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Open Access Research article

Should there be a standardised approach to the diagnostic workup of suspected adult encephalitis? a case series from Australia

Clare Huppatz12, Yash Gawarikar3, Chris Levi34, Paul M Kelly2, David Williams35, Craig Dalton1, Peter Massey1, Rodney Givney46 and David N Durrheim15*

Author Affiliations

1 Hunter New England Population Health, NSW Health, Newcastle, New South Wales, Australia

2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia

3 John Hunter Hospital, NSW Health, Newcastle, New South Wales, Australia

4 University of Newcastle, New South Wales, Australia

5 Hunter Medical Research Institute, Newcastle, New South Wales, Australia

6 Hunter Area Pathology Service, Pathology North, John Hunter Hospital, NSW Health, New South Wales, Australia

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BMC Infectious Diseases 2010, 10:353  doi:10.1186/1471-2334-10-353

Published: 15 December 2010

Abstract

Background

The clinical diagnosis of encephalitis is often difficult and identification of a causative organism is infrequent. The encephalitis syndrome may herald the emergence of novel pathogens with outbreak potential. Individual treatment and an effective public health response rely on identifying a specific pathogen. In Australia there have been no studies to try to improve the identification rate of encephalitis pathogens. This study aims to review the diagnostic assessment of adult suspected encephalitis cases.

Methods

A retrospective clinical audit was performed, of all adult encephalitis presentations between July 1998 and December 2007 to the three hospitals with adult neurological services in the Hunter New England area, northern New South Wales, Australia. Case notes were examined for evidence of relevant history taking, clinical features, physical examination, laboratory and neuroradiology investigations, and outcomes.

Results

A total of 74 cases were included in the case series. Amongst suspected encephalitis cases, presenting symptoms and signs included fever (77.0%), headache (62.1%), altered consciousness (63.5%), lethargy (32.4%), seizures (25.7%), focal neurological deficits (31.1%) and photophobia (17.6%). The most common diagnostic laboratory test performed was cerebrospinal fluid (CSF) analysis (n = 67, 91%). Herpes virus polymerase chain reaction (n = 53, 71.6%) and cryptococcal antigen (n = 46, 62.2%) were the antigenic tests most regularly performed on CSF. Neuroradiological procedures employed were computerized tomographic brain scanning (n = 68, 91.9%) and magnetic resonance imaging of the brain (n = 35, 47.3%). Thirty-five patients (47.3%) had electroencephalograms. The treating clinicians suspected a specific causative organism in 14/74 cases (18.9%), of which nine (12.1%) were confirmed by laboratory testing.

Conclusions

The diagnostic assessment of patients with suspected encephalitis was not standardised. Appropriate assessment is necessary to exclude treatable agents and identify pathogens warranting public health interventions, such as those transmitted by mosquitoes and those that are vaccine preventable. An algorithm and guidelines for the diagnostic workup of encephalitis cases would assist in optimising laboratory testing so that clinical management can be best tailored to the pathogen, and appropriate public health measures implemented.