Encephalitis viral
Encephalitis viral
Encephalitis viral
Encephalitis viral
Dr. Kiking Ritarwan MKT, SpS Dr. Kiking Ritarwan MKT, SpS Email: kritarwan@ yahoo.com Email: kritarwan@ yahoo.comENCEPHALITIS VIRUS
ENCEPHALITIS VIRUS
Virus Representative virus for Neurologic Disease Virus Representative virus for Neurologic Disease
DNADNA
-- Herpesviruses HSV,VZV,CMV,EBVHerpesviruses HSV,VZV,CMV,EBV -- Papovavirus PMLPapovavirus PML
-- Posvirus VacciniaPosvirus Vaccinia
-- Adenovirus Adenovirus serotypeAdenovirus Adenovirus serotype
RNARNA
RNARNA
-- Enterovirus ( Picornavirus) Poliovirus, coxsackivirus, echovirus, enterovirus 70Enterovirus ( Picornavirus) Poliovirus, coxsackivirus, echovirus, enterovirus 70--71, Hepatitis A71, Hepatitis A -- Togavirus, alphavirus ( arbovirus) Equine encephalitisTogavirus, alphavirus ( arbovirus) Equine encephalitis
-- Flavivirus (arbovirus) St louis enceph, Japanese and Tic Borne encephFlavivirus (arbovirus) St louis enceph, Japanese and Tic Borne enceph -- Orbovirus (Arbovirus) Colorado Tick feverOrbovirus (Arbovirus) Colorado Tick fever
-- Bunyavirus (arbovirus) California encephBunyavirus (arbovirus) California enceph -- Togavirus, rubivirus RubellaTogavirus, rubivirus Rubella
-- Orthomyxovirus InfluenzaOrthomyxovirus Influenza -- Rhabdovirus RabiesRhabdovirus Rabies
R I
R I
V V
Saluran pernafasan : parotitis, varicella, Saluran pernafasan : parotitis, varicella,
morbilli morbilli
Saluran makanan : polio, enterovirusSaluran makanan : polio, enterovirus
Mukosa kelamin : Herpes simpleksMukosa kelamin : Herpes simpleks
Inokulasi : spt gigitan binatang (rabies a Inokulasi : spt gigitan binatang (rabies a
nyamuk) nyamuk)
HIV and the brain (1)
HIV and the brain (1)
MeningitisMeningitis
HIV itselfHIV itself TB TB CryptococcalCryptococcal CryptococcalCryptococcal SyphiliticSyphilitic
Space occupying lesionsSpace occupying lesions
ToxoplasmosisToxoplasmosis TuberculomasTuberculomas Lymphoma Lymphoma
HIV and the brain (2)
HIV and the brain (2)
EncephalitisEncephalitis
HIV dementiaHIV dementia
Progressive multifocal leukoencephalopathy Progressive multifocal leukoencephalopathy
Progressive multifocal leukoencephalopathy Progressive multifocal leukoencephalopathy
(PML) (PML) CMV, HSV, HZV encephalitisCMV, HSV, HZV encephalitis ToxoplasmosisToxoplasmosis
HIV and the spinal cord
HIV and the spinal cord
Vacuolar myelopathyVacuolar myelopathy SyphilisSyphilis HZV, HSV, CMV, HTLVHZV, HSV, CMV, HTLV--11 TB TB TBTB LymphomaLymphoma
HIV and the peripheral nervous system (1) HIV and the peripheral nervous system (1)
RadiculopathyRadiculopathy TBTB CMVCMV
Inflammatory demyelinating Inflammatory demyelinating
polyneuropathies polyneuropathies
GuillainGuillain--BarreBarre
HIV and the peripheral nervous system (2) HIV and the peripheral nervous system (2)
Distal sensory neuropathyDistal sensory neuropathy
Mononeuropathies, mononeuritis multiplexMononeuropathies, mononeuritis multiplex DrugsDrugs INHINH D4T, ddID4T, ddI
D4T associated HIV neuromuscular weakness D4T associated HIV neuromuscular weakness
syndrome syndrome
Diffuse Infiltrative Lymphocytosis Syndrome Diffuse Infiltrative Lymphocytosis Syndrome
(DILS) (DILS)
Mekanisme kerusakan neuron pada infeksi HIV Mekanisme kerusakan neuron pada infeksi HIV
Untuk masuk ke dalam SSP, HIV harus terlebih dahulu menginfeksi sel Untuk masuk ke dalam SSP, HIV harus terlebih dahulu menginfeksi sel
yang memiliki reseptor CD4 yang memiliki reseptor CD4
Mekanisme masuknya virus HIV kedalam SSP adalah dengan cara Mekanisme masuknya virus HIV kedalam SSP adalah dengan cara
menumpang pada monosit yang terinfeksi virus menumpang pada monosit yang terinfeksi virus
Selanjutnya di dalam SSP, monosit yang telah terinfeksi Selanjutnya di dalam SSP, monosit yang telah terinfeksi
berdeferensiasi menjadi mikroglia berdeferensiasi menjadi mikroglia
Defenition Viral encephalitis
Defenition Viral encephalitis
Is an acute febrile illness with evidence of Is an acute febrile illness with evidence of
damage to the parenchymal tissue of the CNS, damage to the parenchymal tissue of the CNS, producing alteration of consciousness, focal
producing alteration of consciousness, focal neurological signs and seizures.
neurological signs and seizures.
Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,
Herpes simpleksHerpes simpleks
Eastern equineEastern equine
Venezuela St LouisVenezuela St Louis
Japanese Japanese –– B B
Russian tickRussian tick--borneborne
Etiology viral encephalitis
Etiology viral encephalitis
Viral is the most common causeViral is the most common cause
The commonest is HSV type I in adults The commonest is HSV type I in adults
and type 2 in neonates. and type 2 in neonates.
It may occur sporadically or in epidemicsIt may occur sporadically or in epidemics
It may occur sporadically or in epidemicsIt may occur sporadically or in epidemics
5050--70% mortality if untreated70% mortality if untreated
So establishment of on early specific So establishment of on early specific
diagnosis and early initiation of antiviral diagnosis and early initiation of antiviral chemotherapy is of great importance
chemotherapy is of great importance
Patogenesis.
Patogenesis.
Bila virus patogen masuk kedalam tubuh Bila virus patogen masuk kedalam tubuh
pada SSP dapat terjadi:pada SSP dapat terjadi:
Radang akutRadang akut
Radang kronis Radang kronis
Radang kronisRadang kronis
NeoplasmaNeoplasma
Cara penyebaran ke SSP:
Cara penyebaran ke SSP:
Cara penyebaran Contoh virus
Cara penyebaran Contoh virus
Hematogen herpes simplexHematogen herpes simplex
sitomegalovirus sitomegalovirus Epstein Epstein--BarrBarr Coxsackie Coxsackie Coxsackie Coxsackie HIV HIV Morbilli Morbilli Echovirus Echovirus khoriomeningitis limfositik khoriomeningitis limfositik paravirus paravirus
Neurogen Herpes simpleksNeurogen Herpes simpleks
B B--virusvirus Varisela Varisela--ZosterZoster Rabies Rabies Rabies Rabies
Gambaran klinik:
Gambaran klinik:
Tanda dan gejala bervariasi tergantung Tanda dan gejala bervariasi tergantung
virus penyebab. virus penyebab.
Umumnya: demam akut disertai tanda rangUmumnya: demam akut disertai tanda
rang--sang meningeal, sakit kepala, mual, fotofobi, sang meningeal, sakit kepala, mual, fotofobi, muntah, ggn kesadaran, defisit neurologik
muntah, ggn kesadaran, defisit neurologik muntah, ggn kesadaran, defisit neurologik muntah, ggn kesadaran, defisit neurologik fokal dan kejang2.
fokal dan kejang2.
Mortalitas bervariasi dari tinggi (eastern Mortalitas bervariasi dari tinggi (eastern
equine encephalitis) sampai rendah (Vene equine encephalitis) sampai rendah (Vene--zuelan equine encephalitis).
Gejala sisa termasuk kejang2Gejala sisa termasuk kejang2
Komplikasi : Komplikasi : -- perubahan kepribadianperubahan kepribadian
-- ggn ekstrapiramidalggn ekstrapiramidal -- demensiademensia
-- demensiademensia
Kriteria diagnosis ensefalitis viral
Kriteria diagnosis ensefalitis viral
1.1. Bentuk asimptomatik Bentuk asimptomatik analisis LPanalisis LP 2.
2. Bentuk abortif : Nyeri kepala, demam yg tdk Bentuk abortif : Nyeri kepala, demam yg tdk
tinggi, kaku kuduk. ISPA/ Infeksi GIT tinggi, kaku kuduk. ISPA/ Infeksi GIT
3.
3. Bentuk fulminan: Berlangsung bbrp jam Bentuk fulminan: Berlangsung bbrp jam
sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir dengan kematian.
dengan kematian.
4.
4. Bentuk khas ensefalitis: NK, demam, Bentuk khas ensefalitis: NK, demam,
keasadaran menurun, kejang fokal atau keasadaran menurun, kejang fokal atau umum, hemiparesis, ggn koordinasi,
umum, hemiparesis, ggn koordinasi, disorientasi, ggn bicara, ggn mental disorientasi, ggn bicara, ggn mental
Prosedur diagnostik.
Prosedur diagnostik.
LP : CSF jernih, tekanan normal atau LP : CSF jernih, tekanan normal atau
meningkat, Pleositosis limfositik < 1000/ul, meningkat, Pleositosis limfositik < 1000/ul, glukosa dan klorida nornal, protein normal glukosa dan klorida nornal, protein normal atau sedikit meninggi ( 80
atau sedikit meninggi ( 80--200 mg/dl200 mg/dl
MRI atau CT scan MRI atau CT scan SOL (?)SOL (?)
MRI atau CT scan MRI atau CT scan SOL (?)SOL (?)
EEGEEG
Liquor Liquor virus DNA dg “polymerase chain virus DNA dg “polymerase chain
reaction” (prosedur cepat, sensitif, akurat) reaction” (prosedur cepat, sensitif, akurat)
Virus kadang2 dikultur dari Virus kadang2 dikultur dari
liquor,feces,urine nasofaring atau darah. liquor,feces,urine nasofaring atau darah.
Pengobatan.
Pengobatan.
Tidak bisa diidentifikasi Tidak bisa diidentifikasi dianggap dianggap
sebagai ensefalitis herpes simpleks dan sebagai ensefalitis herpes simpleks dan terapi dgn. Acyclovir atau ganciclovir
terapi dgn. Acyclovir atau ganciclovir
Jalan nafas diawasiJalan nafas diawasi
Jalan nafas diawasiJalan nafas diawasi
Keseimbangan cairan dan elektrolit dijagaKeseimbangan cairan dan elektrolit dijaga
Atasi kejangAtasi kejang
Komplikasi neurologi HIV
Komplikasi neurologi HIV
Brain Predominantly nonfocalBrain Predominantly nonfocal
AIDS dementia complex AIDS dementia complex Acute HIV
Acute HIV--related encephalitisrelated encephalitis Cytomegalovirus encephalitis Cytomegalovirus encephalitis Cytomegalovirus encephalitis Cytomegalovirus encephalitis Varicella
Varicella--zoster virus zoster virus encephalitis
encephalitis
Herpes simplex virus Herpes simplex virus encephalitis
encephalitis
Metabolic encephalopathies Metabolic encephalopathies
Predominantly focal Predominantly focal Cerebral toxoplasmosis Cerebral toxoplasmosis Primary CNS lymphoma Primary CNS lymphoma
Progressive multifocal leukoencephalo Progressive multifocal leukoencephalo--pathy pathy Cryptococcoma Cryptococcoma Cryptococcoma Cryptococcoma
Brain abcess / tuberculoma Brain abcess / tuberculoma
Neurosyphilis (meningovascular) Neurosyphilis (meningovascular) Vascular disorders
Spinal cordSpinal cord
Vacuolar myelopathy Vacuolar myelopathy
Herpes simplex or zoster myelitis Herpes simplex or zoster myelitis
Meninges Meninges
Aseptic meningitis (HIV) Aseptic meningitis (HIV) Cryptococcal meningitis Cryptococcal meningitis Cryptococcal meningitis Cryptococcal meningitis Tuberculous meningitis Tuberculous meningitis Syphilitic meningitis Syphilitic meningitis
Metastatic lymphomatous meningitis Metastatic lymphomatous meningitis
Peripheral nerve and root and rootPeripheral nerve and root and root
infectious infectious
herpes zoster herpes zoster
cytomegalovirus lumbar polyradiculopathy cytomegalovirus lumbar polyradiculopathy
Virus or immuneVirus or immune--relatedrelated
acute and chronic inflammatory HIV poly acute and chronic inflammatory HIV poly--neuritis neuritis neuritis neuritis mononeuritis multiplex mononeuritis multiplex
sensorimotor demyelinating polyneuropathy sensorimotor demyelinating polyneuropathy distal painful sensory polyneuritis
distal painful sensory polyneuritis
Muscle Muscle
polymyositis and other myopathies polymyositis and other myopathies
Perjalanan penyakit infeksi HIV
Perjalanan penyakit infeksi HIV
Infeksi virus (2Infeksi virus (2--3 minggu) 3 minggu) sindroma sindroma
retro
retro-- viral akut (2viral akut (2--3 minggu) 3 minggu) gejala gejala menghilang + serokonversi
menghilang + serokonversi infeksi infeksi kronis HIV asimpto matik (rata2 8 thn) kronis HIV asimpto matik (rata2 8 thn) infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 thn)
thn) kematian.kematian.
Window period Window period masa dimana masa dimana
pemeriksa
pemeriksa-- an test serologis utk antibodi an test serologis utk antibodi HIV masih negatif, tapi virus sdh ada dlm HIV masih negatif, tapi virus sdh ada dlm darah (sudah mampu menularkan kpd
darah (sudah mampu menularkan kpd orang lain)
CEREBRAL TOXOPLASMOSIS
CEREBRAL TOXOPLASMOSIS
Reactivation of latent infectionReactivation of latent infection
Toxo seroprevalence 12Toxo seroprevalence 12--46% (SA)46% (SA)
IgG indicates past infection (FN <3IgG indicates past infection (FN <3--6%)6%)
CD4 > 200 virtually excludes Toxo CD4 > 200 virtually excludes Toxo
CD4 > 200 virtually excludes ToxoCD4 > 200 virtually excludes Toxo
Over 80% have CD4 < 100Over 80% have CD4 < 100
Typically multiple ring enhancing lesions on CT/MRITypically multiple ring enhancing lesions on CT/MRI
2727--43% have single lesions43% have single lesions
Up to 10% may have diffuse encephalitis without any Up to 10% may have diffuse encephalitis without any
visible focal lesions visible focal lesions
T h e co u rs e o f H IV /A ID S
MRI CT Scan
Atrofi Meningeal hidrosefalus SOL
Keluhan intrakranial
Skema-1. Algoritme Penatalaksanaan Keluhan Intraserebral bagi Penderita HIV-AIDS
normal Atrofi Meningeal
enhancement hidrosefalus SOL Evaluasi LCS Shunt (kalau perlu) Positif Negatif Terapi sesuai etiologi Observasi
Lesi massa(-) Lesi massa (+) Skema 2
Lesi massa intrakranial
Alert-lethargic stabil
Steroid ? Stupor-koma
Perburukan cepat, massa besar Dengan resiko herniasi Lesi multipel Lesi tunggal
Serologi
Skema-2. Algoritme Penatalaksanaan Lesi massa Intrakranial pada penderita HIV-AIDS
Terapi toksoplasmosis Seumur hidup Terapi sesuai etiologi Dekompresi dan biopsi terbuka Serologi toksoplasma Negatif Positif Obat antitoksoplasmosis Perbaikan
Ya Tidak Biopsi stereotaktik
Toxoplasmosis
Toxoplasmosis –
– Clinical Features
Clinical Features
Usually subacute over weeksUsually subacute over weeks Headache Headache 50%50% Fever Fever 45%45% Fever Fever 45%45%
Behaviour changes Behaviour changes 40%40%
Confusion Confusion 1515--52%52%
Focal signsFocal signs
Toxoplasmosis treatment
Toxoplasmosis treatment
Sulphadiazine and Pyrimethamine is first choiceSulphadiazine and Pyrimethamine is first choice
CoCo--trimoxazole (80/400mg) 4 tablets BD x 4/52trimoxazole (80/400mg) 4 tablets BD x 4/52
then 2 tablets BD x 8/52 then 2 tablets BD x 8/52
Long term secondary prophylaxis 2 tabs DLYLong term secondary prophylaxis 2 tabs DLY
Till sustained CD4 > 200Till sustained CD4 > 200
86% show clinical improvement by 7 days86% show clinical improvement by 7 days
CT
CT -- Multiple ring enhancing lesions
Multiple ring enhancing lesions
Toxo more likelyToxo more likely
Tuberculomas still Tuberculomas still
possible possible possible possible
HIV dementia (AIDS Dementia
HIV dementia (AIDS Dementia
Complex)
Complex)
This progressive dementia occurs in AIDS, This progressive dementia occurs in AIDS,
owing to a direct primary HIV infection of owing to a direct primary HIV infection of neurons or an indirect neurotoxicity
neurons or an indirect neurotoxicity
induced by presence of the virus in the induced by presence of the virus in the induced by presence of the virus in the induced by presence of the virus in the brain
brain
Pathology: the virus may be transported Pathology: the virus may be transported
into the brain by infected peripheral into the brain by infected peripheral monocytes (Trojan horse theory).
Manifestasi klinis demensia HIV: Manifestasi klinis demensia HIV: Cognititive disorders
Cognititive disorders
Gangguan kognitif, kesulitan konsentrasi, Gangguan kognitif, kesulitan konsentrasi,
forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, mania.
mania.
Pd std awal sulit membedakan dgn keluhan psikiatri. Pd std awal sulit membedakan dgn keluhan psikiatri.
Motor abnormalities:
Motor abnormalities: ataksia, hiperreflels. Babinski ataksia, hiperreflels. Babinski
refleks srg muncul. Pada std lanjut : paraparese dgn refleks srg muncul. Pada std lanjut : paraparese dgn inkontinansia urin et alvii
inkontinansia urin et alvii
Behavioural dysfunction : A
Behavioural dysfunction : Apathy, altered personality, pathy, altered personality,
disorientasi. Std akhir
Herpes simplex encephalitis
Herpes simplex encephalitis
Encephalitis non virus:
Encephalitis non virus:
Bakteri:Strepto,staphylo,meningo, salmonella, Bakteri:Strepto,staphylo,meningo, salmonella,
E.coli E.coli
Protozoa: P.Falcifarum, ToxoplasmosisProtozoa: P.Falcifarum, Toxoplasmosis
Protozoa: P.Falcifarum, ToxoplasmosisProtozoa: P.Falcifarum, Toxoplasmosis
Cacing: CystisercosisCacing: Cystisercosis
Jamur: Aspergillus, ActinomycosisJamur: Aspergillus, Actinomycosis
