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Atypical presentation of dengue virus infection.OA Case Reports

The organisms that cause meningitis usually colonize in a person’s respiratory tract. Vaccines are available to prevent some types of bacterial meningitis. Did you know that one of the most prominent symptom of meningitis is a stiff neck? There are many different types of bacteria which cause meningitis but the main ones are Neisseria meningitidis (meningococcal) bacteria and pneumococcal bacteria. Wikipedia mentions: No virus particles, bacteria, or fungi have been conclusively associated with prion diseases, although Saccharomyces cerevisiae has been known to be associated with infectious, yet non-lethal prions, such as Sup35p. The organism may first cause a cold, sinus infection, or ear infection (more common in children), and then travel through the sinuses into the brain and CSF, although this method of transmission is less common. Approximately 80 to 90% of all cases of aseptic meningitis, in which a pathogen is identified, are enteroviruses.

The least common method by which the organisms causing meningitis are transmitted, but one of the most interesting, is called intraneural spread. Louis encephalitis), and cats (toxoplasmosis and cat-scratch disease). Herpes simplex virus type 2 (HSV-2) meningitis primarily develops during or following a primary genital HSV-2 infection that was acquired from sexual contact. Lumbar puncture (spinal tap). Although several neurological manifestations of dengue infection, such as meningoencephalitis, acute disseminated encephalomyelitis, transverse myelitis and Guillain–Barre´ syndrome have been described, the true prevalence is unknown owing to underdiagnosis and under-reporting of these rarer presentations[2,3,4,5]. This is the area around the spinal cord. Despite the high prevalence of dengue infection, meningitis caused by dengue virus has not been reported previously in Sri Lanka.

Streptococcus pneumonia, Haemophilus influenza, Neisseria meningitides and Listeria monocytogenes are some of the bacterial strains that can cause it. The infection causes an immune response which causes the meninge to swell. ‘itis’ is inflammatory. Bacterial meningitis. Serological methods are currently used to confirm infection during outbreaks caused by a single serotype of EV [1]. Rest of the examination was normal. spinal tap (Also called a lumbar puncture.) – a special needle is placed into the lower back, into the spinal canal.

Polymerase chain reaction (PCR) of the CSF to determine any underlying viral cause. The steroid works by decreasing the inflammation and reducing pressure that can build up in the brain. CSF gram stain and fungal stains were negative and CSF bacterial culture was done. Treatment for viral meningitis is usually supportive (aimed at relieving symptoms). He was started on intravenous acyclovir and ceftriaxone. 2. Group B meningococcal bacteria accounts for almost 80% of all cases of meningitis in Ireland according to the Health Protective Surveillance Centre.

By this time, CSF bacterial culture was available and was negative. The therapy usually involves treatment with several different medicines for the first few months, followed by other medicines. Studies show that whenever NAAT results for Enterovirus are available, hospitalization can be reduced by at least 12 to 24 hours, which in turn significantly reduces the costs. Dengue fever is currently the most important mosquito-borne viral infection of public health significance in Sri Lanka[8]. Intracranial pressure is measured in two ways. Reactivation;- It is well known that many triggers can provoke a recurrence. However, since 2010, dengue serotype 1 has become the predominant serotype in Sri Lanka, accounting for more than 95% of dengue infections[8].

Our case occurred during the dengue epidemic of 2013 and did not have the typical clinical features of dengue infection. There was no history of arthralgia, myalgia, abdominal pain and bleeding manifestations. The main symptoms were high-grade fever with severe generalised headache, which was refractory to analgesics. Headache is a very common symptom in patients with dengue fever, and severe or very severe headache is reported in 79% of patients with dengue fever[9]. As CSF analysis is not done routinely to differentiate ‘non-specific dengue headache’ from dengue meningitis, a number of patients with dengue meningitis may remain undiagnosed[6]. However, in addition to headache, presence of neck stiffness with a positive Kernig’s sign in our patient pointed toward the clinical diagnosis of meningitis. A number of neurological manifestations, such as meningoencephalitis, acute disseminated encephalomyelitis, transverse myelitis and Guillain–Barre´ syndrome, have been reported in association with dengue infection[2,3,4].

This study had several limitations. Meningitis is a rare manifestation of dengue fever, and only few such cases have been reported in the literature[5,6,7]. The healthcare team educates the family after hospitalization on how to best care for the patient at home, and outlines specific clinical problems that require immediate medical attention by his/her physician. In most cases, diagnosis depends on detection of the virus itself (by culture, polymerase chain reaction or dengue NS1 antigen) or detection of host immune reaction (IgM antibody) in the serum. All these methods, which are validated for serum, with suitable modifications, have been used for CSF with a high specificity[12,13]. Mortality rates reported in cases of dengue patients with neurological manifestation ranged from 5% to 8.35%[3,4]. However dengue meningitis has a benign outcome similar to other types of viral meningitis.


This case report demonstrates that meningitis can be the first manifestation of dengue infection. In endemic areas, dengue infection should be considered and tested as a probable etiological agent of viral meningitis. Regular monitoring of platelet count and detection of dengue IgM or NS1 antigen in serum and CSF may help in reaching correct diagnosis. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal. We all express our gratitude to Margaret Martin for her critical reading and grammar check of the manuscript, and to the patient, who kindly gave consent for his case to be presented in this article. 1.

. Centre for disease control and prevention. CDC: Dengue; 2013 [updated 4 September 2013; cited 14 October 2013]. Available from: http://www.cdc.gov/dengue/ . 2. Gulati S, Maheshwari A. A typical manifestations of dengue.

Trop Med Int Health 2007 Sep;12(9):1087-95. 3. Thisyakorn U, Thisyakorn C, Limpitikul W, Nisalak A. Dengue infection with central nervous system manifestations. Southeast Asian J Trop Med Public Health 1999 Sep;30(3):504-6. 4. Pancharoen C, Thisyakorn U.

Neurological manifestations in dengue patients. Southeast Asian J Trop Med Public Health 2001 Jun;32(2):341-5. 5. Goswami RP, Mukherjee A, Biswas T, Karmakar PS, Ghosh A. Two cases of dengue meningitis: a rare first presentation. J Infect Dev Ctries 2012 Feb 13;6(2):208-11. 6.

Soares CN, Cabral-Castro MJ, Peralta JM, Freitas MR, Puccioni-Sohler M. Meningitis determined by oligosymptomatic dengue virus type 3 infection: report of a case. Int J Infect Dis 2010 Feb;14(2):e150-2. 7. Bhat RY, Varma C. Meningitis as a primary presentation of dengue infection. J Microbiol Infect Dis 2013 Mar;3(1):39-40.

8. Malavige GN, Fernando N, Ogg G. Pathogenesis of dengue viral infections. Sri Lankan J Infect Dis 2011 Jan;1(1):2-8. 9. Domingues RB, Kuster GW, Castro FL, Souza VA, Levi JE, Pannuti CS. Headache features in patients with dengue virus infection.

Cephalalgia 2006 Jul;26(7):879-82. 10. Varatharaj A . Encephalitis in the clinical spectrum of dengue infection. Neurol India 2010 Jul–Aug;58(4):585-91. 11. Lum LC, Lam SK, Choy YS, George R, Harun F.

Dengue encephalitis: a true entity?. Am J Trop Med Hyg 1996 Mar;54(3):256-9. 12. Araújo FM, Brilhante RS, Cavalcanti LP, Rocha MF, Cordeiro RA, Perdigão AC. Detection of the dengue nonstructural 1 antigen in cerebral spinal fluid samples using a commercially available enzyme-linked immunosorbent assay. J Virol Methods 2011 Oct;177(1):128-31. 13.

Puccioni-Sohler M, Soares CN, Papaiz-Alvarenga R, Castro MJ, Faria LC, Peralta JM. Neurologic dengue manifestations associated with intrathecal specific immune response. Neurology 2009 Oct;73(17):1413-7.