Acute Onset Of Fever Research Articles

A-282 Purpura fulminans caused by Haemophilus influenzae: case report of unusual etiology

Abstract Background Fulminant purpura is a clinical syndrome characterized by a purplish, ischemic-looking skin rash, commonly accompanied by systemic symptoms ranging from acute febrile syndrome to septic shock. Due to high lethality of possible infectious etiologies, immediate recognition and early initiation of empirical antimicrobial therapy are crucial to ensure better outcomes. Interdisciplinary collaboration among healthcare teams, infectious disease specialists and microbiologists is essential to ensure accurate and early microbiological diagnosis. Methods This work aims to report a case of Haemophilus influenzae-induced purpura fulminans that occurred in Fortaleza-CE, a coastal city in northeastern Brazil, highlighting clinical recognition and microbiological identification, based on review of medical records. Results Case report A 59-year-old man, originally from Germany, was on vacation in Brazil. He presented to emergency medical service with an acute onset of fever, abdominal pain and diarrhea, progressing to decreased level of consciousness and purplish ischemic skin lesions with hemorrhagic bullae on trunk and extremities (Figure 1), with no history of trauma. Upon admission, the blood exams showed bicytopenia - 1900 leukocytes/µL (86% segmented) and 51,000 platelets/µL - and very high C-reactive protein (41.58 mg/dL). Although empirical antimicrobial therapy with vancomycin and piperacillin-tazobactam was initiated, patient progressed to septic shock, hepatic dysfunction, requiring mechanical ventilation, vasopressor support, and renal replacement therapy. Blood cultures from hospital admission were positive after about 14 hours and allowed isolation of small and translucent colonies in Chocolate PVX plate Agar (BioMerieux™). Maldi tof analysis by Vitek MS identified H. influenzae (99.9 % accuracy). Despite prolonged hospitalization due to multiple organ dysfunctions, patient had a positive outcome. Conclusions This case illustrates the importance of immediate recognition of the syndrome coupled with assertive empirical treatment and early microbiological diagnosis for a positive clinical outcome, even in a severe presentation. Multiprofessional approach is essential for accurate and early diagnosis.

Extensive thigh pyomyositis secondary to cystic fistulae due to anaerobic-bacterial infection in a kidney transplant recipient

BackgroundManaging infectious complications after kidney transplantation (KT) remains a major challenge. Infections are the leading non-cardiovascular cause of death among kidney transplant recipients (KTr). The urinary tract is particularly vulnerable to infections in this group, leading to high levels of morbidity and mortality, as well as significant economic costs.Case presentationThis case report presents the first documented instance of extensive thigh pyomyositis resulting from cystic fistulae in an 84-year-old KTr. The patient was referred to our hospital with acute onset fever, pain in the inner thighs and pyuria. A CT scan revealed bilateral pyomyositis of the thighs, characterized by multiple abscesses in the adductor muscles and hydroaerobic levels. Additionally, cystic fistulae complicated by pubic symphysis osteitis were identified.ConclusionIn KTr, lower limb pyomyositis resulting from a urinary tract infection is an extremely rare and significantly worsens the overall prognosis for these patients.

Investigation of the frequency and selected prevalence factors of EHV‐4 viremia in horses with acute onset of fever and respiratory signs

Investigation of the frequency and selected prevalence factors of <scp>EHV</scp>‐4 viremia in horses with acute onset of fever and respiratory signs

Free-living amoebic encephalitis - Case series.

Free-living amoeba is ubiquitous in fresh water, mud, and moist soil; although seldom pathogenic to humans, Naegleria fowleri, Acanthamoeba spp., and Balamuthia spp. are known to cause infections of the central nervous system. We report two interesting cases, both of which presented with a rapid-onset and fulminant course. The first case details a 36-year-old male with a history of surgically corrected nasal bone fracture 15 years back, who presented with acute onset of fever, headache and convulsions. Direct smears of cerebrospinal fluid (CSF) revealed motile trophozoites resembling N. fowleri and were later confirmed by molecular diagnosis (polymerase chain reaction [PCR]). Subsequently, the source was identified as water used for religious purposes. Unfortunately, the patient succumbed to cardiac arrest. The second case is that of a 4-year-old boy from Palakkad district, Kerala, who presented with sudden onset of nasal discharge, fever, headache, vomiting, seizures and altered sensorium. His CSF smear examination showed motile trophozoites resembling Acanthamoeba spp. While undergoing treatment, he seized thrice before going into cardiac arrest. Despite extensive resuscitation measures, the child could not be revived and passed away. The postmortem CSF sample sent for molecular analysis confirmed infection by Acanthamoeba spp. Rapid progression and lack of definite treatment options make this a highly fatal condition. Although clinical presentations of both patients were indicative of pyogenic meningitis, parasitic infection was suspected when the CSF was found turbid with no bacteria, high protein, and low sugar. High index of suspicion helped us to get an early preliminary diagnosis from direct microscopy.

The first confirmed outbreak of chikungunya reported in Timor-Leste, 2024.

Timor-Leste is a mountainous, half-island nation with a population of 1.3 million, which shares a land border with Indonesia and is 550 km from Darwin, Australia. Since independence in 2002, Timor-Leste has achieved significant development; however, high levels of poverty remain. Chikungunya virus (CHIKV) is endemic in over 100 countries in Africa, Asia, Europe and in the Americas. It is transmitted by the bite of infected Aedes aegypti or Ae. albopictus mosquitoes, which are present in Timor-Leste and which contribute to annual rainy-season dengue virus (DENV) outbreaks. Symptomatic people typically suffer from acute onset of fever, usually accompanied by severe arthritis or arthralgia. Joint pain can be debilitating for several days, and may sometimes last for weeks, months or years. Unlike DENV infection which has significant mortality, most people recover completely. Between 2002 and 2023, there were 26 cases of CHIKV notified in Australia who acquired their infection in Timor-Leste; however, laboratory testing capability for CHIKV in Timor-Leste only became available in 2021 using polymerase chain reaction (PCR). The first locally diagnosed case was notified in November 2023. In January 2024, an outbreak of CHIKV was recognised in Timor-Leste for the first time, with 195 outbreak cases reported during 1-31 January 2024; all were PCR positive. There were no cases hospitalised, and no deaths. The median age of cases was 17 years (range 1-76 years); 51% were males. Cases were reported across the country; most (88/195) were from Dili, although the highest incidence was seen in the neighbouring municipality of Ermera (monthly incidence rate of 58.8 cases per 100,000 population). This first reported outbreak of CHIKV in Timor-Leste highlights the need for improved mosquito-borne illness control and response strategies, including minimising breeding sites and promoting early presentation for treatment and differential diagnosis from DENV, and consideration of the deployment of Wolbachia-infected mosquitoes, particularly as they have shown to reduce the transmission of CHIKV, DENV and Zika virus, all of which pose threats in Timor-Leste.

Kikuchi–Fujimoto disease: A rare cause of cervical lymphadenopathy

Kikuchi–Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare and generally self-limiting disease of uncertain etiology that presents with fever and cervical lymphadenopathy in both the pediatric and adult populations. Here, we present the case of a 5-year-old male who presented with acute onset of fever and cervical lymphadenopathy which was initially diagnosed and managed as staphylococcal lymphadenitis. He underwent an excisional biopsy when symptoms persisted, which confirmed the diagnosis of KFD and was managed conservatively. This case study emphasizes awareness of this entity in the differential diagnosis of fever with persistent lymphadenopathy. Due to its characteristic overlap with other disorders such as tuberculous lymphadenitis, and lymphoma, KFD remains an arduous diagnosis for physicians. Therefore, awareness about its symptoms helps in minimizing potentially harmful unnecessary evaluations and thereby preventing misdiagnosis and inappropriate treatment.

Rift valley fever outbreak in Sembabule District, Uganda, December 2020

BackgroundRift Valley Fever (RVF) is a viral zoonosis that can cause severe haemorrhagic fevers in humans and high mortality rates and abortions in livestock. On 10 December 2020, the Uganda Ministry of Health was notified of the death of a 25-year-old male who tested RVF-positive by reverse-transcription polymerase chain reaction (RT-PCR) at the Uganda Virus Research Institute. We investigated to determine the scope of the outbreak, identify exposure factors, and institute control measures.MethodsA suspected case was acute-onset fever (or axillary temperature > 37.5 °C) and ≥ 2 of: headache, muscle or joint pain, unexpected bleeding, and any gastroenteritis symptom in a resident of Sembabule District from 1 November to 31 December 2020. A confirmed case was the detection of RVF virus nucleic acid by RT-PCR or serum IgM antibodies detected by enzyme-linked immunosorbent assay (ELISA). A suspected animal case was livestock (cattle, sheep, goats) with any history of abortion. A confirmed animal case was the detection of anti-RVF IgM antibodies by ELISA. We took blood samples from herdsmen who worked with the index case for RVF testing and conducted interviews to understand more about exposures and clinical characteristics. We reviewed medical records and conducted an active community search to identify additional suspects. Blood samples from animals on the index case’s farm and two neighbouring farms were taken for RVF testing.ResultsThe index case regularly drank raw cow milk. None of the seven herdsmen who worked with him nor his brother’s wife had symptoms; however, a blood sample from one herdsman was positive for anti-RVF-specific IgM and IgG. Neither the index case nor the additional confirmed case-patient slaughtered or butchered any sick/dead animals nor handled abortus; however, some of the other herdsmen did report high-risk exposures to animal body fluids and drinking raw milk. Among 55 animal samples collected (2 males and 53 females), 29 (53%) were positive for anti-RVF-IgG.ConclusionsTwo human RVF cases occurred in Sembabule District during December 2020, likely caused by close interaction between infected cattle and humans. A district-wide animal serosurvey, animal vaccination, and community education on infection prevention practices campaign could inform RVF exposures and reduce disease burden.

Characterization of Equine Rhinitis B Virus Infection in Clinically Ill Horses in the United States during the Period 2012-2023.

Equine rhinitis B virus is a lesser-known equine respiratory pathogen that is being detected with increasing frequency via a voluntary upper respiratory biosurveillance program in the United States. This program received 8684 nasal swab submissions during the years 2012-2023. The nasal swabs were submitted for qPCR testing for six common upper respiratory pathogens: Streptococcus equi subspecies equi (S. equi), equine influenza virus (EIV), equine herpesvirus type 1 (EHV-1), equine herpesvirus type 4 (EHV-4), equine rhinitis A virus (ERAV), and equine rhinitis B virus (ERBV). The overall ERBV qPCR-positivity rate was 5.08% (441/8684). ERBV was detected as a single pathogen in 291 cases (65.99% of positives, 291/441) and was detected as a coinfection with at least one other respiratory pathogen in 150 cases (34.01%, 150/441). Young horses, less than a year of age, with acute onset of fever and respiratory signs and horses used for competition are more likely to test qPCR-positive for ERBV. Horses with ERBV may present with fever, nasal discharge, ocular discharge, and/or cough. Coinfection is a common feature of ERBV infection and S. equi, EHV-4 and EIV were the most common pathogens coinfected with ERBV. This report provides important information regarding the clinical relevance of ERBV in the horse and begins investigating the impact of coinfection on clinical disease.

Diagnostic challenges in tuberculous meningitis: a case report with negative genexpert result.

Tuberculous meningitis (TBM) is a severe form of tuberculosis affecting the meninges, primarily caused by Mycobacterium tuberculosis. Diagnosis of TBM poses numerous challenges due to its nonspecific clinical presentation and the limitations of diagnostic tests like GeneXpert. The authors report a case of a 22-year-old female from Eastern Nepal presenting with acute-onset fever, headache, vomiting, and neck pain. Cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, elevated protein, low glucose levels, and cobweb coagulum indicative of TBM. However, the GeneXpert test revealed negative results. In resource-limited settings like Nepal, where access to GeneXpert MTB/Rif is limited, CSF analysis and clinical algorithms play a crucial role in diagnosing TBM. Relying solely on GeneXpert results may lead to false negatives, so a high level of suspicion based on patient risk factors is essential. Prompt initiation of empirical antitubercular therapy is vital for a favorable outcome in TBM cases. Negative MTB PCR results from CSF can be misleading in diagnosis of tubercular meningitis. Therefore, comprehensive evaluations, including detailed patient history, physical examination, and CSF fluid analysis, are crucial in high tuberculous prevalence countries to ensure accurate and timely diagnosis.

Rapid deterioration of a case of anti–N-methyl-D-aspartate receptor encephalitis with an ovarian teratoma, mimicking viral encephalitis

Anti–N-methyl-D-aspartate receptor (NMDAR) encephalitis has recently emerged as an autoimmune encephalitis syndrome. Younger females are more likely to develop this condition which usually presents as a multistage illness with predominant neuropsychiatric manifestations. It is associated with the neuroglial surface antibodies developing against NMDAR. The association of ovarian teratoma has been well recognised in this condition and tumour resection will intensify the recovery of the illness along with immunotherapy. We present a case of 19-year-old female who presented with acute onset of fever, encephalopathy and facial myorhythmia mimicking acute viral encephalitis. Her clinical status deteriorated within a short period. Later, her CSF became positive for NMDAR antibody and a right ovarian teratoma was detected. Her clinical status markedly improved with immunotherapy and excision of the teratoma following a diagnosis of Anti-NMDAR encephalitis. As a potentially treatable neurological condition, clinicians should be aware of this autoimmune encephalitis syndrome causing encephalitis.

Accuracy of yellow fever case definition of epidemiologic surveillance, São Paulo, 2018.

To evaluate the accuracy of yellow fever (YF) suspected case definitions from the Brazilian Ministry of Health (BMH) and World Health Organization (WHO), as well as propose and evaluate new definitions of suspected cases, considering confirmed and discarded cases. The retrospective study was conducted at the Instituto de Infectologia Emílio Ribas (IIER), using the Epidemiologic Surveillance Form of YF cases. From the confirmed and discarded cases of YF, a logistic regression model was developed. The independent variables were used in a proposed definition of a suspected case of YF and its accuracy was evaluated. In total, 113 YF suspect cases were reported, with 78 confirmed (69.0%). The definitions by BMH and WHO presented low sensitivity, 59% and 53.8%, and reduced accuracy, 53.1% and 47.8%, respectively. Predictive factors for YF were thrombocytopenia, leukopenia, and elevation of transaminases greater than twice normal. The definition including individual with acute onset of fever, followed by elevation of ALT or AST greater than twice the reference value AND leukopenia OR thrombocytopenia presented high sensitivity (88.3%), specificity (62.9%), and the best accuracy (80.4%), as proposed in the model. The YF suspected case definitions of the BMH and the WHO have low sensitivity. The inclusion of nonspecific laboratory tests increases the accuracy of YF definition.

Hepatic Superscan in Methotrexate-Associated Lymphoproliferative Disorder.

A 60-year-old man on methotrexate for treatment of adult-onset Still disease presented with acute onset of fever, pancytopenia, and deranged liver function. Besides FDG-avid lesions in spleen and skeleton, his 18F-FDG PET/CT study showed diffuse and intense uptake in the liver with significantly suppressed heart and brain activity (reminiscent of a hepatic superscan). Subsequent biopsy confirmed the diagnosis of methotrexate-associated lymphoproliferative disorder.

Systematic Review of Brain-Eating Amoeba: A Decade Update.

Primary amoebic meningoencephalitis (PAM) is a rare but lethal infection of the brain caused by a eukaryote called Naegleria fowleri (N. fowleri). The aim of this review is to consolidate the recently published case reports of N. fowleri infection by describing its epidemiology and clinical features with the goal of ultimately disseminating this information to healthcare personnel. A comprehensive literature search was carried out using PubMed, Web of Science, Scopus, and OVID databases until 31 December 2022 by two independent reviewers. All studies from the year 2013 were extracted, and quality assessments were carried out meticulously prior to their inclusion in the final analysis. A total of 21 studies were selected for qualitative analyses out of the 461 studies extracted. The cases were distributed globally, and 72.7% of the cases succumbed to mortality. The youngest case was an 11-day-old boy, while the eldest was a 75-year-old. Significant exposure to freshwater either from recreational activities or from a habit of irrigating the nostrils preceded onset. The symptoms at early presentation included fever, headache, and vomiting, while late sequalae showed neurological manifestation. An accurate diagnosis remains a challenge, as the symptoms mimic bacterial meningitis. Confirmatory tests include the direct visualisation of the amoeba or the use of the polymerase chain reaction method. N. fowleri infection is rare but leads to PAM. Its occurrence is worldwide with a significant risk of fatality. The suggested probable case definition based on the findings is the acute onset of fever, headache, and vomiting with meningeal symptoms following exposure to freshwater within the previous 14 days. Continuous health promotion and health education activities for the public can help to improve knowledge and awareness prior to engagement in freshwater activities.

Voluntary Biosurveillance of Streptococcus equi Subsp. equi in Nasal Secretions of 9409 Equids with Upper Airway Infection in the USA

This study aimed to describe selected epidemiological aspects of horses with acute onset of fever and respiratory signs testing qPCR-positive for S. equi and to determine the effect of vaccination against S. equi on qPCR status. Horses with acute onset of fever and respiratory signs from all regions of the United States were included in a voluntary biosurveillance program from 2008 to 2020 and nasal secretions were tested via qPCR for S. equi and common respiratory viruses. A total of 715/9409 equids (7.6%) tested qPCR-positive for S. equi, with 226 horses showing coinfections with EIV, EHV-1, EHV-4, and ERBV. The median age for the S. equi qPCR-positive horses was 8 ± 4 years and there was significant difference when compared to the median age of the S. equi qPCR-negative horses (6 ± 2 years; p = 0.004). Quarter Horse, Warmblood, and Thoroughbred were the more frequent breed in this horse population, and these breeds were more likely to test qPCR-positive for S. equi compared to other breeds. There was not statistical difference for sex between S. equi qPCR-positive and qPCR-negative horses. Horses used for competition and ranch/farm use were more likely to test qPCR-positive for S. equi (p = 0.006). Horses that tested S. equi qPCR-positive were more likely to display nasal discharge, fever, lethargy, anorexia, and ocular discharge compared to horses that tested S. equi qPCR-negative (p = 0.001). Vaccination against S. equi was associated with a lower frequency of S. equi qPCR-positive status.

Acute-Onset Fever and Abdominal Pain Leading to Shock in a Healthy 13-year-old Girl

Acute-Onset Fever and Abdominal Pain Leading to Shock in a Healthy 13-year-old Girl

Clinico-epidemiological presentation of acute encephalitis syndrome in patients visiting a tertiary hospital in Kathmandu, Nepal: A descriptive cross-sectional study

Introduction: Acute encephalitis syndrome is diagnosed when a person of any age, and at any time of the year, presents with the acute onset of fever and a change in mental status and/or new onset of seizures. It has an ill-defined clinico-epidemiological presentation in Nepal, making it a challenging medical condition. The objective of this study was to study the clinical profile of acute encephalitis syndrome. Methods: All consecutive admissions at Tribhuvan University Teaching Hospital between April 2017 and December 2018 were screened for acute encephalitis syndrome. The diagnosis was confirmed by history, examination, laboratory findings, brain imaging, and electroencephalography. All patients who met the inclusion criteria were enrolled. For data entry and analysis, statistical package for the social sciences software version 16.0 was used. Descriptive statistics as frequencies and mean ± standard deviations were computed. Results: The mean age of the study population was 49.56±22.28 years with male predominance 42(58.3%). Among the diagnosed etiologies, 1.38% had Japanese encephalitis, 4.12% had herpes encephalitis, and 4.12% had autoimmune encephalitis. Out of the 72 patients, 52 patients (72.22%) had Glasgow coma scale &gt;12, 15 patients (20.83%) had 8 to 12, and five patients (6.94%) had coma (Glasgow coma scale &lt;8). Among the clinical findings, altered mental status (91.66%) was the most commonly noticed manifestation followed by fever. Conclusions: Most patients had altered sensorium with less severe brain injury based on the Glasgow coma scale score during the presentation. Its low diagnostic yield, however, often leads to an increase in unknown etiologies. The syndrome was more prevalent in hilly regions.

1167. Changing spectrum of aetiology of Acute Fever with Jaundice (Tropical Jaundice) in Adults presenting to Emergency Care--- A study from a Tertiary Care Hospital in North India

Abstract Background The spectrum of infections causing the above acute onset fever with jaundice has changed over the last few years from the conventional hepatotropic viruses to new emerging infections. Methods 250 adult patients ≥ 14 years of age) with acute fever (body temperature &amp;gt; 101ᵒF of 14 days or less in duration) without any localized source of infection on initial clinical evaluation accompanied with jaundice (hyperbilirubinemia ≥ 1.5 mg/dl or elevation of ALT or AST ≥ three times upper limit) were enrolled.All these patients with fever and jaundice were evaluated on the basis of a standard proforma and were evaluated for malaria (peripheral smears/rapid diagnostic kits), scrub typhus( PCR /IgM ELISA), leptospirosis(IgM ELISA), enteric fever by blood cultures and dengue by dengue (NS1 antigen test and IgM ELISA), Hepatitis(IgM ELISA of EBV/HSV, IgM ELISA of HAV/HEV and HBsAg with IgM HBc ELISA if HBsAg positive) Results 62.5 % were males and 37.5 % were females. The mean duration of fever before the presentation was 8.1 ± 2.58 days. 10 patients (4%) died, while 133 patients (96%) improved with treatment. Scrub typhus 57 (22.8%), Hepatitis E 33 (13.2%), malaria 9 (3.6%), dengue fever, enteric fever, hepatitis A and leptospirosis in 26 (10.4%), 6 (2.4%), 6 (2.4%) patients and 4 (1.6%) patient respectively were the prominent aetiology a patient presenting with fever and jaundice. Probable sepsis (Fulfilling SIRS criteria with a negative culture) accounted for 40(16%) patients. In 69(27.6%) cases no diagnosis could be made on serological testing Conjunctival suffusion (OR=23.17), respiratory crepitations (OR=5.17), thrombocytopenia (OR=1.14), normal INR (OR=0.29) were significant predictors of a diagnosis of scrub typhus in patients with fever and jaundice. Severe anaemia (Hb&amp;lt; 8), Hypoalbuminemia, severe thrombocytopenia (Platelet count &amp;lt; 50,000) and a near-normal INR at admission were predictors of a malarial vs a viral aetiology of Tropical jaundice. Co-infection with scrub typhus and malaria was seen in 6 patients (vivax-5 and falciparum-1) and viral hepatitis A &amp; E was observed in 10 patients. Conclusion Neglected Tropical diseases like Scrub typhus infection is emerging as common aetiology of acute onset tropical jaundice in adults presenting to emergency services. Disclosures All Authors: No reported disclosures.

Measles outbreak in Semuto Subcounty, Nakaseke District, Uganda, June–August 2021

Semuto Subcounty reported rubella/measles outbreaks in January 2020 and June-August 2021. This study investigated the outbreak in 2021 to determine the scope, and the factors associated with transmission. A probable case was defined as a resident of Semuto Subcounty with acute onset of fever and a generalized maculopapular rash with either cough/cold or red eyes from 1 June to 31 August 2021. A confirmed case was defined as a probable case with a blood sample positive for measles-specific IgM. A village-matched case-control study was conducted with 30 cases and 122 controls (1:4 ratio). A control was defined as an individual aged 6 months-9 years, sampled at random, with no signs or symptoms of measles from 1 June to 31 August 2021, residing in the same village as the matched case. Adjusted Mantel-Haenszel odds ratios (ORMH) and confidence intervals (CIs) were calculated. Of the 30 cases (27 probable and three confirmed), 16 (53%) were male. The subcounty attack rate (AR) was 3.2/1000. Children aged 5-9 years were the most affected (AR 5.0/1000). Twenty-two (79%) cases and 116 (97%) controls had ever received measles vaccine (ORMH 0.13, 95% CI 0.03-0.52). Interaction with symptomatic persons at water collection points (ORMH 4.4, 95% CI 1.6-12) and playing at community playgrounds (ORMH 4.2, 95% CI 1.7-11) increased the odds of infection. Socializing/congregating at water collection points and community playgrounds facilitated the transmission of measles in this outbreak.

Clinicoepidemiological profile and outcome among children with acute encephalitis syndrome from Central India

Background: Acute encephalitis syndrome (AES) is defined as the acute onset of fever and a change in mental status and/or new onset of seizures (excluding simple febrile seizures) in a person of any age at any time of the year. Aims and Objectives: The objectives of the study were as follows: (a) To study clinicoepidemiological profile and outcome among children with AES admitted at M.Y.H. Hospital and MGM Medical College, Indore, M.P., and (b) to study prognostic factors associated with bad outcomes. Materials and Methods: This prospective observational study was conducted over 12 months (July 2019–August 2020) at the pediatric department of our hospital. Inclusion criteria: Inpatient children aged 6 months–14 years meeting the case definitions of acute encephalitis syndrome. Exclusion criteria: Simple febrile seizures. Results: Out of 50 AES cases, majority were between 1 and 5 years of age (40%). There were more males 31 (62%) than 19 (38%) females. Most of the cases were reported during the monsoon period 29 (58%) followed by post-monsoon 13 (26%) and pre-monsoon 8 (16%). Out of 50 cases, all had fever and altered sensorium, 37 (74%) had convulsions, 14 (28%) had vomiting, and 9 (18%) had headache. Out of 50 cases, 42 (84%) had viral etiology including 7 (14%) of dengue encephalitis and 1 (2%) of case of human immunodeficiency virus encephalitis. Only 5 (10%) cases had bacterial etiology. Those who needed inotropes and mechanical ventilation showed significant mortality. Conclusion: The peak of AES cases occurred during the monsoon period. A higher proportion of such cases had viral etiology on cerebrospinal fluid analysis. Use of inotropes and mechanical ventilation was identified to be associated with significant mortality.

Who Is at Risk? A Critical Case of Japanese Encephalitis.

Japanese encephalitis (JE) is critical epidemic encephalitis caused by the JE virus (JEV) in Southeast Asia. The World Health Organization defined "acute encephalitis syndrome" (AES) as an acute onset of fever with a change of mental status and/or new-onset seizure, mainly for the surveillance of JE. The key clues for the diagnosis include the patient age group of unvaccinated era or waning vaccine-induced immunity and the history of possible mosquito bites in epidemic areas. We report a 47-year old man who is in an unvaccinated era with potential waning immunity. The patient presented with fever and altered mental status for 2 days. He was speechless and could not follow commands. The patient had gone camping in the countryside a week before the visit. At the emergency department, neck stiffness was noted. There was a leukocytosis with a left shift by blood cell count. The brain computed tomography was essentially normal. The cerebrospinal fluid (CSF) sample via lumbar puncture showed leukocytosis, a high protein level, and a low sugar level in comparison to serum tests. Further antibody test of CSF confirmed the diagnosis. Magnetic resonance imaging (MRI) of the brain revealed a high signal in the right thalamus and a mildly swollen left caudate nucleus 4 days after admission. He was extubated and finally discharged with partial dependency on activities of daily living. This case reminds us of the JE in AES. Emergency physicians should be aware of the suspicious case of unvaccinated age or waning immunity and possible mosquito bites in epidemic areas. The role of MRI on JE was also discussed in this article.