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TABLE 94.10
EVALUATION OF A CHILD WITH SUSPECTED ENCEPHALITIS OR MENINGOENCEPHALITIS
All suspected cases
CSF

Cell count and differential, protein/glucose, bacterial culture, HSV PCR, enteroviral PCR
Consider holding CSF in the laboratory for additional diagnostic studies (see below)
Serum
CBC, chemistries, blood cultures, EBV/CMV serologies, HIV, HSV PCR, Bartonella
serologies, Mycoplasma serologies
Other
Enteroviral PCR (respiratory, stool), PCR of respiratory specimens
Specific risk factor or features
Tuberculosis risk
Should be suspected in any child with CSF pleocytosis and a high CSF protein and/or low
factors
CSF glucose: chest radiograph (abnormal in approximately 90% of children with
tuberculosis meningitis; tuberculin skin test; interferon gamma release assay; gastric
aspirate or sputum for acid-fast culture; CSF PCR for Mycobacterium tuberculosis
Immunocompromised Acid-fast culture for tuberculosis, cryptococcal antigen (serum, CSF), human herpesvirus
6 and 7, JC virus, Toxoplasma serum IgG; cultures for Listeria monocytogenes, VZV
PCR, histoplasmosis serologies/urinary antigen
Sexually active
Summer/fall

Winter

RPR/VDRL for syphilis
West Nile IgM (CSF, serum), Arboviral panel (CSF, serum), and serologies for other
geographically appropriate arboviruses (e.g., St. Louis, La Crosse, and the equine
encephalitides)

Serologies for Rickettsia rickettsii (Rocky Mountain spotted fever) and ehrlichiosis as
well as Borrelia burgdorferi (Lyme disease) if in the appropriate geographic region
Influenza PCR

Raw or unpasteurized Toxoplasma IgG, serologies for Coxiella, culture for Listeria monocytogenes, evaluation
food products
for Gnanthostoma if history of travel to Southeast Asia or Latin America
Animal exposures
Rabies (bites from unimmunized dogs/cats or contact with bats or wild carnivores),
Bartonella (cat scratches or bites from cat fleas), LCMV (exposure to rodent urine or
feces)
Ticks
Insect contact

Swimming in
brackish or
stagnant water
Travel history

Serologies or PCR for Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma, Borrelia
burgdorferi
Serologies for equine encephalitides, St. Louis encephalitis, Japanese encephalitis, West
Nile virus, La Crosse virus and smear for malaria (if appropriate travel histories) for
mosquito contact; Bartonella bacilliformis serologies (sandflies); trypanosomiasis
serologies (tsetse flies)
Wet mount for Naegleria fowleri

Vesicular rash

Serologies for fungal infections endemic in certain regions; consider early consultation

with an infectious diseases specialist. Infections more common outside industrialized
nations are discussed in the section on Infections in Returned Travelers
PCR of lesion for HSV, VZV

Diarrhea and seizure
CSF eosinophilia

Stool for bacterial culture (Shigella, E. coli ) and for rotavirus PCR
Baylisascaris (raccoon roundworm) serologies

CSF, cerebrospinal fluid; HSV, herpes simplex virus; PCR, polymerase chain reaction; CBC, complete blood count; EBV, Epstein–Barr virus; CMV,
cytomegalovirus; HIV, human immunodeficiency virus; VZV, varicella zoster virus; RPR, rapid plasma reagin; VDRL, venereal disease research
laboratory; LCMV, lymphocytic choriomeningitis virus.
From Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2008;47:303–327, by permission of the Oxford University Press.