviation) Glasgow Coma Scale score was 7.4+/-2.7. Generalized hypertonia was found in 39 patients (50.6%), and focal deficits were found in 35 patients (45.4%), including 19 cases of monoparesis and 16 cases of hemiparesis. Gastric hemorrhage was found in 42 patients (54.5%). Extrapyramidal features were found in 24 (31.1%), a hyperepneic breathing pattern was found in 20 (26%), and thrombocytopenia was found in 5 (15.6%) of 32 patients. The mean cerebrospinal fluid cell count was 48.3 cells/mm(3). The serum bilirubin level was normal in all patients, but the aspartate aminotransferase level was elevated in all 21 patients (100%) tested and the alanine aminotranferase level was elevated in 25 (47.2%) of 53 patients. In-hospital mortality was 34%. Clinical features of Japanese encephalitis were severe. Derangements in liver function and thrombocytopenia were found in a significant proportion of patients. These findings were not highlighted during earlier epidemics of the illness and could suggest a possible mutation of the virus towards other flaviviruses.
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Recurrent annual outbreaks of a hepato-myo-encephalopathy syndrome in children in western Uttar Pradesh, India
Article
Full-text available
  • Apr 2007
  • INDIAN J MED RES
Outbreaks of an acute encephalopathy syndrome affecting children, with high case-fatality, have been reported in western Uttar Pradesh, India for the last many years. We investigated these cases in Bijnor district and present our findings. Fifty five children aged 2-10 yr hospitalized from 2003 to 2005 in Bijnor, Uttar Pradesh, with features of acute encephalopathy were selected by defined clinical criteria. Various laboratory investigations were performed. The disease had peak incidence in early winter months. Previously healthy, 2-4 yr old rural children (mean age-3.78 yr) of very low socio-economic background were most vulnerable. Almost all had vomiting preceding unconsciousness and a majority had mild fever and abnormal behaviour/agitation. Abnormal posture of trunk and limbs were distinctive features. Fluctuation of blood pressure was seen in three-quarter cases. Serum aminotransferases, creatine phosphokinase and lactic dehydrogenase levels were found markedly raised virtually in all cases in whom the tests were performed. Serum glucose was found low (<50 mg/dl) in 47.3 per cent cases at presentation. Cerebrospinal fluid (CSF) was under normal or low pressure and without pleocytosis in all cases. No microorganism could be isolated from serum, CSF, urine and visceral specimens. Neuroimaging performed in two cases was also normal. Liver biopsy performed in 21 cases showed acute hepatotoxic injury in all with marked hydropic change and perivenular necrosis. Tibial muscle biopsy done in 8 cases showed focal necrosis while brain biopsy taken in 2 cases had mild spongiosis with focal gliosis. Forty two children succumbed to their illness (case fatality 76.4%), most within 72 h of presentation. Survivors did not show any neurological deficit. Our findings showed that the outbreaks were due to a multi-system disease with toxic injury to liver, muscles and brain (hepato-myo-encephalopathy) and not due to viral encephalitis as believed so far. The cause remains unknown but several features suggest the possibility of phytotoxin-induced pathology.
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National Vector Borne Disease Control Programme, Directorate General of Health Services. New Delhi: Malaria Drug Resistance
  • Jan 2004
  • DGHS. National Vector Borne Disease Control Programme, Directorate General of Health Services
DGHS. National Vector Borne Disease Control Programme, Directorate General of Health Services. New Delhi: Malaria Drug Resistance 2004, New Delhi: Ministry of Health and Family Welfare, 2004.
Clinical features in children hospitalized during the
  • Jan 2005
  • CLIN INFECT DIS
  • 123-131
  • R Kumar
  • P Tripathi
  • S Singh
  • G Bannerji
Kumar R, Tripathi P, Singh S, Bannerji G. Clinical features in children hospitalized during the 2005 epidemic of Japanese encephalitis in Uttar Pradesh, India. Clin Infect Dis 2006; 43:123-131.