Japanese Encephalitis R1 Jin-Yi Hsu
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Japanese Encephalitis
R1 Jin-Yi Hsu
4 day before Day 1
Mrs. Dai 42 y/o housekeeper
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
Mr. Chen 44 y/o. Px: HTN
Unable to communicate
Slurred speech
5 days before Day 1
0
0
3
30
0 3
3
Mr. Chen 44 y/o. Px: HTN
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
Mr. Chen 44 y/o. Px: HTN
Tea color urine
Respiratory distress
Spiking fever
Mr. Chen 44 y/o. Px: HTN
WBC: 16.0 ⬆
Cre: 1.4 ⬆
GOT: 1004 ⬆
GPT: 254 ⬆
CK: 68600 ⬆
Urine Myoglobulin
Mr. Chen 44 y/o. Px: HTN
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
Mr. Chen 44 y/o. Px: HTN
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
5-15 days
Clinical Course
DaysDays
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+
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 Confirm
Asymmetric Symmetric
DiffuseFocal/ Discrete
Infection
Neoplasm
Systemic
Metabolic
Bilateral lesion
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
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 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
DWI ADC
DWI ADC
T1 T2
T1 T2
T1 T1+C
T1 T1+C
T2*T2*
Thalamic aphasiaPatient 1 Patient 2
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