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LETTER TO EDITOR
Year : 2007  |  Volume : 55  |  Issue : 4  |  Page : 418-419

Bilateral thalamic involvement in dengue infection


Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029, India

Date of Acceptance29-May-2007

Correspondence Address:
Jayakumar N Peruvamba
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore - 560 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.37103

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How to cite this article:
Kamble R, Peruvamba JN, Kovoor J, Ravishankar S, Kolar BS. Bilateral thalamic involvement in dengue infection. Neurol India 2007;55:418-9

How to cite this URL:
Kamble R, Peruvamba JN, Kovoor J, Ravishankar S, Kolar BS. Bilateral thalamic involvement in dengue infection. Neurol India [serial online] 2007 [cited 2017 Dec 18];55:418-9. Available from: http://www.neurologyindia.com/text.asp?2007/55/4/418/37103


Sir,

A patient of 11 years presented with fever, headache and vomiting for two days, an episode of tonic clonic seizures, ecchymosis and altered sensorium. Her pupils were 3mm, constricted and reacting and all ocular movements were restricted. She had spasticity with tonic posturing and extensor plantars. The CSF showed protein of 265mg%, glucose-109mg%, no cells and random blood sugar was 213mg%. Tests for malarial parasites, leptospira, Japanese encephalitis, Herpes simplex virus (CSF) and  Salmonella More Details were negative. Dengue IgM antibody test was done twice one week apart and showed rising titers (92 units, 126 units) with normal bleeding and clotting time and low platelet counts (40,000 and 37,000). Ultrasound abdomen and chest X-ray were normal. However, EEG was not done. The CT scan of brain at admission [Figure - 1] showed cerebral edema with symmetrical non-enhancing hypodensities in bilateral thalami, midbrain and posterior part of pons. The patient developed respiratory distress and was on mechanical ventilator for two days. Repeat CT four days later [Figure - 2] showed persistent findings. Patient's sensorium improved and third CT done two weeks after first scan [Figure - 3] showed the thalamic lesions had resolved, whereas the lesions in the posterior pons and midbrain had become more hypodense. Marked generalized cerebral atrophy and ventricular dilatation were seen. At discharge she had mild cognitive impairment and tonic posturing.

Dengue viruses are single-stranded RNA viruses of the flaviviridae family causing dengue fever and dengue hemorrhagic fever. [1] The pathophysiology of neurological symptoms in dengue fever is attributed to cerebral edema, hemorrhage, hemoconcentration due to increasing vascular permeability, coagulopathy and release of toxic substances. Neurotropic potential of dengue virus leading to encephalitis has been suggested. [1],[2]

In our case, the CT scan showed cerebral edema with non-enhancing hypodensities in the thalami, posterior pons and midbrain. Follow-up CT scan after two weeks showed that the lesions in the thalami had resolved, but lesions in the posterior pons and midbrain persisted. These imaging findings, classically described in Japanese encephalitis (JE) [3] have not been reported in dengue infection. Japanese encephalitis was ruled out in our patient by immunological tests. Cerebral edema, encephalitis-like changes (edema and scattered focal lesions), intracranial hemorrhages on MRI [1],[4] have been reported. Yeo et al. have reported selective involvement of bilateral hippocampus in dengue infection in patient presenting with amnesia. [5]

While perivenous encephalitis described in dengue infection [4] could be the cause for infarcts in the posterior pons and midbrain, vasogenic edema may have caused thalamic hypodensity that disappeared on subsequent scans. This finding has not been previously reported in dengue infection and may be missed during its temporal evolution.

In conclusion, dengue infection should be considered in the differential diagnosis of viral encephalopathies with bilateral transient thalamic involvement.

 
 » References Top

1.Cam BV, Fonsmark L, Hue NB, Phuong NT, Poulsen A, Heegaard ED. Prospective case-control study of encephalopathy in children with dengue hemorrhagic fever. Am J Trop Med Hyg 2001;65:848-51.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Kabra SK, Verma IC, Arora NK, Jain Y, Kalra V. Dengue haemorrhagic fever in children in Delhi. Bull World Health Organ 1992;70:105-8.  Back to cited text no. 2  [PUBMED]  
3.Kumar S, Misra UK, Kalita J, Salwani V, Gupta RK, Gujral R. MRI in Japanese encephalitis. Neuroradiology 1997;39:180-4.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Solomon T, Dung NM, Vaughn DW, Kneen R, Thao LT, Raengsakulrach B, et al . Neurological manifestations of dengue infection. Lancet 2000;355:1053-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Yeo PS, Pinheiro L, Tong P, Lim PL, Sitoh YY. Hippocampal involvement in dengue fever. Singapore Med J 2005;46:647-50.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

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