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Viral Central Nervous System Infections in Children

by Mary T. Caserta, MD

Central nervous system infections are extremely serious. Meningitis affects the membranes surrounding the brain and spinal cord. Encephalitis affects the brain itself.

  • Central nervous system infections caused by viruses can cause meningitis and encephalitis.

  • Symptoms usually start with fever and can progress to irritability, refusal to eat, headache, neck pain, and sometimes seizures.

  • The diagnosis of viral central nervous system infections is based on a spinal tap.

  • Many infections are mild, but others are severe and can cause death.

  • Antiviral drugs are usually not effective for treatment of central nervous system infections, so children need to receive supportive measures (such as drugs to control fever and pain and plenty of fluids).

Viruses that infect the central nervous system (brain and spinal cord) include herpesviruses (see also herpes simplex virus infections), arboviruses, coxsackieviruses, echoviruses, and enteroviruses (see also enterovirus infections). Some of these infections affect primarily the meninges (the tissues covering the brain and spinal cord) and result in meningitis. Viral meningitis is sometimes called aseptic meningitis. Other infections affect primarily the brain and result in encephalitis. Infections that affect both the meninges and brain result in meningoencephalitis. Meningitis is far more common among children than is encephalitis.

Did You Know...

  • Antibiotics cannot cure viral infections.

Viruses affect the central nervous system in two ways:

  • They can directly infect and destroy cells in the central nervous system during the acute illness.

  • The immune response to the infection sometimes causes damage to the cells around the nerves after children recover from the infection.

This later damage (postinfectious encephalomyelitis or acute disseminated encephalomyelitis) typically causes symptoms a few weeks after recovery from the acute illness.

Children acquire infections of the central nervous system through various routes. Newborns can develop herpesvirus infections through contact with infected secretions in the birth canal. Other viral infections are acquired by breathing air contaminated with virus-containing droplets exhaled by an infected person. Arbovirus infections are acquired from bites by infected insects (called epidemic encephalitis).

The symptoms and treatment of viral meningitis and of encephalitis in older children and adolescents are similar to those in adults. The inability of infants to communicate directly makes it difficult to understand their symptoms. Usually, however, infants with central nervous system infections have some of the symptoms described below.

Symptoms

Viral central nervous system infections in newborns and infants usually begin with fever. Newborns may have no other symptoms and may initially not otherwise appear ill. Infants older than a month or so typically become irritable and fussy and refuse to eat. Vomiting is common. Sometimes the soft spot on top of a newborn's head (fontanelle) bulges, indicating an increase in pressure on the brain. Because irritation of the meninges is worsened by movement, an infant with meningitis may cry more, rather than calm down, when picked up and rocked. Some infants develop a strange, high-pitched cry. Infants with encephalitis often have seizures or other abnormal movements. Infants with severe encephalitis may become lethargic and comatose and then die.

An infection with herpes simplex virus , which is often concentrated in only one part of the brain, may lead to seizures or weakness appearing in only one part of the body (see Table: Some Infections of Newborns). An infant with herpes simplex virus encephalitis may also have a rash on the skin, in the eyes, or in the mouth. The rash consists of red spots with fluid-filled blisters that crust over or scab before healing.

Postinfectious encephalomyelitis may cause many neurologic problems, depending on the part of the brain that is damaged. Children may have weakness of an arm or leg, vision or hearing loss, a change in behavior, intellectual disability, or recurring seizures. Some of these symptoms are noticed right away. Other symptoms may not be noticed until later, for example when the child has routine tests of hearing, vision, and/or intelligence. Often the symptoms resolve with time, but occasionally they are permanent.

Diagnosis

  • Spinal tap (lumbar puncture)

Doctors are concerned about the possibility of meningitis or encephalitis in every newborn who has a fever, as well as in older infants, children, and adolescents who have fever and are irritable or otherwise not acting normally. To make the diagnosis of meningitis or the diagnosis of encephalitis, doctors do a spinal tap (lumbar puncture—see Figure: ) to obtain cerebrospinal fluid (CSF) for laboratory analysis. In viral infections, the number of white blood cells is increased in the CSF, but no bacteria are seen. Immunologic tests that detect antibodies against viruses in samples of CSF may be done, but these tests usually take days to complete. Polymerase chain reaction (PCR) techniques are available to more quickly identify herpes simplex virus and enteroviruses in the CSF.

A test of brain waves ( electroencephalography) can be used to help diagnose encephalitis caused by herpesvirus. Magnetic resonance imaging (MRI) and computed tomography (CT) may help confirm the diagnosis especially in cases of postinfectious encephalomyelitis.

Prognosis

Prognosis varies greatly with the type of infection. Many types of viral meningitis and encephalitis are mild, and the child recovers quickly and completely. Other types are severe.

Brain infection with herpes simplex virus is particularly grave. Without treatment, about 50% of newborns with herpes simplex infection of the brain die, and two thirds of those who survive have severe brain damage. Even with treatment, about 25% die and up to half of the survivors have brain damage. If the herpes infection involves other parts of the body as well as the brain, mortality is as high as 85%.

Treatment

  • Keeping the infant comfortable

  • Drugs for fever or seizures

  • For postinfectious encephalomyelitis, corticosteroids or other drugs

Most infants require only supportive care. That is, they need to be kept warm and given plenty of fluids and drugs to treat any fever or seizures. Antiviral drugs are not effective for most central nervous system infections. However, infections caused by herpes simplex virus can be treated with acyclovir given by vein.

Postinfectious encephalomyelitis may be treated with corticosteroids or other drugs that lessen the immune response that causes the neurologic damage.

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