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Corresponding Address: Mohan Kumar, md, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, F Block Nehru Hospital, Chandigarh, 160012 India
Affiliations
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
A 30-year-old previously healthy man presented to the emergency department with a
fever and recurrent vomiting for 2 days followed by altered sensorium for 6 h, a history
that was provided by his spouse. There was no history of seizures or recent travel.
The physical examination revealed that he was febrile (38.3°C [101°F]) with a pulse
of 112 beats/min, a blood pressure of 146/98 mm Hg, a respiratory rate of 32 breaths/min,
and there were no rashes anywhere on the body. A neurologic examination revealed obtunded
sensorium (Glasgow coma scale score 6/15), and the motor, sensory, and cerebellar
system could not be examined because of altered mentation. There was hyperreflexia
and neck rigidity. Cardiac, pulmonary, and abdominal examinations were within normal
limits. A clinical possibility of meningo-encephalitis was considered, with a differential
diagnosis of bacterial or viral encephalitis. Viral encephalitis was considered to
be more likely because the patient lived in a location where Japanese encephalitis
was endemic. Cerebrospinal fluid analysis, including polymerase chain reaction testing
for viral antibodies was positive for Japanese encephalitis. A contrast-enhanced magnetic
resonance imaging scan was obtained, which revealed a distinctive finding that contributed
to the determining diagnosis (Figure 1).
Figure 1(A) T2 and (B) diffusion-weighted images show symmetrically enlarged hyperintense
bilateral thalami (black arrows) with intense central diffusion restriction (white
arrows).
