Enterovirus associated meningoencephalitis: A case report

S. Suganya

Infection Control Nurse, Kauvery Hospital, Tennur

Correspondence: M: 9361388804, email: [email protected]

Case Presentation

28 years young lady presented with history of fever of 1-day duration. Next day, she got erythematous vesicles all over her body, which began in her upper limb and extended to her trunk. On Day 3, she was found to be abnormal in the sense that she was not responding swiftly to her husband’s questions and not able to go about her daily routines. On Day 4, she developed altered sensorium associated with bowel and bladder incontinence. She was brought here to the emergency room in a drowsy state.

Past Medical History

There was no history of DM, HT, comorbidities, drug and food allergies and no past surgical history.

But, prior to her illness, her 8-month old baby had developed fever for 1day duration followed by rash with spontaneous resolution, without medications. 2-3days later, she (the patient) developed fever.

On Examination

She was drowsy but arousable,

PR – 64/min, regular, BP – 130/70mmHg, SpO2 – 96% at 4lit O2

CNS Examination – Neck Stiffness++

GCS – 8/15 (E2 V1 M5), B/L Pupils 2mm; RTL, No facial asymmetry

 

 

Motor Examination

 

Tone normal in all 4limbs, Power 4/5 in all 4limbs, DTR + + (deep tendon reflex)

Plantar response – B/L withdrawal response. Neck stiffness +

Primary Management

She was initially started on ceftriaxone, vancomycin and acyclovir.

CT Brain on 04.11.2023

  1. Multifocal subcortical white matter hypo densities in bilateral fronto parietal lobes
  2. No hydrocephalus at present

Her sensorium was not improved.

MRI Brain with contrast: Done on 05.11.2023 which revealed

  1. T2/Flair hyperintensities present involving subcortical white matter of bilateral fronto parieto temporal region with surrounding white matter oedema
  2. Patchy areas of diffusion restriction and mass effect
  3. No evidence of contrast enhancement.

ECHO (31.10.2023)

  1. Normal LV function (EF-66%)
  2. No intracavitary masses, thrombus, vegetations
  3. No pericardial effusion.

USG Abdomen and Pelvis (30.10.2023)

Mild hepatomegaly with grade I fatty change

CSF Evaluation

First time, CSF analysis detected Enterovirus by multiplex PCR.

The second CSF analysis detected Oligo clonal band, Aquaporin 4 antibody and Anti-MOG antibody were negative.

Autoimmune workup and Autoimmune encephalitis panel was also negative.

CSF analysis

CSF glucose – 68mg/dl

CSF protein – 25.9mg/dl

CSF cell count

CSF differential Count – Nil

CSF Total RBC – 8

CSF Total WBC – 2

CSF Gram stain – No growth.

Final Diagnosis

1. Enterovirus Associated Meningoencephalitis

2. ADEM -Like Illness (Acute disseminated encephalomyelitis)

Evolution at the hospital

  1. She received Methylprednisolone for 7days.
  2. She had episodes of restlessness and abnormal cry lasting for about 10-15minutes which was managed with benzodiazepine and Olanzapine.
  3. She improved symptomatically

She was discharged with the following advice.

  1. Antiepileptic drug: Tab. Epilive 500mg RT 1-0-1
  2. H2 Receptor Antogonist: Tab. Rantac 150mg RT1-0-1
  3. Steroids: Tab. Prednisolone 30mg RT 1-0-0 ×2 Weeks
  4. Anxiety Drugs: Tab. Ativan 1mg RT 0-0-2
  5. Vitamin supplements: Tab. Neurobion fort 0-0-1.
Suganya

Ms. S. Suganya

Infection control Nurse (ICN)

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