JAPANESE ENCEPHALITIS VIRUS TRIGGERED OVERLAPPING MILLER FISHER SYNDROME WITH BICKERSTAFF ENCEPHALITIS IN A YOUNG FILIPINO CRUISE LINE WORKER

Japanese encephalitis virus is an RNA flavivirus and one of the rare pathogens that can cause encephalitis. The main vector is the Culex tritaeniorhynchus mosquito. The virus is very close in pathophysiology and structure to the West Nile and St. Louis encephalitis viruses. It is endemic in Asia and Western Pacific areas, mostly during the summer; only a few cases have been reported outside those regions. We present the case of a young Filipino cruise line male worker with signs and symptoms of Japanese encephalitis concomitantly with Miller Fisher syndrome and Bickerstaff brainstem encephalitis. The patient developed obtundation, ataxia, areflexia, flaccid paralysis, and ophthalmoplegia, which were preceded by a few days of constitutional symptoms (fever, malaise, fatigue and anorexia). Physical examination showed various stages of erythema nodosum on the lower extremities. Analysis of cerebrospinal fluid was positive for anti-GQ1b, West Nile IgG and Japanese encephalitis IgM. Despite the neurological complications and bradyarrhythmia occurring during hospitalization, the patient recovered completely under our regimen. LEARNING POINTS: Insidious onset of bilateral paralysis preceded by fever is most likely encephalitis. Japanese encephalitis virus led to the development of variant forms of Guillain-Barré syndrome in our patient. Supportive care resulted in significant recovery despite the severity of the condition.