A Case Report on Viral Meningoencephalitis

 

Anusha Ommi*

Department of Pharmacy Practice, Vignan Institute of Pharmaceutical Technology, Duvvada, Visakhapatnam.

 

ABSTRACT:

Viral infections of the central nervous system (CNS) including meningitis and encephalitis are commonly seen in clinical practice worldwide. Viral meningoencephalitis used to denote a viral infectious process of both the brain/spinal cord and the meninges. Severe viral meningoencephalitis continues to impose high rates of morbidity and mortality. In this case report a 42 year old female patient presented with fever with chills, constipation, abdominal pain, headache and vomitings. On initial examination, the patient showed kernig sign which is indication for meningitis. Clinical presentation and cerebrospinal fluid analysis showed that the patient had viral meningoencephalitis. On second day of admission, she had generalized tonic-clonic seizure (GTCS) attack and went into unconscious state. The patient was treated symptomatically and died due to poor prognosis. Viral meningoencephalitis is a medical emergency where early diagnosis and treatment might help for the better outcome.

 

 

 

INTRODUCTION:

Central nervous system (CNS) infections continue to affect populations worldwide with high morbidity, mortality and risk of long-term sequelae¹. Viral meningitis is a febrile illness associated with clinical signs of meningeal irritation (neck stiffness, the presence of Kernig and/or Brudzinski signs) but without the presence of neurologic dysfunction whereas Viral encephalitis is a febrile illness with evidence of brain parenchymal dysfunction as manifested by an altered state of consciousness and/or objective signs of neurologic dysfunction (seizures, cranial nerve palsies, dysarthria, abnormal reflexes, paralysis, etc)².

 

So the term meningoencephalitis basically describes either patients with meningitis and any alteration in mental status or patients with encephalitis who have concomitant meningeal involvement³. It has been a real diagnostic and therapeutic challenge for clinicians for decades. Central nervous system disorders are leading cause of disability and account for more hospitalization and prolonged care⁴. The diagnostic as well as treatment possibilities in these viral meningoencephalitis patients are often limited. The disease course might be even brutal with rapid onset of irreversible neuronal damage in some patients with meningoencephalitis⁵. This report aimed to present a case of viral meningoencephalitis in 42 year old female patient.

 

CASE PRESENTATION:

A 42 year old female patient presented with a 10 day history of fever and constipation. She had intermittent pain in umbilical and hypogastric region which was aggrevated on food intake and in standing position which was gradually relieved on medication. She had a 5 day history of vomitings, headache and fever with chills. She had no significant history.

 

Upon evaluation in the emergency department, she showed kernig sign, blood pressure of 130/80mmHg, pulse of 86/min and no organomegaly was noticed. On second day of admission, she complained of drowsiness and went into unconscious state after generalized tonic-clonic seizure (GTCS) attack and her blood pressure was 150/80 mmHg. Her Glasgow coma scale (GCS) showed 8/15 score (E3 V1 M4) and later was decreased to 3/15.

 

A complete blood count showed a hemoglobin of 9.7 gm/dl (normal range 12-15gm/dl), total WBC count of 41200 cells/µl (normal range 4000-10000 cells/µl), hematocrit of 29.1% (normal range 36-46%), mean corpuscular volume (MCV) of 60.6 fl (normal range 81-101 fl), mean corpuscular hemoglobin (MCH) of 20.2 pg (normal range 27-32 pg), mean corpuscular hemoglobin concentration (MCHC) of 31.5gm/dl (normal range 32.5-34.5 gm/dl). Fasting blood sugar is of 127mg/dl (normal range <100). The sodium and potassium levels were fluctuating till the last date [increased sodium levels to 153 mmol/lit (normal range 135-145 mmol/lit) whereas potassium levels were decreased to 2.6 mmol/lit (normal range 3.8-5.2 mmol/lit)]. Other tests namely Liver Function test, Arterial Blood Gas report and Urine Analysis were normal.

 

Laboratory studies including serological testing for hepatitis and malarial antigen were negative. A lumbar puncture was performed and cerebrospinal fluid (CSF) showed a total nucleated cell count of 100 cells/µl, with a differential of 75% lymphocytes and 25% polymorphs. In addition, the CSF showed a normal glucose level of 45mg/dl (normal range 40 to 80mg/dl), chloride level of 122 mmol/l (normal range 98-126 mmol/l), adenosine deaminase of 4.47 u/l (normal range <10 negative) and an elevated protein level of 343.3mg/dl (normal range 10-45mg/dl).

 

She was initially treated with inj. Ceftriaxone 2gm twice daily, inj. Pantoprazole 40mg once daily, inj. Lorazepam 3ml in 3ml distilled water, inj. Phenytoin 100mg three times a day, inj. Paracetamol 1gm when required, inj. Acyclovir 500mg in 100ml normal saline every 6^th hourly. Patient was put on mechanical ventilation for her unconscious state and was advised to remove ventilation mask 2^nd hourly for every 15 minutes. She was later started with inj. Noradrenaline 5ml + 45ml normal saline (NS), inj. Dopamine 5ml + 45ml NS on day 3. On day 7 she started with inj. Dexamethasone 8mg three times a day. Patient condition was detoriated and was also not responding to the painful stimuli. On day 9, patient condition was unstable, the SPO₂ was fluctuating from 30% to 80%. The patient died due to cardiorespiratory arrest.

 

DISCUSSION:

Viral infection of the CNS produces inflammation in distinct anatomical regions such as the meninges, brain parenchyma, and cranial nerves or in simultaneously multiple regions. Inflammation isolated to the meninges produces meningitis, whereas involvement of the brain parenchyma results in encephalitis. There may be an inflammatory continuum between these adjacent anatomic regions known as meningoencephalitis⁶. It is often used to denote a viral infectious process of both the brain/spinal cord and the meninges⁷. According to Glaser et al. 2006, approximately 60% of cases with meningoencephalitis remain undiagnosed, despite extensive clinical laboratory testing^8,9.

 

Neurologic symptoms that includes headache, seizures, hearing loss, lethargy/coma, weakness, ataxia, paresthesias, and loss of cognitive skills may be present in patients with chronic meningoencephalitis². In this case the patient presented with headache, weakness, vomitings, fever with chills, seizures and coma. She was also presented with kernig sign which is one of the clinical presentation for meningitis.

 

The most important laboratory test in the diagnosis of viral meningitis/encephalitis is examination of the CSF. The typical profile is a lymphocytic pleocytosis (25 to 500cells/μL) a normal or slightly elevated protein concentration [0.2 to 0.8 g/L (20 to 80mg/dL)], a normal glucose concentration, and a normal or mildly elevated opening pressure (100 to 350 mmH2O)¹⁰. Adenosine deaminase levels were negative in this patient which helped to differentiate Tuberculous Meningitis (TBM) from other forms of meningitis. Numerous previous studies have demonstrated that CSF adenosine deaminase (ADA) activities estimation is useful in the diagnosis of tuberculosis meningitis and can differentiate TBM from normal subjects or from patients with other neurological disorders¹¹.

 

From last few years due to restricted entry of many therapeutic agents to CNS, the diseases of CNS can’t be treated efficiently¹². Specific therapy is limited only to several viral agents, correct diagnosis and supportive and symptomatic treatment (when no specific therapy is available) are mandatory to ensure the best prognosis⁷. The cornerstone of treatment in the majority of viral meningoencephalitis cases is symptomatic treatment only⁵. Although a wide range of viruses can cause CNS infections, the treatment options are limited. Early treatment with acyclovir which is an antiviral drug belonging to the deoxiguanosine family¹³ has been associated with a lower risk of sequelae and death¹.In this case the patient was treated with Acyclovir as an initial treatment for Viral Meningoencephalitis along with symptomatic treatment. However due to poor prognosis, the patient died due to cardiorespiratory arrest.

 

CONCLUSION:

So hereby, I conclude that even after providing the proper symptomatic treatment the patient couldn’t survive because of poor prognosis and as we know that this is a medical emergency, early diagnosis and treatment might help for the better outcome from the disease.

 

CONFLICTS OF INTEREST:

The author declares no conflicts of interest.

 

ETHICAL APPROVAL:

Consent was obtained from the guardian/family member of the patient.

 

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Accepted on 11.05.2020      ©Asian Pharma Press All Right Reserved