Case Report Fatal Dengue Encephalitis

Central nervous system involvement is not an uncommon manifestation of dengue virus infection, but encephalitis is a rare entity. We report the case of a 5-year-old girl with fever and convulsions. She developed coma and shock during the high fever stage without abnormal bleeding.Treatment was supportive and symptomatic. The shock was poorly controlled. High fever persisted for 7.5 days then she expired. Cerebrospinal fluid (CSF) and blood dengue-IgM antibody showed dengue infection. normal neurological signs. The temperature was 39oC, respiratory rate 26/minute, blood pressure 110/70 mmHg, and body weight 18 kg. There was no rash, lymphadenopathy, or hepatosplenomegaly. The results of the rest of the physical examination were normal. A diagnosis of acute encephalitis was made. A complete blood count (CBC) showed hematocrit 34%, WBC 7,600/mm3, neutrophils 67%, lymphocytes 31% and atypical lymphocytes 2%, platelets 153,000/mm3. CSF analysis revealed normal pressure, clear and colorless, RBC 10/ mm3, no WBC, protein 744 mg/dl, sugar 120 mg/dl, blood sugar after lumbar puncture was 153 mg/dl, Indian ink negative, and Gram stain negative. Urinalysis was normal. Initial management was supportive and symptomatic; intravenous fluid, anticonvulsants and antibiotics. Five hours after admission she developed coma but still responded to deep pain. The blood pressure was normal. She developed respiratory insufficiency, then mechanical ventilation was introduced. Shock (BP 70/40 mmHg) and deep coma developed on the second day with high fever (39.0oC), but no abnormal bleeding. Repeat CBC showed a hematocrit of 35%, WBC 5,800/mm3, neutrophils 54%, lymphocytes 42% and atypical lymphocytes 4%, and platelets 138,000/mm3. A vasopressor drug was used without improvement. Shock was poorly controlled and high fever persisted (38.5o-39.5oC) for 3.5 days, then she expired (total fever of 7.5 days). Repeat CBC on the third day showed a hematocrit of 34%, WBC 4,700/mm3, neuFATAL DENGUE ENCEPHALITIS Vol 36 No. 1 January 2005 201 trophils 38%, lymphocytes 52% and atypical lymphocytes 10%, and platelets 124,000/mm3. CSF culture for bacteria and hemoculture were negative. A postmortem examination was refused by her parents.