l~idian J. l~ediat.
, 29 : 7, 1962,
ENTERIC ENCEPHALOPATHY*
SUCHIT PRASAD
Patna
Since the last decade, enteric ence-
phalopathy has come to stay as a distinct
and crippling complication of enteric
fever. While BREXOXNEAIY described the
intestinal lesions in 1820, it is not known
when this malady was reported first in
the literature. This complication is not
infrequently found among neglected cases
of enteric fever. In accorda~ace with its
frequency of occurrence, it comes after
haemorrhage and perforation as the third
most frequent complication. With the
9 advent of better drugs and surgical care,
the incidence of perforation has markedly
decreased (luring recent years. Due to
prolonged neglect and inadequate care,
quite a number of such cases develop
hypertoxaemia leading to meningism and
other nervous complications. Sometimes
encephalopathic symptoms develop from
the very first week of the illness and
other features of marked toxaemia m a y
appear. Thus it would not be correct to
say that encephalopathy in enteric fever
develops only due to a prolonged period
of neglect in treating the case. It is
difficult to understand why certain cases
develop encephalopathy regardless of
whether they are in the first week of
illness or in the stage following a prolonged
period of neglect.
The case reported below illustrates the
latter type, i.e., encephalopathy following
prolonged and continuous high fever.
R e p o r t of a case
Surcsh, an 8-year old ] t i a d u male child
was admitted to the I{ospitat for Children,
P a t n a MedicaI ColIege I-Iospital on J u n e 18, 1958,
with the following complaints : l l i g h a n d
-"From the H o s p i t a l for Children, P a t n a 5Iedical
Col!ege, P a t n a .
7
c o n t i n u o u s fever a n d w~miting for 16 days,
f r e q u e n t hcadache, 16 days, occasional restless-
ness, a n d semi-consciousness for 4 days.
The child h a d been quite well u p to 16 d a y s
before admission w h e n he h a d an a t t a c k of fever.
The t e m p e r a t u r e w a s high and w a s occasionally
a c c o m p a n i e d b y vomiting. S o m e t i m e later, he
complained of headache. T h e t e m p e r a t u r e con-
t i n u e d and r a n g e d b e t w e e n 102 ~ to 103'~1"
(axillary). l i e w a s treated locally. T h e n a t u r e
el t h e t r e a t m e n t w a s n o t k n o w n . The t e m p e r a -
ture subsided a little b u t again increased to
102~ and persisted since then. One week p r i o r
to admission he developed restlessness. H e
b e c a m e semi-conscious four to five d a y s before
hospitalization and did n o t speak or eat his food.
~Ie was a d m i t t e d to the hospital in this state.
D u r i n g p r e v i o u s years, hc had occasional a t t a c k s
of c o u g h and cold.
On e x a m i n a t i o n the child was semi-coltscious
and d e h y d r a t i o n was m a r k e d . There w a s neck
rigidity, a toxic appearance, a dry and coated
t o n g u e with depressed eyes, d r y a n d inelastic
and lustreless skin. The pulse was 100;'minute,
regular, and less full in v o l u m e ; the t e m p e r a t u r e
was 103~F (axitlary) ; K e r n i g ' s sign was positive ;
b o t h lungs were clear clinically; h e a r t s o u n d s
were w e a k ; the u r i n a r y bladder w a s distended ;
the bowels were c o n s t i p a t e d for a long time ;
respiration was quiet b u t shallow and faecal
m a s s e s were palpable per a b d o m e n as h a r d
lmdules.
Investigatio~zs. Blood : Total "~V.13.C.
count w a . ~ 8,800,,"cmm., polymorphs 42%,
l y m p h o c y t c s 48 o/. eosinophils 6 %, m e n ocytes 4 o,;~
and basophils nil. I ' r i n e e x a m i n a t i o n revealed
n o t h i n g a b n o r m a l . Urine culture showed no
g r o w t h of an), pathogenic bacteria. \Vidal
reaction of the biood in the third week showed
B. t),phosus " H ", positive up to 1/250 dilution.
B. lyphosus " 0 ", positive up to 1/83 dilution
and B. paratyphosus " AI-[ " and " B t I ",
negative in all dilutions. A l u m b a r p u n c t u r e
revealed fluid u n d e r tension b u t no t u r b i d i t y .
E x a m i n a t i o n of the C. S. F. showed no change in
the protein, s u g a r and chloride c o n t e n t o1 the
tluid. \ V a s s e r m a n n reaction of the blood was-
negative, t31oud eulturc for /~'. typhc, sus was
n o t sent (as it w a s the third week of the illness).
Treatment given after hospitalization. The
bladder was catheterized a n d urine evacuated.
A w a r m water e n e m a was given and h a r d blackish
bits of stool were passed. ChloramphenicoI was
a d m i n i s t e r e d t h r o u g h the i n t r a m u s c u l a r r o u t e
in t h e doses of 250 rag. every six hotlrs for t h e
 8 INDIAN JOURNAL OF PEDIATRICS
firs~ 72 Ixours, 200 .rag. e v e r y six hour,~ for
a n o t h e r 72 h o u r s , t h e n 250 rag. e v e r y e i g h t h o u r s
for 72 hours, a n d finally 250 rag. e v e r y 12 h o u r s
for 48 h o u r s . V i t a m k n B - c o m p l e x (1 c.c.) d a i l y
was administered intramuscularly.
t h e s e 250 c.c. of S p e r c e n t glucose solution m i x e d
w i t h 500 rag. of v i t a m i n C were a d m i n i s t e r e d
b y i n t r a v e n o u s drip. S o m e t i m e s 5 per c e n t
glucose s o l u t i o n w a s m i x e d with 100 c.c. of
P.V.P. (polyvin y l p y r r o l i d o n e - - M e r i s t o n - - N ) ,
1,000 rag. of v i t a a m n C, v i t a m i n B - c o m p l e x
(Bejectal-plMn, A b b o t t ) a n d n i k e t h a m k l e a d -
m i n i s t e r e d b y i n t r a v e n o u s drip. A Liquid pre-
p a r a t i o n of n i k e t h a m i d e w a s also given orally
m i x e d w i t h a little w a t e r in t h e dosage of 8 d r o p s
every 6 hours.
Follow up history. On t h e n m r n i n g of t h e
fifth d a y of h o s p i t a l i z a t i o n t h e t e m p e r a t u r e fell
g r a d u a l l y to 99010. a n d b e c a m e n o r m a l on t h e
s i x t h day, T h e r e a f t e r t h e t e m p e r a t u r e r e m a i n e d
normal.
T h e blood for ~,Vidal r e a c t i o n w a s s e n t in
t h e t h i r d week (on t h e 18th day) of t h e illness
a n d s h o w e d positive r e s u l t s for b o t h " }I " a n d
" 0 " agglutinins.
T h e child g r a d u a l l y b e c a m e c o n s c i o u s a n d
g a i n e d weight. H e s t a r t e d t a k i n g food a n d
medicitles b y m o u t h . T h e bowels b e c a m e
regular and urine was passed normally. ]'here
w a s m a r k e d i m p r o v e m e n t in t h e d e h y d r a t i o n .
I r o n a n d v i t a m i n s wcre g i v e n b y m o n t h . T h e
a d m i n i s t r a t i o n of chloram.phenicol w a s g r a d u a l l y
t a p e r e d to a v o i d relapse. T h e n e c k b e c a m e
soft a n d t h e h e a d a c h e a n d r e s t l e s s n e s s dis-
a p p e a r e d . T h e diet ~-as g r a d u a l l y c h a n g e d
f r o m a liquid to a semi-solid one a n d was g r a d u a l l y
i n c r e a s e d irt q u a n t i t y . T h e child i m p r o v e d
s t e a d i l y a n d t h e r e w a s a g r a d u a l increase in
weight. T h e child was d i s c h a r g e d after t h r e e
w e e k ' s s t a y in hospital.
Discussion
Enteric encephalopathy, as the term
suggests, is a type of symptom-complex
showing encephalopathic s y m p t o m s during
the period of an attack of enteric fever
or after the disease. Encephalopathic
signs in this case developed due to a
prolonged period of ' e n t e r i c toxaemia '.
The child was already having high and
continuous fever ranging between 102~
"and 103~ for two weeks prior to his
hospitalization. In certain cases, ence-
phalopathic signs develop during the early
periods of the illness. These s y m p t o m s
9 often simulate the features of meningitis
or encephalitis due to other causes. The
term encephalopathy is used because there
is a complete absence of any inflammatory
VOL. ~9 NO, 1 6 3
changes in the brain or its meninges,
although there are indications of some
pathology in the nervous system, e.g..
Besides increased C.S.F. pressure, etc. The
clinical manifestations, i.e., headache,
vomiting, rigidity of the neck, positive
Kernig's sign, mental depression, restless-
ness, etc. are more or less similar to
meningitis or encephalitis. The whole
picture of this pseudo-encephalitis is due
to hypertoxaemia. Besides, it has been
observed that enteric encephalopathy
seldom occurs in grown-up persons and is
more common in the younger age groups,
especially between 6 and 14 years.
PRASAD4 has also reported that it is quite
common in the younger age group.
PRABHUa analysed 73 cases of enteric
fever and found that 16 belonged to t h e
hypcrtoxic type and had a stormy course.
THANAWALA 7 observed 2,056 cases of
enteric fever admitted to the City Fever
Hospita/, Bombay, during the year 1953
and found t h a t 70 cases had meningism
and other encephalopathic signs. KAMA'r
and DAMANY analysed a series of 83 cases
and found that two cases had meningeal
signs, such as restlessness, neck rigidity,
blurred vision, etc. NAH,XTA~ reported
a case of opthalmopiegia following enteric
fever.
In such cases, constipation is usually
marked 3, retention of the urine is also
present 7, and nausea and vomiting are
commonL The dehydration is usually
extreme due to little or no intake of
fluids. This was present in the case
reported here. THANAWALA7 found t h a t
356 cases out of 2,056 cases had m a r k e d
dehydration and 20.2 per cent. of these
cases with dehydration later died. Not
only that, a case was reported to h a v e
been mistaken for m u m p s encephalitis b u t
blood culture was positive for S. typhasus s.
The t r e a t m e n t of such cases consist of
the administration of chloramphenicol
through the intramuscu/ar route, cor-
rection of the dehydration, and other
s y m p t o m a t i c measures. Constipation has
to be relieved b y a mild enema, e.g., w a r m
water enema or glycerine-olive oil enema.
Certain cases having peripheral circtdatory
failure have to be carefully treated and
kept under constant watch. Dehydration
ENTERIC EN CEPHALOPATHY--PRASAD
in such cases is usually marked. All
efforts are directed towards its correction
and plenty of fluids has to be administered.
Glucose solution (5 per cent.) with nike-
thamide, massive doses of vitamin C and
intravenous v i t a m i n B-complex are
administered through the continuous intra-
venous drip. Vitamin C and B-complex
both are to be administered in adequate
amounts to prevent any chance of bleeding
and other vitamin deficiencies. In all
these cases having signs of increased
intracranial pressure this is to be relieved
by therapeutic lumbar puncture provided
there are no contraindications. Otherwise,
it may be deferred to a later date. In the
case reported here, the C. S. F. was under
tension although there was no change in
the chemistry of the fluid. There is no
definite explanation for this. But it is
true that the initial toxaemia might be
responsible for it. While chorea, hemi-
plegia, optic neuritis and peripheral
neuritis have been reported, no such
complication was present here.
Regarding the administration of
chloramphenicol, there is no conformity
of opinion. The intramuscular route is
decidedly the best as the certainty of
administ~ration of the drug is there and
the effects are ensured. It avoids the oral
route, which is not effective since almost
all the cases have either diarrhoea or
constipation. The absorption of the drug
is inadequate and erratic. Besides, a
majority of the hypertoxic cases do have
ulceration and bleeding of lips and gums,
which are great handicaps to oral
administration. The blood concentration
level of the drug is also sufficiently and
adequately maintained b y the parenteral
method. In the case reported here, the
child was put on massive intramuscular
chloramphenicol therapy. The obser-
vations of other workers are similar.
SMADEL0 advocated a 12-hourly schedule
of drug therapy. In this case, a 9~50 mg.
dose every 6-hours in the intit]al stage was
found to be more effective, which was
tapered off gradually. PRASAD5 has also
obtained similar results.
In the case under report, the m a r k e d
toxaemia was treated with plasma-
substitute P.V.P. (Periston-N Bayer)
mixed with glucose solution, v i t a m i n s B and
C and administered intravenously. T h e
result was dramatic and the toxaemia dis-
appeared in a short period. THANAWALA7
treated 289 cases out of 2,056 cases with
P.V.P. and the results were very good.
I t is felt that if chloramphenicol is
administered in massive doses parenterally
with vitamin C and B-complex and ,Mth
P.V.P. in cases of extreme toxaemia,
better results could be obtained.
Summary
A case of enteric fever with encephalo-
p a t h y has been reported.
The child was extremely toxic an
semiconscious with signs of increased
intracranial pressure.
The child was treated with chloram-
phenicol, vitamin C, B-complex, and
P.V.P.
He was cured and discharged a f t e r
nearly three weeks' stay in the hospital.
The case has been briefly discussed.
I express my thanks to Dr. L. S. N. P~.~SAD,
Physician-in-charge, Hospital for Childrcn,
Patna, for his encouragement, while I was
attached to the Hospital ; and to the Superin-
tendent, P a t n a Medical College Hospital, P a t n a ,
for permission to report the case.
References
1. KAMAT, G. ]{. and DAHANY. S. J.--J. Indian
Med. Ass., 3 0 : 145, 1958.
2. N ~ A r A , M. C.--Ibid., 3 7 : 134, 1961.
3. PRABHU, M. G.--Ibid., 25 : 122, 1955.
4. PRASM), L. S. N . - - P e ~ o n a l communicatior~
(1958).
5. Idem.--Pa~na J. Med., 29 : 431, 1955.
6. SMAI)EL, J. E . - - J . A . M . A . , 142 : 315, 1950.
7. THANAWALA, J. K . - - J . I ~ { a ~ Mcd..4.v$.,
2 5 : 125, 1955.