Dengue Encephalopathy (Encephalitic) Definition The involvement of the central nervous system in dengue fever and dengue haemorrhagic

fever has always been thought to be secondary to vasculitis and leaky capillary syndrome with resultant fluid extravasations, cerebral oedema, hypoperfusion, hyponatremia, liver failure and / or renal failure. Serologically verified DHF and CNS symptoms. Possible CNS symptoms included convulsions, spasticity, focal neurological signs, and altered level of consciousness for _ 8 hr (i.e., drowsiness, lethargy, agitation, semicoma or coma). All patients showed neurological manifestations during the febrile stage of the disease. Patients with reduced consciousness were defined clinically as having encephalitis if: there was no metabolic abnormality or other apparent explanation, and they had any of the following: o CSF pleocytosis (corrected white cell count >5/_L) o focal neurological signs o convulsions other than simple febrile convulsions. If they had none of these features they were considered to have an acute encephalopathy. Etiology - A previous study of Thai children examining the first clinical impression of viral encephalitis, indicated that dengue virus was one of the most common causative agents (Thisyakorn and Thisyakorn, 1999). Thus one should consider dengue infection in the differential diagnosis of older children presenting with acute onset of high grade fever and altered level of consciousness or confusion. - Dengue virus type 3, possibly the most neurovirulent type of dengue virus, was dramatically more common during these outbreaks and may account for these new manifestations (Pancharoen and Thisyakorn, 1998a).

Serotypes 2 and 3 have primarily been reported to cause neurologic symptoms, and these patients may experience both primary and secondary infections.

Pathophysiology cerebral edema anoxia microcapillary v frank hemorrhage hemorrhage subdural hematoma, frontal hematoma, cerebellar hematoma, intraventricular hemorrhage. hyponatremia hepatic failure release of toxic substances dengue encephalitis encephalitis is defined as a localised invasion of the CNS by a neurotropic potential of dengue virus. Dengue encephalitis a virusinduced, cytokine-mediated breakdown of the blood-brain barrier. Infiltration of virus-infected macrophages could be one of the pathways by which the virus may enter the brain in dengue encephalitis. prolonged DHF with fluid extravasation renal failure hypotension bleeding and coagulation abnormalities SS - alteration of consciousness (83.3%), - seizure (45.2%) generalized tonic clonic seizures, myoclonus - mental confusion (23.8%) - nuchal rigidity (21.4%) - spasticity of limbs (9.5%) - positive clonus (4.8%) - hemiplegia (2.4%), acute pure motor quadriparesis, paraplegia - muscle tone - positive kernig (2.4%) - were older than those in the other groups - most were experiencing secondary dengue infection - Biceps, triceps, knee and ankle reflexes / - headache - seizure - depressed sensorium - behavioural disorders - cranial nerve palsies - hepatomegaly - splenomegaly - vomiting - purpura, ecchymoses, melena, hematemesis - body ache - tremors

amnesia loss of sensation manic psychosis depression dementia Guillain-Barr syndrome transverse myelitis Liver enzymes (AST, ALT) and bilirubin Hyponatremia In encephalitis : CSF pleocytosis In analysis of the cerebrospinal fluid (CSF), reverse transcriptasepolymerase chain reaction revealed dengue-3specific RNA in one evaluated case Dengue-specific immunoglobulin M was detected in CSF, indicating a localized infection Dengue viral antigens were demonstrated by immunohistochemistry in CNS biopsies from 5 fatal cases of dengue infection associated with encephalopathy. Magnetic resonance imaging scans showed cerebral edema (most), globus pallidus involvement which was possibly due to prolonged hypoxia following status epilepticus, encephalitislike changes were less common. In metabolic and toxic encephalopathy CSF is normal.

Most reported cases of dengue encephalopathy or encephalitis recover without neurological sequelae.

Lab -

Diagnosis - Demonstrating dengue virus in CSF, using techniques of viral isolation, PCR and the presence of dengue IgM. - Demonstrated dengue virus antigen by an immunoperoxidase technique. - Autopsy histologic evidence of encephalitis. Prognosis The mortality rate among children with encephalopathy was 22%, with the survivors experiencing a complete recovery. One encephalitic patient suffered from long term neurological sequelae (spasticity and muscle weakness) 2.4%