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http://dx.doi.org/10.4172/2314-7326.1000e101
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Neuroinfectious Diseases
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Journal o

Dis
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ISSN: 2314-7326

Editorial Open Access

Unveiling the Undiscovered: Etiology of Acute Encephalitis Syndrome in

North India
Amita Jain*, Parul Jain and Bhawana Jain
Department of Microbiology, King George’s Medical University, Lucknow, India

Introduction
Acute Encephalitis Syndrome (AES) poses a great public health
problem in India, occurring both in epidemics and sporadically. The
magnitude of the problem has been estimated to be around 50,000 cas-
es and 10,000 deaths annually [1]. Traditionally Japanese encephalitis
(JE) has been considered to be the most important cause of AES in our
country. The overemphasis on JE is so much so that AES surveillance
is paralleled to JE surveillance for all practical purposes. In 2014, the
total numbers of AES cases and deaths reported from India were 10,853
and 1717 respectively and the corresponding values for JE were 1657
(~15%) and 293 (~17%) respectively [2]. This implies that other undis-
covered or neglected etiology of AES, which accounts for about 85%,
In a resource limited country like India, testing all the AES samples
for all the possible pathogens is a remote possible. Moreover, the vol-
ume of cerebrospinal fluid available for laboratory testing is often small.
Therefore, an algorithmic approach for the diagnosis of encephalitis is
advocated which may serve many purposes, including patient management,
research, and facilitating public health disease surveillance. An algo-
rithm should be designed for each region, based on the local prevalence
of the disease organisms and this will help to diagnose most cases of
AES, using minimum resources within a reasonable period of time. An
attempt was made to design an algorithm for Uttar Pradesh (Figure 1), a
region endemic for both JEV and DV, which can be used as an example.
Suggested Algorithm for Pathogen identification in AES cases in JE, Dengue and malaria endemic north Indian regions

also exists and should also be looked for. Imaging if Patients with clinical features of encephalitis or meningitis# *Collect additional
feasible: samples according to
CT scan/MRI clinical manifestations
AES in India, especially Northern India, as per definition of WHO CSF Serum/ Blood

[3] encompasses several other illnesses; it has malaria, enteric encepha- Contraindication: Papilledema

lopathy, tubercular meningitis, dengue with neurological manifesta-

tions, scrub typhus, bacterial meningitis, etc. It surely is a mixed pot. CSF examination Anti-JEV IgM TLC: RDT for malaria$
Macroscopic antibody by ELISA DLC:

Scientific literature discusses about several other infectious agents; Color:

Traumatic tap: Yes/ No
Malaria parasite: Y/N
Serum Na+ levels:
Biochemical Serum K+ levels: -
only few of them are treatable. Bacterial meningoencephalitis, most Proteins: Serum HCO3- levels:
Glucose: Blood sugar:
commonly caused by Streptococcus pneumoniae, Neisseria meningiti- Microscopic
Total leukocyte count:
-

des, and Haemophilus influenzae type B, is amenable to specific antibi- Predominant cells:
Gram stain:
Anti-DV IgM antibody by ELISA

otic treatment and can be prevented by the available vaccines. Tubercu- -

losis also requires specific treatment. Scrub typhus caused by Orientia Scrub typhus detection by PCR/

tsutsugamushi causes encephalitis that is difficult to diagnose, but can IFA/ IgM antibody by ELISA

Bacterial IS6110 Pan- Depending on the

be treated easily. Enteric encephalopathy is not rare and needs differ- 16s rRNA PCR for M. Herpes history & -

ent management. Malaria is endemic and cerebral malaria is common. gene PCR tuberculosis virus
detection
examination
findings, look for Anti-WNV IgM antibody by ELISA

However, sufficient data is not available from India on these easily treat- +
(DNA
detection
following viruses:
Adenovirus,
-
able causes of AES [4]. by Real
Time
Human Parvovirus
B19, Parvovirus 4,
S. pneumoniae, H. Anti-ChikV IgM antibody by ELISA
PCR) Measles virus, and
Today, world is more concerned about the untreatable and not influenza and N.
meningitides (DNA
Mumps virus etc.
-
known causes. When AES cases from Uttar Pradesh, India, were in- detection by
Multiplex Real Time
vestigated for the etiological diagnosis, viral etiology could be deter- PCR)
Pan-Enteroviruses (RNA
detection by Real Time PCR)
mined for approximately 58% cases, which included Japanese encepha-
*eg lesion scraping if rash is present, saliva in presence of mandibular swell-
litis virus 16%, Dengue virus 11%, Herpes simplex virus, Mumps virus ing/ orchitis.
and measles virus 9% each, and Varicella Zoster virus 4%. Total 42% $Rapid Diagnostic Tests for malaria Note: Detailed clinical history to be col-
cases were AES cases with unknown etiology, which still need to be lected as per preformed format
determined [5]. Dengue encephalitis and neurological manifestations Figure 1: Case definition of AES as per WHO: A person of any age, at any time
of year with the acute onset of fever and a change in mental status (including
are commonly seen [6]. Viruses that have been implicated in outbreaks symptoms such as confusion, disorientation, comatose, or inability to talk) and/
of AES, but have not been studied countrywide include Chandipura or new onset of seizures (excluding simple febrile seizures).
virus, West Nile virus, Nipah virus, Kyasanur Forest Disease Virus, En-
teroviruses and Adenoviruses [7]. Case reports are available on human
Parvovirus B19V as a potential cause of encephalitis and encephalopa-
thy in immunocompetent cases. Human Parvovirus 4 can be an emerg- *Corresponding author: Amita Jain, Department of Microbiology, King George’s
ing cause of encephalitis in patients with acute encephalitis syndrome. Medical University, Lucknow, UP, India, 226003, Tel: 091-9415023928; E-mail:
amita602002@yahoo.com
We detected human parvovirus 4, from CSF of two patients present-
ing as acute encephalitis syndrome in northern India, though causative Received March 27, 2015; Accepted April 28, 2015; Published April 30, 2015
association is yet to be proved [8]. Consideration should be given to Citation: Jain A, Jain P, Jain B (2015) Unveiling the Undiscovered: Etiology
detection of these non-JE AES etiologies, as it will directly impact the of Acute Encephalitis Syndrome in North India. J Neuroinfect Dis 5: e101.
doi:10.4172/2314-7326.1000e101
formulation of health policies of AES in India. This includes identifying
targets for immunization, chart preventive strategies and implement Copyright: © 2015 Jain A, et al. This is an open-access article distributed under
appropriate control measures, especially in outbreak situations and for- the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
mulating other public health interventions. source are credited.

J Neuroinfect Dis
ISSN: 2314-7326 JNID an open access journal Volume 6 • Issue 2 • 1000e101
Citation: Jain A, Jain P, Jain B (2015) Unveiling the Undiscovered: Etiology of Acute Encephalitis Syndrome in North India. J Neuroinfect Dis 5: e101.
doi:10.4172/2314-7326.1000e101
References
1. Campbell GL, Hills SL, Fischer M, Jacobson JA, Hoke CH, et al. (2011) Es-
timated global incidence of Japanese encephalitis: a systematic review. Bull
World Health Organ 89: 766-774, 774A-774E.
2. Sharma SN, Shukla RP, Raghavendra K, Subbarao SK (2005) Impact of DDT
spraying on malaria transmission in Bareilly District, Uttar Pradesh, India. J
Vector Borne Dis 42: 54-60.
3. Japanese encephalitis surveillance standards. From WHO-recommended stan-
dards for surveillance of selected vaccine-preventable diseases.
4. Ravi V, Mani R, Govekar S, Desai A, Lakshman L, et al. (2014) Aetiology and
Laboratory Diagnosis of Acute Encephalitis Syndrome with Special Reference
to India. J Commun Dis 46: 12- 23.
Citation: Jain A, Jain P, Jain B (2015) Unveiling the Undiscovered:
Etiology of Acute Encephalitis Syndrome in North India. J Neuroinfect
Dis 5: e101. doi:10.4172/2314-7326.1000e101
J Neuroinfect Dis
ISSN: 2314-7326 JNID an open access journal
Page 2 of 2
5. Jain P, Jain A, Kumar A, Prakash S, Khan DN, et al. (2014) Epidemiology and
etiology of acute encephalitis syndrome in North India. Jpn J Infect Dis 67:
197-203.
6. Murthy JM (2010) Neurological complication of dengue infection. Neurol India
58: 581-584.
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of acute encephalitis syndrome in India: a systematic review. Natl Med J India
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