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October, slightly later than is customary for the other arboviruses Venezuelan equine encephalitis is common in South and Central America; in the United States it is practically con ned to Florida and the southwestern states California virus encephalitis predominates in the northern Midwest and northeastern states After West Nile, the La Crosse variety is perhaps the most frequent identi able arbovirus encephalitis in the United States Rabies infections occur worldwide, but in the United States they are seen mostly in the Midwest and along the West Coast Japanese B encephalitis (the most common encephalitis outside of North America), Russian spring-summer encephalitis, Murray Valley encephalitis (Australian X disease), and several less common viral encephalitides are infrequent in the United States or, as in the case of West Nile fever, have appeared only recently With the ease and rapidity of travel, many of these will undoubtedly increase in number in North America and parts of Europe where they have not been seen hitherto Infectious mononucleosis, which is a primary infection with EBV, is complicated by meningitis, encephalitis, facial palsy, or polyneuritis of the Guillain-Barre type in a small proportion of cases Each of these neurologic complications can occur in the absence of the characteristic fever, pharyngitis, and lymphadenopathy of infectious mononucleosis The same is true of M pneumoniae In these two diseases there is still uncertainty as to whether they are true infectious encephalitides or postinfectious complications, as discussed in Chap 32 Recent evidence from PCR testing of spinal uid is consistent with a direct infection in some cases Varicella zoster and CMV are other herpes-type viruses that may cause encephalitis They are discussed in relation to the particular clinical settings in which they occur De nite cases of epidemic encephalitis (encephalitis lethargica) have not been observed in acute form since 1930, though an occasional surviving patient with a residual parkinsonian syndrome is still seen in neurology clinics However, various movement disorders including parkinsonism are being seen as a residua of encephalitis from the aviviruses The latency from infection to these complications is brief, or may be present from the outset, quite unlike encephalitis lethargica The relative frequency of the various viral infections of the nervous system can be appreciated from several studies An early series from the Walter Reed Army Institute comprising 1282 patients is particularly noteworthy in that a positive laboratory diagnosis was achieved in more than 60 percent of cases (Buescher et al) a higher rate than in almost any subsequent study of comparable size Aside from the poliovirus (some of the data were gathered before 1959), the common infective agents in cases of both aseptic meningitis and encephalitis were group B Coxsackie virus, echovirus, mumps virus, lymphocytic choriomeningitis virus, arboviruses, HSV, and Leptospira, in that order In a later prospective virologic study of all children examined at the Mayo Clinic during the years 1974 to 1976, a diagnosis of aseptic meningitis, meningoencephalitis, or encephalitis was entertained in 42 cases and an infectious agent was identi ed in 30 of them (Donat et al) The California virus was isolated in 19 cases and one of the enteroviruses (echovirus types 19, 16, 21, or Coxsackie virus) in 8 cases; mumps, rubeola, HSV, adenovirus 3, and M pneumoniae were detected in individual cases (several patients had combined infections) As mentioned, recent outbreaks of West Nile virus, close to 3000 cases yearly in the United States, make it more important than most of the viral infections listed here The related Japanese encephalitis virus is even more ubiquitous on a worldwide basis, causing 10,000 deaths in Asia each year.

In a contemporary and impressively large series of viral infections of the nervous system from the United Kingdom involving more than 2000 patients, viral identi cation in the CSF was attempted by means of PCR, with positive results in only 7 percent, half of which were various enteroviruses (Jeffery et al) The other organisms commonly identi ed were HSV-1, followed by VZV, EBV, and other herpesviruses In patients with AIDS, however, the relative frequencies of the organisms that cause meningoencephalitis are quite different and include special clinical presentations; this applies particularly to CMV infection of the nervous system, as discussed further on, under Opportunistic Infections and Neoplasms of the CNS in AIDS (page 646) Our personal experience has been heavily biased toward HSV encephalitis, seasonal outbreaks of eastern equine encephalitis, and AIDS-related cases

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