Figure 3: Decreased facial crease on left side.
The complete blood count revealed a total leucocyte count (TLC) of
6000/mm with 40% neutrophils, 50% lymphocytes, 8% monocytes, and 2%
eosinophils. The hemoglobin was 9.4 g/L with a mean corpuscular volume
of 79 fL and the platelet count was 320000/mcL. There was mild hepatic
dysfunction with aspartate transaminase of 63 IU/L and alanine
transaminase of 66 IU/L. Total serum bilirubin was 0.5 mg/dL and albumin
was 4 g/dL. Serum sodium, potassium, calcium, and phosphorus were within
normal limit. The renal functions were normal with urea of 16 mg/dL and
creatinine of 0.8 mg/dL.
Blood and urine cultures were sterile. Serological tests for dengue IgM
antibodies and NS1 antigen, herpes simplex and Japanese B encephalitis
IgM antibodies were negative. Simultaneous search for other tropical
infections like malaria, and leptospirosis were negative, however, Scrub
IgM was positive. A guarded lumbar puncture was performed and the CSF
analysis yielded a cell count of 16 cells μ/L with 80% lymphocytes and
20% neutrophils. Total protein was elevated to 125 g/dL, glucose was 82
mg/dL and adenosine deaminase was 2.5 IU/L. No organism was seen on the
Gram stain, Ziehl-Neelsen stain, and India ink stain. CSF cultures were
sterile and PCR was negative for herpes simplex virus (HSV) and
Mycobacterium tuberculosis. The Magnetic resonance imaging (MRI) of
brain was done and MRI of brain reveled multiple mildly increased
T2DM/FLAIR signal in midbrain, pons and in left middle cerebellar
peduncle (Figures 4, 5 and 6).
Ceftriaxone, which was already started at the center where she was
referred, was continued and the dose was doubled to 2gm two times per
day. Acyclovir was added intravenously at a dose of 500 mg times per day
and was discontinued after exclusion of herpes simplex encephalitis.
Dexamethasone was started at a high dose (1gm) to ease cerebral edema.
Ceftriaxone was substituted with doxycycline 100 mg two times per day
intravenously after scrub typhus was diagnosed. Two days later, the
fever subsided, and gradually she was able to communicate verbally and
eat on her own. Objective improvement was documented on MRI. Doxycycline
was administered for a total of 2 weeks.