Dengue fever is a viral infection transmitted by the bite of Aedes aegypti mosquitoes. It is a widespread arboviral disease associated with a substantial global burden of morbidity and mortality. In this case report, a patient who developed neurological complications associated with dengue fever, specifically dengue encephalopathy, is presented. The presence of RESLES further complicated the patient’s clinical presentation. This case highlights the importance of early recognition and management of neurological complications in patients with dengue fever.
Case Presentation 1
A 25-year-old female from Andhra Pradesh, India, presented with a two-day history of fever, headache, vomiting, and a sensation of dizziness, followed by altered consciousness for one day. She reported myalgia but denied experiencing seizures or bleeding episodes. Notably, the patient had a pre-existing medical condition of sinusitis, for which she had been receiving treatment for two years. The patient had not traveled in the two months preceding her symptoms and had no history of smoking or alcohol consumption.
Clinical examination revealed a febrile patient with altered sensorium (Glasgow Coma Scale score of 11/15) and the presence of palatal petechiae and a blanching rash. Vital signs included:
- A heart rate of 110 beats/min.
- Blood pressure of 110/80 mmHg without postural hypotension.
- A respiratory rate of 12/min.
Table 1: Lab investigations showing elevated platelet, ALT, and AST levels
General physical examination and other systemic examinations did not yield significant findings. Laboratory investigations revealed elevated platelet counts, alanine transaminase (ALT), and aspartate aminotransferase (AST) levels (Table 1). Urinalysis and coagulation profiles were within normal limits. Cerebrospinal fluid (CSF) analysis indicated slightly elevated protein levels and negative bacterial cultures, ruling out meningitis (Table 2). The serum dengue IgM antibody test confirmed dengue infection. Blood and urine cultures showed no microbial growth.
Table 2: CSF analysis showing mildly elevated protein levels
The patient received a diagnosis of dengue encephalopathy and was treated symptomatically with intravenous fluids, doxycycline, and paracetamol. Brain MRI revealed a focal central lesion involving the splenium of the corpus callosum, suggestive of a cytotoxic lesion of the corpus callosum and a transient lesion of the splenium. This imaging pattern confirmed the diagnosis of RESLES. The patient showed steady improvement, attaining complete recovery within eight days without neurological deficits. A follow-up MRI conducted one month later demonstrated the full resolution of the splenial lesion.
Figure 1: MRI of the brain
The axial diffusion-weighted image shows a small central lesion involving the splenium of the corpus callosum with increased signal intensity.
Figure 2: MRI brain axial FLAIR shows an oval area of increased signal intensity in the splenium corpus callosum
FLAIR: Fluid-attenuated inversion recovery
Discussion 1,3
Dengue virus, traditionally considered non-neurotropic, has been associated with a variety of neurological manifestations, including encephalopathy. The diagnosis of dengue encephalitis is based on clinical criteria, including fever, altered consciousness, positive dengue antibodies, and the exclusion of other causes of encephalopathy. Notably, recent studies have identified characteristic radiological features associated with dengue encephalopathy.
Transient splenial hyperintensities, also known as “dot signs,” have been recognized as an imaging feature of dengue encephalopathy. These transient splenial hyperintensities are thought to result from factors such as blood-brain barrier disruption, osmotic changes, and inflammation, leading to intramyelinic edema or microvascular leak. Although reversibility is a common feature of reversible splenial lesion syndrome, these lesions should be differentiated from other encephalopathies based on clinical and radiological findings.
The splenial lesion, in this case, presented with symptoms such as confusion, ataxia, dysarthria, seizures, headache, and hemiparesis. Various etiologies have been associated with splenial lesions, including infectious viruses, metabolic disturbances, and drug withdrawal. In the reported case, the splenial lesion showed complete resolution, likely due to the resolution of cerebral edema and viral clearance.
Conclusions 1,2,3
This case report highlights the occurrence of RESLES in a patient with dengue encephalopathy. The patient’s clinical course, along with characteristic radiological findings, supported the diagnosis. The rapid and complete resolution of the splenial lesion following appropriate treatment underscores the importance of recognizing unusual radiological features associated with dengue fever. Effective management of dengue fever is often associated with a favorable prognosis, even with distinct radiological findings.
References
- Saishirini Yerremreddy, Sai N. Reversible Splenial Lesion Syndrome Associated With Dengue Encephalopathy: A Case Report. Cureus. 2023 Nov 1. 10.7759/cureus.48109
- Dengue and severe dengue [Internet]. www.who.int. [cited 2023 Nov 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue?utm_medium=email&utm_source=transaction
- Zhu Y, Zheng J, Zhang L, et al. Reversible splenial lesion syndrome associated with encephalitis/encephalopathy presenting with great clinical heterogeneity. BMC Neurol. 2016, 16:49. 10.1186/s12883-016-0572-9
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