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Indian Pediatr 2015;52:
534 |
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Acute Demyelinating
Encephalomyelitis in a Neonate Secondary to Dengue Infection
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Abdul Razak and *N Karthik Nagesh
Department of Neonatology, Manipal Hospital, Bangalore,
Karnataka, India.
Email:
[email protected]
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A 9-day-old term male neonate was referred to us with
history of fever, lethargy, poor feeding and seizures. The neonate was
delivered by elective caeserian section, and weighed 2.98 kg at birth.
The mother was treated for undiagnosed febrile illness before the
delivery which lasted for a week. On 6th day of life, the child was
re-admitted in view of poor feeding and fever. Septic work- up was
negative. The platelet count decreased from 2.35 × 10 9/L
to 1.3 × 109/L on day 9 of
life. Repeat septic work-up was negative. Basic biochemistry work-up for
seizure was normal. Analysis of cerebrospinal field (CSF), including
polymerase chain reaction (PCV) for herpes simplex virus (HSV) was
negative. Neurosonogram revealed normal study. Platelet count further
dropped to 1.1 x 109/L on
day 11 of life. Dengue panel revealed positive NS1 antigen, positive IgG
and negative IgM antibodies against dengue virus. Magnetic resonance
imaging (MRI) of brain revealed multiple areas of restricted diffusion
of the white matter of the supratentorial compartment involving the
fronto parietal and temporal lobes as well as the internal capsules. A
diagnosis of acute demyelinating encephalitis (ADEM) was made based on
findings of MRI. A metabolic screen (ammonia, lactate and tandem mass
spectroscopy) was negative. The neonate received respiratory support and
anticonvulsants (phenobarbitone and phenytoin) for seizures. Fever
resolved by 10th day, platelet counts normalized by 14th day and
seizures were well controlled. Virus isolation for dengue could not be
performed. As the sensorium was normalized and seizures were well
controlled, further immunotherapy was not initiated. The neonate was
discharged on 17th day of life. The anticonvulsants were tapered and
stopped over next 4 weeks. Repeat MRI brain was not advised as the
follow up neurological and developmental examination was normal at 3
months of life.
There have been few reports of ADEM in children and
adults secondary to dengue infection [1]. This neonate possibly had
primary dengue infection acquired vertically from the mother. The reason
for negative Dengue IgM could be attributed to delayed rise in antibody.
ADEM is not reported in neonates. An experimental study on mice had
showed neonatal central nervous system (CNS) is less conducive to
autoimmunity than the adult CNS because of differential composition of
immune cells within CNS; the neonatal mice were resistant or had
developed milder experimental induced encephalomyelitis [2] which could
derive us to substantiate the milder variety and spontaneous recovery of
ADEM without steroids in our neonate.
References
1. Chowdhury RN, Siddiqui MR, Mahbub MS, Hasan OI,
Talukder A, Nabi S, et al. Dengue fever as a cause of acute
disseminated encephalomyelitis. J Medicine. 2011;12: 185-7.
2. Cravens DP, Kieseier CB, Hussain R, Herndon E,
Arellano B, Ben L, et al. The neonatal CNS is not conducive for
encephalitogenic Th1 T-cells nad B cells during experimental autoimmune
encephalomyelitis. J Neuroinflammation. 2013;10:1-14.
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