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Certain points in the history and clinical findings in a patient with AES may narrow down the diagnostic possibilities. CSF analysis is a must in patient with AES unless there is severe thrombocytopenia or coagulopathy. MRI can suggest Japanese encephalitis, HSE, EBV encephalitis, tuberculous meningitis, neurocysticercosis and other additional complications developed due to CNS infection.
Fig 1 Cranial MRI in FLAIR sequence shows bilateral thalamic, globus pallidus and caudate involvement which are suggestive of Japanese encephalitis. Fig 2 Cranial MRI onT2 sequence of a patient with herpes simplex encephalitis shows bilateral medial temporal and basifrontal involvement. Ceftriaxone intravenously should be started pending the confirmatory results in any patients with AES; however once the specific diagnosis is made specific treatment should be started instead.

The patients with encephalitis manifest with acute onset of fever and altered sensorium with or without seizures, focal deficit  or signs of raised intracranial pressure.
Fluctuating sensorium, lack of focal sings, focal seizures and normal cranial imaging and CSF analysis are suggestive of metabolic encephalopathy and help to differentiate from infectious causes. In a patient with AES, routine blood counts including platelet, serum bilirubin, serum transaminase, serum creatinine and malarial parasitic should be done urgently. MRI (CT) before lumbar puncture is indicated in those patients with deep coma, papilloedema, raised intracranial pressure (hyperventilation, extensor posturing), focal seizure and focal neurological deficit.
This constellation of symptoms and signs is known as acute encephalitic syndrome (AES) which may be produced by  a number of infectious and noninfectious cases.
The salient differentiating features of encephalitis and encephalopathy are summarized in table 1.2.

The other febrile encephalopathy such as typhus is common in hilly areas of North and South India. The specific diagnostic tests may be ordered based on clinical and preliminary investigative findings.
Seasonal occurrence also suggests certain infections such as arbovirus (JE, Dengue) occurs during post monsoon period, mumps during spring and enterovirus infection in rainy season. Recent travel to an endemic area of arbovirus infection, malaria and typhus also can suggest the etiology of AES.

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