Atypical Association of Japanese Encephalitis with Sixth and Seventh Cranial Nerve Palsy during Outbreaks : Does it Require a Second Thought? A Case Report

Abstract

Last year in the month of August and September there had been an increased incidence of Japanese Encephalitis being reported all over West Bengal, India. Keeping this public and medical interest in the backdrop, the authors are reporting a 28 years old female patient admitted to the medical ward with acute onset flaccid paralysis of both lower limbs, diplopia, nasal intonation of voice, difficulty in swallowing and features suggesting facial nerve palsy. The intensivist was called for management of gradually worsening respiratory failure and the patient was put on mechanical ventilator after being shifted to Intensive Therapy Unit. On neurological examination, power of lower limb was diminished with sixth and seventh cranial nerve palsy. The patient was diagnosed to have Japanese Encephalitis infection by a four-fold rise in virus-specific antibody detected in paired acute and convalescent sera by enzyme-linked immunosorbent assay. In nerve conduction velocity test she had bilateral symmetrical demyelinating sensory>>motor polyradiculoneuropathy suggestive of Sural nerve sparing acute inflammatory demyelinating polyneuropathy. Cerebrospinal fluid study revealed albumino-cytological dissociation. She was off the ventilator after 3 days of full course of plasmapheresis and she gradually regained her motor power with physiotherapy and nursing care. Japanese Encephalitis patients are mainly admitted with feature of central nervous system insults and have poor prognosis. Syndromic association of Japanese Encephalitis with sixth/seventh cranial nerve palsy having Guillain-Barre Syndrome without any features of meningo-encephalitis is a rare phenomenon and there are very few case reports in literature regarding this topic. This case report highlights the successful management of such rare experience.