Approach

The mainstay of treatment is supportive care, with particular attention to the management of neurological signs and symptoms. Infection control measures should be implemented as soon as a case is suspected.

Isolation and infection control precautions

Henipaviruses are biosafety level 4 pathogens and appropriate infection control procedures need to be initiated as soon as a case is suspected.

Isolation and infection control precautions are the same as for other level 4 pathogens, such as viral haemorrhagic fevers. Patients who are identified as being at risk of infection should immediately be isolated in a room with private bathroom facilities.

All healthcare personnel attending to the patient must wear appropriate personal protective equipment (PPE) that conforms to published protocols. All contaminated materials (e.g., clothes, bed linens) should be treated as potentially infectious. The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC), as well as national bodies (e.g., UK Department of Health), produce detailed guidance on PPE for Ebola virus, which may be helpful to use in managing suspected cases of henipavirus infection:

Specimens for laboratory investigations (e.g., blood, cerebrospinal fluid, urine) should be collected and sent off according to local, national, and international protocols. Judicious selection of investigations is important in order to reduce risk of transmission to laboratory workers and other healthcare personnel. Careful and clear communication with laboratory staff is required in order to highlight the possibility of Nipah virus (NiV) or Hendra virus (HeV) prior to transport of samples to ensure that appropriate safety precautions are carried out. The WHO produces detailed guidance on specimen collection and transport:

Supportive care

The mainstay of treatment in all symptomatic patients is supportive care with special attention to airway support for those patients with decreased level of consciousness, and respiratory support (non-invasive ventilation and/or intubation and mechanical ventilation) for those patients with acute respiratory distress or failure. Many patients require intensive monitoring in a critical care environment.[22]

Additional considerations include prophylaxis for venous thromboembolism and prevention/treatment of nosocomial infection according to local protocols.

Management of neurological symptoms

Patients exhibiting neurological symptoms (e.g., altered mental status, focal neurological signs) should be evaluated for potential seizures, cerebral oedema, and intracranial hypertension.

If there is seizure activity, anticonvulsants should be administered in accordance with local protocols. In general, benzodiazepines are preferred for the initial management of seizures, with lorazepam being most effective due to its long half-life. Phenytoin is recommended if a second drug is needed to terminate seizures. Certain anticonvulsants may need monitoring of serum drug levels to ensure that therapeutic levels are achieved.

Cranial nerve examination, fundoscopy, and brain imaging (CT or MRI) should be performed to evaluate for cerebral oedema and elevated intracranial pressure. If intracranial pressure is elevated, conservative and/or surgical measures may be required to reduce the pressure. In such instances, the placement of an external ventricular device should be considered. The efficacy of mannitol has not been evaluated in the context of HeV or NiV, and therefore it is not recommended.

Treatment with aciclovir is recommended until herpes simplex virus/varicella zoster virus encephalitis has been ruled out.[49]

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