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Physical Examination

Look for supporting evidence of viral infection. The signs of encephalitis may be diffuse or focal. At the extremes, 80% of patients with HSE present with focal findings. Typical findings include the following:

• Altered mental status
• Personality changes are very common
• Focal findings, such as hemiparesis, focal seizures, and autonomic dysfunction
• Movement disorders (St Louis encephalitis, eastern equine encephalitis [EEE], western equine encephalitis [WEE])
• Ataxia
• Cranial nerve defects
• Dysphagia, particularly in rabies
• Meningismus (less common and less pronounced than in meningitis)
• Unilateral sensorimotor dysfunction (postinfectious encephalomyelitis [PIE])

Findings of HSV infection in neonates (aged 1-45 d) may include the following:

• Herpetic skin lesions over the presenting surface from birth or with breaks in the skin, such as those resulting from fetal scalp monitors
• Keratoconjunctivitis
• Oropharyngeal involvement, particularly buccal mucosa and tongue
• Encephalitis symptoms, such as seizures, irritability, change in level of attentiveness, bulging fontanelles
• Additional signs of disseminated, severe HSV include jaundice, hepatomegaly, and shock

As noted above, Toxoplasma infection causing encephalitis is found in immune-suppressed patients. They exhibit significant encephalopathy with lethargy or personality changes, and 75% present may present with focal neuropathology.

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