Table 1. Characteristics of 3 case-patients with tick-borne encephalitis acquired in the Auvergne-Rhône-Alpes region of France, 2017–2018*.
| Characteristic | Case-patient 1 | Case-patient 2 | Case-patient 3 |
|---|---|---|---|
| Medical history |
Myelofibrosis associated with a JAK 2 mutation, treated with hydroxicarbamide |
None |
Zoster Bell palsy in 1990, arterial hypertension, obesity (BMI 34 kg/m2) |
| Outdoor activity | |||
| Date/duration | 2017 Jun 2/2 d | 2017 Aug 13–19 | All year |
| Location | Allègre region (43270, Haute Loire) | Montarcher forest (42380, Loire) | Saint-Bonnet-le-Courreau (42940, Loire) |
| Type |
Hiking for 10 km |
Hiking, camping |
Farming |
| Tick exposure |
3 nonidentified insect bites on legs and left arm (no eschar, slight erythema at localizations of bites) while hiking |
1 tick bite; tick removed 48 h later |
Yes, frequent |
| Clinical manifestations | |||
| Date of symptom onset | 2017 Jun 17 | 2017 Aug 30 | 2018 Jul 21 |
| Main clinical signs | Headache, left cervicobrachial neuralgia, asthenia, delayed persistent fever (>38.5°C) | Low-grade fever (38.5°C), headache, cervical pain, nausea, vomiting | Dizziness, headache, fever (38.4°C), unable to lift right shoulder |
| Physical findings | No abnormality | Neck stiffness | Proximal deficit in right arm; 3 days later, light deficit in right leg, inability to walk because of motor deficit and dizziness |
| Encephalitis |
No |
No |
Yes |
| Radiologic findings |
Unremarkable cerebral CT scan |
None |
Unremarkable cerebral CT scan and cerebral MRI |
| Biological parameters | |||
| CSF analysis | 2017 Jun 23 | 2017 Sep 2 | 2018 Jul 21 (first one) |
| Leukocytes, cells/mm3 | 5 | 62 (50% PMNs) | 195 (88% lymphocytes) |
| Erythrocytes, cells/mm3 | 2 | 1 | 51 |
| Proteinorachia, g/L | 0.67 | 0.48 | 0.77 |
| Glycorachia/glycemia, mmol/L |
2.98/5.8 |
3.4/5.6 |
3.18/5.68 |
| Etiologic investigations |
Absence of HSV, VZV, or enterovirus by PCR or RT-PCR; presence of TBEV IgM |
Absence of enterovirus by RT-PCR; presence of TBEV IgM |
Absence of HSV, VZV, or enterovirus by PCR or RT-PCR; presence of Borrelia burgdorferi IgG in CSF; Reiber index <2; presence of TBEV IgM |
| Blood analyses |
Blood serology negative for Mycoplasma pneumonia, Bartonella henselae, Coxiella burnetii, Legionella pneumophila, HIV, hepatitis B and C viruses, B. burgdorferi (both in serum and CSF); positive for cytomegalovirus, Epstein-Barr virus, Toxoplasma gondii, and Chlamydia pneumophila, revealed past immunization |
None |
Blood serology for B. burgdorferi IgG >0; blood serology negative for M. pneumonia, B. henselae, C. burnetii, L. pneumophila, HIV, hepatitis B and C viruses |
| Treatment |
2017 Jun 17: paracetamol; 2017 Jun 19: ceftriaxone 1 g/d + levofloxacin 1 g/d; 2017 Jun 23: treatment stopped |
2017 Feb 17: ceftriaxone 100 mg/kg/d; 2017 Sep 4: ceftriaxone stopped, switched to doxycycline 200 mg/d |
2018 Jul 21: acyclovir 3,000 mg/d amoxicillin 12 g/d; 2018 Jul 27: acyclovir stopped, amoxicillin switched to ceftriaxone 2 g/d for 14 d |
| Outcome |
Headache and asthenia waned progressively, fever disappeared; discharged 2017 Jun 29 |
Discharge 2017 Sep 4 |
Discharged 2018 Aug 17 to rehabilitation center because of persistent dizziness and motor deficit in right arm and leg |
| Follow-up |
Consultation 2017 Jul 27; patient felt good, no headache or fever |
Consultation 2017 Sep 18: complete recovery |
Consultation 2018 Sep 19; patient able to walk alone but always with a slight motor deficit of right arm and leg and dizziness |
| Sequelae | No | No | Yes |
*Case-patient 1, 76-year-old man; case-patient 2, 8-year-old boy; case-patient 3, 66-year-old woman. No patients had been vaccinated against arboviruses. BMI, body mass index; CSF, cerebrospinal fluid; CT, computed tomography; HSV, herpes simplex virus; MRI, magnetic resonance imaging; PMN, polymorphonuclear cell; RT-PCR, reverse transcription PCR; TBEV, tick-borne encephalitis virus; VZV, varicella zoster virus.