Journal of the Pediatric Infectious Diseases Society

ORIGINAL ARTICLE

Long-Term Outcomes and Risk Factors Associated With

Acute Encephalitis in Children
Suchitra Rao,1,2 Benjamin Elkon,2 Kelly B. Flett,3 Angela F.D. Moss,4 Timothy J. Bernard,2,5 Britt Stroud,6 Karen M. Wilson7
1
Division of Hospital Medicine and Infectious Diseases; 2Department of Pediatrics, Children's Hospital Colorado, Aurora; 3Division of Pediatric Infectious Diseases, Department
of Medicine, Boston Children's Hospital, Massachusetts; 4Adult and Child Center for Health Outcomes and Delivery Science, University of Colorado School of Medicine, and
5
Divisions of Neurology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora; 6Department of Neurology, Lee Memorial Health System, Fort
Myers, Florida, and 7Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora

Background. Factors associated with poor outcomes of children with encephalitis are not well known. We sought to determine
whether electroencephalography (EEG) findings, magnetic resonance imaging (MRI) abnormalities, or the presence of seizures at
presentation were associated with poor outcomes.
Methods. A retrospective review of patients aged 0 to 21years who met criteria for a diagnosis of encephalitis admitted between
2000 and 2010 was conducted. Parents of eligible children were contacted and completed 2 questionnaires that assessed current
physical and emotional quality of life and neurological deficits at least 1year after discharge.
Results. During the study period, we identified 142 patients with an International Classification of Diseases 9th Revision diag-
nosis of meningitis, meningoencephalitis, or encephalitis. Of these patients, 114 met criteria for a diagnosis of encephalitis, and 76 of
these patients (representing 77 hospitalizations) had complete data available. Forty-nine (64%) patients were available for follow-up.
Patients admitted to the intensive care unit were more likely to have abnormal EEG results (P = .001). The presence of seizures on
admission was associated with ongoing seizure disorder at follow-up. One or more years after hospitalization, 78% of the patients
had persistent symptoms, including 35% with seizures. Four (5%) of the patients died. Abnormal MRI findings and the number of
abnormal findings on initial presentation were associated with lower quality-of-life scores.
Conclusions. Encephalitis leads to significant morbidity and death, and incomplete recovery is achieved in the majority of hos-
pitalized patients. Abnormal EEG results were found more frequently in critically ill children, patients with abnormal MRI results
had lower quality-of-life scores on follow-up, and the presence of seizures on admission was associated with ongoing seizure disorder
and lower physical quality-of-life scores.
Keywords. cerebrospinal fluid; encephalitis; meningoencephalitis; PedsQL; viral infection.

INTRODUCTION long-term sequelae include epilepsy, developmental delay,

Encephalitis is a serious illness that affects children world-
wide. It is defined by the presence of an inflammatory process
of the brain associated with clinical evidence of neurological
dysfunction [1]. The initial presentation can include seizures,
headache, paresis, vision loss, hearing impairment, and behav-
ioral changes [2, 3]. Diagnosis is made by clinical presentation,
cerebrospinal fluid (CSF) findings, and electroencephalography
(EEG) or magnetic resonance imaging (MRI) abnormalities.
For children, neurological impairment, which can lead to sig-
nificant morbidity and death and affect long-term quality of
life, has been reported in 25% to 60% of cases [3, 4]. Common
Received 20 April 2015; accepted 29 September 2015.
Correspondence: S. Rao, MBBS, Department of Pediatrics, Children's Hospital of Colorado,
University of Colorado School of Medicine, B055, 13123 E 16th Ave, Aurora, CO 80045 (suchitra.
rao@childrenscolorado.org).
Journal of the Pediatric Infectious Diseases Society 2017;6(1):207
The Author 2015. Published by Oxford University Press on behalf of The Journal of the
Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail:
journals.permissions@oup.com.
DOI: 10.1093/jpids/piv075
learning disabilities, and chronic headaches [5].
The etiological agent is an important predictor of outcomes
in patients with encephalitis [6], the epidemiology of which is
geographically dependent [1]. Long-term outcomes have been
explored for patients with a number of different viruses, such
as herpes simplex virus (HSV) [710], Japanese encephalitis
[11], enterovirus [12, 13], and Epstein Barr virus [14]. However,
in up to 75% of cases of encephalitis, an etiology is not found
[1, 15]. There have been few published studies regarding the
long-term neurological outcome of pediatric patients with
encephalitis, accounting for those without an etiology, using
standardized outcome measures. The use of standardized mea-
sures can enhance our understanding of the outcomes asso-
ciated with encephalitis and help us to identify potential risk
factors for more severe disease; these measures are used also
for other pediatric neurological insults, such as traumatic brain
injury and stroke [16, 17]. Therefore, there were 2 main objec-
tives of this study. The first objective was to use standardized
measures to explore the long-term outcomes of children with
encephalitis to further characterize the impact of this disease

20 JPIDS2017:6(March) Rao etal

state in quantifiable terms. The second objective was to deter-
mine whether EEG and MRI abnormalities and the presence
of seizures on initial presentation are risk factors for persistent
neurological abnormalities or if they impact quality of life.
METHODS
Study Population
We reviewed the medical records of patients admitted to
Children's Hospital Colorado, Aurora, between 2000 and 2010
with an International Classification of Diseases 9th Revision
(ICD-9) discharge diagnosis code of encephalitis, meningo-
encephalitis, or meningitis. Patients were eligible for the study
if they had a diagnosis of encephalitis, which was defined as
documented encephalopathy (depressed or altered level of con-
sciousness lasting >24 hours, lethargy, or personality change)
plus 2 or more of the following: temperature of >38C; new-on-
set seizure(s); focal central nervous system findings; abnormal
EEG findings compatible with encephalitis; abnormal brain
computed tomography (CT) scan or MRI results; or CSF pleo-
cytosis >2 standard deviations of the mean for their age [18].
Patients with insufficient data, antiN-methyl D-aspartate
receptor encephalitis, or a hematologic/oncologic diagnosis
were excluded from the study. Demographic, clinical laboratory,
EEG, and neuroimaging data of each patient were obtained.
Approval for the study was obtained from the Colorado Multiple
Institutions Review Board (08-1299). Informed written consent
was obtained for the follow-up questionnaires.
Follow-Up
Patients who met the study criteria for a diagnosis of encephali-
tis were eligible for follow-up if at least 1year had passed since
their original diagnosis. Astructured telephone interview was
conducted with parents of eligible patients using 2 question-
naires designed to assess quality of life; they were also mailed if
requested by a parent. The first questionnaire was the Pediatric
Quality of Life Inventory (PedsQL) Generic Core Scales [19],
which is a 23-item scale designed to measure health-related
quality of life in 4 categories: physical functioning (8 items),
emotional functioning (5 items), social functioning (5 items),
and school functioning (5 items). The psychosocial score is
a composite of the emotional, social, and school function-
ing scores. The PedsQL questionnaire was validated previ-
ously, is reliable in patient populations [20], and is suggested
as a core global outcome measure by the National Institute of
Neurological Disorders and Stroke Common Data Elements
[16]. The second questionnaire was used to determine the per-
sistence of specific neurological symptoms or difficulties with
areas of daily living such as weakness, speech, headaches, and
seizures, and it covered areas relevant to encephalitis follow-up
that were not addressed in the PedsQL questionnaire (see
Appendix). The questionnaire was pilot tested with parents of
children with chronic medical conditions and modified on the
basis of results from this testing.
Statistical Analysis
Summary statistics are reported as medians (interquartile
ranges [IQRs]) for continuous data and counts (proportions)
for categorical data. The 2 and Fisher exact tests for associa-
tion were used to compare certain clinical factors on admission
with persistent abnormalities at least 1 year after the diagno-
sis of encephalitis. Persistent neurological abnormalities were
defined as the presence of seizures, behavioral problems, or 1 or
more neurological deficits, such as weakness, speech problems,
developmental delay, and learning problems. Comparisons for
clinical findings at admission and the presence of neurological
deficits, behavioral problems, and seizures at discharge were
also examined with the 2 and Fisher exact tests for association.
Neurological deficits at discharge were defined as the presence
of psychiatric problems or at least 1 physical problem, such as
motor deficits, ataxia/cerebellar signs, or movement disorder.
Spearman partial correlation was used to measure the strength
of the association between PedsQL scores and clinical findings
at admission and at discharge while controlling for the effect
of age at the time that the survey was administered. The fol-
lowing empirical guidelines for interpreting the magnitude
of the correlation coefficients were used: values less than 0.2
indicate weak correlation, values between 0.2 and 0.3 indicate
moderate correlation, and values greater than 0.3 indicate large
correlation. The McNemar test for paired data was used to test
for differences in proportions in abnormalities at admission
and during hospitalization against those present at discharge.
P values were adjusted for multiple comparisons within each
subanalysis by using the Hochberg method, which preserved
the overall type Ierror rate for each subanalysis, allowing the
adjusted P values to be interpreted at the 0.05 level of signifi-
cance. Statistics were performed by using SAS version 9.4 sta-
tistical software (SAS Institute, Cary, NC) and SPSS version 22
(IBM Corp., Armonk, NY).
RESULTS
We identified 142 patients with an ICD-9 diagnosis of men-
ingitis, meningoencephalitis, or encephalitis during our study
period. Of these patients, 114 met our criteria for a diagnosis of
encephalitis and underwent chart review. Twelve patients were
excluded because of a diagnosis of antiN-methyl D-aspartate
receptor encephalitis, and 26 patients were excluded because
of oncologic comorbidity or insufficient data regarding clinical
presentation in the medical record. Seventy-six patients (repre-
senting 77 hospitalizations) had data available for review. One
patient had a repeat hospitalization for encephalitis 3years after
the initial episode; the etiology was not identified for either pre-
sentation. An etiology was identified in 29 (38%) of the cases,
Outcomes in Children After Encephalitis JPIDS 2017:6 (March) 21
Figure1. Flow diagram showing study participants with encephalitis at Children's Hospital Colorado (20002010), from initial assessment through follow-up.
Abbreviations: HSV, herpes simplex virus; ICD-9, International Classification of Diseases 9th Revision.
93% of which were from an infectious source. The most com-
mon etiologies were HSV, enterovirus, and influenza (Figure1).
The median age at diagnosis was 7years (IQR, 213years). One
patient had a previous history of developmental delay, 1 had
a history of seizures, and 2 had a history of migraine. Thirty-
two (42%) patients were admitted to the ICU, and 4 (5%)
patients died. Neurological deficits present on admission and
persistence of deficits at discharge are summarized in Figure2.
Most patients who presented with motor deficits, personality
changes, and/or ataxia/cerebellar signs were likely to have reso-
lution of their symptoms before discharge.
Forty-nine patients were available for follow-up. The median
time to follow-up was 1.3years. Subjects with and without fol-
low-up data were similar in terms of demographics and clinical
characteristics (Table1). Persistent neurological outcomes and
PedsQL scores with normative data [20] are listed in Tables 2
and 3, respectively. Persistent deficits were reported in 38 (78%)
patients. The most common residual neurological symptoms
reported were psychiatric abnormalities, weakness, behav-
ioral or cognitive deficits, vision problems, and headaches.
Seventeen patients (35%) reported ongoing seizures. Patients
22 JPIDS2017:6(March) Rao etal
with an etiology identified had lower median physical scores
than patients without an etiology identified (87.5 vs 97; P = .02),
but their overall and psychosocial scores were not significantly
different. Patients with HSV and influenza had lower median
physical and psychosocial scores, and patients who tested posi-
tive for enterovirus had higher median scores, but these differ-
ences were not statistically significant.
There were no significant associations observed between fac-
tors on admission, such as CSF pleocytosis, CT/MRI or EEG
abnormalities, or neurological deficits present at discharge.
Patients admitted to the ICU were more likely to have had EEG
abnormalities (P =.013).
Long-term outcomes were assessed by evaluating the PedsQL
scores and the presence of neurological symptoms and signs at
least 1year after diagnosis. Having seizures present on admis-
sion was significantly associated with ongoing seizures at
least 1 year after the diagnosis of encephalitis (94% vs 42%; P
= .0036). Partial correlation coefficients of clinical factors on
admission with PedsQL scores at least 1year after diagnosis are
presented in Table4. After removing the effects of age, having
abnormal MRI results on admission was associated with lower
Figure2. Neurological deficits and persistence of symptoms and signs on discharge among patients with encephalitis at Children's Hospital Colorado,
20002010 (N = 49); significant differences in proportions were evaluated by the 2 and Fisher exact tests.
psychosocial and physical scores, and the presence of seizures on
admission correlated with lower physical scores. The presence of
EEG abnormalities on admission did not correlate with PedsQL
scores. However, an increase in the number of clinical factors
on admission (MRI abnormalities, EEG abnormalities, seizures,
and CSF pleocytosis) correlated with lower PedsQL scores.
DISCUSSION
In our study of long-term outcomes of children with encephali-
tis, we found that almost 80% of patients with encephalitis had
persistent neurological symptoms on long-term follow-up. MRI
findings and the presence/absence of seizures on admission
were helpful in predicting long-term outcomes. We found that
abnormal MRI findings and seizures were correlated with lower
quality-of-life scores. The presence of seizures at presentation
was associated with patients having ongoing seizure disorder.
Finally, although EEG abnormalities were more commonly seen
among critically ill patients, EEG findings were not helpful in
predicting long-term outcomes. Given the limited data regard-
ing long-term outcomes in children with encephalitis, these
findings are important for informing which factors on presen-
tation might predict quality-of-life outcomes.
The results of our study suggest a role for MRI for not only
diagnosing and assisting with the etiology of encephalitis but
also the prognostic information it may provide. Although
abnormal MRI findings in our study were not associated with
findings at discharge or gross neurological deficits, they were
potentially associated with more subtle deficits identified by the
PedsQL questionnaire. The strongest correlation was noted for
the psychosocial score, which evaluates mental and emotional
health and incorporates perception of self and ability to func-
tion in the community. Klein etal [2] reported that MRI abnor-
malities were predictive of abnormal neurological outcome at
hospital discharge, but their study did not follow patients to
assess long-term outcomes. Wang etal [3] reported that focal
cortical parenchymal abnormalities that appeared on MRI pre-
dicted poorer long-term outcomes. Despite having detailed
radiographic characterization of the lesions in those patients
with MRI abnormalities, our study did not find an association
between specific MRI abnormalities and adverse outcome, but
this finding might have been limited by samplesize.
In contrast, although EEG is a useful tool for assessing
acute brain dysfunction [4], EEG findings do not predict
long-term outcomes. The results of our study show that
any EEG abnormalities, particularly severe EEG findings,
Outcomes in Children After Encephalitis JPIDS 2017:6 (March) 23
Table1. Demographics, Clinical Characteristics, and Hospital Course of Patients With Encephalitis Seen at Children's Hospital Colorado, 20002010a

Variable Total Patients Follow-Up Group (N = 49) No-Follow-Up Group (N = 27)b

Demographics
Age at diagnosis, years; median (interquartile range) 7 (2.612.7) 6.8 (2.612.8) 7.9 (2.411.6)
Male 41 (54.0) 25 (51.0) 16 (59.3)
Ethnicity/race
White 47 (61.8) 31 (63.3) 16 (59.3)
White (Hispanic) 19 (24.7) 13 (26.5) 5 (18.5)
Black 1 (1.3) 1 (2) 0 (0)
Asian 3 (4) 2 (4) 1 (4)
Other 3 (4) 0 (0) 3 (11)
Unknown 3 (4) 2 (4) 1 (4)

Total Episodes of Encephalitis Follow-Up Group (N = 49) No-Follow-Up Group (N = 28)b

Clinical presentation/comorbidity
Any underlying comorbidity 11 (14.5) 8 (16.7) 3 (10.7)
History of recent acute illness 37 (49.3) 21 (44.7) 16 (57.1)
Headache 30 (39.3) 22 (44.9) 8 (28.6)
Behavioral changes 29 (38.2) 20 (41.7) 9 (32.1)
Altered mental status 77 (100) 49 (100) 28 (100)
Fever 49 (64) 31 (63.3) 18 (64.3)
Seizures 47 (62) 29 (60.4) 18 (64.3)
Central nervous system abnormality 33 (43) 23 (46.9) 10 (35.7)
At least 1 physical finding 45 (59.2) 29 (60.4) 16 (57.1)
Motor deficit 37 (48.7) 23 (47.9) 14 (50.0)
Ataxia/cerebellar signs 21 (27.6) 14 (29.2) 7 (25.0)
Movement disorder 8 (10.7) 6 (12.8) 2 (7.1)
Psychiatric problem 22 (28.9) 16 (33.3) 6 (21.4)
Laboratory/imaging/EEG findings
CSF pleocytosis 61 (80) 40 (83.3) 21 (75.0)
MRI/CT abnormalities 39 (51.3) 26 (54.2) 13 (46.4)
EEG abnormalities 47 (71.2) 31 (73.8) 16 (66.7)
Treatment
IVIg 5 (6.8) 4 (8.9) 1 (3.6)
Steroids 19 (27.5) 11 (25.0) 8 (32.0)
<21days of acyclovir 37 ( 59.7) 19 (51.4) 18 (72.0)
>21days of acyclovir 25 (40.3) 18 (48.6) 7 (28.0)
Hospital course
Rehabilitation admission 20 (29.0) 15 (34.1) 5 (20.0)
ICU admission 32 (44) 18 (38.3) 14 (56.0)
Days in ICU 4 (27) 4.5 (26) 3.0 (27)
Length of stay, days; median (interquartile range) 7.0 (3.921.0) 7.2 (3.021.0) 7.0 (3.922.6)
Death 4 (5.8) 0 (0) 4 (16)
Clinical factors on discharge
At least 1 physical finding 18 (23.7) 11 (22.9) 7 (25.0)
Motor deficit 16 (21.1) 10 (20.8) 6 (21.4)
Ataxia/cerebellar signs 4 (5.3) 2 (4.2) 2 (7.1)
Movement disorder 3 (4) 1 (2.1) 2 (7.1)
Psychiatric problem 8 (10.5) 5 (10.4) 3 (10.7)

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; EEG, electroencephalography; ICU, intensive care unit; IQR, interquartile range; IVIg, intravenous immunoglobulin; MRI, magnetic resonance imaging.
a
Values shown are number (percentage) unless otherwise specified.
b
There was no statistically significant difference between the follow-up and no-follow-up groups.

were more prevalent in patients admitted to the pediatric clinical signs and symptoms at presentation are more likely to
ICU. We did not, however, find an independent association have EEG abnormalities, but they do not necessarily correlate
between EEG abnormalities or ICU stay and poor long-term with long-term outcomes.
outcomes, in contrast to the findings of Wang etal [3]. Our Although EEG findings may not be useful for prognosis,
findings suggest that patients who present with more severe our study results show that seizures on initial presentation

24 JPIDS2017:6(March) Rao etal

Table2. Persistent Neurological Deficits at Least 1 Year After Diagnosis Table3. PedsQL Scores for Patients at Least 1 Year After Diagnosis
of Encephalitis Among Patients Seen at Children's Hospital Colorado, of Encephalitis Among Patients Seen at Children's Hospital Colorado,
20002010 (N = 49) 20002010 (N = 49)

Variable n % (95% CI) Age Category PedsQL Score (Median [IQR])

Neurological deficit Physicala 94 (75100)
Any deficit 38 78 (6690) 24 y of age 95 (53100)
Weakness 16 33 (2046) 57 y of age 97 (30100)
Behavioral problem 15 31 (1844) 812 y of age 89 (6397)
Developmental delay 17 35 (2248) >13 y of age 94 (88100)
Anxiety/depression 18 37 (2351) Psychosociala 75 (6092)
Vision problem 17 35 (2248) 24 y of age 73 (56100)
Speech problem 15 31 (1844) 57 y of age 76 (5691)
Sleep problem 9 18 (729) 812 y of age 78 (6293)
Learning problem 20 41 (2755) >13 y of age 75 (6079)
Swallowing problem 5 10 (218)
Abbreviations: IQR, interquartile range; PedsQL, Pediatric Quality of Life Inventory; SD, standard deviation.
Hearing problem 3 6 (013) a
Parent proxy-report mean scores for PedsQL physical health among 8696 families of healthy children were
Headache 17 35 (2248) 84.08 (SD, 19.7), and mean scores for psychosocial health among 8714 families were 81.24 (SD, 15.34) in a
study by Varni etal [20].
Seizures 17 35 (2248)
Services/aids/medications required
On antiepileptic(s) 12 24 (1236)
did not identify specific outcome domains as we did. It should
Glasses 13 27 (1539)
Hearing aid 1 2 (06) be noted that the most common etiological agents reported by
Speech therapy 24 49 (3563) Misra etal, specifically, Japanese encephalitis and dengue, were
Physical therapy 24 49 (3563) different than those in our study. In addition, our finding that
Occupational therapy 24 49 (3563) the presence of seizures at presentation increased the risk of
Abbreviation: CI, confidence interval. subsequent seizure disorder was described previously [4]. These
findings raise questions about whether identifying and optimiz-
correlated with poorer long-term outcomes, which has been ing seizure management early in the hospital course could serve
corroborated by other reports [2, 3]. From their study, Misra as a neuroprotective strategy, and they warrant furtherstudy.
etal [21] reported that seizures resulting from encephalitis were The majority of previous studies in which long-term out-
associated with poor outcomes at 3months follow-up. The study comes of patients with encephalitis were explored focused on

Table4. Partial Correlations of PedsQL Scores (Obtained at Least 1 Year After Diagnosis) With Clinical Factors on Admission After Adjusting for Age
Among Patients With Encephalitis Seen at Children's Hospital Colorado, 20002010

Physical Score Psychosocial Score Overall Score

Clinical Factor on Admission n Median Spearman rhoa Median Spearman rhoa Median Spearman rhoa
MRI/CT 26 71.9 0.26 88.8 0.43 b
76.5
Abnormal 22 77.4 100 81.4 0.29
Normal
EEG 31 73.3 0.05 90.6 0.14 76.2
Abnormal 11 75.0 100 80.0 0.06
Normal
Seizures 29 75.0 0.08 90.6 0.2 76.3
Yes 19 87.5 96.9 85.0 0.11
No
CSF pleocytosis 40 75.0 0.16 93.8 0.05 78.0
Yes 8 85.8 94.4 84.6 0.09
No
No. of clinical factors present 10 92.5 0.24 100 0.34 92.1
1 14 76.9 93.8 74.2 0.22
2 12 65.3 98.4 68.3
3 13 76.3 87.5 72.9
4

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; EEG, electroencephalography; MRI, magnetic resonance imaging; PedsQL, Pediatric Quality of Life Inventory.
a
Values of 0.10.2 represent weak correlation; values of 0.20.3 represent moderate correlation; and values of >0.3 represent strong correlation.
b
The adjusted P value is <.05.

Outcomes in Children After Encephalitis JPIDS 2017:6 (March) 25

a specific etiological agent [7, 11, 13, 14, 22]. However, given
that the majority of cases of encephalitis are without an etiology,
we sought to explore the long-term outcomes of encephalitis
regardless of whether an agent was identified, because it is more
relevant to the usual clinical setting. We found that the identi-
fication of an etiological agent did not influence quality-of-life
scores, but our data are limited by the lack of standardized test-
ing at our institution.
Although other studies have explored short-term outcomes
during hospitalizations [2] or focused primarily on long-term
outcomes [23, 24], a strength of our study is that we report both
long-term and short-term outcomes. In addition to reporting
initial presentation and outcomes at discharge, we sought to fol-
low patients at least 1year after their initial diagnosis of enceph-
alitis, by which time their deficits are usually persistent [25]. We
selected the PedsQL questionnaire for our study because it was
validated for use in studies of neurological disorders, it is brief
and reliable, and it can be administered by telephone, which
likely contributed to our high response rate. Because this tool
does not account for specific deficits, we included an additional
questionnaire related to neurological deficits, which provided
further insight into the long-term morbidity associated with
encephalitis.
There are limitations to our study. Our study showed an
increase in the number of deficits correlated with lower phys-
ical, psychosocial, and overall PedsQL scores. However, we
were not able to determine whether they were independent
predictors because of our small sample size. There was a sig-
nificant percentage of patients excluded from analysis because
of incomplete medical records, which may have skewed our
data. Selection bias exists because of the nature of our fol-
low-up. Also, there were variable times to patient follow-up for
the completion of the questionnaires. However, because most
patients with encephalitis who show full recovery are likely to
do so within 12months of their initial diagnosis [4], we ensured
that follow-up was obtained at least 1year after their diagnosis,
by which time their clinical characteristics were more likely to
be persistent. In addition, there are certain neurological defi-
cits that are nonspecific and may not be related to encephalitis
(such as the presence of headaches) or may have been present
before the diagnosis of encephalitis. We documented in our
detailed questionnaire only those symptoms that were new after
the diagnosis of encephalitis, but reporting was subject to recall
bias and may have influenced the PedsQL scores. A prospec-
tive longitudinal study that includes active methods of subject
follow-up and formal neuropsychological assessments linking
early indicators to etiology, disease progression, and prognosis
would yield an improved understanding of long-term outcomes.
This study of long-term outcomes of patients hospitalized
with encephalitis found that long-term deficits are seen in
approximately 80% of patients, and subsequent seizure dis-
order is seen in 35% of patients. Abnormal MRI findings at
26 JPIDS2017:6(March) Rao etal
presentation correlate with worse quality-of-life outcomes. The
presence of seizures on presentation predicts subsequent sei-
zure disorder and is associated also with lower physical qual-
ity-of-life scores. Our data suggest that MRI findings might
provide some prognostic information. Close follow-up of these
patients is advised, because they are at risk of impairment
with regards to their quality of life and subsequent epilepsy.
Additional prospective studies with larger cohorts and more
detailed outcome measures are needed to further determine
risk factors that are predictive of poor outcomes.
Note
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the con-
tent of the manuscript have been disclosed.
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APPENDIX
TCH Neurological Outcomes Questionnaire
Child's Name:
Date of Birth:
Your Name:
Relationship to child:
General health:
In general, would you say your child's health is:
ExcellentVery goodGoodFairPoor
Have you been told by a doctor, nurse, or other health profes-
sional that your child has any of the following problems?
Weakness of the arms or legs no yes
Behavior problems no yes
Developmental delay no yes
Depression or anxiety problems no yes
Vision problems no yes
Speech problems no yes
Sleep disturbance no yes
Learning problems no yes
Swallowing problems no yes
Hearing problems or deafness no yes
Headaches no yes
If you have answered yes to any of the above, was this present
before the diagnosis of encephalitis? If so, please circle:Since
your child's encephalitis, does he or she currently:
Use a wheelchair? no yes
Wear glasses? no yes
Wear hearing aids? no yes
Has your child ever needed any of the following services after
discharge from a hospital for encephalitis?
Speech therapy no yes
Occupational therapy no yes
Physical therapy no yes
Seizures:
2. Does your child have seizures since having encephalitis?
noyes
If the answer is yes, answer questions 35 below:
3. What best describes the type of seizure pattern your child has:
Staring episodes
Focal seizures (affecting one part of the body)
Generalized seizures (affecting multiple parts of the body)
Other (describe)
4. During the past 4 weeks, how many seizures has your child
had?
5. Does your child take medication(s) for the seizures?
noyes
Outcomes in Children After Encephalitis JPIDS 2017:6 (March) 27