Japanese Encephalitis

Definition:
- Japanese encephalitis is a mosquito-borne viral disease endemic in Asia and the Western Pacific.
Disease transmission occurs through the bite of infected Culex tritaeniorhynchus mosquitoes.

Aetiology:

1. Pathogen: Japanese encephalitis virus, mosquito-borne flavivirus

2. Transmission:
a. Primary mosquito vector: Culex tritaeniorhynchus (Breeds in rice fields and shallow
water)
b. Pigs and wading birds are major hosts in JEV cycle
c. Pigs develop high levels of viremia and are often kept in close proximity to human
dwelling
d. Humans are dead-end hosts  human-to-human transmission is not possible

Clinical features:

1. Incubation period: 5-15 days

2. >99% of cases are subclinical
3. Non-specific prodromal symptoms: last for 2-3 days
a. Fever
b. Vomiting
c. Headaches
d. Generalized weakness
4. Encephalitis stage:
a. Signs of inflammation of brain parenchyma:
i. Altered level of consciousness
ii. Focal neurological deficit
iii. Abnormal behaviour, psychosis
iv. Seizures
b. Meningeal sign: Neck stiffness, headache
c. Motor disorders:
i. Parkinsonism (cogwheel rigidity, resting tremors, reduced facial expression)
ii. Polio-like flaccid paralysis OR muscular spasticity
5. In severe cases: coma, death.
6. Multiple prolonged seizures and increased intracranial pressure are signs of a poor
prognosis.
7. Recovery often takes weeks to months. Only 1/3 of patients recover fully.

** SIADH can occur as complications of encephalitis.

Diagnostics:

1. Lab findings:
a. FBC: leucocytosis
b. Blood cultures
c. BUSE: hyponatremia secondary to SIADH
d. Serum glucose: to rule out confusion due to treatable hypoglycaemia and to
compare with the cerebrospinal fluid (CSF) glucose value
e. BUN and creatinine: assess hydration status
f. LFT, RFT: assess for end-organ dysfunction
g. Coagulation profile: assess for any possible DIC (contraindication for LP)
h. Urinary electrolyte test: if SIADH suspected
i. Urine or serum toxicology screening: if patient present with toxic delirium or
confusional state
2. Neuroimaging (brain CT/MRI)
a. Bilateral low-density areas on CT brain
b. MRI findings: hyperintense lesions in the thalamus, basal ganglia, midbrain, pons,
and medulla
 Thalamic lesions are a characteristic feature of JEV and are often used to
differentiate it from other diagnoses.
3. Lumbar puncture for CSF analysis, anti-JE antibody
a. CSF analysis in japanese encephalitis:
 Opening pressure: elevated
 Glucose: normal or decreased
 CSF: serum glucose ratio: normal
 Protein: normal or increased
 WBC Cell counts: 5-2000 lymphocytes
b. CSF anti-JE IgM antibody:
 Diagnostic test (OR serum IgM antibodies)
 Usually detectable 3–8 days after illness
 False-positive elevations in serum IgM antibodies can be positive post-
vaccination.
 Convalescent samples of immunoglobulin G (IgG) antibodies can be tested if
acute (IgM) samples are negative.

Management:

1. No specific treatment available.

2. Supportive care is mainstay of treatment:
a. Seizure control
b. Control of intracranial pressure
c. Agitation and restlessness should be controlled with benzodiazepine.
d. Parkinsonism may respond to dopamine agonist (levodopa)
3. Prevention: through national vaccination programmes for school children.
Prognosis:

 ∼ 30% of patients who develop acute encephalitis die.

 In survivors, neurologic, cognitive, and psychiatric sequelae are common.