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Progression of enteroviral encephalitis in children
Berdieva KHILOLAKHON
1
, Gulchehra SADIKOVA
2
Tashkent Pediatric Medical Institute
ARTICLE INFO
ABSTRACT
Article history:
Received January 2021
Received in revised form
15 January 2021
Accepted 20 January 2021
Available online
10 February 2021
The article presents analysis of the results of a dynamic
follow-up of 35 children with enteroviral encephalitis. The
average age of these children suffering enteroviral encephalitis
was 6.04±0.84 years old. Maximal morbidity rate of enteroviral
encephalitis was observed in August and September and
corresponded to the common morbidity rate of all enteroviral
infections.
2181-
1415/© 202
1 in Science LLC.
This is an open access article under the Attribution 4.0 International
(CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/deed.ru)
Keywords:
Enteroviral encephalitis
Diagnostics
Clinical progression
Therapy
Children
Болаларда энтеровирусли энцефалитнинг ривожланиши
АННОТАЦИЯ
Калит сўзлар:
Энтеровирусли энцефалит
Диагностика
Клиника
Даволаш
Болалар
Мақолада энтеровирусли энцефалит
билан касалланган
35 нафар болани
динамик мониторинг натижалари таҳлил
қилинган. Энтеровирус энцефалити бўлган боланинг ўртача
ёши 6,04 ± 0,84 ёшни ташкил этади. Энтеровирус
энцефалитининг максимал тарқалиши август–сентябр
ойларида
кузатилади
ва
умумий
энтеровирус
инфекциясининг кўпайиши билан мос келади.
1
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
E-mail:
2
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
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Прогрессирование энтеровирусного энцефалита у детей
АННОТАЦИЯ
Ключевые слова:
Энтеровирусные
энцефалиты
Диагностика
Клиника
Лечение
Дети
В статье проведен анализ результатов динамического
наблюдения
за
35
детьми
с
энтеровирусными
энцефалитами.
Средний
возраст
детей,
больных
энтеровирусными энцефалитами, составил 6,04±0,84 года.
Максимальная
заболеваемость
энтеровирусными
энцефалитами наблюдается в августе
-
сентябре и совпадает
с
ростом
общей
заболеваемости
энтеровирусными
инфекциями.
Enteroviral infection is characterized by a wide clinical polymorphism, lesion of central
nerve system, gastrointestinal tract, skin and muscles. Compatibility of enteroviruses to nerve
tissue provides often involvement of brain tissue and meanings into the pathological process,
a great range of clinical variants, long term and severity of the disease. 65-70% of all
encephalitis in children are the forms with isolated cerebral lesions [1, 4].
According to some authors the average age of the children with encephalitis varies
between 4.2±1.5 and 5.5 years old [2; 3]. The basic clinical manifestations of encephalitis are
consciousness impairments (86.5%) and epileptic seizures (76.9%). Together with
etiological factor, vital functions, expression of common cerebral and focal symptoms these
serve to be the factors determining the outcome of the disease [4-6]. The part of viruses in the
etiological structure of encephalitis reaches 80-89% of all etiological factors causing the
pathology [1]. Among the viral reasons of encephalitis there are enterovirus (12%), Herpes
Simplex virus (5%), and cytomegalovirus (2%) [3; 6].
THE OBJECTIVE
To study characteristics of epidemiology, clinical progression of encephalitis with
enteroviral etiology in children at the time of therapy.
RESEARCH METHODS AND DATA
The research was based on the data of 35 children with viral encephalitis. The
average age of the children with enteroviral encephalitis was 6.04±0.84 years old. 65.7%
of all these patients were boys.
Analysis of the age characteristics of enteroviral encephalitis revealed its prevalence
among boys of 11-14 years old (37.5%), 6-7 years old (25%), 3-5 years old (18.8%).
Among the girls there was prevalence in the following ages: 3-5 years old (41.7%) and 7-
9 years old (25%).
All the children were checked in compliance with the diagnostic and therapeutic
standards approved by the Ministry of Health of the RUz.
RESULTS OF THE STUDY AND ITS DISCUSSION
Analysis of enteroviral encephalitis morbidity rate confirmed its higher prevalence
in summer and autumn seasons (74.23% of the patients), with maximal rate in August-
September (54.3%). According to the observation results intra-annual dynamics of
enteroviral encephalitis was as follows: December -February (11.42%), April (8.57%),
May (5.71%), June (5.71%), July (8.57%), August (34.3%), September (20%), and October
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(5.71%). In March and November there were no registered patients with enteroviral
encephalitis.
In few cases we revealed participation of water transmission factor (5.71%) and
contact with people suffering ARVD (17.1%) in the development of the disease.
In our studies there was a prevalence of isolated damage of brain.
Encephalomyelopolyradiculoneuritis took only 5.7% in the structure of enteroviral
encephalitis. Other manifestations of enteroviral infection in these patients were hepatitis,
gastroenteritis, herpetic tonsillitis, pancreatitis, exanthema the prevalence rate of which
varied from 2.86 to 11.4%.
Enteroviral encephalitis is characterized by acute start of the disease. At the debut
encephalitis 88.6% of the patients had registered rise of temperature up to sub-febrile
(38.7%) and febrile values (54.8%). Pyretic fever was observed in 6.45% of the cases.
Prostration and weakness were mentioned by 60% of the patients. Neurological
symptoms in the patients with enteroviral encephalitis had debut manifestation both in
hyper excitability (motor dysfunctions, seizures, ICH) and symptoms of CNS suppression.
Common cerebral symptoms such as variable intensity headache, dizziness (37.1%),
intensive and not very intensive vomiting (34.3%), impairments of consciousness (sopor,
amentia)(8.57%). Convulsive syndrome was noted in two patients (3 and 13 years old).
Intracranial hypertension syndrome was registered only in the patients under 1 year old.
Development of focal symptoms was observed at the 2-8th days of the disease. In the debut
of enteroviral encephalitis focal cerebral damage syndrome was manifested by cerebellar
ataxia, disorders of standing and walking (42.9% of the patients), less often there were
oculomotor disorders (diplopia, ptosis, strabismus) (20%), and vary rare speech
disorders such as aphasia (2.86%). In the debut of the pathology 57.1% of the patients had
a combination of two neurological syndromes, while 42.9% had mono syndrome.
In the dynamics of enteroviral encephalitis we determined the prevalence of
combination of several neurological syndromes with the growth of the frequency of their
registration. The rise of temperature (sub-febrile, febrile, pyretic fever) within the acute
period was registered in 77.1% of the patients with enteroviral encephalitis. Average
duration of the fever was 4.95 days out of which febrile and pyretic ones were 2.61 days,
while sub-febrile one was 2.91 days. Maximal duration of temperature reaction was
observed in the patients with concomitant somatic pathology (cardiac vascular system,
gastrointestinal tract) and super ARV infection.
Development of intracranial hypertension (71.5% patients) with incomplete
complex of meningeal symptoms was characteristic for 17 patients (48.57%) with
enteroviral encephalitis. We registered Kernig’s symptom, upper Brudzinski symptom
(28.6%), “heavy head” symptom (31.
4%), and occipital muscles rigidity (25.7%). These
symptoms were predominant in the patients above 4 years old (average age was 8.54 years
old) expression of the symptoms varied from + to +++.
Average term of hypertension was 6.71 days, which did not exceed the term of
hypertension in patients with enteroviral meningitis (6.7±0.42 days). The longest
preserved symptom was “heavy head” (5.45 days), while the soonest eliminated ones were
Kernig and upper Brudzinski’s symptoms (2.8 days).
Various degrees of impairments of consciousness (spoor, coma, stunning) were
registered during the follow up only in 7 patients (20%). The impact of impairments of
consciousness in debut or dynamics of enteroviral encephalitis on the outcome of the
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disease was not reliable. Lethal outcome was registered in one patient with progressing
disorders in consciousness up to deep coma.
Two out of 6 patients with sopor and blackout of consciousness in the acute period
had recovery without complications. Four patients with impairments of consciousness in
acute period recovered with formation of neurological deficit or complications (cerebral
asthenic syndrome).
Short-term convulsive syndrome within the acute period of enteroviral encephalitis
was observed in three patients (8.57%) (general and partial seizures). The outcome of the
disease in the patients with convulsive syndrome in acute period was recovery with lasting
intracranial hypertension and asthenic syndrome and formation of neurological deficit
(spastic tetraparesis).
Pyramidal and extra pyramidal symptom in the patients with enteroviral
encephalitis was tremor of limbs which was registered less often than convulsive
syndrome (5.71%), and was not combined with seizures. For the patients with tremor in
limbs in acute period recovery with further asthenic syndrome was characteristic.
In the cases of enteroviral encephalitis we registered stem, cerebellar, hemispheric
and combined variations of enteroviral encephalitis (cerebellar+stem 3.13%). The basic
manifestations of the cerebellum involvement into the pathologic process were dynamic
and static ataxia, nystagmus, muscular hypotension at the side of focal damage, ataxic walk,
shift to the side of the damaged hemisphere during walking, intention tremor, and falling
at standing. Stem forms were characterized by the development of alternating syndromes
(development of hemiparesis, hemianesthesia, hemiataxia at the side opposite to the
damaged one). Stem form, the basic clinical manifestations of which was deep coma in a
patients with ptosis, strabismus, nystagmus, damage of facial nerve, bulbar and common
cerebral symptoms, finished by lethal outcome.
Results of the study of cerebrospinal liquor in the cases of enteroviral encephalitis
in 56.7% revealed pleocytosis. In six patients amount of cells in the liquor was above 100
х 10
6
/L. In the rest of the cases the average cytosis rate was equal to 18.8 х 10
6
/L х 10
6
/L.
Pleocytosis had lymphocytic and mostly lymphocytic (lymphocytes were more than 70%
of the cells) character. Only in three cases the level of protein in CSL did not exceed the
values normal for certain age. In all other groups the amount of protein was increased, and
in some cases up to 1.1-1.9 g/L. Average protein level in CSL in the cases of enteroviral
encephalitis was equal to 0.67 g/L. According to Skripchenko N.V. [2], rate of detection of
the agent in the cases of encephalitis can reach 90% at the time of diagnostic within early
terms and in a well-equipped laboratory. For etiological diagnostics of enteroviral
encephalitis we used isolation of enterovirus in CSL and feces by means of PCR method.
The agents of the disease were detected in PCR in 77.1% of the cases.
Therapy of encephalitis with enteroviral etiology corresponded to modern
requirements to therapeutic-safety routine, etiotropic, pathogenetical, and symptomatic
therapy. The aim of the performed therapy was correction of liquor hypertension,
disorders in liquor dynamics, and metabolic disorders. Complex therapy included
application of parenteral osmodiuretics, tablet carbohydrase inhibitors, agents improving
cerebral circulation and metabolism, modern antihypoxants, and nootropic agentes. For
the performance of etiotropic therapy we applied recombinant interferon alpha 2
(viferone) suppositories, and cycloferon for injections. Frequency of the aforesaid agents
application varied from 34% among the children above 12 to 81% among the children
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under 7 years old. The term of etiotropic therapy depended on the age of a child, severity
of associated pathology, and dynamics of clinical symptoms.
All patients with enteroviral encephalitis with impairments of consciousness,
expressed neurological impairments and encephalomyelopolyradiculoneuritis received
dehydration therapy (osmodiurrhetic mannitol, diacarb), hormonal therapy (dexazone 1
mg/kg/day). The term of parenteral dehydration varied from 6 to 11 days and depended
on the age of a child, presence of associated neurological symptoms.
The agents improving microcirculation in CNS by means of vasodilatation (cavinton,
vinpocetin) were applied parenterally with further change for enteral way for children
above 7. For the improvement of nucleic acids exchange and stimulation of exchange
processes in nerve tissue within acute period nootropic agents parenteral injection was
prescribed to all patients. Change for enteral injection was performed with background
positive clinical dynamics and improvement of patients’ condition. With neurotrophic and
reparative purpose we applied actovegin in the doses corresponding to pa
tient’s age
parenterally with further change for tablets (actovegin dragge for 1-2 months).
Antihypoxants and antioxidants increasing the activity of antioxidative enzymes and
improving cerebral circulation (mexidol, cytoflavin) were administered by 100% of the
patients in acute period of enteroviral encephalitis. Patients with polyneuropathy
administered agents improving myelination of nerve fibers and impulse transmission to
the CNS such as glyatilin and neuromidin additionally to the aforementioned ones.
Systemic enzyme therapy (vobenzim) was used for the improvement of rheological
properties of blood and increase of the efficacy of antiviral agents. Taking into account that
the agent is produced in a tablet form it was prescribed to children above 7.
Majority of the patients had acute progression of the disease with positive dynamics
of the basic syndromes. Undulating progression was observed in two patients. Average
term of the therapy for patients with enteroviral encephalitis in a specialized unit was 23.9
days. Undulating progression was registered in patients with residual organic damage of
CNS (22.9% patients with syndrome of vegetative-visceral disorders, emotional labile
impairments, hydrocephalic syndrome, atrophic alterations in frontal lobes, brain, cystic
arachnoiditis) and chronic somatic pathology.
The cases of enteroviral encephalitis in children were characterized by the following
early outcomes of the disease: clinical recovery at the moment of discharge from the
hospital (28.57%); clinical recovery with the preservation of asthenic vegetative
manifestations, moderate or little expressed intracranial hypertension (37.1%); formation
of neurological deficit (focal neurological symptoms with various expression, ataxic
syndrome, spastic tetraparesis) requiring performance of the therapy in specialized
psycho neurological unit (31.4%).
Lethal outcome was observed in one case. Clinical recovery was registered in
patients with moderate or severe forms of neuro infection with mild neurological
manifestations, absence of explicit alterations in MRI or CT images of brain.
Correspondingly, lethal outcome and formation of neurological deficit was more typical for
the patients with severe form of the pathology with explicit and/or long-term neurological
manifestations, rough alterations revealed by means of instrumental tests. Analysis of
long-term outcomes of enteroviral encephalitis and meningoencephalitis was not
performed.
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CONCLUSION.
Thus, maximal morbidity rate of enteroviral encephalitis was observed in August
and September and corresponded to the growth of the common morbidity rate of
enteroviral infections. Patients with enteroviral encephalitis had less expressed
intoxication syndrome, common cerebral symptoms, intracranial hypertension syndrome
compared to those with enteroviral meningitis. Enteroviral encephalitis is characterized
by lower pleocytosis rate than that observed in cases of enteroviral meningitis. The agents
of the disease were isolated by means of PCR method in 77.1% of the cases. Acute
progression of the disease with final recovery in the majority of cases was conditioned by
the performance of complex therapy (parenteral osmodiuretics, carbonic anhydrase
inhibitor tablets, agents improving cerebral circulation and metabolism, modern
antihypoxants, and nootropic agents).
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