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The Lancet 2002; 360:261
DOI:10.1016/S0140-6736(02)09481-3
Encephalitis and dengue
Enid J Garc?a-Rivera
a and Jos? G Rigau-P?rez a
Sir
Richard Whitley and John Gnann (Feb 9, p 507)1 review common and emerging pathogens associated with viral central nervous system (CNS) infections. Nevertheless, they do not mention dengue, an acute viral disease transmitted by Aedes mosquitoes, and highly endemic in many tropical and subtropical areas of the world.
Indirect effects of dengue infection on the CNS may be an explanation for encephalopathy, but the presence of IgM antibody to dengue in the cerebrospinal fluid (CSF) and reports of virus isolation from brain tissue and CSF of patients with neurological symptoms suggest direct virus invasion of the CNS.2
Three types of neurological manifestations have been associated with confirmed dengue infection: non-specific symptoms of headache, dizziness, delirium, drowsiness, sleeplessness, and restlessness; severe syndromes of depressed sensorium, lethargy, confusion, seizures, meningismus, paresis, and coma that are sometimes clinically indistinguishable from encephalitis; and delayed syndromes of paralysis of lower or upper extremities or larynx, seizures, tremors, amnesia, loss of sensation, manic psychosis, depression, dementia, and Guillain-Barr? syndrome.
Neurological complications associated with dengue infection can arise in dengue fever and dengue haemorrhagic fever. Any virus serotype may be involved, but DEN-2 and DEN-3 are most frequently reported as the cause of severe neurological disease. Most reported cases of dengue encephalopathy or encephalitis recover without neurological sequelae.3
The frequency of neurological changes as the presenting sign in dengue is unknown, but neurological complications associated with dengue infection have been recognised since the beginning of the 20th century and reported in almost every country in Asia and in many countries in the Americas.3 In one study in Vietnam, 4% of patients admitted to a neurology ward with suspected CNS infections were infected with dengue virus,4 and in Thailand, 18% of children admitted to a hospital with encephalitis-like illness were confirmed as having dengue infection.5 In Indonesia, 70% of virologically confirmed fatal dengue infections (n=30) presented with one or more neurological signs, and 7% were admitted for viral encephalitis, which was listed as the cause of death.3
The re-emergence of dengue as an important pathogen justifies its inclusion in the differential diagnosis of patients with acute onset of encephalitis in endemic countries or with a travel history suggestive of dengue exposure.
<!--start simple-tail=-->References
1. Whitley RJ, Gnann W. Viral encephalitis: familiar and emerging pathogens. Lancet 2002; 359: 507-514. Abstract | Full Text | PDF (399 KB) | MEDLINE | CrossRef
2. Lum LC, Lam SK, Choy YS, George R, Harun F. Dengue encephalitis: a true entity?. Am J Trop Med Hyg 1996; 54: 256-259. MEDLINE
3. Gubler DJ, Kuno G, Waterman SH. Neurologic disorders associated with dengue infection: proceedings of the International Conference on Dengue/Dengue Hemorrhagic Fever, Kuala Lumpur, Malaysia, September 1983: 290-301.
4. Solomon T, Dung NM, Vaughn DW, et al. Neurologic manifestations of dengue infection. Lancet 2000; 344: 1053-1059.
5. Kankirawatana P, Chokephaibulkit K, Puthavathana P, et al. Dengue infection presenting with central nervous system manifestation. J Child Neurol 2000; 15: 544-547. MEDLINE
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DOI:10.1016/S0140-6736(02)09481-3
Encephalitis and dengue
Enid J Garc?a-Rivera
a and Jos? G Rigau-P?rez aSir
Richard Whitley and John Gnann (Feb 9, p 507)1 review common and emerging pathogens associated with viral central nervous system (CNS) infections. Nevertheless, they do not mention dengue, an acute viral disease transmitted by Aedes mosquitoes, and highly endemic in many tropical and subtropical areas of the world.
Indirect effects of dengue infection on the CNS may be an explanation for encephalopathy, but the presence of IgM antibody to dengue in the cerebrospinal fluid (CSF) and reports of virus isolation from brain tissue and CSF of patients with neurological symptoms suggest direct virus invasion of the CNS.2
Three types of neurological manifestations have been associated with confirmed dengue infection: non-specific symptoms of headache, dizziness, delirium, drowsiness, sleeplessness, and restlessness; severe syndromes of depressed sensorium, lethargy, confusion, seizures, meningismus, paresis, and coma that are sometimes clinically indistinguishable from encephalitis; and delayed syndromes of paralysis of lower or upper extremities or larynx, seizures, tremors, amnesia, loss of sensation, manic psychosis, depression, dementia, and Guillain-Barr? syndrome.
Neurological complications associated with dengue infection can arise in dengue fever and dengue haemorrhagic fever. Any virus serotype may be involved, but DEN-2 and DEN-3 are most frequently reported as the cause of severe neurological disease. Most reported cases of dengue encephalopathy or encephalitis recover without neurological sequelae.3
The frequency of neurological changes as the presenting sign in dengue is unknown, but neurological complications associated with dengue infection have been recognised since the beginning of the 20th century and reported in almost every country in Asia and in many countries in the Americas.3 In one study in Vietnam, 4% of patients admitted to a neurology ward with suspected CNS infections were infected with dengue virus,4 and in Thailand, 18% of children admitted to a hospital with encephalitis-like illness were confirmed as having dengue infection.5 In Indonesia, 70% of virologically confirmed fatal dengue infections (n=30) presented with one or more neurological signs, and 7% were admitted for viral encephalitis, which was listed as the cause of death.3
The re-emergence of dengue as an important pathogen justifies its inclusion in the differential diagnosis of patients with acute onset of encephalitis in endemic countries or with a travel history suggestive of dengue exposure.
<!--start simple-tail=-->References
1. Whitley RJ, Gnann W. Viral encephalitis: familiar and emerging pathogens. Lancet 2002; 359: 507-514. Abstract | Full Text | PDF (399 KB) | MEDLINE | CrossRef
2. Lum LC, Lam SK, Choy YS, George R, Harun F. Dengue encephalitis: a true entity?. Am J Trop Med Hyg 1996; 54: 256-259. MEDLINE
3. Gubler DJ, Kuno G, Waterman SH. Neurologic disorders associated with dengue infection: proceedings of the International Conference on Dengue/Dengue Hemorrhagic Fever, Kuala Lumpur, Malaysia, September 1983: 290-301.
4. Solomon T, Dung NM, Vaughn DW, et al. Neurologic manifestations of dengue infection. Lancet 2000; 344: 1053-1059.
5. Kankirawatana P, Chokephaibulkit K, Puthavathana P, et al. Dengue infection presenting with central nervous system manifestation. J Child Neurol 2000; 15: 544-547. MEDLINE
Back to top