Diagnostic dilemma—Dengue or Japanese encephalitis?
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Dengue infection has a myriad of clinical manifestations ranging from an asymptomatic course to life-threatening dengue shock syndrome. Neurological complications can be categorized into dengue encephalopathy, encephalitis, neuromuscular complications, and neuro-ophthalmic involvement. Among these, the most common form of neurological involvement in dengue is usually in the form of diffuse encephalopathy caused by metabolic disturbances, hepatic or renal involvement, or hypotension. Cerebrospinal fluid (CSF) analysis is usually normal in dengue encephalopathy, whereas it shows varying degrees of pleocytosis and elevated proteins in cases of dengue encephalitis. Neurotropism is a classical feature of Japanese encephalitis (JE) with classical basal ganglia and thalamic involvement on magnetic resonance imaging (MRI). In recent years, central nervous system (CNS) manifestations due to dengue have been well recognized with evidence of viral antigens and antibodies in the CSF and MRI features of brain parenchymal involvement. Here, we report a case wherein the patient had magnetic resonance imaging evidence of bilateral thalamic and brainstem involvement with positive serologies for both dengue and JE. We also discuss the diagnostic challenge in these cases.

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