What does the literature say about childhood encephalitis?
Recent studies show that the treatment of encephalitis in children is haphazard and improvements need to the made. In general children with suspected encephalitis are previously healthy without any neurological conditions. Risk factors are immunosuppressed or travelled overseas. Because it is uncommon and the signs/symptoms are non-specific, initiating treatment is recommended even if there is no significant likelihood that they have the disease.
The cause of encephalitis can be due to an infectious agent directly or indirectly by other inflammatory pathologies affecting the brain parenchyma. Herpes simplex virus type 1 is the most common cause of sporadic encephalitis.
Symptoms of encephalitis are non-specific, typically children will present with ‘flu-like’ symptoms (headache, nausea, vomiting and altered level of consciousness). Other complaints such as seizures and focal neurological signs are present. There is overlap with acute bacterial meningitis as they can have symptoms of fever, headache and neck stiffness.
There are specific questions that must be asked by physician
- Vaccination history
- Travel history
- History of a rash in child or contacts
- Presence of cold sore or stomatitis may be caused by HSV 1
The absence of meningism should not be used to rule out encephalitis.
Physicians should look for other symptoms such as raised blood pressure, papilloedema, abnormal pupil responses, abnormal flexion or extension to painful stimulus, altered breathing.
The failure to control the seizures is a risk factor for raised intracranial pressure, increased metabolic activity, acidosis and vasodilation
Early diagnosis is very important in order to treat the clinical syndrome and seek aetiology of the disease. Routinely it is advised to perform FBC, urea and electrolytes, liver function test, capillary glucose, blood gas, lactate, urinalysis and CSF.
The best test to accurately determine encephalitis is autopsy or brain biopsy which is not practical. Surrogate markers include inflammatory cells in the spinal fluid or changes in brain imaging. CSF may be negative in the early stages of the disease. Neuroimaging is key in order to provide direct evidence of brain involvement from an infectious process or provide alternative diagnosis (space occupying legion, abscesses, vascular events etc). MRI is more sensitive.
CT may misdiagnose HSV infection in the early stages of the condition whilst MRI will be able to detect other conditions (Kirkham 2012).
Treatment is started with broad spectrum antimicrobials and antiviral medication while awaiting results of diagnostic studies. Studies show that if therapy is commenced late, poor prognosis will ensue. So there should be a low threshold for starting acyclovir in suspected cases of encephalitis.
However, there are also guidelines that suggests starting Aciclovir should not be commenced in children with known epilepsy with an increase in seizure and known febrile illness or acute head injury.
Prognosis is generally poor for children with long-term neurological outcomes even despite appropriate therapy. Up to 67% of children will have long-term morbidity.
In sum there are many unanswered questions about the ideal management and treatment of encephalitis due to lack of reporting, unknown aetiology in the majority of cases and few data on long-term outcomes. The triage and appropriate treatment of children presenting with seizures, reduced level of consciousness or behavioural problems is complex and a controversial issue.
Thomson C, Knew R, Riodan A, Kelly D, Pollard AJ. Encephalitis in children. Archives of Disease in Childhood, 28 February 2012, Vol.97(2), p.150
Kirkham F. Guidelines for the management of encephalitis in children. Developmental Medicine & Child Neurology 2013, 55: 107–110
Unwanted hair growth in women is a problem called hirsutism. It caused by hair follicles that react to increased level of androgen hormones. If facial hair growth in women is not caused by androgen, then this condition is called hypertrichosis.
Women with hirsutism develop unwanted or excessive hair growth in places that normally occur in men. For instance they develop hair growth on the face, upper lip, chin, chest and legs. Hirsutism in itself is not a disease if it occurs in women when they have a normal menstrual cycle.
Women and men have the same number of hair follicles on the body. The only places that lack hair follicles are the soles of the hand, feet and lips. There are three types of hair follicles
- Lanugo hair; this is thin baby hair found on newborns and is shed within a few weeks to be replaced by vellus hair
- Vellus hair; this is short hair without pigment and cover most of the skin
- Terminal hair; this is long, thick pigment hair found on the head, eyebrows, armpits and pubic region.
Vellus hair can grow into terminal hair under the influence of androgen hormone. There are three stages of hair growth in men and women
- Anagen – the phase that determines the length of the hair, the longer the hair stays in this phase, the longer the hair will be
- Catagen – the phase in which the hair follicle renews itself and nothing happens – this lasts about 2 weeks
- Telogen – the phase in which the hair sheds from the skin
The skin is full of receptors and enzymes. Testosteron can be converted into androgen hormone in the skin by an enzyme called 5-alpha reductase. The androgen attaches to receptors on the vellus hair follicle to stimulate them and they then grow into terminal hairs. Women with an abnormal interaction between androgen formed in the skin and the hair receptors will develop hirsutism.
If women with hirsutism have normal menstrual cycles then this condition is not pathological and no further tests are needed. A GP could advice hair removal via laser-treatment at a skin therapy clinic. If women have hirsutism and an irregular menstrual cycle, then a GP should proceed with further tests such as determine the level of androgen hormones. A high level of androgen hormone can be caused by disease of the adrenal glands or in women with polycystic ovarium syndrome (PCOS).
The GP will want to know about the following conditions in order to determine whether it is hirsutism
- location of unwanted hair growth
- how the condition has progressed
- if this occurs in other female family members
- changes in menstruation
- use of contraception
- desires to have child(ren)
- weight loss or weight gain
- use of medication in particular anabolic steroids or danazol (used to treat endometriosis or fibrous cystics breast disease)
- use of anti-hair treatment
- the psychological consequences of excessive hair growth
- worries with regards to fertility
Next the GP will perform a physical examination and will look for presence of terminal hair growth on the breast, abdomen, back, upper legs, upper arms and face. A score from 0 (no terminal hair growth) to 4 (excessive terminal hair growth) is given based on the findings. A score of more than 8 in a light-skinned woman is classified as hirsutism.
The GP will then look at signs of
- obesity or excess fat tissue on the body
- masculine voice
- male-pattern boldness
- small breasts
- increased muscle
- enlarged clitoris
- large thyroid gland
- signs of systemic illness
A referral to a gynaecologist or endocrinologist is made when there are signs of hormonal imbalance and or changes in menstrual cycle.
There are no medication available for women who have hirsutism and normal menstrual cycle. In case of changes in menstruation and no wishes to bear children, women can opt to take an oral contraception pill. The effect is that oestrogen will stimulate testosteron binding SHBG that in turns inactivates testosteron. This in turns means that 5-alpha reductase is not able to convert the inactivated testosterone into androgen. Without androgen, vellus hair is not able to grow as terminal hair and hence reduces the presence of unwanted hair growth.
Obese women with hirsutism are encouraged to loose weight since testosteron is converted to oestradiol in fatty tissue. Oestradiol decreased follicle stimulating hormones (FSH) such that ovaries are not able to release an egg for ovulation. This causes changes in menstrual cycles.
Hirsutism is a response to hormone androgen receptors on thin hair follicles that cause them to grow into thick long hair. The presence of unwanted hair growth in the face, breast, back, upper limbs and lip can be scored 0-24 points. A score of 8 or more signals the presence of hirsutism. A GP will need to know if this occurs with a normal or abnormal menstrual cycle before he or she decides on referral to specialist care.
I want to see a real doctor!
At 10:15 am Louisa and her husband sat at the waiting room of the GP practice. When I called her surname, I noticed some sign of relief . The couple stood up and followed me into my consultation room. I sat behind my desk and motioned them to enter. After an awkward pause I gestured for the husband to sit opposite me, his wife Louisa then pulled the chair adjacent to my desk and sat down. I looked at her and asked
“Hello Louisa, how can I help you?”
“Well doctor that is why we are here, she can’t sleep, she needs something to get her to sleep. She wakes up 2 or 3 times a night screaming, having nightmares”. Her husband answered.
I continued to look at Louisa, she had her arms crossed in front of her, her right fingers plucking the short-sleeves of her beige cardigan, I turned my gaze away from her towards her husband, he was a slender man and when he spoke, a shiny gold tooth of his right upper incisor was visible. I looked at Louisa.
“Can you tell me what’s going on?” I asked
“Her father died 2 weeks ago, she hasn’t slept since, I am concerned that she is going to collapse, she can’t go on like this, that is why we are here so she can sleep” continued her husband. Louisa looked at me then glanced towards the floor. I lowered my head slightly in order to make eye contact with her.
“I am sorry about the loss of your father. What is an unexpected passing?” I asked
“No, it wasn’t really unexpected, we knew he was ill, but we did not know it was going to go so quickly” her husband replied. He looked at her.
“I am sorry about that, so I understand you are not sleeping well and having nightmares, could this be part of grief you are experiencing?”
“I don’t know… that is why we are here, we are not doctors, she needs to sleep, soon she’ll collapse on the floor as well and that can’t happen” exclaimed her husband, his voice slightly raised.
She straightened her back and sat upright, brushed her brow and flicked a stray strand of hair away from her eyes, her hair was pulled tightly behind her. For the next 20 minutes I tried to get to the reason they came and what it is they wanted me to do. This is what I am taught during my general practitioner training. Get the patient to state something along the line of “ the reason I am here doctor is for….” In reality that hardly ever happens. In fact it takes verbal skills and intellectual acrobatic abilities to get patients to talk about the real reason they come to see their GP.
Today the consultation took various turns, at a certain point I felt I had some control. I spoke about her father and tried to know how he died. Louisa showed feelings as her eyes started to swell with tears. I handed her a box of tissues on my desk. It was placed there 3 weeks ago by my assistant and it dawned on me at that moment that it had not yet been used. The soft top tissue was still flat inside the package. And as Louisa plucked one out, 2 tissues stood erect and the package looked more like a box of tissues. She sat there and wiped her eyes.
“I can see that it is hard for you to talk about your emotions, am I safe to say that you may even bottle them up?” I asked
She nodded and even smiled briefly back at me.
“It may help to talk to someone about your emotions… We have a nurse practitioner who specialises in talking about things like sadness and grief. We can discuss if this is an option for you at a later point, but from what I understand now, you are not able to sleep, you want to get some rest and you would like some help, in the form of tablets?”
“I never mentioned tablets or pills! are you even listening?” inflicted the husband. I remained silent. He leaned forward and put his left hand on the desk looked at me and said
“Are you new? You’re here for a short period of time right?”
I nodded, he then said something I could have predicted
“I want to speak to our real doctor…uhm you know doctor, what’s her name?”
I glanced at the computer screen and recognized the initials NP next to Louisa’s name, the initials of their “real doctor”.
“Nathalie Peters, doctor Peters” I replied.
“Yes, doctor Peters. We want to see her”
“That is fine, that is not a problem at all. I would like to know if I can hear this from Louisa too”. I turned towards her and said “I have asked quite a few questions to better understand the situation, and I would really like to hear some of them from you, could you tell me?”
“What he says…, it’s what he says”. She gestured to him whilst he leaned back in his chair he looked at me and said
“Look, we want to make sure that she does not have cancer, is there like a check-up, or blood tests she can do to catch the disease in advance?”
“I see, did your father die of cancer?” I asked Louisa.
“Yes, he did, lung cancer, it was everywhere in his body, even her sister a few years ago, she too died of numerous cancers in her body” replied the husband.
“I am really sorry to hear this Louisa, the passing of two family members to cancer is terrible. From what I understand your father died of lung cancer and your sister of breast cancer…”
“See you don’t listen, did I say breast cancer? you are not listening! I said she died of lung cancer and it was all over her body”. Replied the husband, he leaned forward again, but this time he did not put his hand on the table. There was another silence. I glanced at Louisa, who sat there with her hands folded in front of her, she was rolling the moist tissue in her right hand as if it should suddenly evaporate.
“Yes, you are right, I made a mistake, I am sorry, I assumed it was breast cancer because you mentioned she had it in her body, which I took to be metastasis…”
“Yeah that is what you keep doing, first you assume she needs pills to help her sleep, now you assume her sister has breast cancer, you are not listening”. He glared at me
I knew I messed up. I was 40 minutes behind schedule. I needed to gain back control of this situation. I gestured to Louisa to walk to the examination table, I wanted to examine her to make sure we ‘don’t miss anything’.
On a normal day, a general physical examination usually takes me about 2 minutes, from the time I put the blood pressure manchet around the patient’s arm, secure the oximeter on a finger to the time I auscultate heart, lungs, palpate the abdomen to feel for tenderness or swelling. If I do an extended examination that includes a neurological one then it could take me another 2 minutes. But with Louisa, my general physical examination took much longer. I unfolded the blood pressure meter from the black bag it stays secure in, took out the manchet and gently placed it around her right upper arm. I then took the oximeter and asked her to show me her left index finger. I secured the oximeter on the finger and pushed the on button. I turned back to the blood pressure meter and inflated it, collapsing the brachial artery that goes under the cubital fossa of her elbow. Normally I do not visualise the full anatomy of the vessels and muscles during a physical examination, I do it automatically. In this particular situation, I needed time to repair the mis-communication between Louisa, her husband and me. I released the cuff to deflate it and waited for the first ‘dub dub’ as the brachial artery was released. Her blood pressure was fine, but I decided to redo it again, just to make sure.
“130 over 60. Your blood pressure is perfect” I said.
I leaned over to the oximeter on her left index finger and read out “pulse 86 and 98 percent oxygen your heart beat and the oxygen level in your blood are also normal”.
Then I auscultated her lungs followed by her heart whilst she sat upright. I asked her to lay back down and felt her tummy, pressed in all four quadrants, she said she did not feel any pain and I was delighted. I also checked her neck and upper shoulders for any swollen glands. There were none. Whilst I performed her physical examination, two thoughts came to my mind. Did I want to repair this relationship, absolutely. Did I want to scream at her husband and tell him to get out of my office because in fact I was talking to Louisa…absolutely! The latter was obviously not something to even contemplate, but I think I would have felt good if I could do that. I realised that in order to get the trust back, I had to go through her husband. I turned to Louisa and said
“Louisa, I have examined you and can say that I am not able to find anything serious at the moment. That is not to say that there are no other examinations we can do to rule out underlying diseases. Before I continue, I just want to say that I hope I am not giving you the impression that I am not listening. I am here to listen, that is my job. I also want you to know that I understand your concerns. You have lost two very important people in your life, they died of cancer. You came here today with your husband to find out if there are any check-ups that can be done to catch cancer early. Before you go down that route, it is important to ask more questions and discuss which type of tests need to be done. Dr Peters is coming back next week. How about I schedule an appointment with you and her for 20 minutes? In the meantime I suggest that you, Louisa, keep a diary of what is going on. It may help you and doctor Peters look for patterns and decide on the next steps to take. And as for the nurse practitioner who specialises in dealing with sadness and grief, let me book an appointment with her on the same day as doctor Peters, that way you won’t need to come back twice. Does that work for you?” I quickly looked at her husband, he replied
“Yes, it does, and if the conversation with the psychology nurse doesn’t go well, you don’t have to go back ok” he said as he looked at his wife. Louisa nodded, took her phone from her bag and typed the date and time of both appointments. She asked me for the name of the psychology nurse practitioner.
“Her name is Melissa” I said. Her husband got up and started walking towards the door.
“What about your sleep, Louisa, do you need something for that? I know I mentioned pills earlier on, what would you like for your sleep issue?” I asked.
“Can she have tablets then doctor, would that not make her addicted to them, she needs to work again soon you know. She’s been at home for 2 weeks, not able to work and having to deal with her father’s house and moving things, she is so weak and tired. She can’t go on like this, she needs to get back to work. We need food on the table” exclaimed her husband.
“Yes, I can prescribe her 5 tablets of temazepam, which she can take at night”
“Will that make me sleep?” asked Louisa
“Yes, you will be able to sleep and get the rest you need. And no, you will not get addicted, that is why I am prescribing only 5 tablets”
“Thank you doctor, that would be great, I will try them” she answered
“No problem, again I am sorry for your loss and if anything changes in your health between now and your appointment with doctor Peters, let us know ok.”
“Yes, I will” she smiled and walked towards her husband who stood already by the door.
The couple left, I slumped back in my seat, and looked at the computer screen. It was 11:30 am and there were 4 patients waiting to be seen before my lunch break at 13:00 pm.
For over 3 months you feel tired and work is getting more hectic. On this particular evening when you go to bed, you notice that you are anxious. It’s probably the deadline you won’t make that worries you. Your team has worked really hard, but with the Covid-19 situation, things are just delayed. As you turn off the lights and place your head on the pillow, all of a sudden you notice your heart pounding. It won’t stop, you toss and turn, trying to think about happy things. But your heart beats faster, and then it skips a beat. You sit erect in your bed, knocking over your pillow. Anxiously you put two fingers on your left wrist, the way you have seen on television. You notice the thud thud thud of your pulse against your fingers and your chest is rising faster and faster.
Eventually you fall asleep. You wake up tired, like many mornings.
When you speak to your GP that afternoon, you mention having muscle aches and that in fact you do not feel like doing much on most days. Things are just getting too much. But what worries you the most is your heart rate and palpitations. You ask your GP if your thyroid is playing up.
Your GP examines you physically and notes no alarming findings that could explain your symptoms. Your blood pressure and pulse are within normal range. Your thyroid gland is not enlarged.
Your GP says it could be a number of possible things and lists the following
- Anxiety syndrome
- Regularly irregular heartbeat
At this stage your GP tries to reassure you that your symptoms are less likely caused by a thyroid problem.
For now, a general health check with blood tests should be requested.
It is affecting your sleep and day to day functioning. It is important to highlight these changes to your GP so that a general blood test is done to check your blood count, kidney, liver and thyroid function and blood sugar level.
In order for your GP to consider depression, there are two very important symptoms that must be present.
- Low mood during most of the day (>8 hours a day)
- Clear lack of interest or enjoyment in things you do during most of the day. For example, lack of interest or enjoyment in your work, sport, interaction with friends or family.
In order for your GP to diagnose you with depression, you must have at least 5 symptoms made up of at least 1 of the very important symptoms above and the other symptoms listed below.
- Weight loss or weight gain
- Sleepless nights or too much sleep
- Agitation or lack of motivation
- Tiredness and lack of energy
- Feelings of worthlessness or excessive guilt
- Difficulty concentrating or not able to make decisions
- Recurrent thoughts of death, suicidal thoughts, attempt to commit suicide or a specific plan to end one’s life
If you feel that you are not getting the message clear to your GP make sure to highlight how your feelings IMPACT your life using these 5 dimensions:
- Behaviour: Let your GP know whether you take initiative to make changes. If you are more of a passive spectator into your condition, tell your GP what it takes to motivate you to make changes.
- Social: Share this information early on because it is a very vital part of getting you the help you need. Let your GP know what and who your social support is, whether it’s family, friends, colleagues, or curious neighbours.
- Physical: speak about pre-existing conditions, use of medication (type and dosage), alcohol consumption, smoking habits and physical impairments.
- Emotional: Be detailed as much as possible about your emotions, for instance speak about the feelings that this situation causes you (sadness, anger, guilt, shame or powerlessness)
- Mental: Explore what triggers cause you to feel this way, could it be stress from work or your private life? Isolation or the loss of something important in your life (a job, a loved-one, not passing an exam). Even (past) events like abuse (physical, sexual, emotional), aggression, conflicts at work and war can trigger emotions.
You can prepare for your consultation with your GP by filling out the Four-dimensional symptom questionnaire (4DSQ)
This questionnaire is useful to explore symptoms that you have had in the past 7 days. If you bring this questionnaire with you to discuss with your GP it can save time. It mainly helps as a tool to speak about things that may be challenging to interpret during a consultation. The 4DSQ does not diagnose you with depression – further tests and consults are still needed.
Your GP along with a nurse practitioner can start management to help you that consists of
- Advice on how to better structure your day and activities
- Engage in sports or hobbies that interest you
- Learning Problem Solving treatment which is a short psychological treatment based on cognitive behavioural therapy (CBT). The main goal is to learn how to be active in dealing with the problem by formulating positive and concrete goals. This increases your ability to manage with your mood and find solutions that work for you.
Don’t feel afraid to speak to your GP and the nurse practitioner about how you are feeling and how this is impacting your life. They have plenty of tools to help you on your road to feeling more like yourself again.
However, your GP will always assess you on an individual basis to see what the best management option is for you. Sometimes reviewing your life structure, setting goals and learning simple self-help psychological therapies are sufficient in helping manage depressed mood. Other times further referral to a psychologist, discussions regarding antidepressant medication or a referral to psychiatrist may be required.
Remember, if it all gets too much and you are having any suicidal thoughts and feel like you are in crisis, you must call emergency services on 112. Alternatively you can speak to someone on the Netherlands suicide prevention hotline on 0800-0113 available 24/7 or visit www.113.nl for more advice.