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Making QR Code 2d barcode in Microsoft Office PART 4

PART 4
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MAJOR CATEGORIES OF NEUROLOGIC DISEASE
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always important to keep in mind the possibility of neoplasia, HIV, tuberculosis, cryptococcosis, sarcoidosis, syphilis, borreliosis, and inadequately treated bacterial meningitis each of which may simulate aseptic meningitis and each of which presents an urgent diagnostic problem By contrast, the various viral forms of aseptic meningitis are usually self-limited and benign; establishing a speci c etiologic diagnosis is usually not necessary
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THE SYNDROME OF ACUTE ENCEPHALITIS
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From the foregoing discussion it is evident that the separation of the clinical syndromes of aseptic meningitis and encephalitis is not always easy In some patients with aseptic meningitis, mild drowsiness or confusion may be present, suggesting cerebral involvement Conversely, in some patients with encephalitis, the cerebral symptoms may be mild or inapparent, and meningeal symptoms and CSF abnormalities predominate These facts make it dif cult to place complete reliance on statistical data from various virus laboratories about the relative incidence of meningitis and encephalitis The common practice is to assume that viral meningitis causes only fever, headache, stiff neck, and photophobia; if any other CNS symptoms are added, the condition is generally called meningoencephalitis As has been emphasized, it appears that the same spectrum of viruses gives rise to both meningitis and encephalitis It is our impression that many cases of enteroviral and practically all cases of mumps and LCM encephalopathy are little more than examples of intense meningitis Rarely have they caused death with postmortem demonstration of cerebral lesions, and surviving patients seldom have residual neurologic signs Conversely, several agents, notably the arboviruses, may cause encephalitic lesions with only mild meningeal symptoms The core of the encephalitis syndrome consists of an acute febrile illness with evidence of meningeal involvement (sometimes only headache), added to which are various combinations of the following symptoms and signs: convulsions, delirium, confusion, stupor, or coma; aphasia; hemiparesis with asymmetry of tendon re exes and Babinski signs; involuntary movements, ataxia, and myoclonic jerks; nystagmus, ocular palsies, and facial weakness The spinal uid invariably shows a cellular reaction and the protein is slightly elevated Imaging studies of the brain are most often normal but may show diffuse edema or enhancement of the cortex and, in certain infections, subcortical and deep nuclear involvement as well as, in the special case of HSV encephalitis, selective damage of the inferomedial temporal and frontal lobes One or another of these ndings predominates in certain types of encephalitis, but the clinical diagnosis of encephalitis in the setting of a febrile aseptic meningitis always rests on the demonstration of derangement of the function of the cerebrum, brainstem, or cerebellum Differentiation of Viral from Postinfectious Encephalitis The acute encephalitis syndrome described above may take two forms: the more common direct invasion of brain and meninges (true viral encephalitis) and a postinfectious encephalomyelitis that is based on an auto-immune reaction to the systemic viral infection but in which virus is not present in neural tissue The distinction between postinfectious encephalomyelitis (page 790) and infectious encephalitis may be dif cult, especially in younger patients who have a proclivity to develop the postinfectious variety The latter, termed acute disseminated encephalomyelitis (ADEM), occurs after a latency of several days, as the infectious illness is subsiding It is expressed by a low-grade fever and cerebral symptoms such as
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confusion, seizures, coma, ataxia, etc The spinal uid shows slight in ammation and elevation of protein sometimes a more intense reaction, and there are usually characteristic con uent bilateral lesions in the white matter in imaging studies, ndings that differ from those of viral encephalitis When there is no coexistent epidemic of encephalitis to suggest the diagnosis or the systemic illness is absent or obscure, a differentiation between the two may not be possible on clinical grounds alone The fever is generally higher in the infectious type but even this difference does not always hold in young children with ADEM Since ADEM is essentially a demyelinative process, we mention it in this chapter but discuss it more fully in Chap 36 We also place in special categories for later discussion the now rare postinfectious acute encephalopathy with hepatic failure that follows in uenza and other viral infections (Reye syndrome, page 969) and postinfectious cerebellitis, which is discussed further on page 641
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