Approach

There is no specific antiviral treatment for tick-borne encephalitis (TBE).[6] For all patient groups, therapy consists of supportive care plus empirical intravenous aciclovir, and management of complications.[22]​[29]

TBE is a notifiable disease in some countries.[1]

Urgent hospital admission plus aciclovir

All suspected cases of viral encephalitis should be admitted to hospital and fully evaluated.

Some patients with milder symptoms and signs can be managed in a regular nursing unit, with access to an ICU bed if needed. All other patients, and in particular those with complications (e.g., significant electrolyte abnormalities, strokes, raised intracranial pressure [ICP], cerebral oedema, coma, seizures activity, or status epilepticus), should be managed in an ICU, preferably a neurointensive care unit.[30][31]

Empirical treatment with intravenous aciclovir should be started promptly.[29] Suspected TBE is treated like herpes simplex virus (HSV) encephalitis. In HSV patients, this recommendation is supported by randomised controlled trials of biospy-proven cases, showing reduced mortality with early administration of aciclovir.[27][32]

Supportive care

Supportive care is the cornerstone of treatment. This may include:

  • Endotracheal intubation and mechanical ventilation

  • Circulatory and electrolyte support

  • Prevention and management of secondary bacterial infections

  • DVT prophylaxis, and

  • Gastrointestinal (ulcer) prophylaxis.

Once herpes simplex virus/varicella zoster virus infection is ruled out, empirical aciclovir should be stopped.

In patients with elevated ICP, management with corticosteroids and/or mannitol may be considered.[33] Consensus guidelines do not recommend routine use of corticosteroids or hyperosmolar therapy for treatment of ICP in patients with TBE; however, this is based on poor quality evidence as data for TBE are lacking.[29] In practice, these agents are often used.

Initial measures are: elevation of the head of the bed to between 30° and 45°, avoiding compression of the jugular veins, and hyperventilation to a PaCO₂ of around 30. Subsequently, hyperosmolar therapy with mannitol boluses or hypertonic saline can be used to decrease ICP.

Shunting or surgical decompression (by craniectomy) is indicated in some cases where medical management has failed to control elevated ICP, and for impending uncal herniation.[24] This can be considered no matter the aetiology of encephalitis; however, most outcome data have been published for viral encephalitis.

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