Sir,
A previously healthy, 22-year-old woman presented with fever for 3 days, altered sensorium, and diarrhea for 1 day. There were no skin rashes, joint pains, bleeding from any site, blackish discoloration of stool, sore throat, yellowish discoloration of any part of body, abnormal body movement, discharge from ear, or drug intake. Past medical history and family history were not significant. On examination, she was febrile and unconscious (Glasgow coma score E1V1M4). Central nervous system examination revealed neck rigidity and positive Kernig’s and Brudzinski’s sign. Respiratory system examination revealed bilateral fine basal crepitations and conducted sounds. Examination of the cardiovascular and gastrointestinal system was normal.
A provisional diagnosis of acute febrile illness with delirium and acute gastroenteritis (?viral ?cerebral malaria ?acute bacterial meningitis/viral meningitis) with aspiration was made. She was managed empirically with intravenous antipyretics, antibiotics, antivirals, and other supportive management. Baseline investigations revealed thrombocytopenia (platelets 33,000/mm3 and serum aspartate aminotransferase/alanine transaminase 3108/7648 U/L). Kidney function test and serum electrolytes were normal. Nonconstrast computed tomography of the head showed bithalamic and pontine hypodensity. Procalcitonin, typhidot, widal titers, malaria card test, malaria serology, leptospira, scrub typhus, and chikungunya serology were all negative. Cerebrospinal fluid (CSF) analyses including CSF adenosine deaminase, CSF culture, Gram stain and CSF Indian ink were negative/sterile. Dengue NS1 was however positive in the CSF. Contrast-enhanced magnetic resonance imaging brain revealed hemorrhagic encephalitis [Figure 1 ]. Japanese encephalitis IgM in CSF, herpes simplex virus, Zika virus, and Cytomegalovirus serology were reported as negative. However, surprisingly, CSF dengue IgM was positive.
Figure 1: Contrast-enhanced magnetic resonance imaging brain showing hemorrhages associated with edema predominantly involving bilateral thalami and pons, suggestive of hemorrhagic encephalitis
In view of dengue hemorrhagic encephalitis, intravenous methylprednisolone pulse was given. The patient showed clinical improvement with treatment and became conscious, oriented, and afebrile after 3 days. The patient was discharged in stable condition.
Dengue encephalopathy is an immune-mediated inflammatory response, whereas encephalitis occurs due to direct invasion of the virus.[ 1 ] The neurological manifestations mainly due to DENV-2 and DENV-3 can be attributed to the neurotropic nature of the virus, leading to encephalitis, meningitis, or myelitis.[ 1 ] In cases of encephalitis/encephalopathy/adrenal crisis, the use of high-dose steroids has been advocated since the underlying mechanism is primarily immune mediated.[ 2 ]
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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network guidelines, notably the CARE guideline, during the conduct of this report.
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Conflicts of interest
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REFERENCES
1. Varatharaj A. Encephalitis in the clinical spectrum of dengue infection. Neurol India 2010;58:585–91.
2. Available from:
https://doi.org/10.1016/j.ijid.2014.03.1087 . Last accessed on 2022 Mar 23.
