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22 year old male was referred  with fever and   altered sensorium and seizures with suspicion of brain stem encephalitis. MRI shows enlarged  pons with cytotoxic oedema (with reduced ADC values ) and vasogenic oedema with unremarkable vertebra basilar flow voids  or bleed  or significant 4th ventricle compression, consistent with Rhombencephalitis. 

Teaching points by Dr MGK Murthy, Dr GA Prasad & Mr Mahesh

Also referred as Brainstem encephalitis. Infectious, Autoimmune and Paraneopalstic aetiologies are possible 
  • Infectious causes (100% Abnormal MRI)   Listeria (commonest, healthy young adults , biphasic time course with Flu like symptoms, CSF pleocytosis, positive CSF and blood cultures  , best treated with Ampicillin),  Enterovirus1 (second commonest in Asia-pacific preponderance with no specific treatment available), Herpes Simplex (HSV1 (80%) , HSV2 with 50% showing supratentorial involvement as well  , respond well with acycolovir), Epstein Barr virus and Human Herpes virus etc
  • Autoimmune (90% abnormal MRI) usually is Behcets disease (CSF pleocytosis)  (25% recover with steroids  and immune suppression) 
  • Paraneoplastic varieties (MRI usually normal) (CSF pleocytosis with protein normal) (anti neuronal antibodies positive) (prognosis poor) 

Rhombencephalitis-MRI Reviewed by Sumer Sethi on Wednesday, March 18, 2015 Rating: 5

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