20160720 Japanese encephalitis
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Japanese encephalitis is a vaccine-preventable, but fatal encephalitis. I will present two case of Japanese encephalitis, and they had some neurologic deficit on language, motor function and even brainstem function. Though Low clinical illness rate, but high disability or mortality rate developed in these patients
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20160720 Japanese encephalitis
- 2. 4 day before Day 1 Mrs. Dai 42 y/o housekeeper
- 3. 4 day before Day 1 Mrs. Dai 42 y/o housekeeper
- 4. WBC: 14.68 CRP: 3.29 WBC: 222 /uL Protein: 47.6 Glucose: 65
- 5. CT when admission Brain swelling No mass lesion!?
- 6. WBC: 14.68 CRP: 3.29 WBC: 222 /uL Protein: 47.6 Glucose: 65 Seg:45%
- 8. 4 day before Day 1-5 Day 6 Right-hand action tremor? Bradycardia Aphasia
- 9. MRI Day 5 Left thalamic lesion Left P-O cortical lesion
- 10. CT when admission Brain swelling Left thalamic hypo-dense lesion
- 11. Anti-TPO: Neg Vit. B12: 234 pg/ml Folate: 11.57 ng/mL Crypto Ag: Neg TPPA: Neg
- 12. 4 day before Day 1-5 Day 6 Non-fluent speech Bradycardia Obey order
- 14. Final diagnosis 1. Japanese encephalitis over left thalamic and left P-O cortical lesion
- 15. 5 days before Day 1 Day 5 Mr. Chen 44 y/o. Px: HTN
- 16. 5 days before Day 1 0 0 3 3 0 0 3 3 Mr. Chen 44 y/o. Px: HTN Unable to communicate Slurred speech
- 17. 5 days before Day 1 0 0 3 3 0 0 3 3 Mr. Chen 44 y/o. Px: HTN Unable to communicate Slurred speech
- 18. WBC: 8.53 CRP: 3.11 Cre: 1.8 K: 3.0 ➡ WBC: 145 /uL Protein: 95.1 Glucose: 79
- 19. MRI when admission Bilateral thalamus, especially L’t Left cerebral peduncle Left upper pons
- 20. WBC: 8.53 CRP: 3.11 Cre: 1.8 K: 3.0 ➡ WBC: 145 /uL Protein: 95.1 Glucose: 79 Seg:14.5%
- 21. 5 days before Day3 Mr. Chen 44 y/o. Px: HTN Tea color urine Respiratory distress Spiking fever
- 22. Mr. Chen 44 y/o. Px: HTN WBC: 16.0 Cre: 1.4 GOT: 1004 GPT: 254 CK: 68600 Urine Myoglobulin
- 23. Mr. Chen 44 y/o. Px: HTN WBC: 16.0 Cre: 1.4 GOT: 1004 GPT: 254 CK: 68600 Urine Myoglobulin Multi-organ involvement
- 24. Acyclovir Doxycycline / Claforan Day 1 Day 3
- 25. 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
- 26. 1st JE. IgM: Negative Influenza A,B: Negative HIV : Negative HSV/ CMV/ VZV : Negative Lepto/ Lyme : Negative All culture: Negative
- 27. CT when day 7 Bilateral thalamus Bilateral cerebral peduncle Bilateral pons
- 28. MRI when day 10 Bilateral thalamus, especially L’t Bilateral midbrain, especially L’t Bilateral pons, especially L’t Leptomeaneal enhancement, L’t
- 29. 2nd JE. IgM: Positive Mr. Chen 44 y/o. Px: HTN
- 30. Final diagnosis 1. Japanese encephalitis over bilateral thalamic, pontine, midbrain lesion and left leptomeningeal enhancement 2. Atypical infection with hepatic and renal impairment and rhabdomyolysis Autoimmune?
- 31. Question?
- 36. Low Clinical Illness Rate
- 40. Normal Disability Death Disability or Death !
- 41. CSF Examination Mild/ moderate pleocytosis Mild Protein Glucose — Lymphocyte dominantly
- 42. Laboratory Examination Day 3 Day 10 Antibody Day 90
- 43. Laboratory Examination Day 3 Day 10 1st test 2nd test
- 44. How to Confirm IgM + or PCR 1st 2nd Antibody 4x Antibody IgM+
- 45. How to Confirm IgM + or PCR 1st 2nd Antibody 4x Antibody IgM+
- 46. How to Confirm IgM + or PCR 1st 2nd Antibody 4x Antibody IgM+Patient 1 Patient 2
- 47. How to Confirm Asymmetric Symmetric DiffuseFocal/ Discrete Infection Neoplasm Systemic Metabolic Bilateral lesion
- 48. How to Confirm Asymmetric Symmetric DiffuseFocal/ Discrete Infection Neoplasm Systemic Metabolic Bilateral lesion
- 49. How to Confirm Asymmetric Symmetric DiffuseFocal/ Discrete Infection Neoplasm Systemic Metabolic Bilateral lesion
- 50. How to Confirm Patient 1 Patient 2
- 51. How to Treat Supportive care
- 52. How to Treat Supportive care Day 3 Day 10 Antibody Day 90
- 53. Prognostic factor Prospective, follow-up 8.3 years 108 children in Malaysia Serologically confirmed 1997-2005
- 54. Prognostic factor At discharge Long-term follow-up
- 55. Prognostic factor At discharge Long-term follow-up
- 56. Poor prognostic factor GCS =< 8 Seizure + Shock +
- 57. Treatable Prognostic Factor Seizure Shock
- 58. Thalamic aphasia Patient 1 Patient 2
- 59. Thalamic aphasia Patient 1 Patient 2
- 60. Thalamic aphasia Repetition: intact Fluency: variably affected Comprehensive: variably affected Lexical-semantic deficits
- 62. Etiology of Rhabdomyolysis Non-exertional & Non-traumatic Drugs Toxin Infections Electrolyte Endocrine Inflammatory
- 63. Thanks for your attention R1 Jin-Yi Hsu
- 64. DWI ADC
- 65. DWI ADC
- 66. DWI ADC
- 67. T1 T2
- 68. T1 T2
- 69. T1 T1+C
- 70. T1 T1+C
- 71. T2*T2*
- 73. Thalamic aphasia Patient 1 Patient 2