20160720 japanese encephalitis

Japanese Encephalitis

R1 Jin-Yi Hsu

4 day before Day 1

Mrs. Dai 42 y/o housekeeper

WBC: 14.68 ⬆

CRP: 3.29 ⬆

WBC: 222 /uL ⬆

Protein: 47.6

Glucose: 65

CT when admission

Brain swelling

No mass lesion!?

WBC: 14.68 ⬆

CRP: 3.29 ⬆

WBC: 222 /uL ⬆

Protein: 47.6

Glucose: 65

Seg:45%

Acyclovir

Ceftriazone

Day 1

Dexamethasone

4 day before Day 1-5 Day 6

Right-hand action tremor?

Bradycardia

Aphasia

MRI Day 5

Left thalamic lesion

Left P-O cortical lesion

CT when admission

Brain swelling

Left thalamic hypo-dense lesion

Anti-TPO: Neg

Vit. B12: 234 pg/ml

Folate: 11.57 ng/mL

Crypto Ag: Neg

TPPA: Neg

4 day before Day 1-5 Day 6

Non-fluent speech

Bradycardia

Obey order

JE. IgM: Positive

Final diagnosis

1. Japanese encephalitis over left thalamic and left P-O cortical lesion

5 days before Day 1 Day 5

Mr. Chen 44 y/o. Px: HTN

5 days before Day 1

0

0

3

30

0 3

3


Unable to communicate

Slurred speech

WBC: 8.53

CRP: 3.11 ⬆

Cre: 1.8 ⬆

K: 3.0 ⬇

WBC: 145 /uL ⬆

Protein: 95.1 ⬆

Glucose: 79

MRI when admission

Bilateral thalamus, especially L’t

Left cerebral peduncle

Left upper pons

WBC: 8.53

CRP: 3.11 ⬆

Cre: 1.8 ⬆

K: 3.0 ⬇

WBC: 145 /uL ⬆

Protein: 95.1 ⬆

Glucose: 79

Seg:14.5%

5 days before Day3


Tea color urine

Respiratory distress

Spiking fever


WBC: 16.0 ⬆

Cre: 1.4 ⬆

GOT: 1004 ⬆

GPT: 254 ⬆

CK: 68600 ⬆

Urine Myoglobulin


WBC: 16.0 ⬆

Cre: 1.4 ⬆

GOT: 1004 ⬆

GPT: 254 ⬆

CK: 68600 ⬆

Urine Myoglobulin

Multi-organ involvement

Acyclovir

Doxycycline / Claforan

Day 1

Day 3

DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 DAY9

Light reflex / - / - - + + + +

Oculomotor - - - - (L’t) - (L’t) - (L’t) - (L’t)

Corneal reflex - - - - -

Babinski sign Bil. dorsi-

Bil. dorsi-

Bil. dorsi-

Bil. dorsi-

Bil. dorsi-

GCS E1VTM2 E1VTM3 E1VTM3 E1VTM3 E1VTM3

1st JE. IgM: Negative

Influenza A,B: Negative

HIV : Negative

HSV/ CMV/ VZV : Negative

Lepto/ Lyme : Negative

All culture: Negative

CT when day 7

Bilateral thalamus

Bilateral cerebral peduncle

Bilateral pons

MRI when day 10

Bilateral thalamus, especially L’t

Bilateral midbrain, especially L’t

Bilateral pons, especially L’t

Leptomeaneal enhancement, L’t

2nd JE. IgM: Positive


Final diagnosis

1. Japanese encephalitis over bilateral thalamic, pontine, midbrain lesion and left leptomeningeal enhancement2. Atypical infection with hepatic and renal impairment and rhabdomyolysisAutoimmune?

Question?

Japanese Encephalitis

R1 Jin-Yi Hsu

Low Clinical Illness Rate

5-15 days

Clinical Course

DaysDays

Normal Disability Death

Disability or Death !

CSF Examination

Mild/ moderate pleocytosis

Mild Protein ⬆

Glucose —

Lymphocyte dominantly

Laboratory Examination

Day 3 Day 10

Antibody

Day 90

Laboratory Examination

Day 3 Day 10

1st test 2nd test

How to Confirm

IgM + or PCR

1st 2nd Antibody 4x ⬆

Antibody IgM+

How to Confirm

IgM + or PCR

1st 2nd Antibody 4x ⬆

Antibody IgM+Patient 1

Patient 2

How to Confirm

Asymmetric Symmetric

DiffuseFocal/ Discrete

Infection

Neoplasm

Systemic

Metabolic

Bilateral lesion

How to ConfirmPatient 1 Patient 2

How to Treat

Supportive care

How to Treat

Supportive careDay 3 Day 10

Antibody

Day 90

Prognostic factor

Prospective, follow-up 8.3 years

108 children in Malaysia

Serologically confirmed

1997-2005

Prognostic factor

At discharge Long-term follow-up

Poor prognostic factor

GCS =< 8

Seizure +

Shock +

Treatable Prognostic Factor

Seizure Shock

Thalamic aphasiaPatient 1 Patient 2

Thalamic aphasia

Repetition: intact

Fluency: variably affected

Comprehensive: variably affected

Lexical-semantic deficits

Etiology of Rhabdomyolysis

Trauma

Non-trauma Exertional

Non-Exertional

Etiology of Rhabdomyolysis

Non-exertional & Non-traumatic

Drugs

Toxin

Infections

Electrolyte

Endocrine

Inflammatory

Thanks for your attention

R1 Jin-Yi Hsu

DWI ADC

T1 T1+C

T2*T2*

Thalamic aphasiaPatient 1 Patient 2

20160720 japanese encephalitis

Health & Medicine