Dados do Trabalho

Título

Diagnostic challenge in a young man: dengue encephalitis or post-dengue acute disseminated encephalomyelitis (ADEM)?

RESUMO

Case report: A 25-year-old male patient presented a clinical course suggestive of dengue, with a positive NS1 test. With less than 24 hours of symptoms, he began progressive mental confusion, focal seizures, and subsequent sensorium lowering. Brain magnetic resonance imaging was performed, which showed foci of diffusion restriction and hyper signal on T2/FLAIR bilaterally in the brainstem, hippocampus, and thalamus topographies, a pattern suggestive of encephalitis. An electroencephalogram was performed, which showed bursts of slow waves predominantly frontally bilaterally and rare epileptiform paroxysms in the parietal topography bilaterally. A lumbar puncture was performed, which showed only an increase in protein (100mg/dL). Treatment of seizures was performed with Phenytoin and Levetiracetam. Discussed as a team and opted to perform Immunoglobulin for 5 days, with subsequent significant improvement of the condition. At hospital discharge, the patient had improved orientation and had no focal deficits.
Discussion: Dengue is the main cause of encephalitis with normal cellularity in the cerebrospinal fluid in endemic regions. Although there are no characteristic lesions for dengue encephalitis, the patient had lesions characteristic for encephalitis in general, that is, involvement of the limbic system, in addition to hyperproteinorraquia and a suggestive clinical course. Therefore, dengue encephalitis was our main diagnostic hypothesis. However, there was also a differential diagnosis with ADEM, which is a post-infectious autoimmune encephalitis. Despite differences in pathogenesis and histological findings, their clinical course and signs in imaging tests can be very similar. Therefore, since it was not possible to rule out ADEM and given the patient's clinical severity at the time, we chose to perform an Immunoglobulin infusion for 5 days.
Final comments: There is no specific treatment for dengue encephalitis, with most patients having a good prognosis. ADEM can be treated with immunosuppressive medications. Given the diagnostic doubt, we chose to use Immunoglobulin, and the patient had a good response and recovery.

Palavras Chave

Encephalitis . Dengue . Encephalomyelitis