What is the treatment for dengue leukoencephalitis?

Treatment of Dengue Leukoencephalitis

Dengue leukoencephalitis requires immediate supportive care with close monitoring for complications, as there is no specific antiviral therapy available for dengue-related neurological manifestations. 1

Immediate Management Priorities

Airway and Neurological Support

• Patients with falling level of consciousness require urgent assessment by Intensive Care Unit staff for airway protection and ventilatory support, management of raised intracranial pressure, optimization of cerebral perfusion pressure, and correction of electrolyte imbalances. 1
• Transfer to a neurological specialist unit should occur as soon as possible and definitely within 24 hours if diagnosis is not rapidly established or the patient fails to improve. 1

Diagnostic Confirmation

• Dengue PCR (days 1-8 post symptom onset) or dengue IgM/IgG serology should be obtained to confirm the diagnosis. 1
• Dengue RNA detection in cerebrospinal fluid confirms neurological involvement. 2
• MRI should be performed as soon as possible, which may show abnormal signal intensity in white matter (leukoencephalitis pattern) or other characteristic findings. 1, 3

Specific Treatment Approach

Supportive Care (Primary Treatment)

• Manage symptomatically with daily complete blood count monitoring, particularly watching for high hematocrit and falling platelets that indicate risk of dengue shock syndrome. 1
• Maintain adequate hydration and electrolyte balance, as hyponatremia may occur with encephalitis. 1
• Avoid aspirin due to bleeding risk associated with dengue-related thrombocytopenia. 1

Corticosteroid Consideration

• For acute disseminated encephalomyelitis (ADEM) pattern on MRI, high-dose intravenous methylprednisolone (1 g daily for 5 days) should be administered, as this immune-mediated complication responds to immunosuppression. 1, 3
• The distinction between direct viral encephalitis versus post-infectious ADEM is critical, as ADEM shows characteristic open ring enhancement and peripheral diffusion restriction on MRI. 3

Seizure Management

• Seizures, including epilepsia partialis continua, may occur and require standard antiepileptic therapy. 4
• Status epilepticus management follows standard protocols with benzodiazepines and second-line agents as needed. 1

Critical Monitoring Parameters

Hematological Surveillance

• Daily complete blood count to monitor for thrombocytopenia, rising hematocrit (hemoconcentration indicating plasma leakage), and potential progression to severe dengue. 1, 2
• Procalcitonin may be elevated even without bacterial co-infection, so this should not automatically trigger antibiotic use. 2

Neurological Assessment

• Serial Glasgow Coma Scale monitoring for deterioration. 1
• Watch for development of focal neurological deficits, cranial nerve palsies, or signs of increased intracranial pressure. 5

Important Pitfalls to Avoid

Do Not Delay Supportive Care

• Unlike HSV encephalitis where acyclovir is immediately indicated, there is no specific antiviral treatment for dengue encephalitis—do not delay supportive measures while pursuing diagnostic confirmation. 1

Distinguish from Bacterial Meningitis

• The presence of leptomeningeal enhancement on imaging may mimic bacterial meningitis, but dengue encephalitis typically presents with thrombocytopenia rather than elevated white blood cell count. 2
• Avoid unnecessary antibiotics unless bacterial co-infection is strongly suspected based on CSF findings. 1

Recognize ADEM Pattern

• If MRI shows demyelinating lesions consistent with ADEM rather than direct viral encephalitis, corticosteroids are indicated and can lead to complete resolution within weeks. 3
• This immune-mediated complication requires different management than direct viral invasion. 1

Multidisciplinary Care Requirements

• Access to neuroimaging (MRI and CT) under general anesthesia if needed. 1
• Neurophysiology (EEG) availability for seizure monitoring. 1
• Infectious disease consultation for endemic area considerations and differential diagnosis. 1
• Intensive care capabilities for management of severe cases with altered consciousness or hemodynamic instability. 1