Clinical Characteristics of Severe Japanese Encephalitis: A Case Series from South Korea

Jun-Sang Sunwoo Department of Neurology, Soonchunhyang University School of Medicine, Seoul, South Korea

Search for other papers by Jun-Sang Sunwoo in
Current site
Google Scholar
PubMed
Close
,
Soon-Tae Lee Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Soon-Tae Lee in
Current site
Google Scholar
PubMed
Close
,
Keun-Hwa Jung Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Keun-Hwa Jung in
Current site
Google Scholar
PubMed
Close
,
Kyung-Il Park Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea

Search for other papers by Kyung-Il Park in
Current site
Google Scholar
PubMed
Close
,
Jangsup Moon Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Jangsup Moon in
Current site
Google Scholar
PubMed
Close
,
Ki-Young Jung Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Ki-Young Jung in
Current site
Google Scholar
PubMed
Close
,
Manho Kim Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
Protein Metabolism Medical Research Center, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Manho Kim in
Current site
Google Scholar
PubMed
Close
,
Sang Kun Lee Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Sang Kun Lee in
Current site
Google Scholar
PubMed
Close
, and
Kon Chu Department of Neurology, Comprehensive Epilepsy Center, Seoul National University Hospital, Seoul, South Korea
Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea

Search for other papers by Kon Chu in
Current site
Google Scholar
PubMed
Close
Restricted access

Japanese encephalitis (JE) virus is a major cause of devastating viral encephalitis, especially in Asia. Although a successful vaccination program led to its near-elimination over three decades in South Korea, the incidence of JE has increased since 2010. The present study investigated the clinical manifestations, laboratory findings, and factors affecting neurological outcomes of reemerging JE. We retrospectively reviewed medical records of laboratory-confirmed JE patients who presented with acute encephalitis syndrome at three tertiary hospitals between 2010 and 2015. A total of 17 patients with JE were identified. Their median age was 51 years, and 10 (58.5%) were men. The most common symptoms and signs were fever (94.1%), altered consciousness (94.1%), and headache (80.2%). Hyporeflexia (47.1%), seizures (35.2%), abnormal brainstem reflex (23.5%), and flaccid weakness (17.6%) were also noted. Brain imaging revealed thalamic lesions in all patients, with the hippocampus, midbrain, basal ganglia, and cerebral cortex affected to varying degrees. Sixteen patients (94.1%) required management in the intensive care unit with mechanical ventilation due to neurological deterioration. At the time of discharge, 11 (64.7%) had poor recovery, defined as Glasgow coma scale scores of less than 8, and remained ventilator dependent. Comparison between the two outcome groups indicated that midbrain involvement (P = 0.028) and rapid deterioration (P = 0.005) were associated with severe neurological sequelae. Given that JE is a vaccine-preventable disease, vaccination for adults should be considered in response to the reemergence of JE.

Author Notes

Address correspondence to Kon Chu, Department of Neurology, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, South Korea 03080. E-mail: stemcell.snu@gmail.com

Financial support: This work was supported by a grant from the Seoul National University Hospital Research Fund (0320150430) and the Soonchunhyang University Research Fund.

Authors’ addresses: Jun-Sang Sunwoo, Department of Neurology, Soonchunhyang University School of Medicine, Seoul, South Korea, E-mail: ultrajs4@gmail.com. Soon-Tae Lee, Keun-Hwa Jung, Jangsup Moon, Ki-Young Jung, Manho Kim, Sang Kun Lee, and Kon Chu, Department of Neurology, Seoul National University Hospital, Seoul, South Korea, E-mails: staelee@gmail.com, jungkh@gmail.com, jangsup.moon@gmail.com, jungky10@gmail.com, kimmanho@snu.ac.kr, sangkun2923@gmail.com, and stemcell.snu@gmail.com. Kyung-Il Park, Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea, E-mail: ideopki@gmail.com.

  • 1.

    van den Hurk AF, Ritchie SA, Mackenzie JS, 2009. Ecology and geographical expansion of Japanese encephalitis virus. Annu Rev Entomol 54: 17–35.

    • Search Google Scholar
    • Export Citation
  • 2.

    Campbell GL, Hills SL, Fischer M, Jacobson JA, Hoke CH, Hombach JM, Marfin AA, Solomon T, Tsai TF, Tsu VD, Ginsburg AS, 2011. Estimated global incidence of Japanese encephalitis: a systematic review. Bull World Health Organ 89: 766–774, 774A–774E.

    • Search Google Scholar
    • Export Citation
  • 3.

    Sikka V, Chattu VK, Popli RK, Galwankar SC, Kelkar D, Sawicki SG, Stawicki SP, Papadimos TJ, 2016. The emergence of zika virus as a global health security threat: a review and a consensus statement of the INDUSEM Joint working Group (JWG). J Glob Infect Dis 8: 3–15.

    • Search Google Scholar
    • Export Citation
  • 4.

    Griffiths MJ, Turtle L, Solomon T, 2014. Chapter 26—Japanese encephalitis virus infection. Alex CT, John B, eds. Handbook of Clinical Neurology. Amsterdam, The Netherlands: Elsevier, 561–576.

    • Search Google Scholar
    • Export Citation
  • 5.

    Solomon T, Dung NM, Kneen R, Thao LTT, Gainsborough M, Nisalak A, Day NPJ, Kirkham FJ, Vaughn DW, Smith S, White NJ, 2002. Seizures and raised intracranial pressure in Vietnamese patients with Japanese encephalitis. Brain 125: 1084–1093.

    • Search Google Scholar
    • Export Citation
  • 6.

    Sarkari NB, Thacker AK, Barthwal SP, Mishra VK, Prapann S, Srivastava D, Sarkari M, 2012. Japanese encephalitis (JE). Part I: clinical profile of 1,282 adult acute cases of four epidemics. J Neurol 259: 47–57.

    • Search Google Scholar
    • Export Citation
  • 7.

    Solomon T, 2004. Flavivirus encephalitis. N Engl J Med 351: 370–378.

  • 8.

    Liu W, Gibbons RV, Kari K, Clemens JD, Nisalak A, Marks F, Xu ZY, 2010. Risk factors for Japanese encephalitis: a case-control study. Epidemiol Infect 138: 1292–1297.

    • Search Google Scholar
    • Export Citation
  • 9.

    Sohn YM, 2000. Japanese encephalitis immunization in South Korea: past, present, and future. Emerg Infect Dis 6: 17–24.

  • 10.

    Arai S, Matsunaga Y, Takasaki T, Tanaka-Taya K, Taniguchi K, Okabe N, Kurane I; Vaccine Preventable Diseases Surveillance Program of Japan, 2008. Japanese encephalitis: surveillance and elimination effort in Japan from 1982 to 2004. Jpn J Infect Dis 61: 333–338.

    • Search Google Scholar
    • Export Citation
  • 11.

    Korea Centers for Disease Control and Prevention, 2015. Infectious Disease Surveillance Yearbook. Available at: http://is.cdc.go.kr/dstat/jsp/stat/statboard_detail.jsp?boardid=1527&boardseq=23&rcontext=01. Accessed February 18, 2016.

    • Search Google Scholar
    • Export Citation
  • 12.

    Lee EJ, Cha GW, Ju YR, Han MG, Lee WJ, Jeong YE, 2016. Prevalence of neutralizing antibodies to Japanese encephalitis virus among high-risk age groups in South Korea, 2010. PLoS One 11: e0147841.

    • Search Google Scholar
    • Export Citation
  • 13.

    Korea Centers for Disease Control and Prevention, 2016. Infectious Disease Statistics System. Available at: http://is.cdc.go.kr/dstat/index.jsp. Accessed February 18, 2016.

    • Search Google Scholar
    • Export Citation
  • 14.

    Sunwoo JS, Jung KH, Lee ST, Lee SK, Chu K, 2016. Reemergence of Japanese Encephalitis in South Korea, 2010–2015. Emerg Infect Dis 22: 1841–1843.

    • Search Google Scholar
    • Export Citation
  • 15.

    Solomon T, Thao TT, Lewthwaite P, Ooi MH, Kneen R, Dung NM, White N, 2008. A cohort study to assess the new WHO Japanese encephalitis surveillance standards. Bull World Health Organ 86: 178–186.

    • Search Google Scholar
    • Export Citation
  • 16.

    Lee DW, Choe YJ, Kim JH, Song KM, Cho H, Bae GR, Lee JK, 2012. Epidemiology of Japanese encephalitis in South Korea, 2007–2010. Int J Infect Dis 16: e448–e452.

    • Search Google Scholar
    • Export Citation
  • 17.

    Cha GW, Cho JE, Ju YR, Hong Y-J, Han MG, Lee W-J, Choi EY, Jeong YE, 2014. Comparison of four serological tests for detecting antibodies to Japanese encephalitis virus after vaccination in children. Osong Public Health Res Perspect 5: 286–291.

    • Search Google Scholar
    • Export Citation
  • 18.

    Solomon T, Dung NM, Kneen R, Gainsborough M, Vaughn D, Khanh VT, 2000. Japanese encephalitis. J Neurol Neurosurg Psychiatry 68: 405–415.

  • 19.

    Park JH, Lee DW, 2012. Dengue fever in South Korea, 2006–2010. Emerg Infect Dis 18: 1525–1527.

  • 20.

    Hwang J, Ryu H-S, Kim H, Lee S-A, 2015. The first reported case of West Nile encephalitis in Korea. J Korean Med Sci 30: 343–345.

  • 21.

    Wu YC, Huang YS, Chien LJ, Lin TL, Yueh YY, Tseng WL, Chang KJ, Wang GR, 1999. The epidemiology of Japanese encephalitis on Taiwan during 1966–1997. Am J Trop Med Hyg 61: 78–84.

    • Search Google Scholar
    • Export Citation
  • 22.

    Umenai T, Krzysko R, Bektimirov TA, Assaad FA, 1985. Japanese encephalitis: current worldwide status. Bull World Health Organ 63: 625–631.

  • 23.

    Borah J, Dutta P, Khan SA, Mahanta J, 2011. A comparison of clinical features of Japanese encephalitis virus infection in the adult and pediatric age group with acute encephalitis syndrome. J Clin Virol 52: 45–49.

    • Search Google Scholar
    • Export Citation
  • 24.

    Solomon T, Kneen R, Dung NM, Khanh VC, Thuy TT, Ha DQ, Day NP, Nisalak A, Vaughn DW, White NJ, 1998. Poliomyelitis-like illness due to Japanese encephalitis virus. Lancet 351: 1094–1097.

    • Search Google Scholar
    • Export Citation
  • 25.

    Misra UK, Kalita J, Srivastava M, 1998. Prognosis of Japanese encephalitis: a multivariate analysis. J Neurol Sci 161: 143–147.

  • 26.

    Solomon T, Willison H, 2003. Infectious causes of acute flaccid paralysis. Curr Opin Infect Dis 16: 375–381.

  • 27.

    Kakoti G, Dutta P, Ram Das B, Borah J, Mahanta J, 2013. Clinical profile and outcome of Japanese encephalitis in children admitted with acute encephalitis syndrome. BioMed Res Int 2013: 152656.

    • Search Google Scholar
    • Export Citation
  • 28.

    Ooi MH, Lewthwaite P, Lai BF, Mohan A, Clear D, Lim L, Krishnan S, Preston T, Chieng CH, Tio PH, Wong SC, Cardosa J, Solomon T, 2008. The epidemiology, clinical features, and long-term prognosis of Japanese encephalitis in central Sarawak, Malaysia, 1997–2005. Clin Infect Dis 47: 458–468.

    • Search Google Scholar
    • Export Citation
  • 29.

    Basumatary LJ, Raja D, Bhuyan D, Das M, Goswami M, Kayal AK, 2013. Clinical and radiological spectrum of Japanese encephalitis. J Neurol Sci 325: 15–21.

    • Search Google Scholar
    • Export Citation
  • 30.

    Kalita J, Misra UK, 2000. Comparison of CT scan and MRI findings in the diagnosis of Japanese encephalitis. J Neurol Sci 174: 3–8.

  • 31.

    Shoji H, Hiraki Y, Kuwasaki N, Toyomasu T, Kaji M, Okudera T, 1989. Japanese encephalitis in the Kurume region of Japan: CT and MRI findings. J Neurol 236: 255–259.

    • Search Google Scholar
    • Export Citation
  • 32.

    Kalita J, Misra UK, Pandey S, Dhole TN, 2003. A comparison of clinical and radiological findings in adults and children with Japanese encephalitis. Arch Neurol 60: 1760–1764.

    • Search Google Scholar
    • Export Citation
  • 33.

    Handique SK, Das RR, Barman K, Medhi N, Saharia B, Saikia P, Ahmed SA, 2006. Temporal lobe involvement in Japanese encephalitis: problems in differential diagnosis. AJNR Am J Neuroradiol 27: 1027–1031.

    • Search Google Scholar
    • Export Citation
  • 34.

    Li F, Wang Y, Yu L, Cao S, Wang K, Yuan J, Wang C, Wang K, Cui M, Fu ZF, 2015. Viral infection of the central nervous system and neuroinflammation precede blood-brain barrier disruption during Japanese encephalitis virus infection. J Virol 89: 5602–5614.

    • Search Google Scholar
    • Export Citation
  • 35.

    Thammaroj J, Santosh C, Bhattacharya JJ, 2005. The hippocampus: modern imaging of its anatomy and pathology. Pract Neurol 5: 150–159.

  • 36.

    Marinkovic S, Milisavljevic M, Puskas L, 1992. Microvascular anatomy of the hippocampal formation. Surg Neurol 37: 339–349.

  • 37.

    Misra UK, Kalita J, Srivastav A, Pradhan PK, 2008. The prognostic role of magnetic resonance imaging and single-photon emission computed tomography in viral encephalitis. Acta Radiol 49: 827–832.

    • Search Google Scholar
    • Export Citation
  • 38.

    Ghosh D, Basu A, 2009. Japanese encephalitis-a pathological and clinical perspective. PLoS Negl Trop Dis 3: e437.

  • 39.

    Misra UK, Kalita J, 2001. Seizures in Japanese encephalitis. J Neurol Sci 190: 57–60.

  • 40.

    Kalita J, Nair PP, Misra UK, 2008. Status epilepticus in encephalitis: a study of clinical findings, magnetic resonance imaging, and response to antiepileptic drugs. J Neurovirol 14: 412–417.

    • Search Google Scholar
    • Export Citation
  • 41.

    Bauer G, Trinka E, 2010. Nonconvulsive status epilepticus and coma. Epilepsia 51: 177–190.

Past two years Past Year Past 30 Days
Abstract Views 79 79 16
Full Text Views 893 173 0
PDF Downloads 465 78 0
 
Membership Banner
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save