16 year old male with fever and altered sensorium

A 16 year old boy from Tamil Nadu was admitted with fever, altered sensorium and generalised clonic tonic seizures since 3 days. On examination, the neck was stiff with a GCS score of 4. Both pupils were sluggishly reactive to light. On admission, he underwent endotracheal intubation and mechanical ventilation. Complete blood count, liver and renal function tests were within normal limits. Blood smears were negative for malarial parasites. An MRI of the brain showed severe cerebral edema, with basal ganglionic and thalamic hyperintensities but no evidence of tentorial or uncal herniation.

A deferred CSF analysis revealed a protein of 72 mg/dl, leukocyte count of 170 cells/μl with 95% neutrophils and glucose of 65 mg/dl. CSF HSV PCR was negative. An initial dengue serology was non-reactive. However D8 dengue serology was positive for IgG and IgM antibodies. The result of a CSF Japanese Encephalitis IgM assay was positive.

The patient recovered slowly over the hospital stay with severe residual neurologic sequelae. Hospital stay was complicated by hospital acquired pneumonia caused by ESBL producing E coli. The positive dengue serology in the blood was thought to represent an anamnestic response. Japanese encephalitis was diagnosed in view of consistent clinical and radiologic findings with a positive CSF IgM assay.

Japanese Encephalitis with severe neurologic sequelae