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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 69-70

Acute cerebellitis associated with dengue fever


Department of General Medicine, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India

Date of Submission13-Sep-2014
Date of Acceptance19-Feb-2015
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. K Venugopal
Department of General Medicine, Vijayanagara Institute of Medical Sciences, Bellary - 583 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.319846

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  Abstract 


Dengue fever is caused by dengue virus of Flavivirus family transmitted by Aedes aegypti. It causes acute febrile illness with various constitutional symptoms with bleeding manifestations and shock in some instances. Neurological involvement has been frequently reported reported. However, cerebellar involvement is very rare. Here we report a case of 32-year-old male patient presented with fever of 8 days, giddiness, unsteadiness of gait with swaying to the right, slurring of speech and incoordination. Diagnosis of acute cerebellitis was made, and involvement of the cerebellum in this patient was attributed to dengue fever. Patient treated for dengue fever, cerebellar symptoms were gradually improved in the course of hospital stay. He got discharged and on follow-up there was complete resolution of cerebellitis.

Keywords: Acute cerebellitis, dengue fever, neurological manifestations


How to cite this article:
Venugopal K, Huggi V, Bharathraj M Y, Lingaraja M, Ganiger M, Suresh C. Acute cerebellitis associated with dengue fever. J Mahatma Gandhi Inst Med Sci 2021;26:69-70

How to cite this URL:
Venugopal K, Huggi V, Bharathraj M Y, Lingaraja M, Ganiger M, Suresh C. Acute cerebellitis associated with dengue fever. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Jul 24];26:69-70. Available from: https://www.jmgims.co.in/text.asp?2021/26/1/69/319846




  Introduction Top


Dengue fever also known as break bone fever is caused by dengue virus. It is an RNA virus of the family Flaviviridae. It is transmitted by Aedes aegypti. It causes symptoms like fever, headache, muscle pain, back pain, joint pain and other constitutional symptoms. In small proportion of patients, it produces dengue hemorrhagic fever characterized by capillary leak, low platelet count and bleeding manifestations, and dengue shock syndrome is characterized by hypotension. Most life-threatening complication of dengue includes acute respiratory distress syndrome. Dengue produces various neurological complications ranges from myositis to life threatening intracerebral hemorrhage. Cerebellar involvement following viral infections has been reported in various literatures. However, cerebellar involvement in dengue is not clear and very unusual. Hereby, we report a case of dengue fever causing acute cerebellitis with complete recovery in 2 weeks.


  Case Report Top


A 32-year-old nonsmoker, nonalcoholic male patient presented to our hospital with a history of fever of 8 days duration. Fever was insidious in onset, mild to moderate grade, intermittent and was not associated with chills. Fever was associated with headache, back pain, abdominal pain and three episodes of vomiting. Vomitus contained food particles. Patient also gave a history of slurring of speech, swaying to both sides with predominant toward the right side while walking and not able to eat due to incoordination. On examination, he was febrile with the temperature of 100.5°F, pulse rate of 102 beats/min, blood pressure of 100/70 mmHg. His higher mental functions were normal, he had scanning type of speech without aphasia, and motor system examination revealed decreased tone in both upper and lower extremities with normal muscle power and reflexes. Sensory examination was normal. Cerebellar system examination showed dysdiadokinesia, past pointing, wide-based gait, ataxia in the form of swaying to the right side, scanning speech, inability to do tandem walking and negative Romberg sign. There was no nystagmus or tremors. His skull and spine were normal. Cardiovascular system revealed tachycardia with loud first heart sound. Abdominal examination revealed mild tenderness in the right hypochondria, with no organomegaly. Respiratory system was apparently normal. His complete blood picture showed total leucocyte count of 3200 cells/cumm, hemoglobin of 12.5 g%, and platelet count of 32,000 cells/cumm. Random blood glucose was 127 mg%, and his renal parameters and electrolytes were normal. Liver function tests revealed serum glutamic oxaloacetic transaminase of 112 and serum glutamate pyruvate transaminase of 120 IU/L with normal bilirubin and proteins. Peripheral smear for malarial parasite and Widal test for typhoid were negative.

Patient's platelet counts and hematocrit were monitored daily. There was no evidence of capillary leak or shock. There were no bleeding manifestations. He was treated symptomatically for fever with paracetamol 500 mg 3 times a day, with adequate hydration and antacid. The patient's fever came down on 5th day, but cerebellar symptoms persisted. Plain computed tomography scan of the brain performed on 6th day was normal [Figure 1]. Patient was not affordable to get magnetic resonance imaging done. Dengue NS1 antigen was positive. Cerebrospinal fluid (CSF) analysis done on 6th day had positive IgM. A provisional diagnosis of acute cerebellitis due to viral infections was made. Other causes of cerebellitis like human immunodeficiency virus (HIV), syphilis, cytomegalovirus, Epstein–Barr virus (EBV) and herpes simplex virus (HSV) were excluded. Diagnosis of dengue infection was made and acute cerebellitis in this patient attributed to dengue due to the positivity of dengue NS1antigen in serum, IgM dengue antibodies in CSF, normal brain imaging and by excluding other causes.
Figure 1: Normal computed tomography imaging of the brain

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Patient was discharged on 10th day when fever and other constitutional symptoms are reduced. At the time of discharge, patient was hemodynamically stable with normal platelet counts and gradual improvement of his cerebellar symptoms. Patient was called for a follow-up after 15 days. On follow-up, he was completely normal with resolution of his cerebellar symptoms.


  Discussion Top


Neurological complications occur in 0.5–6.0% of patients with dengue infection.[1]

Neurological manifestations of dengue fever include hypokalemic palsy, myositis, Guillain–Barre syndrome, intra cerebellar hemorrhage, encephalopathy, optic neuritis, occulomotor palsy, maculopathy, acute disseminated encephalomyelitis and lumbosacral plexopathy.[2],[3] Cerebellar involvement in dengue is not clear. Exact pathogenesis of neurological manifestations in dengue is not clear. It can be related to the neurotrophic effect of the virus, systemic effects of the infection and can be immune mediated.[2]

Acute cerebellitis in relation to virus infection can be primary-infective or postinfective.[4] Acute primary-infective cerebellitis mostly occurs secondary to infections such as varicella zoster virus, EBV, measles, mumps, rubella, HSV and Coxsackie virus. Postinfective cerebellitis have been reported following infection with varicella zoster virus, Coxsackie virus, EBV and HIV.[5] Cerebellar disorders due to HSV infection are rare and always associated with herpes simplex encephalitis.[6] Although commonly due to viruses, bacterial infections have also been associated with cerebellitis, including Borrelia burgdorferi (Lyme disease), Mycoplasma pneumoniae, Legionella and Coxiella burnettii (Q fever). In addition, cerebellitis may follow immunizations, such as hepatitis, smallpox and measles vaccination.[7] Cerebellar syndrome in association with dengue fever has been reported in only four instances.[5] In many cases, however, the precise causative agent is not isolated.

In our patient, presence of acute cerebellitis can be attributed to dengue infection due to positivity of NS1 antigen, by excluding other possible viral infections that causes cerebellitis and normal brain imaging. Hence, we are reporting this serious, self-limiting entity that hampers the routine activities of patient. In uncomplicated cases of cerebellitis, treatment is usually supportive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hendarto SK, Hadinegoro SR. Dengue encephalopathy. Acta Paediatr Jpn 1992;34:350-7.  Back to cited text no. 1
    
2.
Koshy JM, Joseph DM, John M, Mani A, Malhotra N, Abraham GM, et al. Spectrum of neurological manifestations in dengue virus infection in Northwest India. Trop Doct 2012;42:191-4.  Back to cited text no. 2
    
3.
Murthy JM. Neurological complication of dengue infection. Neurol India 2010;58:581-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Sawaishi Y, Takada G. Acute cerebellitis. Cerebellum 2002;1:223-8.  Back to cited text no. 4
    
5.
Withana M, Rodrigo C, Chang T, Karunanayake P, Rajapakse S. Dengue fever presenting with acute cerebellitis: A case report. BMC Res Notes 2014;7:125.  Back to cited text no. 5
    
6.
Ciardi M, Giacchetti G, Fedele CG, Tenorio A, Brandi A, Libertone R, et al. Acute cerebellitis caused by herpes simplex virus type 1. Clin Infect Dis 2003;36:e50-4.  Back to cited text no. 6
    
7.
Karunarathne S, Udayakumara Y, Fernando H. Epstein-Barr virus co-infection in a patient with dengue fever presenting with post-infectious cerebellitis: A case report. J Med Case Rep 2012;6:43.  Back to cited text no. 7
    


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