retrospective diagnosis of encephalitis

[Sandra-Tyner-MD]

  I have a very serious forensic problem that demands that I make a retrospective diagnosis of what I am convinced was an episode of viral encepahlitis.  I did not have an LP and I did not realize that I would need definitive documentation of the illness until some eight weeks after virtually complete recovery.
  At three months post recovery I saw a neurovirologist and had routine serologies, oligoclonal bands, and an MRI.  All of the studies were negative except a 1:640 EBV and the MRI.
  The MRI showed some hyperintensity of the periventircular white matter and there is some question as to whether there are some ischemic small vessel changes in the subcortical white matter of the parietal and frontal lobes.  There is a question of one lacunae.  
  It so happens that I also have idiopathic CNS hypersomnia (primary disorder of vigilance) and take high doses of Mg. pemoline.  The neurovirologist I consulted feels that the pemoline's dopaminergic properties induced a vasculitis.  He proposes that I have studies of the large vessels and an angiogram. Another neuroradiologist is relatively unconcerned.
  The pemoline theory is not only devastating to my forensic case, it is also devastating to me personally because it is far more effective than other stimulants taken in similar doses.  Pemoline has never been reported to cause a vasculitis (but reports are on acute overdoses) and there was a paper published in the Eur J of Pharm 1986 Jun 24;125(3):437-447 enititled Effects of the indirect dopamiminomimetic diethylpemoline on local cerebral glucose utilization and local cerebral blood flow in the conscious rat in which the authors conclude that it is mainly the altered neuronal activity and metabolic demand after dopaminergic stimulation that effect changes in blood flow rather than a direct dopaminergic effect upon brain vasculature.
  I therefore believe that my consultant's opinion is not only speculative but that he is wrong.  
  I would like to know whether I can make a case for the MRI as the retrospective evidence of viral encepahlitis that I am looking for.  
  I would be willing to send the MRI to you or Dr. Calabresi to review since there is some disagreement about the reading.
  I would also be willing to see a neurovirologist who could assist me in this case.  It is very important.
  I would appreciate your help very much.
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The definitive retrosective diagnosis of encephalitis is probably not
possible in your case, You do not mention the symptoms at the time of your
illness which are probably the most significant pieces of evidence in
establishing your diagnosis.
The symptoms and signs in encephalitis are not subtle, involving confusion,
altered conciousness, fevers, focal neurological dysfunction and possibly seizures.
The MRI findings you mention are highly non-specific and could be seen in
practically anyone over the age of 50 or someone who is hypertensive.
If you had encephalitis there should be focal hyperintenstiy of the lobes
involved, usually the temporal lobes.
The EBV titer suggests infection at some time in the past but is not
specific for the site of infection.
I would agree that the pemoline theory sounds unlikely, CNS vasculitis
like encephalitis is associated with more specific clinical findings and
one would not have to reach for such an unusual cause to explain the relatively
non-specific and commonly seen changes you describe on your MRI.






























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