Treatment of Chronic Viral Encephalitis in Immunocompromised Patients

Initial Diagnostic Approach

The American Academy of Neurology recommends that immunocompromised patients with suspected encephalitis should receive an MRI as soon as possible, as CT may miss lesions due to impaired inflammatory response 1, 2, 3
The Infectious Diseases Society of America suggests that a CT head scan should be considered before lumbar puncture in patients with known severe immunocompromise 1, 2, 3
The Centers for Disease Control and Prevention recommend that CSF workup should be broader than in immunocompetent patients because CSF may be acellular despite active infection, so microbial testing should proceed regardless ofontent of cell count 1, 2, 3
Mandatory CSF PCR testing includes: HSV 1 & 2, VZV, enteroviruses, EBV, and CMV 1, 2, 3, 4

The American College of Physicians recommends intravenous acyclovir 10 mg/kg every 8 hours for a minimum of 21 days for HSV-1 and HSV-2 encephalitis in immunocompromised patients 1, 2, 3, 5
The Infectious Diseases Society of America suggests reassessing with CSF PCR at completion of IV therapy to confirm viral clearance 1, 2, 3
The National Institutes of Health recommend long-term oral suppressive therapy until CD4 count >200 × 10⁶/L to prevent relapse 1, 2, 3
The American Academy of Neurology recommends combination therapy with ganciclovir 5 mg/kg IV every 12 hours PLUS foscarnet 60 mg/kg IV every 8 hours for 3 weeks for CMV encephalitis 5

The British HIV Association recommends that patients with HIV should be treated in an HIV center with specialized expertise 1, 2, 3
The Centers for Disease Control and Prevention suggest that immunocompromised patients present with subtle, subacute symptoms rather than acute fulminant disease 1, 2, 3
The American College of Physicians recommends that encephalitisاجر should be considered even if history is prolonged, clinical features are subtle, there is no fever, or CSF white cell count is normal 1, 2, 3

The Infectious Diseases Society of America recommends repeat lumbar puncture at end of treatment to confirm CSF negativity for HSV by PCR 5
The National Institutes of Health suggest that patients should have access to neurological specialist opinion within 24 hours 6
The American Academy of Neurology recommends that all patients require assessment for rehabilitation regardless of age 3