Dear Editor
After reading the case report by Shah and Ambulkar[1] in the latest issue of your journal with great interest, we feel that few clarification is required and also would like to make the following comments which is expected to benefit the general readers of JFMPC.
First, we strongly disagree with a diagnosis of “encephalitis” in the presented case. The 5½-year-old girl was hospitalized with acute onset fever, vomiting for 1 day, and one episode of generalized clonic convulsion without any postictal drowsiness. On examination, there were neither any signs of meningeal irritation nor focal neurological deficit. The diagnosis of encephalitis requires altered mental status lasting ≥24 h with no alternative cause identified.[2] Looking at the clinical picture, the patient appeared to be a case of viral “aseptic meningitis” rather than “encephalitis.”
Second, in view of the central nervous system involvement, hepatitis, myocarditis, myositis, and coagulopathy with thrombocytopenia and a previous rash, the authors’ suspected a possible Coxsackie infection. They confirmed the diagnosis with a positive Coxsackie IgM ELISA. However, except the previous history of typical rashes, all other features can be present in a case of enteroviral infection other than coxsackie as well.[3] Furthermore, the coxsackie IgM ELISA has a poor specificity and can be positive in cases of other enteroviral infections (e.g., echovirus and poliovirus type 3) and infectious mononucleosis and in Mycoplasma pneumoniae infection as well.[4] A positive coxsackie IgM ELISA has also been found in asymptomatic children possibly secondary to a nonclinical infection.[5] The positive coxsackie IgM ELISA in this particular patient simply could be due to the infection 2 months back. Therefore, in this case, a definite diagnosis of coxsackievirus CNS infection would better have been done with a cerebrospinal fluid polymerase chain reaction.[6]
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References
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