/na~aaff. Pediat, 42: 356, 1976
ENCEPHALITIS* of a Case
P.N. SEN GUPTA AND P.N. Blsw.,s Asansol Post-vaccinal encephalitis or encephaloT h e p l a n t a r reflex was extensor on Superficial abdominal myelitis is a rare syndrome. It is a serious both the sides. reflexes were diminished on both the sides. complication of smallpox immunization Deep reflexes i.e. ankle, knee, biceps and with a mortality rate of 30% to 50% (Ford triceps jerks were diminished on both the 1960). T h e following is a description of sides. He had incontinence of urine. The post-vaccinal encephalitis in a child who heart and lungs were normal. T h e abdofortunately survived. men was soft; liver and spleen were not palpReport of a Case able and no other mass was palpable. J.P., aged 6 years, a m a l e child, was It m a y be mentioned that rigidity of a d m i t t e d to the Central Hospital, Asansol, the neck was variable from day to day. on 14.3.75 with complaints of vertigo On most of the days, the neck was found for 2 days, headache and high fever for one to be supple, but on other days it appeared day, inability to speak and g r a d u a l l y beto be slightly rigid. coming drowsy followed by unconsciousThe total leucocyte count was ness for the previous three days. He had 9600/c. m m . , p o l y m o r p h s 76%, lymphocytes had p r i m a r y smallpox vaccination about 20%, eosinophils 4%. E.S.R. 60 m m . 1st 10 days before. His sister had suffered hour. Malarial parasite was not seen in from smallpox in the recent past and the the blood film. Cerebrospinal fluid (C.S.F.) child had been in contact with her. e x a m i n e d on 18.3.75 was d e a r , colourO n examination on the 3rd day of the less, and contained less than 3 cells/c.mm., illness, the child was unconscious. T h e protein 80 rag./100 ml.~ chloride 700 t e m p e r a t u r e was 103 ~ F, pulse 150]minute, rag./100 mL and sugar 70 rag./100 ml. respiration 48/minute, B.P. I00/70 m m of Hg. T h e site of vaccination showed cutaneous inflammatory reaction. The pupils were circular, normal in size and reacting to light. Nutrition of the muscles was normal. Spasticity of both u p p e r and lower l i m b muscles and some trismus were present. T h e neck was soft. K e r n i g ' s sign was negative on the right side and doubtfully positive on the left. *From the Department of Medicine, Central Hospital,
Asansol. Received on July 24, 1975,
C.S.F. examined on 24.3.75 was clear, colourless and transparent. Microscopically, it showed 5 cells/c mm., all lymphocytes. G r a m stain revealed an occasional leucocyte, no organism. Protein was 60 mg./100 ml., chloride 700 mg./100 ml. and sugar 75 mg./100 ml. Widal test did not suggest the presence of enteric fever. Nothing a b n o r m a l was detected in the urine. Urine for culture showed no growth obtained after 24 hours of incubation. X - r a y of the chest was
OUPTA AND BISWAS ~ P O S T - V A C C I N A L ENCEPHALITIS
within normal limits except for a slight prominence o f broncho-vascular markings. Although there is no specific drug for this disease, the patient was put on antibiotics to prevent secondary infection during the course o f the disease. He was also given corticosteroids and other symptomatic therapy. On the day of admission, when no definite diagnosis was made he was inilially put on Mist. alkali et soda sMicylas 10ml. thrice daily, paracetamol tablet 250 mg. thrice daily and oral penicillin 6 hourly. On 16.3.75, i.e. the 3rd day of admission, a provisional diagnosis of post-vaccinal encephalitis was m a d e and the patient was put on Chloramphenicol injections 125 mg. 6 hourly, Inj. betamethasone sodium phosphate 4 rag. in 1 ml. I.M. stat and 0.5 ml. I M. 6 hourly and in gradually tapering doses f o r 2 weeks. Paracetamal 250 mg. was Iziven 8 hourly for high temperature. From 19 3.1975 Chloramphenicol injections were omitted and he was put on streptopenicillin injections. From 2.4.75he was put cn crystalline penicillin 500,000 units I . M . B . D . only. A slight improvement in the level of consciousness was noticed on 18.3.75 and a gradual fall in temperature from 19.3.75 but aphasia persisted. O n 29.3.75 the child occasionally attempted to cry. From 1.4.75 his speech became normal and he was fully conscious and afebrile. T h e patient improved gradually and was discharged on 13.4.75, after a m o n t h of admission in good condition without any residual symptoms.
smallpox 10 days before onset of the illness. He developed headache, high fever, mental confusion and subsequently pa~sed into coma in a m a t t e r of 3 or 4 days. Findings on clinical examination were characteristic o f encephalitis. Total and differential leucocyte count and examination o f the C.S.F. (which had a high ptotein content only) ruled out the possibility o f pyogenic or tuberculous meningitis or any other acute pyogenic infection. Thus the diagnosis was m a d e on history, clinical and laboratory findings and by eliminating other possibilities which may be simulated by similar clinical conditions. Here it may be mentioned that only 93 cases of post-vaccinal encephalitis were reported in England between November 1922 and November 1927 (i.e. 93 cases in 5 years). In Holland it has been estimated that one case occurred in over 5,000 persons vaccinated. Post-vaccinal encephalitis occurs rarely after p r i m a r y vaccination and extremely rarely after re-vaccination. It has been observed that it is practically unknown in infants vaccinated below one year o f age and most cases have occurred in primary vaccination o f children o f school age (Walton 1969).
We are thankful to Lt. Col. Dr. S.K Choudhury, Medical Superintendent, Central Hospital. Asansoi, for his kind permissio~ to publish the case notes.
Discussion In the present case, the 6-year-old child had primary vaccination against
Walton,John N. (1969). Brain's Diseases of the Nervous System. Oxford Uatv#r~i~ Press, London. p. 482.