Biomed Res Int. 2013;2013:152656. doi: 10.1155/2013/152656.

Clinical profile and outcome of Japanese encephalitis in children admitted with acute encephalitis syndrome.

Kakoti G1, Dutta P1, Ram Das B2, Borah J1, Mahanta J1.

• 1Regional Medical Research Centre, ICMR, Northeast Region, P.O. Box No. 105, Dibrugarh, Assam 786 001, India.
• 2Department of Community Medicine, Assam Medical College, Dibrugarh Assam 786002, India.

ABSTRACT:

Japanese encephalitis (JE) is an arthropod borne viral disease. Children are most commonly affected in Southeast Asian region showing symptoms of central nervous system with several complications and death. The clinical characteristics and outcomes in pediatric JE patients hospitalized with acute encephalitis syndrome (AES) are still poorly understood. A prospective study was conducted in pediatric ward of Assam Medical College Hospital to evaluate the clinical profile and outcome of JE in children. A total of 223 hospitalized AES cases were enrolled during March to December 2012. Serum and cerebro spinal fluids were tested for presence of JE specific IgM antibody. 67 (30%) were found to be JE positive. The most common presenting symptoms in JE patients were fever (100%), altered sensorium (83.58%), seizure (82.08%), headache (41.79%), and vomiting (29.85%). Signs of meningeal irritation were present in 55.22% of cases. Around 40.29%, JE patients had GCS ≤ 8. Among the JE patients, 14.7% died before discharge. The complete recoveries were observed in 63.9% of cases, while 21.3% had some sort of disability at the time of discharge. JE is still a major cause of AES in children in this part of India. These significant findings thus seek attentions of the global community to combat JE in children.

PMID: 24490147

 

SUPPLEMENT:

Japanese encephalitis (JE) is the most prevalent and significant mosquito borne viral encephalitis of man, occurring with an estimated 30,000 to 50,000 of cases and 15,000 deaths annually. Children remain the main victims of the disease. About 20% to 30% of JE cases are fatal and 30–50% result in permanent neuropsychiatric sequelae. At present, there is no specific agent available against JE. Treatment of JE is therefore essentially symptomatic and intensive supportive care is important to avoid neurological sequelae. A better understanding of the clinical profile and outcome of JE in children hospitalized with AES cases may help in early diagnosis and initiating, prompt supportive care.

In our study, around 30% of hospitalized children with AES were diagnosed as confirmed JE to support the fact that JE is still one of the leading from of viral encephalitis of children in this NE part of India (Figure-1. shows Study Center).

Children mostly affected were from rural areas (90%) and belong to low socioeconomic group (63%). This may be due to favorable epidemiological factors like presence of waterlogged paddy field supporting profuse breeding of vector mosquitoes, piggeries in close proximity to residence, nonuse of bed nets and outdoor playing habits of children. The age group mainly affected was 5 to 12 years and the youngest one was 5 months old.

Currently in Assam, JE vaccination with live vaccine (SA-14-14-2) has been included in routine immunization programme in National Immunization Schedule (NIS). Previously to clear the backlog in children 1–15 years of age mass vaccination programme was conducted in 11 JE endemic districts of Assam in a phase wise manner since May 2006. However, it was evident from the hospitalized AES cases that the vaccination programme could not cover the target children adequately. (not vaccinated (80.5%), (Figure 2. shows JE Vaccination status)

Among the clinical presentation, (Figure 3. shows Clinical Profile of JE cases) fever, altered sensorium, seizures, headache and vomiting was the most common symptoms observed in this study. In children, similar manifestations were also noted in earlier studies [1, 2]. Signs of meningeal irritation were frequently observed in more than half of the study patients as recorded in other studies [3, 4]. Elevated cell count (>5 cell/mm3) in CSF was noted in 77%of patients with lymphocytic predominance and elevated CSF protein level (>40mg/dL) was recorded in 52.5% of study children.

In our study, 21.13% JE patients had neurological sequelae at the time of discharge, (Figure-4. shows a Child with neurological sequelae following JE). While 14.7% had died in hospital. Mortality was associated with GCS within 3 to 8. We could not establish any association of mortality with the meningeal signs and elevated level of CSF cell count and CSF protein. In contrary to this, the study conducted by Avabratha et al. in Bellary, Karnataka, revealed association between mortality and meningeal signs [2].

In summary, our study revealed that JE is still a major explanation of AES in children in this part of India. In spite of existing JE vaccine programme, the target children could not be covered adequately. The most common clinical presentations were fever, altered sensorium, seizure, headache, vomiting and signs of meningeal irritation. The case fatality rate was recorded as high as 14.7% due to JE in children admitted with AES. These significant research findings warrant careful consideration of control strategy for management of the menace of this arboviral encephalitis in saving the life of children.

References

1. K.-M. Chen, H.-C. Tsai, C.-L. Sy et al., “Clinical manifestations of Japanese encephalitis in southern Taiwan,” Journal of Microbiology, Immunology and Infection, vol. 42, no. 4, pp. 296–302, 2009.

2. K. S. Avabratha, P. Sulochana, G. Nirmala, B. Vishwanath, M. Veerashankar, and K. Bhagyalakshmi, “Japanese encephalitis in children in Bellary Karnataka: clinical profile and Sequelae,” International Journal of Biomedical Research, vol. 3, no. 02, pp. 100–105, 2012.

3. M. Gourie-Devi, “Clinical aspects and experience in the management of Japanese encephalitis patients,” in Proceeding of the National Conference on Japenese Encephalitis, pp. 25–29, Indian Council of Medical Research, New Delhi, India, 1984.

4. R. Potula, S. Badrinath, and S. Srinivasan, “Japanese encephalitis in and around Pondicherry, south India: a clinical appraisal and prognostic indicators for the outcome,” Journal of Tropical Pediatrics, vol. 49, no. 1, pp. 48–53, 2003.

Acknowledgements:

This work was supported by a Grant from Department of Science and Technology, Government of India under Women Scientist-A Scheme.

Contact:

Dr. Prafulla Dutta
Scientist – F (Deputy Director Sr. Gr.)
Regional Medical Research Centre
NE region (ICMR)
Dibrugarh-786001
Assam, India
Email: duttaprafulla@yahoo.com
pic1

Figure 1. Study Center

pic2

Figure 2. JE Vaccination status

 
pic3

Figure 3. Clinical Profile of JE cases

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Figure 4. A child with neurological sequelae following JE

 

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