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Atypical Dengue Meningitis in Makkah, Saudi Arabia with Slow Resolving, Prominent Migraine like Headache, Phobia, and Arrhythmia.

Mamdouh KH, Mroog KM, Hani NH, Nabil EM - J Glob Infect Dis (2013)

Bottom Line: We report two cases of clinical meningitis with positive dengue virus (DENV) IgM in cerebrospinal fluid, followed for minimal 3 months for their prominent attacks of migraine like headache, phobia, and arrhythmia.Both cases showed resistant migraine like headaches to classic anti-migraine therapy except for strong NSAID and narcotics with tendency to have severe to extreme severe daily migraine like headache on early to late afternoon time, associated with non-fatal arrhythmias and extreme death phobia, that resolve slowly in a minimal 3 month period.In conclusion, dengue meningitis in the endemic area may present atypically.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Alnoor Specialist Hospital, King Abdullah Medical City, Holy Makkah, Kingdom of Saudi Arabia.

ABSTRACT
Although dengue meningitis is a rare presentation of dengue infection, our aim is to focus on atypical presentation of dengue meningitis that may appear in dengue endemic area like the Makkah region. We report two cases of clinical meningitis with positive dengue virus (DENV) IgM in cerebrospinal fluid, followed for minimal 3 months for their prominent attacks of migraine like headache, phobia, and arrhythmia. With special consideration to attack time, type, severity, and respond to classical therapy, using regular ECG monitoring, visual analog pain score and neuropsychological assessments were done. Both cases showed resistant migraine like headaches to classic anti-migraine therapy except for strong NSAID and narcotics with tendency to have severe to extreme severe daily migraine like headache on early to late afternoon time, associated with non-fatal arrhythmias and extreme death phobia, that resolve slowly in a minimal 3 month period. In conclusion, dengue meningitis in the endemic area may present atypically.

No MeSH data available.


Related in: MedlinePlus

Headache was moderate to extremely painful (VAS score 6-10)
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Figure 1: Headache was moderate to extremely painful (VAS score 6-10)

Mentions: Millions of Muslims living in dengue hyper-endemic areas come yearly to Makkah for Hajj, with the possibility of introduction of dengue viruses.[11] Since 1994, Makkah province became a dengue endemic area with high rate of dengue infection during spring and early summer.[1213] The dengue infection in both cases was suspected on appearance of fever, headache, and low platelets count in dengue endemic area, which was strong evidence in large Brazilian study.[14] Meningitis suspected and CSF study done in both cases due to the appearance of headache, fever, and neck rigidity. The dengue meningitis in both cases was confirmed by finding positive CSF IgM. Normal CSF cellularity in one case was not exclusion of meningitis as most dengue meningoencephalitis reported in large Brazilian study showed normal CSF cellularity.[15] Both cases had low grade fever which resolved within several days without purpura, rash, or bleeding, suggesting associated DF syndrome rather than dengue hemorrhagic one. Both cases had moderate to extremely painful migraine like headache with VAS score ranging between 6 and 10 [Figure 1]; first case showed headache similar to cluster headache with retroorbital pain, eye tearing, and blurring vision, while the second case showed similar to classic migraine with severe unilateral to bilateral tempro-parietal burning and central scratching pain associated with nausea, vomiting, dizziness, phonophobia, and photophobia. It was the initial and the most prominent symptom in both cases.[16] Both cases showed unique relation to day time with terrifying sense of near death associated with crying, weeping, and fluctuating bouts of significant bradycardia and supraventicular tachycardia that was not reported before. The afternoon time (between 1 pm and 11 pm) was the time of extreme severe pain, phobia, and arrhythmia [Figure 2]. Both cases had normal cardiac enzymes and echocardiography that role out rare reported dengue myocarditis.[17] Both cases showed no to little respond to classic anti-migraine therapy with good respond to narcotic. Tramadol and NSAID were partially effective. Classic migraine abortive therapy like ergotamine and triptan was the worse therapy [Table 1]. This analgesic resistance was evident in few reported cases.[1819] Both cases prolonged course and associated severe headache, phobia, and arrhythmias may explain by what reported that dengue virus positive CSF may have higher risk for development of severe forms of dengue infection.[202122] Both cases recovered completely over several months without any residual neurological deficit [Table 2]. This benign course was shown on rarely reported dengue viral meningitis.[23]


Atypical Dengue Meningitis in Makkah, Saudi Arabia with Slow Resolving, Prominent Migraine like Headache, Phobia, and Arrhythmia.

Mamdouh KH, Mroog KM, Hani NH, Nabil EM - J Glob Infect Dis (2013)

Headache was moderate to extremely painful (VAS score 6-10)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3958991&req=5

Figure 1: Headache was moderate to extremely painful (VAS score 6-10)
Mentions: Millions of Muslims living in dengue hyper-endemic areas come yearly to Makkah for Hajj, with the possibility of introduction of dengue viruses.[11] Since 1994, Makkah province became a dengue endemic area with high rate of dengue infection during spring and early summer.[1213] The dengue infection in both cases was suspected on appearance of fever, headache, and low platelets count in dengue endemic area, which was strong evidence in large Brazilian study.[14] Meningitis suspected and CSF study done in both cases due to the appearance of headache, fever, and neck rigidity. The dengue meningitis in both cases was confirmed by finding positive CSF IgM. Normal CSF cellularity in one case was not exclusion of meningitis as most dengue meningoencephalitis reported in large Brazilian study showed normal CSF cellularity.[15] Both cases had low grade fever which resolved within several days without purpura, rash, or bleeding, suggesting associated DF syndrome rather than dengue hemorrhagic one. Both cases had moderate to extremely painful migraine like headache with VAS score ranging between 6 and 10 [Figure 1]; first case showed headache similar to cluster headache with retroorbital pain, eye tearing, and blurring vision, while the second case showed similar to classic migraine with severe unilateral to bilateral tempro-parietal burning and central scratching pain associated with nausea, vomiting, dizziness, phonophobia, and photophobia. It was the initial and the most prominent symptom in both cases.[16] Both cases showed unique relation to day time with terrifying sense of near death associated with crying, weeping, and fluctuating bouts of significant bradycardia and supraventicular tachycardia that was not reported before. The afternoon time (between 1 pm and 11 pm) was the time of extreme severe pain, phobia, and arrhythmia [Figure 2]. Both cases had normal cardiac enzymes and echocardiography that role out rare reported dengue myocarditis.[17] Both cases showed no to little respond to classic anti-migraine therapy with good respond to narcotic. Tramadol and NSAID were partially effective. Classic migraine abortive therapy like ergotamine and triptan was the worse therapy [Table 1]. This analgesic resistance was evident in few reported cases.[1819] Both cases prolonged course and associated severe headache, phobia, and arrhythmias may explain by what reported that dengue virus positive CSF may have higher risk for development of severe forms of dengue infection.[202122] Both cases recovered completely over several months without any residual neurological deficit [Table 2]. This benign course was shown on rarely reported dengue viral meningitis.[23]

Bottom Line: We report two cases of clinical meningitis with positive dengue virus (DENV) IgM in cerebrospinal fluid, followed for minimal 3 months for their prominent attacks of migraine like headache, phobia, and arrhythmia.Both cases showed resistant migraine like headaches to classic anti-migraine therapy except for strong NSAID and narcotics with tendency to have severe to extreme severe daily migraine like headache on early to late afternoon time, associated with non-fatal arrhythmias and extreme death phobia, that resolve slowly in a minimal 3 month period.In conclusion, dengue meningitis in the endemic area may present atypically.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Alnoor Specialist Hospital, King Abdullah Medical City, Holy Makkah, Kingdom of Saudi Arabia.

ABSTRACT
Although dengue meningitis is a rare presentation of dengue infection, our aim is to focus on atypical presentation of dengue meningitis that may appear in dengue endemic area like the Makkah region. We report two cases of clinical meningitis with positive dengue virus (DENV) IgM in cerebrospinal fluid, followed for minimal 3 months for their prominent attacks of migraine like headache, phobia, and arrhythmia. With special consideration to attack time, type, severity, and respond to classical therapy, using regular ECG monitoring, visual analog pain score and neuropsychological assessments were done. Both cases showed resistant migraine like headaches to classic anti-migraine therapy except for strong NSAID and narcotics with tendency to have severe to extreme severe daily migraine like headache on early to late afternoon time, associated with non-fatal arrhythmias and extreme death phobia, that resolve slowly in a minimal 3 month period. In conclusion, dengue meningitis in the endemic area may present atypically.

No MeSH data available.


Related in: MedlinePlus