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# Hiroki Matsuura contributed to write manuscript, diagnosis, and discussion. Kentaro Deguchi contributed to discussion, patient care, and supervision. We do not have any funding sources in the writing of the manuscript or the decision to submit for publication. We do not have any conflict of interest.
# Hiroki Matsuura contributed to write manuscript, diagnosis, and discussion. Kentaro Deguchi contributed to discussion, patient care, and supervision. We do not have any funding sources in the writing of the manuscript or the decision to submit for publication. We do not have any conflict of interest.
Affiliations
Department of General Internal Medicine, Okayama City Hospital
# Hiroki Matsuura contributed to write manuscript, diagnosis, and discussion. Kentaro Deguchi contributed to discussion, patient care, and supervision. We do not have any funding sources in the writing of the manuscript or the decision to submit for publication. We do not have any conflict of interest.
A 67-year-old woman with acute onset of fever, disorientation, and confusion was transferred to our emergency department. Physical findings revealed neck stiffness, left dominant tremulous arms with cogwheel rigidity of her extremities. Computed tomography showed mild atrophy without cerebral bleedings. Magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery (FLAIR) sequence was shown in Figure (Fig. 1. on day 2, and Fig. 2. on day 5). What is the diagnosis?
Fig. 1FLAIR-MRI on day 2 showed trivial alteration in the bilateral thalami, hippocampus, caudate nuclei, and substantia nigra.
FLAIR-MRI demonstrated progressively marked hyperintense signal alterations in the bilateral thalami, internal capsules, hippocampus, caudate nuclei, and substantia nigra. A lumbar puncture was performed and the cerebrospinal fluid (CSF) revealed 62 cells/μL, for white blood cells and elevated protein level of 112 mg/dL. The CSF glucose level was normal. Her family reported an extremely limited immunization history in her childhood. However, her family also disclosed that she was hobby farmers and she didn't take measures for mosquito bite prevention. Subsequently, real-time reverse transcriptase polymerase chain reaction for Japanese encephalitis virus (JEV) in cerebrospinal fluid was positive. Based on the clinical findings, we made a diagnosis of Japanese encephalitis. Japanese encephalitis is one of the most prevalent arthropod-transmitted viral encephalitis in many Asian countries, northern Australia, and the western Pacific rim [
]. It is a viral infection caused by JEV belonging to the genus Flavivirus. JEV is transmitted to humans by infected mosquitoes, particularly Culex mosquito species [
]. Transmission principally occurs in rural agricultural areas, often related to rice cultivation and flood irrigation. The vast majority of infections with JEV are asymptomatic, and less than 1 % of JEV infections develop symptomatic neuroinvasive disease [
]. MRI is more sensitive and specific than CT in revealing thalamic lesions in Japanese encephalitis. There are still no effective treatments for Japanese encephalitis. Current strategies for suppression of JEV infection include appropriate vaccination program of humans and swine, mosquito control, and community education.
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