Indian J Pediatr DOI 10.1007/s12098-015-1784-5
SCIENTIFIC LETTER
Isolated Cerebellitis in Scrub Typhus Maya Dattatraya Bhat 1 & K. N. Vykuntaraju 2 & Ullas V. Acharya 1 & Premlatha Ramaswamy 2 & Chandrajit Prasad 1
Received: 6 October 2014 / Accepted: 27 April 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: A 6-y-old girl presented to the emergency of a pediatric hospital with five day history of fever, difficulty in walking, slurring of speech of three day duration and one episode of generalized tonic-clonic seizures. On admission, the patient was afebrile and had enlarged cervical lymph nodes. Cerebrospinal fluid (CSF) analysis was normal. Neurological examination revealed scanning type of speech with positive cerebellar signs. The power in all the limbs was 4/5 with decreased tone. There were no meningeal signs. Blood examination revealed a total WBC count of 10, 500 cells/mm3, an erythrocyte sedimentation rate of 25 mm/h and elevated C-reactive protein of 26.9 mg/L. CT scan of the brain performed on the eighth day of illness revealed effaceFig. 1 a, b, c T2 sagittal, axial and FLAIR images respectively depicting hyperintensity in the superior cerebellum (arrows)
* Chandrajit Prasad [email protected] 1
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka 560029, India
2
Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
ment of the cerebellar folia with early hydrocephalus. Weil Felix test was positive, OXK titre of 1:320 was suggestive of scrub typhus. MRI of the brain revealed, diffuse increased signal intensity in the cerebellar cortex on T2 and FLAIR images, suggesting an inflammatory process confined to the cerebellum (Fig. 1). Furthermore, the cerebellar cortex appeared swollen, a finding consistent with diffuse cerebellitis. No enhancement was evident on post contrast scans. The central nervous system manifestations of scrub typhus range from aseptic meningitis to encephalomyelitis [1, 2]. Aseptic meningitis has been reported in about 11 % of patients with scrub typhus [1]. The authors attributed it to involvement of the small vessels in the brain [3]. Others have proposed an
Indian J Pediatr
immune mediated process in the pathogenesis of scrub typhus. Leptomeningeal enhancement has been described previously [4]. Lee et al. described isolated involvement of the spinal cord [5]. Cerebellar involvement in scrub typhus is rare and has been described in two instances previously. In conclusion, we would like to reiterate that the diagnosis of scrub typhus is based on classical clinical features and serological tests but uncommonly it may manifest with atypical features and imaging picture like in the present case and knowledge of the same can aid in prompt diagnosis. Conflict of Interest None. Source of Funding None.
References 1.
2. 3.
4.
5.
Kim JH, Lee SA, Ahn T-B, et al. Polyneuropathy and cerebral infarction complicating scrub typhus. Clin Neurol. 2008;4:36–9. Silpapojakul K, Ukkachoke C, Krisanapan S. Rickettsial meningitis and encephalitis. Arch Intern Med. 1991;151:1753–7. Chua CJ, Tan KS, Ramli N, et al. Scrub typhus with central nervous system involvement: a case report with CT and MR imaging features. Neurol J Southeast Asia. 1999;4:53–7. Ben RJ, Feng NH, Ku CS. Meningoencephalitis, myocarditis and disseminated intravascular coagulation in a patient with scrub typhus. J Microbiol Immunol Infect. 1999;32:57–62. Lee KL, Lee JK, Yim YM, Lim OK, Bae KH. Acute transverse myelitis associated with scrub typhus: case report and a review of literatures. Diagn Microbiol Infect Dis. 2008;60:237–9.
SCIENTIFIC LETTER
Isolated Cerebellitis in Scrub Typhus Maya Dattatraya Bhat 1 & K. N. Vykuntaraju 2 & Ullas V. Acharya 1 & Premlatha Ramaswamy 2 & Chandrajit Prasad 1
Received: 6 October 2014 / Accepted: 27 April 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: A 6-y-old girl presented to the emergency of a pediatric hospital with five day history of fever, difficulty in walking, slurring of speech of three day duration and one episode of generalized tonic-clonic seizures. On admission, the patient was afebrile and had enlarged cervical lymph nodes. Cerebrospinal fluid (CSF) analysis was normal. Neurological examination revealed scanning type of speech with positive cerebellar signs. The power in all the limbs was 4/5 with decreased tone. There were no meningeal signs. Blood examination revealed a total WBC count of 10, 500 cells/mm3, an erythrocyte sedimentation rate of 25 mm/h and elevated C-reactive protein of 26.9 mg/L. CT scan of the brain performed on the eighth day of illness revealed effaceFig. 1 a, b, c T2 sagittal, axial and FLAIR images respectively depicting hyperintensity in the superior cerebellum (arrows)
* Chandrajit Prasad [email protected] 1
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka 560029, India
2
Department of Pediatrics, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
ment of the cerebellar folia with early hydrocephalus. Weil Felix test was positive, OXK titre of 1:320 was suggestive of scrub typhus. MRI of the brain revealed, diffuse increased signal intensity in the cerebellar cortex on T2 and FLAIR images, suggesting an inflammatory process confined to the cerebellum (Fig. 1). Furthermore, the cerebellar cortex appeared swollen, a finding consistent with diffuse cerebellitis. No enhancement was evident on post contrast scans. The central nervous system manifestations of scrub typhus range from aseptic meningitis to encephalomyelitis [1, 2]. Aseptic meningitis has been reported in about 11 % of patients with scrub typhus [1]. The authors attributed it to involvement of the small vessels in the brain [3]. Others have proposed an
Indian J Pediatr
immune mediated process in the pathogenesis of scrub typhus. Leptomeningeal enhancement has been described previously [4]. Lee et al. described isolated involvement of the spinal cord [5]. Cerebellar involvement in scrub typhus is rare and has been described in two instances previously. In conclusion, we would like to reiterate that the diagnosis of scrub typhus is based on classical clinical features and serological tests but uncommonly it may manifest with atypical features and imaging picture like in the present case and knowledge of the same can aid in prompt diagnosis. Conflict of Interest None. Source of Funding None.
References 1.
2. 3.
4.
5.
Kim JH, Lee SA, Ahn T-B, et al. Polyneuropathy and cerebral infarction complicating scrub typhus. Clin Neurol. 2008;4:36–9. Silpapojakul K, Ukkachoke C, Krisanapan S. Rickettsial meningitis and encephalitis. Arch Intern Med. 1991;151:1753–7. Chua CJ, Tan KS, Ramli N, et al. Scrub typhus with central nervous system involvement: a case report with CT and MR imaging features. Neurol J Southeast Asia. 1999;4:53–7. Ben RJ, Feng NH, Ku CS. Meningoencephalitis, myocarditis and disseminated intravascular coagulation in a patient with scrub typhus. J Microbiol Immunol Infect. 1999;32:57–62. Lee KL, Lee JK, Yim YM, Lim OK, Bae KH. Acute transverse myelitis associated with scrub typhus: case report and a review of literatures. Diagn Microbiol Infect Dis. 2008;60:237–9.
