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

1. Japanese
Encephalitis
R1 Jin-Yi Hsu

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%

7. Acyclovir
Ceftriazone
Day 1
Dexamethasone

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

13. JE. IgM: Positive

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?

32. Japanese
Encephalitis
R1 Jin-Yi Hsu

36. Low Clinical Illness Rate

37. 5-15 days
Clinical Course
Days
Days

38. 5-15 days
Clinical Course
Days
Days

39. 5-15 days
Clinical Course
Days
Days

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

61. Etiology of Rhabdomyolysis
Trauma
Non-trauma
Exertional
Non-Exertional

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