CASE REPORT |
https://doi.org/10.5005/jp-journals-11001-0082 |
Psychosis Following Japanese Encephalitis: A Case Report
1-3Department of Psychiatry, Tezpur Medical College and Hospital, Tezpur, Assam, India
Corresponding Author: Chakravarty P J, Department of Psychiatry, Tezpur Medical College and Hospital, Tezpur, Assam, India, Phone: +91 9365533182, e-mail: pranjaljc@gmail.com
Received on: 25 June 2024; Accepted on: 28 October 2024; Published on: 16 November 2024
ABSTRACT
Japanese encephalitis (JE) is a preventable cause of mosquito-borne encephalitis. Encephalitis is a state of inflammation of the brain parenchyma, commonly resulting from either an infectious cause or when the body’s immune system gets activated inappropriately against the neural antigens. Most human infections of the JE virus are asymptomatic or result in only mild symptoms. Psychiatric symptoms, in conjunction with neurological features, may be seen in the acute phase and more commonly during the convalescent period. A case of JE has been reported here in which the patient presented with irrelevant talk, suspiciousness, and verbally and physically abusive behavior, with a history of fever eleven days before presentation. He was started on tab. quetiapine 50 mg and levetiracetam 1 gm, and there was near complete remission after 10 days. The uniqueness of this case is the presence of psychotic symptoms with intact sensorium and cognition, and there was no amnesia.
How to cite this article: Singla V, Chakravarty PJ, Seal RK. Psychosis Following Japanese Encephalitis: A Case Report. East J Psychiatry 2024;24(2):62-63.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Case report, Encephalitis, Neurpsychychiatric, Psychosis.
INTRODUCTION
Japanese encephalitis (JE) is the most common preventable cause of mosquito-borne encephalitis in Asia. It is transmitted by Culex tritaenorrhynchus, which prefers to breed in closed water bodies. Children are most affected, and usually, people who reside in endemic areas develop immunity by adulthood.1 Encephalitis is a state of inflammation of the brain parenchyma, commonly resulting from either an infectious cause or when the body’s immune system mistakenly attacks the brain. Most human infections are asymptomatic or result in only mild symptoms. However, a small percentage of infected persons develop inflammation of the brain (encephalitis), with symptoms such as sudden onset of headache, high fever, disorientation, seizure, tremors, dystonia, Parkinsonian features, and coma. Psychiatric symptoms, in conjunction with neurological features, may be seen in the acute phase and more commonly during the convalescent period.1,2 The neuropsychiatric symptoms may sometimes be the only presenting feature in these patients. Patients with JE can present with neuropsychiatric symptoms like cognitive impairment, affective instability, behavioral problems, obsessive-compulsive features, personality changes, headache, and meningism. These are frequently reported in adults, while children often develop seizures.3 As the disease progresses, patients may develop dystonia, choreoathetoid movements that mimic extrapyramidal symptoms of Parkinson’s disease. Broadly, the three neuropsychiatric sequelae that have been described for JE are amnestic syndrome, childhood mental retardation, and adulthood behavioral disorders. The wide range of symptomatology of the condition incurs a huge socioeconomic burden on society.4 Neuroimaging analysis of patients with JE shows classical changes in the thalamus, basal ganglia, temporal lobes, and midbrain.5,6 Cases in which there is sparing of the autonomic nervous system may contribute to the nonfatal outcomes.1 Mostly, antipsychotics and mood stabilizers improve the behavioral symptoms in severe cases. However, the majority of patients recover from behavioral symptoms spontaneously.2
CASE DESCRIPTION
Here, we present a case of a 17-year-old Hindu male who studied up to class 9, belonging to a lower socioeconomic status, with no contributory past, family, or personal history, and no history of substance use. He was admitted to the medicine ward with complaints of fever, headache, and vomiting for 7 days. He was discharged after 4 days with improvement. Seven days after discharge, he again presented to the emergency department with headache, increased talkativeness, suspiciousness, and verbally and physically abusive behavior. The patient was afebrile and was referred to the psychiatry outpatient department (OPD) for abnormal behavior and was admitted to the psychiatry ward. He presented with hearing or seeing things that others could not, irrelevant talk, decreased sleep, and frequent irritability. On mental status examination, he was alert, conscious, irritable, gesturing, emotionally incontinent, with decreased psychomotor activity, irrelevant speech at times, inappropriate affect, delusions of persecution and grandiosity, and impaired judgment. Investigations revealed IgM enzyme-linked immunosorbent assay (ELISA) positive for JE virus (JEV) (Table 1). On further evaluation of history, it was found that there were several patients with fever and altered sensorium in the patient’s neighborhood. The patient was started on a low dose of tab. quetiapine (50 mg, later increased to 75 mg at bedtime). He was also started on tab. levetiracetam 1000 mg/day for possible seizure episodes. There were no significant findings on magnetic resonance imaging (MRI). Gradually, his symptoms improved and were almost remitted in 10 days, and the patient was discharged on the same medications. On follow-up 2 weeks after discharge, he was normal without any behavioral symptoms. Levetiracetam was stopped, and quetiapine was reduced to 25 mg as he was experiencing increased sedation.
| Investigations | Results |
|---|---|
| Total leukocyte count (TLC) | 17300/m3 |
| Platelets | 1.8 lacs/m3 |
| Aspartate aminotransferase (AST) | 43 IU/L |
| Alanine aminotransferase (ALT) | 42 IU/L |
| C-reactive protein (CRP) | 8 mg/dL |
| Serum sodium | 141 mEq/L |
| Serum potassium | 4.5 mEq/L |
| CSF analysis | Glucose—95 mmol/L, protein—78 mg/dL, IgM ELISA for JE—positive |
| IgM ELISA for JE (serum) | Positive |
| Widal test, malarial parasite | Negative |
| MRI brain | No significant abnormality |
DISCUSSION
JE infection is associated with a high frequency of long-term disability with neurological and mental impairment, subnormal intelligence, and lower IQ. For a large proportion of the survivors, life after JE becomes much harder.7 Broadly, 30–50% may have to live with permanent neuropsychiatric sequelae, or conditions resulting from the disease, but in specific outbreaks, the rate of damage can be higher. A 2017 study from eastern Uttar Pradesh, India, for instance, reported that 74.6% of the sample—children hospitalized with JE at a regional referral hospital—developed neurological sequelae at different levels of severity. An estimated 15.4% of the children died after discharge, and 63% lived with disabilities.8 Most studies on JE sequelae are on children. A study from India revealed late sequelae following JE in adult patients after 14 years of JE.9 Currently, childhood cases have been greatly reduced by immunization with vaccines. Recently, reporting of behavioral symptoms in autoimmune encephalitis has increased enormously. The uniqueness of this case is the presence of psychotic symptoms with intact sensorium, cognition, and memory. Amnesia is usually an accompanying feature in most cases of JE sequelae and has also been reported in previous literature. Further, there were no behavioral symptoms in the acute phase in this case. The case highlights the behavioral symptoms following JE and the self-limiting nature of such behavioral symptoms, although there are long-term neuropsychiatric sequelae in cases that need continued monitoring and care.
PAPER PRESENTATION
Presented at Mid-Year Conference of Indian Psychiatric Society Assam State Branch in Dhubri, 18th May 2024.
ORCID
Singla Vivek https://orcid.org/0009-0008-7923-9271
Chakravarty P J https://orcid.org/0000-0001-5667-8193
REFERENCES
1. Monnet FP. Behavioural disturbances following Japanese B encephalitis. Eur Psychiatry 2003;18(6):269’273. DOI: 10.1016/j.eurpsy.2003.09.001
2. Yang M, Xiao N, Chen S, et al. Clinical analysis of psychiatric symptoms of Japanese encephalitis during the convalescent period: a single center study in Chongqing, China. Brain Dev 2019;41(7):614’617. DOI: 10.1016/j.braindev.2019.02.016
3. Flannery P, Yang I, Keyvani M, et al. Acute psychosis due to anti-N-methyl D-aspartate receptor encephalitis following COVID-19 vaccination: a case report. Front Neurol 2021;12:764197. DOI: 10.3389/fneur.2021.764197
4. Campbell GL, Hills SL, Fischer M, et al. Estimated global incidence of Japanese encephalitis: a systematic review. Bull World Health Organ 2011;89(10):766’774, 774A–774E. DOI: 10.2471/BLT.10.085233
5. Simon LV, Sandhu DS, Goyal A, et al. Japanese Encephalitis. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470423/
6. Doval N, Kar SK, Malhotra HS. Unfolding the mystery: rare presentation of Japanese encephalitis as catatonia. Int J Nutr Pharmacol Neurol Dis 2015;5(4):159’162. DOI: 10.4103/2231-0738.167499
7. Yin Z, Wang X, Li L, et al. Neurological sequelae of hospitalized Japanese encephalitis cases in Gansu province, China. Am J Trop Med Hyg 2015;92(6):1125. DOI: 10.4269/ajtmh.14-0148
8. Srivastava N, Deval H, Mittal M, et al. Extent of disability among paediatric Japanese encephalitis survivors and predictors of poor outcome: a retrospective cohort study in North India. BMJ Open 2022;12(10):e060795. DOI: 10.1136/bmjopen-2022-060795
9. Kvam KA, Stahl JP, Chow FC, et al. Outcome and sequelae of infectious encephalitis. J Clin Neurol 2024;20(1):23’36. DOI: 10.3988/jcn.2023.0240
________________________
© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.