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CORRESPONDENCE
Year : 2017  |  Volume : 146  |  Issue : 6  |  Page : 791-792

Acute encephalitis or encephalopathy: What next?


Department of Microbiology, Barts Health NHS Trust, London, E1 2ES, UK

Date of Submission23-Oct-2017
Date of Web Publication13-Apr-2018

Correspondence Address:
Benny P Cherian
Department of Microbiology, Barts Health NHS Trust, London, E1 2ES
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1684_17

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How to cite this article:
Cherian BP. Acute encephalitis or encephalopathy: What next?. Indian J Med Res 2017;146:791-2

How to cite this URL:
Cherian BP. Acute encephalitis or encephalopathy: What next?. Indian J Med Res [serial online] 2017 [cited 2021 Jul 28];146:791-2. Available from: https://www.ijmr.org.in/text.asp?2017/146/6/791/230129

Sir,

I read with interest the editorial by Narain et al[1]. The authors tried to give an overview of a complex clinical syndrome with the available information to date. However, many unanswered questions remain, and the critical issues identified by the authors still baffle the reader. The authors described a clinical syndrome which varied from a toxic or metabolic encephalopathy and infectious encephalitis. While the case-fatality rates in the case series described here are high, there is no clarity as to what was the driver for this mortality: is it intractable seizures and is it metabolic as suggested in some as profound hypoglycaemia, while hypoglycaemia might have accounted for part of the clinical picture, the joint investigation team [2] found the cerebrospinal fluid (CSF) glucose to be normal in majority of the affected children (70%). Did they have airway compromise and died due to lack of ventilatory support, how many of the deceased had post-mortem studies as the limited magnetic resonance imaging studies showed diffuse encephalitis, what was their electrolyte status and the correction of electrolytes if any at the time of presentation? What is the explanation for normal CSF glucose and low blood glucose?

The authors refer to a study by Shrivastava et al[2] and other references in this article including NCDC bulletin [3]. Shrivastava et al[2] specifically discussed the localized outbreak of illness which was thought to be a toxic encephalopathy. In addition, authors discussed aetiology of illness ranging from scrub typhus, Japanese B encephalitis and included a specific reference to enterovirus mediated illness [4]. Clinical guidelines [5],[6] referred to in this article refers to a clinical syndrome definition which is a Japanese B encephalitis case definition with fever and altered sensorium as predominant symptoms. Where is the overarching case definition for this syndrome?

Finally, the authors discuss opportunities for further work on this tragic clinical problem where the young lives are lost with not yet identifiable problem. The Indian government has already committed to substantial funding on possibly a multi-prong approach to control this [1].

However, where is the case definition or case management algorithms for clinicians working in remote villages or States? What decision support systems or diagnostic support are we offering them? If we have identified respiratory failure as the cause of death, is there any suggestion made for respiratory support in those States affected by the illness.

There is an urgent need for better surveillance of this illness; it is not clear from this when and how these data are going to be collected or used. How are the State government health sector and central government bodies working together and the coordination achieved? Is the NCDC proposing an outbreak management template for future use and investigative algorithm and a clinical management pathway for the future outbreaks? What is the role of national institutions such as ICMR-National Institute of Virology in this?

While the authors need to be applauded for highlighting this problem, there are many more unanswered questions or unclear proposed plans.

Conflicts of Interest: None.



 
   References Top

1.
Narain JP, Dhariwal AC, MacIntyre CR. Acute encephalitis in India: An unfolding tragedy. Indian J Med Res 2017; 145 : 584-7.  Back to cited text no. 1
[PUBMED]    
2.
Shrivastava A, Srikantiah P, Kumar A, Bhushan G, Goel K, Kumar S, et al. Outbreaks of unexplained neurologic illness-Muzaffarpur, India, 2013-2014. MMWR Morb Mortal Wkly Rep 2015; 64 : 49-53.  Back to cited text no. 2
    
3.
National Centre for Disease Control, India. Outbreak of Acute Encephalitis Syndrome in Bihar; 2012. Available from: http://www.ncdc.gov.in/writereaddata/linkimages/NCDC%20Newsletter3457335027.pdf, accessed on August 20, 2017.  Back to cited text no. 3
    
4.
Sapkal GN, Bondre VP, Fulmali PV, Patil P, Gopalkrishna V, Dadhania V, et al. Enteroviruses in patients with acute encephalitis, Uttar Pradesh, India. Emerg Infect Dis 2009; 15 : 295-8.  Back to cited text no. 4
    
5.
Guidelines for Surveillance of Acute Encephalitis Syndrome (With Special Reference to Japanese Encephalitis). NVBDCP; 2006. Available from: http://www.nvbdcp.gov.in/Doc/AES%20guidelines.pdf, accessed on July 15, 2007.  Back to cited text no. 5
    
6.
Guidelines: Clinical Management of Acute Encephalitis Syndrome Including Japanese Encephalitis. NVBDCP; 2009. Available from: http://nvbdcp.gov.in/Doc/Revised%20guidelines%20on%20AES_JE.pdf, accessed on September 29, 2016.  Back to cited text no. 6
    




 

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