Suspicion Of Encephalitis Research Articles

An unusual presentation of encephalitis which mimicked generalised tetanus

Movement disorders are frequent mimickers of more severe neurological presentations, whenever it is diagnosed one should suspect a central nervous system infection as an underlying cause. A 11 year old girl presented in casuality with intermittent generalised muscle spasm, clear sensorium, trismus and risus sardonicus. Initially managed as a case of tetanus, rapid resolution of spasms made suspicion of encephalitis as underlying cause of dystonia which mimicked tetanus. Blood investigation and CSF analysis were normal. CECT brain showed hyper dense lesions bilateral temporal lobes suggestive of viral encephalitis. Child was managed with intravenous acyclovir and dexamethasone after which child improved considerably. Acute dystonia is a close mimicker of tetanus. Any patient presenting with new onset movement disorder should be investigated for central nervous system infection even though it has been reported as a rare cause for the same.

An Unusual Presentation of a Child with Hyperoxaluria

Introduction: Hyperoxaluria is a common abnormal finding in patients with nephrolithiasis, especially in children in contrary to adults. Overall, it is a rare disorder with the four main types of primary, enteric, dietary and idiopathic. The disorder is characterized by overproduction of oxalate that leads to nephrocalcinosis and eventual development of end-stage renal failure. Case Presentation: We report the case of a 2-year-old boy presented with multiple episodes of seizure, gastrointestinal bleeding, loss of consciousness and rise in blood urea nitrogen (BUN) and creatinine (Cr). He underwent imaging study and lumbar puncture with the suspicion of encephalitis. With more history-taking, we understood that he was previously under treatment for nephrocalcinosis. Finally, he underwent dialysis and the level of consciousness improved. His diagnosis was confirmed by renal biopsy and establishing the existence of extensive tubular and interstitial crystal deposition in his kidneys. Conclusions: The case illustrates the need for the early diagnosis of this disorder to prevent systemic oxalosis that affects many organs resulting in severe morbidity and mortality and raising the suspicion of primary hyperoxaluria in childhood progressive renal failure with massive nephrocalcinosis, especially if accompanied by a positive family history. In these cases, complications should be explained to increase drug compliance.

Investigation of coagulation behavior using Rotational Thromboelastometry (Rotem®) in patients with neuroinfectious diseases

Background: European tick-borne encephalitis (TBE) commonly presents with neurological disturbances, whereas primary psychiatric manifestations are rare. Aim: To report a case of acute TBE presenting as major depressive episode. Case report: A 72-year-old man had been suffering from fatigue, poor appetite and tremor of the left hand for 2 weeks. Progression of these symptoms made him believe that he had acquired an incurable and fatal disorder. He repeatedly noted in his diary that 'the end is not far off”. Generalized weakness and fluctuating level of consciousness lead to examination at the Neurologic Department. His psychiatric medical history was unremarkable. Brain MRI, EEG and laboratory examination was normal. Diminished drive, dysthymia, hopelessness and suicidal ideation were found on mental state exam. Diagnosed with major depression he was hospitalized in the psychiatric ward. One day later, he developed a generalized seizure and lab findings supported the diagnosis of European TBE (CSF: 13 cells/μL; protein 60 mg/dL; positive TBE-IgM in serum and CSF). Depressive symptoms declined gradually with a combination of psychotherapy, mirtazapin and sertralin. The tremor responded well to propanolol and was seen as unrelated to TBE. He was discharged home 30 days from admission with minimal residual fatigue and low dose mirtazapin. Conclusion Acute life-threatening psychiatric manifestations can be the predominant presenting but successfully treatable feature of TBE. We conclude that awareness for this condition should be raised in endemic regions and high-level of suspicion for encephalitis maintained with the occurrence of seizures or focal-neurological deficits in acute psychiatric conditions.

Tick-borne encephalitis presenting as major depressive episode: a case report

Background: European tick-borne encephalitis (TBE) commonly presents with neurological disturbances, whereas primary psychiatric manifestations are rare. Aim: To report a case of acute TBE presenting as major depressive episode. Case report: A 72-year-old man had been suffering from fatigue, poor appetite and tremor of the left hand for 2 weeks. Progression of these symptoms made him believe that he had acquired an incurable and fatal disorder. He repeatedly noted in his diary that 'the end is not far off”. Generalized weakness and fluctuating level of consciousness lead to examination at the Neurologic Department. His psychiatric medical history was unremarkable. Brain MRI, EEG and laboratory examination was normal. Diminished drive, dysthymia, hopelessness and suicidal ideation were found on mental state exam. Diagnosed with major depression he was hospitalized in the psychiatric ward. One day later, he developed a generalized seizure and lab findings supported the diagnosis of European TBE (CSF: 13 cells/μL; protein 60 mg/dL; positive TBE-IgM in serum and CSF). Depressive symptoms declined gradually with a combination of psychotherapy, mirtazapin and sertralin. The tremor responded well to propanolol and was seen as unrelated to TBE. He was discharged home 30 days from admission with minimal residual fatigue and low dose mirtazapin. Conclusion Acute life-threatening psychiatric manifestations can be the predominant presenting but successfully treatable feature of TBE. We conclude that awareness for this condition should be raised in endemic regions and high-level of suspicion for encephalitis maintained with the occurrence of seizures or focal-neurological deficits in acute psychiatric conditions.

Anti NMDA-receptor encephalitis: a severe case (34 year-old male) with psychotic disorders

Case report We report the case of a 34 years-old male with antiNMDA receptor encephalitis who exhibited the classical pattern. The patient described psychiatric symptoms, seizures, movement disorders, altered state of consciousness and autonomic dysfunction, over the course of 40-50 days. After a 20-day hospitalization in a psychiatric ward, the case was redirected to our infectious disease – intensive care facility, where he required advanced life support. The interdisciplinary team of infectious diseases, intensive care and neurology specialists raised the diagnosis suspicion of encephalitis. The patient received empirical corticotherapy and therapeutic plasma exchange, with significant clinical improvement in the second week of treatment, coinciding with the diagnostic confirmation by positive results for anti-NMDA receptor antibodies in both serum and cerebrospinal fluid. The patient continued his recovery in a specialized neurology department. Infectious disease specialists are often confronted with encephalitis of unknown etiology.

Varicella-zoster meningoencephalitis — Case report

Introduction: Encephalitis is defined as inflammation of the brain parenchyma and meningoencephalitis when there is meningeal involvement. A viral etiology is the most common and the diagnostic method of choice is the polymerase chain reaction (PCR) of viral nucleic acids in cerebrospinal fluid (CSF). Herpes simplex virus is the leading cause of encephalitis and varicella-zoster virus (VZV) a less common cause, particularly in immunocompetent individuals. Case report: Woman, 67 years old, retired nurse, brought to the emergency room by disorientation. Physical examination: slowed, disoriented, incoherent and repetitive speech; subfebrile (T-37, 2 °C); no meningeal signs or skin lesions were identified. Laboratory tests revealed leukocytosis (10.5 × 10 ^9/L) with neutrophilia (86.9%). Computed tomography and magnetic resonance imaging (MRI) of the brain were performed and there were no lesions on brain parenchyma. Lumbar puncture (LP): 5 leukocytes/mm3; erythrocytes 2327/mm3; glucose: 80 mg/dl, and protein 26.7 mg/dl. Blood, cerebrospinal fluid cultures and capsular antigens were collected. The patient had clinical worsening at 48 h with fever (T-38, 7 °C), agitation, seizures, left hemiparesis and meningeal signs. LP was repeated: leukocytes 40/mm (98% of polymorphonuclear cells), glucose: 113 mg/dl, and protein: 30.4 mg/dl. CSF cultures were repeated and viral PCR in cerebrospinal fluid was requested. Human immunodeficiency virus testing was negative. Empirically ceftriaxone, ampicillin and acyclovir 10 mg/Kg ev, 8/8 h was established. Electroencephalography revealed severe cortical structural damage in the left hemisphere. MRI of the brain was repeated and showed no lesions. Microbiological study was negative and VZV PCR in CSF was positive. She completed 21 days of acyclovir. The patient had a good clinical and neurologic outcome with resolution of all the symptoms. Conclusion: VZV meningoencephalitis. The case stands out for infection of the central nervous system by VZV in an immunocompetent patient, along with the importance of a high clinical suspicion of viral encephalitis even in the presence of pleocytosis with a predominance of polymorphonuclear cells in the early phase of infection. The suspicion of encephalitis is critical in the decision of early antiviral therapy to prevent neurological sequelae.