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The common arthropod-borne viruses (arboviruses) that cause encephalitis in the United States and their geographic range have been listed earlier There are alternating cycles of viral infection in mosquitoes and vertebrate hosts; the mosquito becomes infected by taking a blood meal from a viremic host (horse or bird) and injects virus into the host, including humans The seasonal incidence of these infections is practically limited to the summer and early fall, when mosquitoes are biting In the equine encephalitides, regional deaths in horses usually precede human epidemics In St Louis encephalitis, the urban bird or animal or possibly the human becomes the intermediate host West Nile outbreaks are preceded by illness in common birds such as crows and jays St Louis, California and La Crosse agents are endemic in the United States because of the cycle of infection in small rodents The clinical manifestations of the various arbovirus infections are almost indistinguishable from one another, although they do vary with the age of the patient The incubation period after mosquito bite transmission is 5 to 15 days There may be a brief prodromal fever with arthralgias or rash (eg, West Nile fever) In infants, there may be only an abrupt onset of fever and convulsions In older children, the onset is usually less abrupt, with complaints of headache, listlessness, nausea or vomiting, drowsiness, and fever for several days before medical attention is sought; convulsions, confusion, stupor, and stiff neck then become prominent Photophobia, diffuse myalgia, and tremor (of either action or intention type) may be observed in this age group and in adults Asymmetry of tendon re exes, hemiparesis, extensor plantar signs, myoclonus, chorea, and sucking and grasping re exes may also occur McJunkin and colleagues have described the clinical features of 127 patients with La Crosse infection seen at their medical center over a decade, and their data are representative of other arboviral infections In addition to the typical features of viral encephalitis, they emphasize, in a proportion of patients, hyponatremia, raised intracranial pressure with cerebral swelling, and, most notable to us, signal changes in the MRI that simulate herpes encephalitis It affects children mainly, causing fever, seizures, and focal neurologic signs, but is otherwise benign in most instances, with full recovery A special syndrome of febrile, accid, paralytic poliomyelitis resulting from West Nile virus infection has also been described It evolves over several days and in a few cases is accompanied by facial paralysis (see Jeha et al) A few cases have begun with an extrapyramidal syndrome; these syndromes occur also with the other aviviruses (Japanese encephalitis, Murray valley, St Louis).

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The CSF ndings are much the same as in aseptic meningitis (lymphocytic pleocytosis, mild protein elevation, normal glucose values) Recovery of virus from blood or CSF is usually not possible and PCR testing has not been routinely applied However, antiviral IgM is present within the rst days of symptomatic disease and can be detected and quanti ed by means of ELISA Some patients have not developed antibodies by the time of admission to the hospital and the test may have to be repeated The MRI may be normal or show signal changes and edema in the cortex, basal ganglia, or thalamus (the latter is described in the Japanese virus group) The fever and neurologic signs subside after 4 to 14 days unless death supervenes or destructive CNS changes have occurred No antiviral agents are known to be effective in the treatment of arboviral encephalitis; one must rely entirely on supportive measures; on occasion, brain swelling reaches a degree that requires speci c therapy, as outlined on pages 317 and 766 The pathologic changes consist of widespread degeneration of single nerve cells, with neuronophagia as well as scattered foci of in ammatory necrosis involving both the gray and white matter The brainstem is relatively spared In some cases of eastern equine encephalitis, the destructive lesions may be massive, involving the major part of a lobe or hemisphere and are readily displayed by MRI, but in the other arbovirus infections the foci are microscopic in size (see Deresiewicz et al) West Nile virus may also produce a regional pattern of neuronal damage that affects the anterior horn cells of the spinal cord, as mentioned above A pathologic description of this process has been provided by our colleagues and by others (see Asnis et al) Perivascular cuf ng by lymphocytes and other mononuclear leukocytes and plasma cells as well as a patchy in ltration of the meninges with similar cells are the usual histopathologic hallmarks of viral encephalitis Of the arbovirus infections in the United States, eastern equine encephalitis is among the most serious, since a large proportion of those infected develop encephalitis; about one-third die and a similar number, more often children, are left with disabling abnormalities mental retardation, emotional disorders, recurrent seizures, blindness, deafness, hemiplegia, extrapyramidal motor abnormalities, and speech disorders While only a small proportion of those exposed become infected, the poliomyelitis and parkinsonian syndromes of the aviviruses may be permanent residua as mentioned earlier (see Solomon) The mortality rate in other arbovirus infections varies from 2 to 12 percent in different outbreaks, and the incidence of serious sequelae is about the same.

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