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Título

Acute cerebellar ataxia associated with Dengue fever: Case report and literature review

RESUMO

Case presentation: A 70-year-old female was admitted due to vertigo and imbalance associated high fever, headache, photophobia, myalgia, nausea, and emesis for 5 days. She denied other symptoms, as well as exposure to predisposing agents. At physical examination, there was a global asymmetric cerebellar syndrome, without other abnormalities. Laboratory work-up showed lymphocytosis, leucopenia, thrombocytopenia, and increased liver enzymes. Serologic exams were negative for syphilis, human immunodeficiency virus, hepatitis B and C viruses, cytomegalovirus (CMV), rubella, toxoplasmosis, and trypanosomiasis in peripheral blood, and for CMV, herpes simplex and varicella-zoster viruses, and toxoplasmosis in cerebrospinal fluid. Brain MRI with angiography was unremarkable (Figure 1). During hospital stay, there was complete recovery of the systemic symptoms and gradual improvement of the cerebellar syndrome. She was discharged for outpatient follow-up, during which a positive IgM (MAC-ELISA) for Dengue virus was identified. Fifty-four days after symptom onset, she had a normal neurological exam, remaining with a mild subjective imbalance complaint.
Discussion: Despite uncommon, neurological involvement in Dengue fever is well recognized, both due to direct viral lesion and to immunomediated mechanism. Encephalitis and encephalopathy are the most frequent manifestations; however, meningitis, stroke, myelitis, Guillain-Barré syndrome, and neuritis have also been reported. Association between cerebellar syndrome and Dengue, however, is extremely rare, with only seven other cases published (Table 1). Acute cerebellar ataxia, part of a spectrum of cerebellar dysfunction related to inflammatory conditions, is characterized by normal neuroimaging and complete recovery in two months to three years. As etiologies are numerous, a throughout investigation must be performed before establishing this causal relationship. In our patient, it was possible to confirm recent infection by Dengue and to exclude other agents associated with ataxia.
Final considerations: The present report corroborates with the recognition of Dengue virus as a cause of acute cerebellar ataxia. Considering the infection’s incidence worldwide, it is probable that this association is underdiagnosed, especially considering the number of cases of acute ataxia without an identified etiology. Active investigation of Dengue infection should be a part of the work-up in such cases.

Palavras Chave

Dengue, arboviruses, cerebellum, ataxia