Template:ID-Encephalitis

1. Empiric antimicrobial therapy^[1]

Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
Note (1): Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies.
Note (2): Other empiric antimicrobial agents should be administered on the basis of specific epidemiologic or clinical clues.

2. Specific epidemiologic considerations^[1]

2.1 Agammaglobulinemia — Enteroviruses, Mycoplasma pneumoniae
2.2 Age

2.2.1 Neonates — Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii
2.2.2 Infants and children — Eastern equine encephalitis virus, Japanese encephalitis virus, Murray Valley encephalitis virus, influenza virus, La Crosse virus
2.2.3 Elderly persons — Eastern equine encephalitis virus, St. Louis encephalitis virus, West Nile virus, sporadic CJD, L. monocytogenes

2.3 Animal contact

2.3.1 Bats — Rabies virus, Nipah virus
2.3.2 Birds — West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, Cryptococcus neoformans (bird droppings)
2.3.3 Cats — Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii
2.3.4 Dogs — Rabies virus
2.3.5 Horses — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virus
2.3.6 Old World primates — B virus
2.3.7 Raccoons — Rabies virus, Baylisascaris procyonis
2.3.8 Rodents — Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintana
2.3.9 Sheep and goats — C. burnetii
2.3.10 Skunks — Rabies virus
2.3.11 Swine — Japanese encephalitis virus, Nipah virus
2.3.12 White-tailed deer — Borrelia burgdorferi

2.4 Immunocompromised persons — Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

2.5 Ingestion

2.5.1 Raw or partially cooked meat — T. gondii
2.5.2 Raw meat, fish, or reptiles — Gnanthostoma species
2.5.3 Unpasteurized milk — Tickborne encephalitis virus, L. monocytogenes, C. burnetii

2.6 Insect contact

2.6.1 Mosquitoes — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, West Nile virus, La Crosse virus, Plasmodium falciparum
2.6.2 Sandflies — Bartonella bacilliformis
2.6.3 Ticks — Tickborne encephalitis virus, Powassan virus, Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma phagocytophilum, C. burnetii (rare), B. burgdorferi
2.6.4 Tsetse flies — Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense

2.7 Occupation

2.7.1 Exposure to animals — Rabies virus, C. burnetii, Bartonella species
2.7.2 Exposure to horses — Hendra virus
2.7.3 Exposure to Old World primates — B virus
2.7.4 Laboratory workers — West Nile virus, HIV, C. burnetii, Coccidioides species
2.7.5 Physicians and health care workers — Varicella zoster virus, HIV, influenza virus, measles virus, M. tuberculosis
2.7.6 Veterinarians — Rabies virus, Bartonella species, C. burnetii

2.8 Person-to-person transmission — Herpes simplex virus (neonatal), varicella zoster virus, Venezuelan equine encephalitis virus (rare), poliovirus, nonpolio enteroviruses, measles virus, Nipah virus, mumps virus, rubella virus, Epstein-Barr virus, human herpesvirus 6, B virus, West Nile virus (transfusion, transplantation, breast feeding), HIV, rabies virus (transplantation), influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum

2.9 Recent vaccination — Acute disseminated encephalomyelitis

2.10 Recreational activities

2.10.1 Camping/hunting — Agents transmitted by mosquitoes and ticks
2.10.2 Sexual contact — HIV, T. pallidum
2.10.3 Spelunking — Rabies virus, H. capsulatum
2.10.4 Swimming — Enteroviruses, Naegleria fowleri

2.11 Season

2.11.1 Late summer/early fall — Agents transmitted by mosquitoes and ticks, enteroviruses
2.11.2 Winter — Influenza virus

2.12 Transfusion and transplantation — Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborne encephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum, R. rickettsii, C. neoformans, Coccidioides species, H. capsulatum, T. gondii

2.13 Travel

2.13.1 Africa — Rabies virus, West Nile virus, P. falciparum, T. brucei gambiense, T. brucei rhodesiense
2.13.2 Australia — Murray Valley encephalitis virus, Japanese encephalitis virus, Hendra virus
2.13.3 Central America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, P. falciparum, Taenia solium
2.13.4 Europe — West Nile virus, tickborne encephalitis virus, A. phagocytophilum, B. burgdorferi
2.13.5 India, Nepal — Rabies virus, Japanese encephalitis virus, P. falciparum
2.13.6 Middle East — West Nile virus, P. falciparum
2.13.7 Russia — Tickborne encephalitis virus
2.13.8 South America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, B. bacilliformis (Andes mountains), P. falciparum, T. solium
2.13.9 Southeast Asia, China, Pacific Rim — Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus, P. falciparum, Gnanthostoma species, T. solium
2.13.10 Unvaccinated status — Varicella zoster virus, Japanese encephalitis virus, poliovirus, measles virus, mumps virus, rubella virus

3. Specific clinical considerations^[1]

3.1 General findings

3.1.1 Hepatitis — Coxiella burnetii
3.1.2 Lymphadenopathy — HIV, Epstein-Barr virus, cytomegalovirus, measles virus, rubella virus, West Nile virus, Treponema pallidum, Bartonella henselae and other Bartonella species, Mycobacterium tuberculosis, Toxoplasma gondii, Trypanosoma brucei gambiense
3.1.3 Parotitis — Mumps virus
3.1.4 Rash — Varicella zoster virus, B virus, human herpesvirus 6, West Nile virus, rubella virus, some enteroviruses, HIV, Rickettsia rickettsii, Mycoplasma pneumoniae, Borrelia burgdorferi, T. pallidum, Ehrlichia chaffeensis, Anaplasma phagocytophilum
3.1.5 Respiratory tract findings — Venezuelan equine encephalitis virus, Nipah virus, Hendra virus, influenza virus, adenovirus, M. pneumoniae, C. burnetii, M. tuberculosis, Histoplasma capsulatum
3.1.6 Retinitis — Cytomegalovirus, West Nile virus, B. henselae, T. pallidum
3.1.7 Urinary symptoms — St. Louis encephalitis virus

3.2 Neurologic findings

3.2.1 Cerebellar ataxia — Varicella zoster virus (children), Epstein-Barr virus, mumps virus, St. Louis encephalitis virus, Tropheryma whipplei, T. brucei gambiense
3.2.2 Cranial nerve abnormalities — Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis, T. pallidum, B. burgdorferi, T. whipplei, Cryptococcus neoformans, Coccidioides species, H. capsulatum
3.2.3 Dementia — HIV, human transmissible spongiform encephalopathies (sCJD and vCJD), measles virus (SSPE), T. pallidum, T. whipplei
3.2.4 Myorhythmia — T. whipplei (oculomasticatory)
3.2.5 Parkinsonism — Japanese encephalitis virus, St. Louis encephalitis virus, West Nile virus, Nipah virus, T. gondii, T. brucei gambiense
3.2.6 Poliomyelitis-like flaccid paralysis — Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses (enterovirus-71, coxsackieviruses), poliovirus
3.2.7 Rhombencephalitis — Herpes simplex virus, West Nile virus, enterovirus 71, L. monocytogenes

4. Pathogen-directed antimicrobial therapy^[1]

4.1 Viruses

4.1.1 Adenovirus

Preferred regimen: supportive

4.1.2 B virus (herpes B virus)

4.1.2.1 Established disease

Preferred regimen: Valacyclovir 1,000 mg PO tid OR Ganciclovir 5 mg/kg IV q12h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily indefinitely OR Valacyclovir 1 g PO tid indefinitely
Alternative regimen: Acyclovir 15 mg/kg IV q8h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily OR Valacyclovir 1 g PO tid indefinitely

4.1.2.2 Prophylaxis after bite or scratch

Preferred regimen: Valacyclovir 1,000 mg PO tid

4.1.3 Cytomegalovirus (CMV)

Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance AND Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

4.1.4 Chikungunya virus

Preferred regimen: supportive

4.1.5 Eastern equine encephalitis virus

Preferred regimen: supportive

4.1.6 Epstein-Barr virus (EBV)

Preferred regimen: supportive ± Corticosteroids
Note: Acyclovir is not recommended.

4.1.7 Hendra virus

Preferred regimen: supportive

4.1.8 HSV-1 and HSV-2

Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
Preferred regimen (neonates): Acyclovir 20 mg/kg IV q8h for 21 days

4.1.9 Human herpesvirus 6 (HHV-6)

Preferred regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance

Preferred regimen (2): Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

4.1.10 Human immunodeficiency virus (HIV)

Preferred regimen: HAART

4.1.11 Influenza virus

Preferred regimen: Oseltamivir 75 mg PO bid

4.1.12 Japanese encephalitis virus

Preferred regimen: supportive
Note: Interferon alpha is not recommended.

4.1.13 JC virus

Preferred regimen: Reversal or control of immunosuppression OR HAART in patients with AIDS

4.1.14 La Crosse virus

Preferred regimen: supportive

4.1.15 Louping ill virus

Preferred regimen: supportive

4.1.16 Lymphocytic choriomeningitis virus (LCMV)

Preferred regimen: supportive

4.1.17 Me Tri virus

Preferred regimen: supportive

4.1.18 Measles virus

Preferred regimen: supportive
Note: Ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.

4.1.19 Monkeypox virus

Preferred regimen: supportive
Alternative regimen: Cidofovir OR vaccinia immune globulin

4.1.20 Mumps virus

Preferred regimen: supportive

4.1.21 Murray Valley encephalitis virus

Preferred regimen: supportive

4.1.22 Nipah virus

Preferred regimen: supportive
Alternative regimen: Ribavirin

4.1.23 Nonpolio enteroviruses

Preferred regimen: supportive
Note: Consider intraventricular γ-globulin for chronic and/or severe disease.

4.1.24 Poliovirus

Preferred regimen: supportive

4.1.25 Powassan virus

Preferred regimen: supportive

4.1.26 Rabies virus^[2]

4.1.26.1 Not previously vaccinated

Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
Preferred regimen (2): Human rabies immune globulin (HRIG) 20 IU/kg
Preferred regimen (3): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14

4.1.26.2 Previously vaccinated

Preferred regimen (1): Wound cleansing with soap and water followed by povidine-iodine solution irrigation if available.
Preferred regimen (2): Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area), 1 each on days 0 and 3
Note: If anatomically feasible, the full dose of HRIG should be infiltrated around and into the wounds, and any remaining volume should be administered at an anatomical site intramuscularly distant from vaccine administration. In addition, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

4.1.27 Rocio virus

Preferred regimen: supportive

4.1.28 Rubella virus

Preferred regimen: supportive

4.1.29 Snowshoe hare virus

Preferred regimen: supportive

4.1.30 St. Louis encephalitis virus

Preferred regimen: supportive
Alternative regimen: IFN-α-2b

4.1.31 Tickborne encephalitis virus

Preferred regimen: supportive

4.1.32 Toscana virus

Preferred regimen: supportive

4.1.33 Vaccinia

Preferred regimen: supportive ± Corticosteroids (if suggestive of post-immunization)

4.1.34 Venezuelan equine encephalitis virus

Preferred regimen: supportive

4.1.35 Varicella zoster virus (VZV)

Preferred regimen: Acyclovir 10–15 mg/kg IV q8h for 10–14 days ± Corticosteroids
Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days THEN 5 mg/kg IV qd for maintenance ± Corticosteroids

4.1.36 West Nile virus

Preferred regimen: supportive

4.1.37 Western equine encephalitis virus

Preferred regimen: supportive

4.2 Bacteria

4.2.1 Anaplasma phagocytophilum (human granulocytotrophic ehrlichiosis)

Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks

4.2.2 Bartonella bacilliformis (Oroya fever, Carrion's disease)

Preferred regimen: Chloramphenicol 25 mg/kg q6h for 14 days OR Doxycycline 100 mg PO/IV bid for 8 weeks OR Ampicillin 2 mg IV q4h for 3-6 weeks OR Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks

4.2.3 Bartonella henselae (cat scratch disease)

Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks OR Azithromycin 250 mg PO qd for 8 weeks ± Rifampin 300 mg PO bid for 8 weeks

4.2.4 Borrelia burgdorferi (Lyme disease)

Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks OR Cefotaxime 2g IV q8h for 2-4 weeks OR Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks

4.2.5 Coxiella burnetii (Q fever)

Preferred regimen: Doxycycline 100 mg IV/PO bid for 8 weeks AND Ciprofloxacin 500-750 mg PO bid for 8 weeks AND Rifampin 300 mg PO bid for 8 weeks

4.2.6 Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)

Preferred regimen: Doxycycline 100 mg IV/PO bid for 8 weeks

4.2.7 Listeria monocytogenes

Preferred regimen: Ampicillin 2 mg IV q4h for 3-6 weeks AND Gentamicin 5 mg/kg/day IV divided q8h for 3-6 weeks
Alternative regimen: Trimethoprim-Sulfamethoxazole 4 mg/kg IV q6h for 3-6 weeks

4.2.8 Mycobacterium tuberculosis

Preferred regimen: (Isoniazid 300 mg PO qd for 10-12 months AND Rifampicin 450-600 mg PO qd for 10-12 months AND Pyrazinamide 1.5-2g mg PO qd for 2 months AND Ethambutol 15 mg/kg PO qd for 2 month) ± Dexamethasone (if suggestive of meningitis)^[3]

4.2.9 Mycoplasma pneumoniae

Preferred regimen: Azithromycin 250 mg PO qd for 8 weeks OR Doxycycline 100 mg PO/IV bid for 8 weeks

4.2.10 Rickettsia rickettsii (Rocky Mountain spotted fever)

Preferred regimen: Doxycycline 100 mg PO/IV bid for 8 weeks
Alternative regimen, pregnant patient: Chloramphenicol 25 mg/kg q6h for 14 days

4.2.11 Treponema pallidum (syphilis)

Preferred regimen: Penicillin G 20MU IV q4hr in divided doses for 2-4 weeks
Alternative regimen: Ceftriaxone 2g IV q24h for 2-4 weeks

4.2.12 Tropheryma whipplei (Whipple's disease)

Preferred regimen: Ceftriaxone 2g IV q24h for 2-4 weeks, followed by Trimethoprim-Sulfamethoxazole for 1–2 years OR Cefixime for 1–2 years

4.3 Fungi

4.3.1 Coccidioides

Preferred regimen: Fluconazole 400-800 mg IV qd for 3-4 weeks
Alternative regimen: Itraconazole 200 mg IV bid for 2 days THEN 200 mg IV qd for 12 days OR Voriconazole OR Amphotericin B (intravenous and intrathecal)

4.3.2 Cryptococcus neoformans

Preferred regimen (1): Amphotericin B deoxycholate AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
Preferred regimen (2): Amphotericin B lipid complex AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
Preferred regimen (3): Amphotericin B deoxycholate AND Flucytosine for 6–10 weeks, followed by Fluconazole for 8 weeks
Note: Consider placement of lumbar drain or VP shunt.

4.3.3 Histoplasma capsulatum

Preferred regimen: Amphotericin B liposomal for 4–6 weeks, followed by Itraconazole for at least 1 year and until resolution of CSF abnormalities

4.4 Protozoa

4.4.1 Acanthamoeba

Preferred regimen (1): Trimethoprim-Sulfamethoxazole AND Rifampin AND Ketoconazole
Preferred regimen (2): Fluconazole AND Sulfadiazine AND Pyrimethamine 100-200 mg PO once THEN 50-100 mg PO qd for 6 weeks

4.4.2 Balamuthia mandrillaris

Preferred regimen: (Azithromycin OR Clarithromycin) AND Pentamidine AND Flucytosine AND Fluconazole AND Sulfadiazine AND (Thioridazine OR Trifluoperazine)

4.4.3 Naegleria fowleri

Preferred regimen: Amphotericin B (intravenous and intrathecal) AND Rifampin AND (Azithromycin OR Sulfisoxazole OR Miconazole)

4.4.4 Plasmodium falciparum

Preferred regimen: Quinine OR Quinidine OR Artesunate OR Artemether
Alternative regimen (1): Atovaquone-Proguanil
Alternative regimen (2): Exchange transfusion (for > 10% parasitemia or cerebral malaria)

4.4.5 Toxoplasma gondii

Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin 900 mg IV q 6hr qd for 6 weeks
Alternative regimen (1): Trimethoprim-sulfamethoxazole
Alternative regimen (2): Pyrimethamine AND (Atovaquone OR Clarithromycin OR Azithromycin OR Dapsone)

4.4.6 Trypanosoma brucei gambiense (West African trypanosomiasis)

Preferred regimen: Eflornithine OR Melarsoprol 2-3.6 mg/kg IV q24h for 3 days THEN repeat the same regimen after 7 days THEN repeat the same regimen again (total of 3 regimens after 7 days of the 2nd regimen

4.4.7 Trypanosoma brucei rhodesiense (East African trypanosomiasis)

Preferred regimen: Melarsoprol

4.5 Helminths

4.5.1 Baylisascaris procyonis

Preferred regimen: Albendazole AND Diethylcarbamazine AND Corticosteroids

4.5.2 Gnathostoma

Preferred regimen: Albendazole OR Ivermectin

4.5.3 Taenia solium (cysticercosis)

Preferred regimen: Albendazole AND Corticosteroids
Alternative regimen: Praziquantel AND Corticosteroids

4.6 Prion

4.6.1 Human transmissible spongiform encephalopathy

Preferred regimen: supportive

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.
↑ Rupprecht, Charles E.; Briggs, Deborah; Brown, Catherine M.; Franka, Richard; Katz, Samuel L.; Kerr, Harry D.; Lett, Susan M.; Levis, Robin; Meltzer, Martin I.; Schaffner, William; Cieslak, Paul R.; Centers for Disease Control and Prevention (CDC) (2010-03-19). "Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR-2): 1–9. ISSN 1545-8601. PMID 20300058.
↑ Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J; et al. (2009). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". J Infect. 59 (3): 167–87. doi:10.1016/j.jinf.2009.06.011. PMID 19643501.

[Guidelines2008-1] 1.0 ^1.1 ^1.2 ^1.3 Tunkel, Allan R.; Glaser, Carol A.; Bloch, Karen C.; Sejvar, James J.; Marra, Christina M.; Roos, Karen L.; Hartman, Barry J.; Kaplan, Sheldon L.; Scheld, W. Michael; Whitley, Richard J.; Infectious Diseases Society of America (2008-08-01). "The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (3): 303–327. doi:10.1086/589747. ISSN 1537-6591. PMID 18582201.

[2] Rupprecht, Charles E.; Briggs, Deborah; Brown, Catherine M.; Franka, Richard; Katz, Samuel L.; Kerr, Harry D.; Lett, Susan M.; Levis, Robin; Meltzer, Martin I.; Schaffner, William; Cieslak, Paul R.; Centers for Disease Control and Prevention (CDC) (2010-03-19). "Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 59 (RR-2): 1–9. ISSN 1545-8601. PMID 20300058.

[pmid19643501-3] Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J; et al. (2009). "British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children". J Infect. 59 (3): 167–87. doi:10.1016/j.jinf.2009.06.011. PMID 19643501.

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Template:ID-Encephalitis

References

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