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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 6  |  Page : 683-684

Diffusion restriction in pons resembling "reverse moustache" in dengue encephalitis


Department of Neurology, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India

Date of Submission26-Oct-2014
Date of Decision26-Oct-2014
Date of Acceptance26-Oct-2014
Date of Web Publication16-Jan-2015

Correspondence Address:
Rohan R Mahale
Department of Neurology, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.149408

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How to cite this article:
Mehta A, Mahale RR, Javali M, Srinivasa R. Diffusion restriction in pons resembling "reverse moustache" in dengue encephalitis. Neurol India 2014;62:683-4

How to cite this URL:
Mehta A, Mahale RR, Javali M, Srinivasa R. Diffusion restriction in pons resembling "reverse moustache" in dengue encephalitis. Neurol India [serial online] 2014 [cited 2019 Aug 25];62:683-4. Available from: http://www.neurologyindia.com/text.asp?2014/62/6/683/149408


Sir,

A 12-year-old boy presented with a history of high-grade fever and chills of 5 days duration. He had holocranial headache with two episodes of vomiting. He lapsed into altered sensorium on the day of admission. No history of seizures. He was febrile and drowsy, irritable, and not following verbal commands. There was terminal neck stiffness. Pupils were equal and reactive. Fundus examination was normal. No paucity of limb movements. Plantar response was extensor. Brain magnetic resonance imaging (MRI) showed hyperintense signal changes in basis pontis with patchy signal changes in bilateral thalamus on fluid-attenuated inversion recovery (FLAIR). There was diffusion restriction in the periphery of basis pontis resembling "reverse moustache" [Figure 1]. The platelet count was 50,000/mm 3 . Immunoglobulin M (IgM) antibodies and nonstructural protein 1 (NS1) antigen for dengue virus were positive in the serum. Cerebrospinal fluid (CSF) analysis was positive for dengue IgM antibodies. A diagnosis of dengue encephalitis was made. He was treated with intravenous dexamethasone for 3 days and showed improvement in level of consciousness.
Figure 1: Magnetic resonance imaging (MRI) brain fluid-attenuated inversion recovery (FLAIR) sequence axial view showing hyperintense signal change in basis pontis predominantly in the periphery (white arrow) (a); Diffusion-weighted imaging (DWI) showing hyperintense signal (b) and apparent diffusion coefficient (ADC) showing hypointense signal (c) in basis pontis with "reverse moustache" appearance (white arrow)

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Dengue fever has a variable clinical spectrum ranging from asymptomatic infection to life-threatening dengue hemorrhagic fever and dengue shock syndrome. However, neurological complications, in general, are unusual. Dengue encephalopathy is usually secondary to multisystem derangement like shock, hepatitis, coagulopathy, and concurrent bacterial infection. However, in dengue encephalitis, there is direct neuronal infiltration by the dengue virus. Although dengue is classically considered a non-neurotropic virus, [1] there is increasing evidence for dengue viral neurotropism. [2] In a recent study on the cranial imaging in dengue virus infection, MRI abnormalities were reported in 9 out of 21 serologically confirmed patients with dengue: Lesions in thalamic and basal ganglia in 3, focal cortical areas in 3, white matter in 2, and meningeal enhancement in 3 patients. [3] Extensive lesions involving the midbrain, cerebellum, thalamus, and medial temporal region on both sides of the MRI brain have been reported in a serologically confirmed patient with dengue. [2] Borawake et al., reported a child with dengue encephalitis with extensive parenchymal hyperintense lesions in the bilateral cerebellar cortex, vermis of the cerebellum, entire pons and midbrain, bilateral medial temporal lobes, and both thalami on MRI. [4] Our patient had serologically confirmed dengue infection with predominant lesions in pons and patchy involvement of thalami. The pattern of diffusion restriction in pons in our patient resembled "reverse moustache", which is an interesting pattern not reported so far.

 
  References Top

1.
Nathanson N, Cole GA. Immunosuppression and experimental virus infection of the nervous system. Adv Virus Res 1970;16:397-428.  Back to cited text no. 1
    
2.
Rao S, Kumar M, Ghosh S, Gadpayle AK. A rare case of dengue encephalitis. BMJ Case Rep 2013;2013.  Back to cited text no. 2
    
3.
Bhoi SK, Naik S, Kumar S, Phadke RV, Kalita J, Misra UK. Cranial imaging findings in dengue virus infection. J Neurol Sci 2014;342:36-41.  Back to cited text no. 3
    
4.
Borawake K, Prayag P, Wagh A, Dole S. Dengue encephalitis. Indian J Crit Care Med 2011;15:190-3.  Back to cited text no. 4
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