Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India.

PURPOSE: To evaluate the spectrum of acute infectious encephalitis/encephalopathy syndrome (AIES) in intensive care unit (ICU) and the predictors of mechanical ventilation (MV) and outcome of these patients. METHODS: AIES patients diagnosed on the basis of fever, altered sensorium, seizure and cerebrospinal fluid pleocytosis admitted to the neurology ICU were prospectively included. The demographic and clinical details, hematological, biochemical, MRI and etiological findings of the patients were noted. Need of MV, death in hospital and 3-month functional outcome were analyzed. RESULTS: One hundred sixty-four out of 258 (64%) AIES patients needed ICU admission. Their median age was 35 (2-85) years and 71 (43%) were females. The etiology was viral in 44 (herpes and Japanese encephalitis in 12 each, dengue in 17, mumps, measles and varicella in 1 patient each), non-viral in 64 (scrub typhus in 48, falciparum malaria in 6, leptospira in 3 and bacterial in 7) and undetermined etiology in 56 (34%) patients. Sixty-nine (42%) patients needed MV. On multivariate analysis, Glasgow Coma Scale (GCS) score, Sequential Organ Failure Assessment (SOFA) score and raised intracranial pressure were independent predictors of MV. Forty-three (26%) patients died, and all were in the MV group. Higher SOFA score and untreatable etiology were independent predictors of mortality. At 3-month follow-up, 14% had poor and 86% had good outcome. Low GCS score, focal weakness and status epilepticus independently predicted poor outcome. CONCLUSION: Twenty-six percent patients with AIES died in ICU, and 86% had good recovery at 3 months. Admission SOFA scores and untreatable etiology predicted mortality.

Is VEGF a marker of severity of scrub typhus infection?

Vascular endothelial growth factor (VEGF) and its receptors have been reported as severity markers of septicemia. Scrub typhus (ST) results in multi-organ dysfunction but the role of VEGF has not been evaluated. We report VEGF and its receptors in ST and its correlation with severity, outcome and laboratory findings. Thirty patients with ST diagnosed by solid phase immune chromatographic assay and Weil-Felix tests were included. Their clinical details, Glasgow Coma Scale (GCS), SOFA and modified Rankin Scale (mRS) scores and laboratory findings were noted. VEGF, VEGFR1 and VEGFR2 were done by ELISA at admission and repeated at 1 month. Outcome was defined at 1 month. Serum VEGF and VEGF-R1 levels were significantly higher and VEGFR2 was significantly lower in the ST patients compared to the controls. These levels significantly improved at 1 month. VEGF level correlated with SOFA score (p = 0.05) and SGPT (p = 0.04). VEGFR1 correlated with hemoglobin (p = 0.04), platelet count (p = 0.03), serum CK (p = 0.001), weakness (p = 0.04) and mRS score (p = 0.04). VEGFR2 did not correlate with any clinical or laboratory parameters. All the patients recovered with doxycycline. Serum VEGF and VEGFR1 levels increased in ST and suggest disease severity but do not predict outcome.

VEGF and its receptors in dengue virus infection.

Vascular permeability determines the severity of dengue virus infection. Vascular endothelial growth factor (VEGF) and its (receptor 1) R1 and (receptor 2) R2 receptors may provide insight about the neurological complications of dengue. We report VEGF and its R1 and R2 receptors level in dengue patients and correlate these with neurological complications. Consecutive patients with dengue were subjected to clinical and neurological evaluations. Their blood counts, serum chemistry, including liver and kidney function tests, serum creatine kinase (CK), and albumin were measured. VEGF, VEGFR1 and VEGFR2 were measured by ELISA in the patients and 16 matched controls. Twenty four patients with dengue were included whose ages ranged between 15 and 67 years, and nine of whom were females. Serum VEGF level was insignificantly lower in dengue patients whereas VEGFR1 was significantly higher (P = 0.01) and VEGFR2 was significantly lower (P = 0.005) compared to controls. VEGFR2 correlated with systolic blood pressure, coagulopathy, and serum CK levels. None of the other clinical and biochemical parameters correlated with VEGF and VEGFR1 levels. VEGFR1 and R2 normalized at 1 month. VEGFR2 correlates with the clinical severity of dengue and muscle dysfunction.

Neurological manifestations of scrub typhus.

OBJECTIVE: To evaluate the neurological manifestations of scrub typhus and correlate their clinical, EEG and MRI findings. METHODS: A cross-sectional study over 2 years included patients with scrub typhus diagnosed by solid phase immunochromatographic assay or Weil-Felix test. A detailed clinical evaluation including Glasgow Coma Scale (GCS) was documented. Blood counts, chemistry, ECG, chest radiograph, cerebrospinal fluid (CSF), EEG and cranial MRI were performed. Outcome on discharge and at 1 month were categorised into good and poor based on modified Rankin Scale. RESULTS: Thirty-seven patients with ages ranging between 3 and 71 years were included; 51% of whom were females. All patients had fever and myalgia. Thirty-one (84%) patients had impaired consciousness, and six were deeply comatose (GCS score ≤8). Eight patients presented with status epilepticus. MRI revealed meningeal enhancement in only 1/25 (4%) patient and EEG showed generalised slowing in 6/28 (21.4%). Among 31 patients with altered sensorium, CSF studies were conducted on 28. Nineteen patients had meningoencephalitis and 9 encephalopathy, but no significant differences were observed in clinical, laboratory, EEG and MRI findings. All patients responded within 48 h to doxycycline and had good recovery at 1 month. Patients with low GCS score had significantly more focal neurological deficit (r=0.5; p=0.002), longer hospital stay (r=-0.4; p=0.03) and more disability on discharge (r=-0.4; p=0.01). CONCLUSIONS: Meningoencephalitis/encephalopathy may be seen in two-third of patients with scrub typhus. Scrub typhus should be included in the differential diagnosis of febrile encephalopathy.