Adnan Naeem1, Fatima Mubarak2
1 Aga Khan University Hospital, Karachi, Sindh PAKISTAN
2 M.B.B.S, FCPS, Associate Professor, Radiology, Aga khan University Hospital, Karachi
22 years, female
A 22-year-old female patient came to our emergency department initially with complaints of fever, headache, vomiting and shortness of breath for 10 days and dizziness with gait disturbance for 3 days.
Physical examination showed unsteady gait and horizontal nystagmus. Bilateral lower limb petechial haemorrhage and decreased breath sounds were also present.
Laboratory investigations showed decreased platelet count. Blood films for malarial parasite were negative. Dengue IgM serology was performed which was positive. Rest of laboratory investigations were unremarkable.
Since patient was complaining of drowsiness, MRI brain was performed which showed symmetric T2/FLAIR hyperintense signals in the bilateral cerebellar hemispheres with swelling of both cerebellar hemispheres and effacement of basal cisterns Fig 1. (A, B). These abnormal signal areas were showing diffusion restriction on DWI/ADC Fig 1. (D, E). There was also evidence of signal dropout/blooming on SWI sequences in above mentioned abnormal signals areas representing punctate haemorrhages Fig 3. Faint marginal enhancement was noted on post-contrast imaging Fig 1. F , Fig.3. There was also evidence of effacement of prepontine and premedullary cisterns.
Based on these MRI features with clinical and laboratory correlation, diagnosis of dengue fever with acute cerebellitis was made.
Dengue fever is viral infection caused by dengue virus which is single stranded RNA virus. It is transmitted mainly by the mosquito Aedes aegypti .
The clinical picture of disease ranges from self-limited mild fever to plasma leakage with shock, haemorrhage or may even lead to organ failure resulting in death .
Dengue viral infection may sometimes present with atypical manifestation such as myocarditis, acute kidney injury and cholecystitis .
Neurological manifestation of dengue fever occurs in 0.5% to 20% cases in hospital setting . There are several neurological manifestations most common for exammple encephalitis and encephalopathy . Some other rarer neurological manifestation include acute disseminated encephalomyelitis, Guillain–Barré syndrome, acute viral myositis and hypokalaemic quadriparesis .
Although not common, there are some reports of cases of acute cerebellitis with dengue fever in literature and in these cases patients presented with cerebellar signs such as nystagmus, dysarthria, bilateral limb, and gait ataxia [5, 6]. In our case, although patient presented with mild drowsiness, there were abnormal cerebellar signs.
Although exact mechanism is not known, the direct invasion of virus and immune-mediated mechanisms are postulated to be the cause this neurological sequelae .
Imaging features of dengue cerebellar involvement in previously published cases consist of T2-hyperintense areas in cerebellum , and patchy abnormal signal intensities in pons, medulla and cerebellar peduncles .
In our case after diagnosis, the patient was managed with oral steroid therapy and fluid replacement therapy. During the course of hospital stay the platelet count gradually recovered, neurological symptoms were improved and liver function tests returned to normal. After one week the patient was discharged in stable condition.
In this case report, we presented the rare manifestation of dengue fever in the form of acute cerebellitis. Although it is a rare condition, in endemic areas if patient presents with the history of dengue fever and neurological signs are present, then we should look for neurological manifestation of dengue viral infection.
Written informed patient consent for publication has been obtained.
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