Ralapanawa DMPUK,, Kularatne SAM,, Jayalath WATA. with bowel and bladder retention. Touch and pain sensations were decreased below level of L1. Deep tendon reflexes were 3+ in all four limbs and plantars were bilateral extensor. Laboratory investigations showed positive IgM serology for dengue. Cerebrospinal fluid (CSF) analysis showed 60 cells with 60% polymorphs and 40% lymphocytes; and normal protein and sugar level (Table 1). MRI brain and spine revealed T1 hyperintensity in cervico-dorsal region (Fig. 1). Serum antibody for neuromyelitis optica antibody was negative. Table 1 Laboratory investigations thead th align=”left” valign=”top” rowspan=”1″ colspan=”1″ em Variable /em /th th align=”left” valign=”top” rowspan=”1″ colspan=”1″ em Case 1 /em /th th align=”left” valign=”top” rowspan=”1″ colspan=”1″ em Case 2 /em /th /thead Hemoglobin (g/dL)14.613.6White cell count (per mm3)40004700Differential count (%)???Neutrophils/lymphocytes45/5056/44Platelet count (per mm3)8900037000Aspartate aminotransferase (U/L)154355Alanine aminotransferase (U/L)67194CSF analysis???Total cells60No cells???Differential counts (%)???Neutrophils/lymphocytes60/40????Protein/sugar (mg/dL)40/5427/11Dengue serology for IgMPositivePositiveDengue NS1 AgNegativePositive Open in a separate window Open in a separate window Fig. 1 MRI brain and spine showing T1 hyperintensity in cervicodorsal area With a diagnosis of dengue-associated acute transverse myelitis (ATM), intravenous methylprednisolone 1 g daily was given for 5 days and patient had complete neurological recovery. CASE 2 A 48-year-old gentleman was admitted with complaints of fever for 5 days and weakness of all four limbs and neck for 1 day. Fever was intermittent, maximum recorded up to 102F, and associated with chills. Patient had ascending weakness of all four limbs associated with weakness of neck muscles without any sensory, bladder or bowel involvement. There was no antecedent history of respiratory or gastrointestinal tract infection. Physical examination revealed areflexic flaccid paralysis of all four limbs (legs more than arms), neck muscle weakness and right lower motor neuron type facial nerve palsy. Laboratory investigations showed positive NS1 antigen and IgM serology for dengue. Cerebrospinal fluid was acellular with normal protein and sugar (Table 1). Nerve conduction study (NCS) showed pure motor axonal and demyelinating polyneuropathy. Patient was started on intravenous immunoglobulin as five daily infusions for a total dose of 2 g/kg body weight followed by a complete neurological improvement. DISCUSSION Dengue is among the most common arboviral infections worldwide, and is endemic in many tropical regions. It is the prototypic arthropod-borne infection, notable for its marked heterogeneity of disease manifestations. Multiorgan ENOblock (AP-III-a4) involvement with capillary leak syndrome, internal organ bleeding, renal failure, liver injury, myocarditis, encephalopathy, and circulatory shock is characteristic of severe ENOblock (AP-III-a4) disease. Dengue is a flavivirus and is closely related to other mosquito-borne neurotropic flavivirus causing significant neurological involvement such as Japanese encephalitis, Zika virus, West Nile virus, and St. Louis encephalitis virus.1 Most dengue infections are asymptomatic. The incidence of neurological manifestations ranges from 1 to 5% with encephalopathy or encephalitis being the commonest neurological manifestations.1 Parainfectious ATM and Guillain-Barr syndrome (GBS) are rare complications and found in less than 10% cases of dengue with neurological involvement.2,3 Both direct infection and post infectious immune mediated neural injury have been postulated as pathogenesis for these neurological complications.1C3 During Zika virus associated GBS outbreak, few cases were found to have dengue antibodies in serum or CSF, ENOblock (AP-III-a4) raising the possibility of primary dengue infection and false positive Zika virus serologies due to cross reactivity.4 Dengue-associated GBS cases were more common among adults than children. Nerve conduction study shows acute inflammatory demyelinating polyneuropathy in most cases. Majority of these cases have been treated with intravenous immunoglobulins. Plasmapheresis, corticosteroids or conservative treatment were used in some cases. Most of the cases have full recovery. 5 Dengue associated Rabbit Polyclonal to CPZ ATM is diagnosed on the basis of spinal imaging and CSF analysis, and majority of these cases have been treated with intravenous corticosteroids with complete neurological recovery. 6 Dengue virus infection may have wide spectrum of neurological manifestations apart from encephalopathy or encephalitis. Therefore patients with dengue infection, especially from endemic area, should be looked for early detection of these complications.