A CASE REPORT

A 41-years old woman, suffering from fever and headache

since three days, was admitted because of a tonic clonic
seizure.
The patient had been complaining of chronic headache and
recurrent labialis herpes simplex.
On admission physical examination revealed afebrile, able
to react to verbal stimulus and to localize pain, but confused
when asked simple questions.

Routine laboratory blood analysis were normal.

Brain computed tomography (CT) on admission showed
hyperintense lesion in the right parietal lobe without mass
effect.
CSF analysis showed pleocytosis with WBC 100/cumm,
increased protein concentration, 88 mg/dl and glucose 48
mg/dl; smears for bacteria, fungi and mycobacteria were
negative as well as cultures.

Later, based on clinical findings, CT and EEG pattern (focal

right temporal alterations of cerebral activity), and PCR
detection of HSV-1 DNA in the cerebrospinal fluid diagnosis
of Herpes simplex encephalitis was made.

Acyclovir therapy (10 mg/kg 8 hourly) was administered for

21 days.
CSF analysis was performed again after two weeks and
revealed WBC 50/cumm, protein 55 mg/dl, glucose 54 mg/dl;
cerebral images showed a reduction of hyperintense lesion
in the right temporal lobe and disappearance of oedema in
the frontal regions.
The patient was discharged with minimal cognitive
impairment of memory and speech.

VIRAL ENCEPHALITIS
AND
ARBOVIRUSES CAUSING
DISEASE OF NERVOUS
SYSTEM

Introduction
Causative agents
Pathogenesis in general
Clinical features in general
Laboratory diagnosis in general
Treatment and prevention

Introduction
Encephalitis: An inflammation of the brain characterized
sudden fever, headache, vomiting, photophobia, stiff neck
and back, confusion, impaired judgment, drowsiness, weak
muscles, clumsy and unsteady gait, and irritability.
Viral infection is the most common and important cause,
with over 100 viruses implicated worldwide.
Incidence of 3.5-7.4 per 100,000 persons per year.

Causative agents
Herpes viruses (HSV-1 & 2, VZV, EBV, CMV, herpes virus 6)
Adenoviruses
Influenza A
Enteroviruses, Poliovirus
Measles, mumps & rubella viruses
Rabies
Arboviruses :Japanese encephalitis, St. Louis encephalitis,
West Nile encephalitis virus, Eastern, Western and
Venezuelan equine encephalitis virus, Colorado tick fever.
Arenaviruses Lymphocytic choriomeningitis virus

What is Arbovirus?
Arboviruses = arthropod-borne viruses
Arboviruses are maintained in nature through biological
transmission between susceptible vertebrate hosts by
blood-feeding arthropods
Vertebrate infection occurs when the infected arthropod
takes a blood meal

Family and
Genus

Viruses causing
Encephalitis

Febrile illness

Hemorrhagic fever

Togaviridae
Alphavirus
(mosquito borne)

Western and eastern equine

encephalitis
Venezuelan equine encephalitis

Chikungunya
Onyong-nyong
Semliki forest
Sindbis
Ross river virus

Chikungunya

Flaviviridae
Flavivirus
Mosquito borne

St. Louis encephalitis

West Nile
Murray valley
Japanese B

Dengue types 1-4

Dengue
Yellow fever

Tick-borne
Bunyaviridae
a.Bunyavirus
(mosquito-borne)
b.Phlebovirus
(Phlebotomus or
mosquito-borne)
c. Nairovirus (tick
borne)

Kyasanur Forest disease

Omsk hemorrhagic fever

Russian springsummer encephalitis

California encephalitis
La Crossie

Chittor virus
Sandfly fever
Rift valley fever

Nairobi sheepdisease
Ganjam virus

Reovirus
Orbivirus
(Tick-borne)

Colorado tick
Borne virus

Rhabdoviridae
Vesiculovirus
(mosquito borne,
sandfly borne)

Vesicular stomatitis
virus
Chandipura virus

Major arboviruses that cause encephalitis

Flaviviridae
Japanese encephalitis
St. Louis encephalitis
West Nile
Togaviridae
Eastern equine encephalitis
Western equine encephalitis
Bunyaviridae
La Crosse encephalitis

Properties of Arboviruses
Property

Alphavirus

Flavivirus

Bunyavirus

Rhabdovirus

Reovirus

Symmetry

Cubic

Cubic

Helical

Bullet-shaped

Cubic

Size
(diameter
in nm)

60-65

40-50

90-100

170X100

60-80

Nucleic
Acid

ss-positive
sense RNA

ss-positive ss-negative
sense RNA sense RNA

ss-negative
sense RNA

ds-RNA

Pathogenesis of arboviruses in general

The virus enters the body through the bite of the insect
vector. It multiplies in the reticuloendothelial system and
leads to viraemia.
The virus is than transported to the target organs, such as:
CNS in encephalitis
Capillary endothelium in hemorrhagic fevers
Liver in yellow fever.

Clinical features in general

Arboviruses cause the following clinical syndromes such as:
Febrile illness with or without rash and arthralgia
Encephalitis
Hemorrhagic fever and systemic disease
Yellow fever.

Laboratory diagnosis of arboviruses in general

Diagnosis is established by virus isolation or serology.
Specimens
Blood, CSF, brain specimen
Serological tests
Haemagglutination inhibition, virus neutralization test,
ELISA , complement fixation.
Detection of specific IgM antibody within 1-3 days after
the onset of illness.
The detection of 4 fold or more rise in antibody titre
provide a good evidence of infection.

Virus Isolation
Inoculation intracerebrally into suckling mice causes
fatal encephalitis
Tissue culture in vero, BHK-21 and mosquito cell lines
can be used for viral culture.
Growth of the virus is detected by immunofluorescence,
haemagglutination inhibition, ELISA etc.

LABORATORY CRITERIA FOR CONFIRMATION:

Cerebrospinal fluid (CSF) isolation of the virus,
OR
A 4-fold change in serum antibodies to a specific virus (no
arboviral),
OR
Antibodies to a specific virus present in CSF at a
comparable or higher amount compared to serum antibodies

Japanese B encephalitis
Structure and properties
Family: Flaviviridae
Genus: Flavivirus
Size: 40-50nm,
Shape: Spherical icosahedral
capsid
Lipid envelope, glycoprotein
peplomers & membrane protein
Genome: ss-positive sense RNA.
Four genotypes 1, 2, 3 and 4.

History of Japanese Encephalitis

1800s recognized in Japan
1924 Japan epidemic. 6125 cases, 3797 deaths
1935 virus isolated in brain of Japanese patient who
died of encephalitis
1938 virus isolated from Culex mosquitoes in Japan
1948 Japan outbreak
1949 Korea outbreak
1966 China outbreak
Today extremely prevalent in South East Asia. 30,00050,000 cases reported each year.

Widely distributed in Japan, China, Korea and south east

Asia.

Distribution of Japanese Encephalitis

Have several extra human

hosts: herons and egrets birds
act as reservoir and pigs as
amplifier hosts.

Mode of transmission

Culex tritaeniorhyncus:
Habitat :
Rice field (water logged)
Water collection + submerged
vegetation
Pond with aquatic vegetations

Pathogenesis
The virus is transmitted by bite of mosquito
(Culex tritaeniorhyncus)

Multiplication of the virus in reticuloendothelial system

leading to viraemia (extraneural replication)

Invasion of CNS (cerebral cortex, thalamus, hippocampus,

substantia niagra, globus pallidus, brain stem, cerebellum,spinal
cord and leptomeninges) leading to neuronal degeneration,
necrosis and infiltration of inflammatory cells, with prominent
perivascular accumulations (cuffing) of macrophages and
lymphocytes and parenchymal cellular nodules

Aseptic meningitis+ encephalitis

Clinical features
I.P. 5-15 days
1. Prodromal stage: 1-6 days, fever, headache, malaise.
2. Acute encephalitic stage:
High Fever 38-40.7C
Nuchal rigidity
Focal CNS signs
Characteristic attitude with head retracted and arms
and knees bent and shoulders pressed to the chest,
Convulsions and altered sensorium progressing to
coma in many cases.

3. Late stage or sequelae:

Active inflammation subsides

Temperature and ESR normal
Neurological signs improve but residual neurological
deficits may persist (paralysis, Parkinsonism, mental
deterioration,

psychiatric

difficulties).
Case fatality rate is 20-50%

disorders

and

speech

Diagnosis
1. Isolation in mosquito cell line, mammalian cell line and
suckling mouse brain.
2. Serologic diagnosis: IgM capture ELISA which detects
specific IgM in CSF and blood within 7 days of onset of
disease. Paired sera taken in the first few days after onset
and 2-3 weeks later will show rising antibody levels. IgG
antibodies will cross react with other flaviviruses.
3. RT-PCR on early serum, CSF etc.
4. CSF- Pleocytosis and aseptic meningitis

IgM CAPTURE ASSAY

SPECIFIC IgM Abs IN SERA : ACUTE INFECTION
IgM Abs DEVELOP : BY 3RD- 4TH DAY
NEGATIVE IN EARLY ADMISSION

HRP labeled
anti-human
IgM
conjugate

TMB

IgM antibody
Well coated with
antigen

IgM ELISA

Newborn Swiss albino mice: Day 1

JEV infected suckling mice: Day 10

(Ready for virus isolation)

(About to Die)

Prevention and Treatment

A. Vaccines
1. Formalin inactivated mouse brain vaccine
using Nakayama strain: 2 doses in 2 weeks
interval and booster dose 6-12 months later.
Immunity is short lived. Inactivated(Biken)
vaccine
2. The cell culture-derived inactivated JE vaccine
based
on
the
Beijing
P-3
strain.
Inactivated(Biken) vaccine
3. Live attenuated vaccine derived from baby
hamster kidney cells from JE strain SA 14-14-2:
2 doses one year apart.

B. Mosquito Vector control: DDT, BHC, fenitrothion,

malathion, sumithion (250ml/hectare spraying), larvicidal
measures, use of mosquito repellants and nets.

Small species of Larvivorous fish: Top: desert

killifish; middle; male guppy bottom: mosquito fish.