Correspondence Address:
Jamir Pitton Rissardo
Av. Roraima, 1000 - Camobi, Santa Maria - RS 97105-900
Brazil

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Dear Editor,

We read the manuscript entitled, “Clinical profile of dengue and its effect of on biochemical parameters: A hospital-based cross-sectional study” on the esteemed “MRIMS Journal of Health Sciences” with a great interest. Ayyadevara assessed the clinical features and biochemical parameters of 40 patients with dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. The individuals who developed shock related to dengue had the worst hepatic function impairment and those with hemorrhagic fever developed more frequently white and red blood cell abnormalities. Furthermore, the author suggests that these biochemical parameters could be used to monitor the progress during the management.^[1]

Dengue is a mosquito-borne viral disease caused by one of four dengue virus serotypes. The clinical symptoms caused by this infection are varied. In this context, neurological manifestations affect almost one of every five dengue virus-infected patients. When we specifically analyze movement disorders, it is believed that more than 10% of the patients with dengue encephalitis develop abnormal movements.^[2]

Herein, we would like to discuss the movement disorders associated with dengue. The abnormal movements already reported with dengue were dystonia, parkinsonism, ataxia, myoclonus, and stereotypy [Table 1]. The most common presentation was dystonia and parkinsonism. On the other hand, the rarest reported association was stereotypy and parkinsonism. It is noteworthy that myoclonus is more related to ataxia than parkinsonism. In the literature, there was no report of dengue-induced chorea or parkinsonism associated with myoclonus.{Table 1}

Dengue is one of the most common viral infections encountered in tropical countries. In this way, clues to assist a possible diagnosis of this Flaviviridae infection are important. Yadav et al. screened the literature for the cases of dystonia presenting as a manifestation of infectious diseases. They observed that rashes or skin lesions and low platelets levels are possible clinical high yield facts that are related to dengue.^[3] We would like to include the presence of lymphopenia that with a positive epidemiologic factor could be remarkable signs of dengue.

Ganaraja et al. described a 25-year-old male with parkinsonism and stereotypy in dengue encephalitis. The authors hypothesized that the inability to identify the dengue virus in all the reported movement disorders cases may support an immune-inflammatory pathway to explain the symptoms in these individuals. Furthermore, Ganaraja et al. stated that even though the first description of delayed parkinsonism following encephalitis was in 1918, parkinsonism occurring directly after dengue encephalitis was only described in 2013.^[4]

Dengue is considered the most rapidly expanding communicable disease. However, it is probably one of the rarest causes of movement disorders among the emerging infections in South Asia. There are the studies of abnormal movements associated with dengue involving adults and pediatric patients.^[2] Young-adult individuals appear to more commonly develop movement disorders when compared to the pediatric population.^[4]

Mishra and Pandey reported a young-adult female patient presenting with headache, fever, altered sensorium, generalized dystonia, and parkinsonism within the 1 month of onset. Cerebrospinal fluid analysis revealed positive immunoglobulin G antibodies to dengue with lymphocytic pleocytosis, elevated protein, and normal sugar levels. Her brain magnetic resonance imaging showed a characteristic double doughnut sign, which is characterized by bilateral thalamic lesions with patchy diffusion restriction. This case is interesting because it may support the hypothesis of neurotropism and neuroinvasion by this virus.^[5]

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Conflicts of interest

There are no conflicts of interest.

References