Recurrent infectious encephalitis in adolescent: a case report and its differential diagnoses

Case presentation: JASB, male, 11 years, complaining of headache, dizziness, diplopia, and dysarthria for 3 weeks, denying flu syndrome, trauma, or substance use. On physical examination: hypotonia, dysdiadochokinesia, paresis of cranial nerves III and IV, drunken gait, and positive Romberg test. A cranial tomography was performed as an initial imaging test, with no changes. Due to the severity of the case, pulse therapy was started empirically. Magnetic resonance imaging (MRI), 7 days after admission, shows hypersignal in basal ganglia, trunk, pons, peduncle, and cerebellum (T2 and FLAIR). Chemocytology and culture of cerebrospinal fluid were normal. After 13 days of admission, serology was positive IgG for Epstein Barr Virus (EBV) and Herpesvirus, negative IgM. After pulse therapy, prednisolone and acyclovir were prescribed. The patient was discharged after 32 days, with gradual weaning from corticoids and resolution of the condition. However, after 3 months, he was readmitted for diplopia and strabismus; MRI maintained the previous pattern, and new pulse therapy was performed.

Discussion: The child presented an unknown etiology condition; however, considering the MRI and age group, the scenario is similar to cerebellar ataxia due to viral encephalitis with an etiological focus on EBV. To reach a conclusion, must consider the differential diagnoses. Acute cerebellar ataxia is usually linked to viral encephalitis and 90% of cases resolve within 4 months. Recurrence is rare. The investigation of viral PCR in the cerebrospinal fluid is of great value for the etiology. Despite herpesvirus's leading viral agent, on MRI, affects the temporal lobes, cingulate gyrus, orbitofrontal cortex, and insula, which is not consistent with the case. EBV is a significant cause of encephalitis in adolescence, and there is usually no history of mononucleosis. Its tropism is in the basal ganglia, cerebellum, trunk, and thalamus, which agrees with our findings. Finally, acute disseminated encephalomyelitis, a demyelinating disease whose MRI suggests hypersign on T2 and FLAIR, asymmetrical, < 5 cm, usually confluent, must be excluded.

Final comments: The case describes a rare evolution for presenting recurrence, and despite the lack of viral screening, the clinic and image refer to EBV, which is not the main etiologic agent of viral encephalitis. Furthermore, the pediatric community should be aware of the differential diagnoses of neuroinfections and early ordering of tests.

 

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Artikel online veröffentlicht:
18. September 2023