St. Louis Encephalitis

St. Louis Encephalitis

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St. Louis encephalitis virus (SLEV) belongs to the family Flaviviridae (group B arborviruses). The principal reservoirs of SLEV include wild birds and domestic fowl, and the virus is transmitted to humans by mosquitoes (Culex tarsalis, C quinquefasciatus, C pipiens). The clinical manifestations of SLEV infection range from mild flulike syndromes to fatal encephalitis. [1] (See Etiology and Pathophysiology.)

Increase public health awareness in endemic areas. Educate patients to avoid outdoor exposure, to wear long sleeves outdoors, and to apply mosquito repellent.

For patient education information, see the Brain and Nervous System Center, as well as Encephalitis.

St. Louis encephalitis is caused by an enveloped, single-stranded, positive-sense ribonucleic acid (RNA) virus of the Flaviviridae subgroup. St. Louis encephalitis virus (SLEV) has a relatively conserved nucleotide sequence.

SLEV is an arbovirus transmitted via a mosquito vector from wild birds to humans. Birds, primarily passerine birds such as finches and sparrows, are the principal hosts of the virus. Vectors include the mosquitoes C pipiens, C tarsalis, and C quinquefasciatus.

Risks factors for clinical SLEV infection include the following:

Individuals older than 70 years have a 10-fold increased risk of clinical illness

Exposure to endemic areas or outdoor activities increases risk

Male sex is a risk factor

Most SLEV infection outbreaks occur in people of low socioeconomic status, which is probably due to less access to heath care and poor environmental control of mosquitoes

Comorbidity with atherosclerosis, heart disease, and hypertension is associated with an increased mortality rate of St. Louis encephalitis

A primary viremia follows reproduction of the SLEV at the site of inoculation. In cases of subclinical SLEV infection, the pathogen is cleared by the reticuloendothelial system (the liver, spleen, and lymph nodes) before invasion of the central nervous system (CNS) can occur.

Continued viral replication gives rise to a secondary viremia. Saturation of the filtering capacity of the reticuloendothelial system enables invasion of the CNS. The probability of CNS infection depends on the efficiency of viral replication at the extraneural sites and the degree of viremia. The virus enters the CNS either through the cerebral capillary endothelial cell/astrocyte complex (the blood-brain barrier) or across fenestrated endothelium in areas of the CNS that do not have the usual blood-brain barrier capacity (ie, choroid plexus). Rarely, SLEV tracts retrograde from a peripheral site (the olfactory nerve) that was infected during the viremia.

Many of the flaviviruses exhibit various types of neurotropism. The specific neurotropic mechanisms in SLEV have not been established.

Focal neuronal degeneration with necrosis occurs, leading to the development of glial nodules. Upon healing, spongiform changes occur. The perivascular inflammatory infiltrates are made up of activated T cells and macrophages.

St. Louis encephalitis virus (SLEV) is widely distributed from Canada to Argentina. However, human cases have almost exclusively occurred in the United States, especially in eastern and central states. The infections occur as periodic focal outbreaks of encephalitis in the midwestern, western, and southwestern United States, followed by years of sporadic cases. The annual incidence of 0.003-0.752 cases per 100,000 population. SLEV infections have caused large urban epidemics of encephalitis. Outbreaks occur from August through October; however, where the climate is milder, cases can occur year round. The annual reported SLEV neuroinvasive disease cases fluctuate with periodic epidemics. During the last 5 decades, 10,000 cases were reported, with an average of 102 cases reported annually (range 2-1,967). [2, 3, 4, 5, 6]

Outbreaks of SLEV infection have occurred in Canada and Mexico. Sporadic cases have occurred in South America and the Caribbean.

SLEV infection is reported more often in males than in females, probably due to more outdoor exposure.

The severity of symptoms of SLEV infection increases with age. Older patients are at greater risk of developing clinical illness (especially those >60 y). The literature has reported that up to 90% of elderly individuals who are infected with SLEV develop clinical illness.

The mortality rate of St. Louis encephalitis is 2-30%. This figure is higher in older patients. [7]

Of persons who survive St. Louis encephalitis, 20% develop sequelae, including irritability, memory loss, various types of movement disorders, or motor deficits. The medical literature also contains reports of syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia in patients with St. Louis encephalitis. [8]

Halperin JJ. Encephalitis: Diagnosis and Treatment. New York, NY: Informa Healthcare; 2008.

Day JF. Predicting St. Louis encephalitis virus epidemics: lessons from recent, and not so recent, outbreaks. Annu Rev Entomol. 2001. 46:111-38. [Medline].

Day JF, Stark LM. Avian serology in a St. Louis encephalitis epicenter before, during, and after a widespread epidemic in south Florida, USA. J Med Entomol. 1999 Sep. 36(5):614-24. [Medline].

Day JF, Stark LM. Frequency of Saint Louis encephalitis virus in humans from Florida, USA: 1990-1999. J Med Entomol. 2000 Jul. 37(4):626-33. [Medline].

Day JF, Stark LM. Transmission patterns of St. Louis encephalitis and eastern equine encephalitis viruses in Florida: 1978-1993. J Med Entomol. 1996 Jan. 33(1):132-9. [Medline].

Reimann CA, Hayes EB, DiGuiseppi C, et al. Epidemiology of neuroinvasive arboviral disease in the United States, 1999-2007. Am J Trop Med Hyg. 2008 Dec. 79(6):974-9. [Medline].

Day JF. Predicting St. Louis encephalitis virus epidemics: lessons from recent, and not so recent, outbreaks. Annu Rev Entomol. 2001. 46:111-38. [Medline].

White MG, Carter NW, Rector FC, et al. Pathophysiology of epidemic St. Louis encephalitis. I. Inappropriate secretion of antidiuretic hormone. II. Pituitary-adrenal function. 3. Cerebral blood flow and metabolism. Ann Intern Med. 1969 Oct. 71(4):691-702. [Medline].

Sejvar JJ, Bode AV, Curiel M, Marfin AA. Post-infectious encephalomyelitis associated with St. Louis encephalitis virus infection. Neurology. 2004 Nov 9. 63(9):1719-21. [Medline].

Rahal JJ, Anderson J, Rosenberg C, Reagan T, Thompson LL. Effect of interferon-alpha2b therapy on St. Louis viral meningoencephalitis: clinical and laboratory results of a pilot study. J Infect Dis. 2004 Sep 15. 190(6):1084-7. [Medline].

Charurut Somboonwit, MD, FACP Associate Professor of Internal Medicine, Division of Infectious Disease and International Medicine, University of South Florida College of Medicine; Clinical Research and Communicable Diseases Director, USF Health and Hillsborough Health Department

Charurut Somboonwit, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Fariba M Donovan, MD, PhD Intercoastal Medical Group

Fariba M Donovan, MD, PhD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Joseph T Katta, DO Fellow in Infectious Disease and International Medicine, University of South Florida College of Medicine

Joseph T Katta, DO is a member of the following medical societies: American College of Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Eduardo Gotuzzo, MD Adjunct Professor, Department of Medicine, University of Alabama School of Medicine

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary D Nettleman, MD, MS, MACP Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine

Mary D Nettleman, MD, MS, MACP is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical Research, Infectious Diseases Society of America, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Norvin Perez, MD Medical Director, Juneau Urgent and Family Care

Norvin Perez, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Emad Soliman, MD, MSc Consulting Staff, Department of Neurology, St John’s Riverside Hospital

Emad Soliman, MD, MSc is a member of the following medical societies: American Academy of Neurology and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

St. Louis Encephalitis

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