Treatment Approach for Rhombencephalitis

Initial Management

Patients with suspected rhombencephalitis require urgent neurological specialist assessment and should be managed in a setting where clinical neurological review can be obtained as soon as possible and definitely within 24 hours of referral 1

Intravenous aciclovir at 10 mg/kg three times daily should be started within 6 hours of admission if viral encephalitis is suspected, as recommended by the Infectious Diseases Society of America 2
For immunocompetent adults, continue aciclovir for 14-21 days for confirmed HSV encephalitis, with a strength of evidence level of high 2
For VZV encephalitis, intravenous aciclovir 10-15 mg/kg three times daily is recommended, with dose adjustment for renal impairment, according to the Centers for Disease Control and Prevention 3
For immunocompromised patients with HSV encephalitis, extend treatment to at least 21 days and perform repeat CSF PCR to confirm viral clearance, as suggested by the National Institutes of Health 4

For VZV encephalitis with vasculitic component, consider adding a short course of corticosteroids (e.g., 60-80 mg of prednisolone daily for 3-5 days), as recommended by the American Academy of Neurology 3
For autoimmune or paraneoplastic causes of rhombencephalitis, immunosuppressive therapy with corticosteroids and either plasma exchange or IVIg may be beneficial, according to the European Academy of Neurology 6, 7

Repeat CSF PCR at the end of treatment course for HSV encephalitis to confirm clearance, as recommended by the Infectious Diseases Society of America 2
Monitor renal function frequently when using aciclovir, as it can cause renal impairment through crystalluria in up to 20% of patients, with a strength of evidence level of moderate 2

In immunocompromised patients, consider a wider range of pathogens including CMV, EBV, toxoplasma, cryptococcus, and tuberculosis, as suggested by the Centers for Disease Control and Prevention 4
For immunocompromised children with VZV encephalitis, treatment duration may need to be longer than the standard 10 days, according to the American Academy of Pediatrics 4