53
Table 7. Nervous System Toxicities
7.6 Encephalitis
Workup/Evaluation
• Neurologic consultation.
• MRI brain with/without contrast may reveal T2/FLAIR changes typical of what is
seen in autoimmune encephalopathies or limbic encephalitis or may be normal.
• Lumbar puncture with CSF analysis for opening pressure, cell count and differential,
cytolog y for malignant cells that could indicate leptomeningeal metastases, protein,
glucose, gram stain, viral/bacterial cultures, PCR for HSV and other viral PCRs
depending on suspicion, oligoclonal bands, autoimmune encephalopathy, and
paraneoplastic panels.
• May see elevated WBC with lymphocytic predominance and/or elevated protein.
• EEG to evaluate for subclinical seizures.
• Serum studies: Chem panel, CBC, ESR, CRP, ANCA (if suspect vasculitic process),
thyroid panel including thyroid peroxidase (TPO) and thyroglobulin, am cortisol
and ACTH, GQ1b antibodies (Bickerstaff encephalitis, rhomboencephalitis), celiac
antibody panel, paraneoplastic and autoimmune encephalitis panels.
• Rule out concurrent anemia/thrombocytopenia, which can present with severe
headaches and confusion.
Grading Management
G1: Mild: No interference with
function and symptoms not
concerning to patient.
Note: any cranial nerve problem
should be managed as moderate.
• Hold ICPi and discuss resumption with patient
only after taking into account the risks and
benefits.
• As above for aseptic meningitis suggest
concurrent IV acyclovir until PCR results
obtained and negative.
• Trial of methylprednisolone 1–2 mg/kg/day.
• Neurolog y consultation
• If severe or progressing symptoms or oligoclonal
bands present, consider pulse corticosteroids
(methylprednisolone 1 gram IV daily for 3–5
days) plus IVIG 2 g/kg over 5 days (0.4 g/kg/
day) or plasmapheresis.
• Taper steroids following acute management over
at least 4–6 weeks.
• If positive for autoimmune encephalopathy
or paraneoplastic antibody or limited or
no improvement, consider Rituximab in
consultation.
• Admit patient for G3–4
G2: Moderate: Some interference
with ADLs, symptoms
concerning to patient (i.e.,
pain but no weakness or gait
limitation).
G3–4: Severe: Limiting self-care
and aids warranted
(cont'd)
