Cranial imaging findings in dengue virus infection

https://doi.org/10.1016/j.jns.2014.04.018Get rights and content

Highlights

  • Cranial imaging reveals nonspecific changes in dengue virus encephalitis/encephalopathy.

  • Abnormal MRI lessions are secondary to hypoxia or ischemia.

  • outcome in dengue is not related to MRI abnormality.

Abstract

Background

The aim of this study is to evaluate cranial CT or MRI changes in dengue encephalitis and their correlation with clinical and biochemical findings.

Methods

Twenty-one serologically confirmed patients with dengue with altered sensorium were included who underwent MRI (20)/CT (1) scan study. Their clinical details including seizure, hypotension, bleeding diathesis, focal neurologic deficit, and Glasgow Coma Scale (GCS) score were noted. Blood counts, hematocrit, renal and liver function tests, electrolytes, cerebrospinal fluid (CSF) and ECG were done. MRI findings on T1, T2, FLAIR, DWI and T1 gadolinium contrast were noted.

Results

The median age of the patients was 30 (5–69) years and 5 were females. MRI was abnormal in 9(45%) and CT scan in 1 patient with dengue shock syndrome revealed cerebellar and subdural hematoma. The MRI lesions were in thalamic and basal ganglia in 3, focal cortical areas in 3, white mater in 2 and meningeal enhancement in 3 patients. Seven of these patients had CSF pleocytosis. The presence of abnormal imaging was not related to outcome. One patient died, 1 was bed ridden and 19 had complete recovery on discharge.

Conclusion

Cranial imaging reveals nonspecific changes and is not related to hematological and biochemical changes or outcome.

Introduction

Dengue is the most important mosquito borne disease after malaria [1]. Its incidence has increased many folds in last half a century. About 4 billion people live in dengue endemic areas of Asia, Africa, Australia, America and Europe [1], [2]. Dengue virus is a RNA virus of flaviviridae group and results in dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Dengue virus is a non-neurotropic virus but increasing number of studies on central nervous system (CNS) involvement in dengue virus infection has been reported [3], [4], [5], [6], [7]. The neurological involvement in dengue virus infection can occur due to metabolic alteration, such as liver or kidney dysfunction, hyponatremia, hemorrhagic diathesis in the CNS, DSS, hypoxia and hypotension, direct CNS invasion of dengue virus (DENV) producing encephalitis and post infective autoimmune mediated CNS injury [4], [5], [6]. Cranial MRI has provided information about the extent and nature of CNS injury in viral infections. There are characteristic MRI changes in viral encephalitis; frontotempoal changes in herpes simplex encephalitis; thalamus, basal ganglia and brain stem involvement in Japanese encephalitis (JE) and eastern equine encephalitis [8], [9], [10]. There are few reports of MRI changes in DENV infection and have revealed a wide variety of changes such as intra cerebral hemorrhage and thalamic, basal ganglia, cortical and sub cortical involvement [6], [11], [12], [13], [14], [15]. In the dengue endemic area, JE or other viral encephalitis are also prevalent; hence these MRI changes need to be critically evaluated. Prospective MRI studies using different sequences may help not only in localizing the abnormality but may also shed light on the underlying pathology, such as necrosis, edema, haemorrhage and demyelinating features. In the present study, we report the MRI/CT findings in patients with DENV infections and correlate these with their clinical and laboratory findings.

Section snippets

Material and methods

The patients with abnormal cranial imaging (CT/MRI) were prospectively evaluated from our dengue registry maintained since 2003. The diagnosis of dengue encephalopathy was based on signs and symptoms of acute encephalitic syndrome with the presence of dengue antigen (NS1) and/or IgM antibody against dengue virus in serum. Patients with malaria, Leptospira, Chikungunya, JE, herpes simplex virus (HSV) encephalitis and Epstein Barr virus encephalitis were excluded. The patients were subjected to

Results

There were 21 patients with DENV infections who underwent cranial MRI or CT scan study (Fig. 1, Fig. 2, Fig. 3, Fig. 4). Their median age was 30 (5–69) years and 5 were females; 3 patients were below the age of 15 years. The median GCS score was 12 (3–15) and eight patients had generalized tonic clonic seizures (Table 1). Systolic blood pressure was below 90 mm of Hg in 3 patients. Two patients had jaundice, 4 ecchymosis/petechiae and 2 had epistaxis and gum bleeding, 4 sub-conjunctival

Discussion

In the present study on dengue encephalopathy or encephalitis, imaging was abnormal in 47.6% (10/21) patients (9 MRI and one CT). The MRI changes are non-specific and include intracerebral hemorrhage, thalamic involvement and cortico-subcortical white matter changes. This study evaluates the MRI changes in the patients with dengue encephalopathy or encephalitis and have correlated these changes with clinical and laboratory findings. MRI findings in dengue virus infection have also been reported

Conflict of interest

None.

Acknowledgment

This project was funded by the Council of Science and Technology, Government of Uttar Pradesh, India (CST/SERPD/D-996). We also thank Mr. Rakesh Nigam and Deepak Kumar Anand for secretarial help.

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