Danijel Šimašek

Ljiljana Perić

Mihael Mišir

Nikica Perić

Tatjana Vilibić-Čavlek

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81Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaCliniCal aspeCts of West nile virus infeCtionsin humans in CroatiaLjiljana Perić1, Danijel Šimašek1, Tatjana Vilibić-Čavlek2, Mihael Mišir3, Nikica Perić41University Hospital Osijek, Clinic of Infective Diseases;2Department of Virology, Croatian National Institute of Public Health; School of Medicine University of Zagreb;3University Hospital Osijek, Clinic of Neurology;4University Hospital Osijek, Clinic of UrologySummaryDuring August and September of the year 2012th there were 5 patients with meningoen-cephalitis treated at Clinic of Infective Diseases, University Hospital Centre Osijek. In all of them West Nile virus was confirmed to be cause, serologically (ELISA IgG and IgM positive). These are the first confirmed cases of West Nile encephalitis in Eastern Slavonia, Croatia (Budimci, Vukovar, Belisće, Kuševac, Petrijevci). Patients ranged in age from 48 to 77 years. One year ago, three of these patients were treated in Neurology; two of them due to the stroke, and third because the vertigo. Patients were admited to the hospital on the 4th to 6th day from the begining of general infectious symptoms, and the first day of neurological symptoms. Two patients had confusion, disorientation and hallucinations, two patients had somnolence and sopor, and two patients had tremor. During first two days of treatment, all patients had raised body temperature in range from 37.2º C to 38.3º C. Cerebrospinal fluid analysis in all patients spoke in favor of serous meningitis. The number of leukocytes (mainly lymphocytes) ranged from 10 to 517 x106/L, there was a moderate protein elevation and marginal lactate elevation. Glucose and chlorides were within normal range. All patients had EEG changes dysrithmic, diffuse or laterally. CT scan of the brain was normal in two patients, two patients had diffuse brain atrophy, and one had chronic vascular lesions. MRI scan of the brain in two patients was normal. Patients were treated with anti-edematous therapy with infusion 10% Mannitol and 10% Dextrose and other symptomatic therapy. Clinical signs improved within 5 days of treatment. Hospitalization lasted 2-3 weeks. All patients were discharged without neurological sequelae.Keywords: West Nile virus infection; meningoencephalitis; Eastern Slavonia; Croatia.UDK UDK 616-022.1(497.5)Original scientific paperReceived:   7 June 2013Accepted: 18 September 201382Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaINTRODUCTIONAbout 80% of West Nile virus (WNV) infections are asymptomatic. Most WNV infections are mild and often clinically unapparent.  Approximately 20% of those infected develop a generally mild illness (West Nile fever). The incubation period is thought to range from 3 to 14 days [1,2,3]. Symptoms generally last 3 to 6 days.The mild form of WNV infection as a febrile illness of sudden onset often accom-panied by: malaise, headache, anorexia, myalgia, nausea, rash, vomiting, lympha-denopathy, eye pain [4,5,6]. Symptoms occurring among patients hospitalized with severe disease include: fever, gastrointestinal symptoms, weakness, severe neurolo-gical disease. A minority of patients with severe disease developed a maculopapu-lar or morbilliform rash involving the neck, trunk, arms, or legs [7]. Approximately 1 in 150 infections will result in severe neurological disease [7]. The most significant risk factor for developing severe neurological disease is advanced age [1].Neurological presentations include: encephalitis, meningoencephalitis, menin-gitis, West Nile poliomyelitis, acute flaccid paralysis, ataxia, extrapyramidal signs, optic neuritis, cranial nerve abnormalities, polyradiculitis [4,5,8]. Encephalitis is more commonly reported than meningitis.Signs and symptoms of neurological diseases include: high fever, severe headac-he, stiff neck, disorientation or confusion, sopor or coma, tremors or muscle jerking, lack of coordination, convulsions, pain, partial paralysis or sudden weakness [9,10]. Signs and symptoms of West Nile fever usually last a few days, but signs and symp-toms of encephalitis or meningitis can linger for weeks, and certain neurological effects, such as muscle weakness, may be permanent. Myocarditis, pancreatitis, and fulminant hepatitis have been rare described [11].MATERIALS AND METHODSFive patients with serologically confirmed West Nile virus infection and  me-ningoencephalitis were analysed, according to following criteria shown in the ta-ble: age, sex, place of residence, personal anamnesis, tick bite, swimming in sta-gnant water, period of disease before hospitalization, highest body temperature, headache, vomiting, duration of neurological symptoms before hospitalization, photophobia, neck stiffnes, neurological  symptoms, white blood cell count, platelet count, laboratory information on levels of alanine aminotransferase, aspartate ami-notransferase, gamma-glutamyl transferase and urea, liquor white blood cell count, electroencephalography, CT and MRI scan of the  brain, serological tests (ELISA - Enzyme-linked immunosorbent assay test).83Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaRESULTS AND DISCUSSIONData on our patients are shown in following six tables, sorted according to diffe-rent criteria. Table 1. Details from personal anamnesis in patients Patient Age (in years) SexPlace of residence Personal anamnesisTick biteSwimming in stagnant water 1. D.M. 48 F Budimci Vertigo - -2. S.K. 77 F Vukovar Hypertension - -3. P.B. 76 M Belišće Stroke, hypertension - -4. R.V. 48 F Kuševac   - - -5. V.S. 65 M PetrijevciHypertension,chr. radiculopathy,stroke- -Table 2. General symptoms in patientsPatient Period of disease before hospitalization (in days)Highest body temperature Headache Vomiting1. D.M. 4 38 ºC + +2. S.K. 3 38,5 ºC + -(Nausea)3. P.B. 3 38 ºC + -(Nausea)4. R.V. 5 38,3 ºC + +5. V.S. 6 38,5 ºC + +84Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaTable 3. Neurological symptoms of patientsPatientDuration of neurological symptoms before hospitalization (in days)Photophobia Neck stiffness Neurological symptoms 1. D.M. 1. + + Apathy, somnolence, sopor 2. S.K. 1. + + Anxiety, irritability, hallucination 3. P.B. 1. - - Anxiety, irritability hallucination, tremor 4. R.V. 1. + + Apathy, somnolence 5. V.S. 1. - - Tremor Table 4. Blood analysis data         PatientWhite blood cell count 3,4 – 9,7 x109/L Platelet count 158 – 424x109/LAST (11-38 U/l)ALT (12-48 U/l)GGT (11-55 U/l)Urea2,8-8,3 mmol/L1. D.M. 5,0 214 AST 64, ALT 99, GGT 42 5,5 2. S.K. 11,0   190  AST 37, ALT 80, GGT 49 12 3. P.B. 5,1   143 Normal AST and ALT,  GGT 94 13,24. R.V. 14,1  187 Normal value 6,2 5. V.S. 3,5  84  AST 51, ALT 65, GGT 41 5,885Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaTable 5. Diagnostic tests usedPatients/Lumbar puncture done on day Liquor white blood cell count x106/L Electro-encephalography (EEG)CT and MRI Scan of the brain 1. D.M.14 .day10 (ly 100%) Diffuse dysrithmic CT scan of the brain - normal 2. S.K.1. day517 (ly 15, mono 3, neutro 82 % ) Unilateral dysrithmic CT scan of the brain - diffuse brain atrophy 3. P.B.2. day120 (ly 26, mono 9, neutro 65% ) Difusse dysrithmicCT scan of the brain - diffuse brain atrophy MRI scan of the brain - Normal4. R.V.1. day272 (ly 74, mono 19, neutro 16 %) Unilateral dysrithmic CT scan of the brain - normal 5. V.S.12. day17 (ly 75, mono 23, neutro 2%) -MR of the brain - chronic vascular lesion Table 6. Serological test resultsPatientsDay of disease when serum sample was taken ELISA Positive >1,1 RU/mLIgMELISAPositive >22 RU/mLIgG1. D.M. 21. 1,7 1322. S.K. 15. 3,3 403. P.B. 6. 3,2 Neg4. R.V. 13. 4,1 1255. V.S. 8. 3,5 Neg86Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaAll patients were residents of different settlements from eastern Slavonia. Pa-tients ranged in age from 48 to 77 years.  Most of them had some chronic illness. Three of these patients were treated in Neurology; two of them due to the stroke, and third because the vertigo. During first two days of treatment, all patients had raised body temperature in range from 37.2º C to 38.3º C. Patients were admited to the hospital on the 4th to 6th day from the beginning of general infectious symptoms, and the first day of neurological symptoms. Two patients had confusion, disorien-tation and hallucinations, two patients had somnolence and sopor, and two patients had tremor. All of them had headache and most of them vomiting. Three patients had photophobia and neck stiffness. One had leukopenia, two thrombocytopenia and three elevated aminotransferase levels. Cerebrospinal fluid analysis in all patients spoke in favor of serous meningitis. The number of leukocytes (mainly lymphocytes) ranged from 10 to 517 x106/L. All patients had EEG changes dysrithmic, diffuse or laterally. CT scan of the brain was normal in two patients, two patients had diffuse brain atrophy, and one had chronic vascular lesions. MRI scan of the brain in two patients was normal. Serum samples were collected 6th to 21th day of illnes, and  in all patients West Nile virus was proved to be cause, serologically (ELISA IgG and IgM positive).CONCLUSIONDuring August and September of the year 2012th there were 5 patients with me-ningoencephalitis treated at Clinic of Infective Diseases, Osijek University Hospital Centre. In all of them West Nile virus was confirmed to be cause, serologically (ELI-SA IgG and IgM positive). These are the first confirmed cases of West Nile encepha-litis in Eastern Slavonia, Croatia (Budimci, Vukovar, Belisce, Kusevac, Petrijevci).We showed clinical manifestations, neurological symptoms and certain labo-ratory tests in first patients with West Nile virus meningoencephalitis in Eastern Slavonia, Croatia.  Patients were treated with anti-edematous therapy with infusion 10% Mannitol and 10% Dextrose and other symptomatic therapy. Clinical signs improved within 5 days of treatment. Hospitalization lasted 2-3 weeks. All patients were discharged without neurological sequelae. From now on, in differential diagnosis of patients with acute meningoencepha-litis occuring during warmer months, West Nile virus infection must be taken in consideration.87Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaReferences[1]  Campbell G, Marfin A, Lancioti R, Gubler D. West Nile virus. Lancet Infect Dis. 2002;2:519–29.[2]  Murray S, Weir E. West Nile virus. CMAJ. 2005;173:484.[3]  West Nile virus encephalitis -NY. Centers for Disease Control and Prevention. Mor-bidity and Mortality Weekly Report. MMWR. 1999;48:944–6.[4] Petersen LR. Clinical manifestations and diagnosis of West Nile virus infection. http://www.uptodate.com/ index. Accessed Sept. 5, 2012.[5] Ferri FF. Ferri’s Clinical Advisor 2013: 5 Books in 1. Philadelphia, Pa.: Mosby Else-vier; 2012. [6]  West Nile virus and other arboviral diseases - United States, 2011. Centers for Dis-ease Control and Prevention. Morbidity and Mortality Weekly Report. MMWR. 2012;61:510. [7]  Hubalek Z, Halouzka J. West Nile fever - a reemerging mosquitoborne viral disease in Europe. Emerg Infect Dis. 1999;5:643–50.[8]  Glass J, Samuels O, Rich M. Poliomyelitis due to West Nile virus. N Engl J Med. 2002;347:1280-1281. [9]  Watson J, Pertel P, Jones R, et al. Clinical characteristic and functional outcomes of West Nile fever. Ann Intern Med. 2004;141:360–5.[10]  Weiss D, Carr D, Kellachan J, et al. Clinical findings of West Nile virus infection in hos-pitalized patients, New York and New Jersey, 2000. Emerg Infect Dis. 2001;7:654–8.[11]  Lichtensteiger CA, Heinz-Taheny K, Osborne TS, Novak RJ, Lewis BA, Firth ML. West Nile virus encephalitis and myocarditis in wolf and dog. Emerg Infect Dis. 2003;9:1303–06. SažetakKlinička obilježja infekcije virusom zapadnog Nila kod ljudi u HrvatskojTijekom kolovoza i rujna 2012. godine u Klinici za infektologiju KBC-a Osijek liječeno je pet bolesnika s meningoencefalitisom, u kojih je serološki (ELISA IgG i IgM pozitivni) dokazan virus zapadnog Nila. To su prvi dokazani slučajevi meningoencefalitisa uzrokova-nog virusom zapadnog Nila u istočnoj Slavoniji (Budimci, Vukovar, Belišće, Kuševac, Petri-jevci). Bolesnici su bili u dobi od 48 do 77 godina. Tri su se bolesnika godinu prije liječila na neurologiji: dva zbog cerebrovaskularnog inzulta, a treći zbog vertiginoznog sindroma. Hospitalizirani su od četvrtog do šestog dana prisutnih općih infektivnih simptoma, a prvog dana prisutnog poremećaja svijesti. Smetenost, dezorijentiranost i halucinacije imala su dva bolesnika. Somnolencija i sopor bili su prisutni također kod dva bolesnika, a kod dva boles-nika bio je prisutan i tremor.  88Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaPovišenu temperaturu svi su bolesnici imali prva dva dana liječenja i ona je iznosila od 37,2 ºC do 38,3 ºC. U svih je bolesnika nalaz likvora govorio u prilog seroznog meningitisa. Broj leukocita (pretežno limfocita) varirao je od 10 do 517 x106/L. Prisutna je bila umjerena proteinorahija i granično povišene vrijednosti laktata. Glukoza i kloridi bili su u granicama normale. U svih bolesnika EEG je bio dizritmički promijenjen, difuzno ili postranično. CT mozga bio je uredan kod dva bolesnika, kod dva bolesnika bila je prisutna difuzna atrofija mozga, a kod jednog kronična vaskularna lezija. Nalaz MR-a mozga kod dva bolesnika bio je uredan. Uz antiedematoznu terapiju (infuzije 10% manitola i 10% dekstroze) i drugu simptomatsku terapiju, unutar pet dana liječenja uslijedilo je poboljšanje. Bolničko liječenje trajalo je 2 – 3 tjedna. Svi su otpušteni bez neuroloških posljedica.Ključne riječi: infekcija virusom zapadnog Nila; meningoencefalitis; istočna Slavonija; Hrvatska.Corresponding author: Danijel Šimašek E-mail: bentonbenton@net.hr

Klinička obilježja infekcije virusom zapadnog Nila kod ljudi u Hrvatskoj

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81Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaCliniCal aspeCts of West nile virus infeCtionsin humans in CroatiaLjiljana Perić1, Danijel Šimašek1, Tatjana Vilibić-Čavlek2, Mihael Mišir3, Nikica Perić41University Hospital Osijek, Clinic of Infective Diseases;2Department of Virology, Croatian National Institute of Public Health; School of Medicine University of Zagreb;3University Hospital Osijek, Clinic of Neurology;4University Hospital Osijek, Clinic of UrologySummaryDuring August and September of the year 2012th there were 5 patients with meningoen-cephalitis treated at Clinic of Infective Diseases, University Hospital Centre Osijek. In all of them West Nile virus was confirmed to be cause, serologically (ELISA IgG and IgM positive). These are the first confirmed cases of West Nile encephalitis in Eastern Slavonia, Croatia (Budimci, Vukovar, Belisće, Kuševac, Petrijevci). Patients ranged in age from 48 to 77 years. One year ago, three of these patients were treated in Neurology; two of them due to the stroke, and third because the vertigo. Patients were admited to the hospital on the 4th to 6th day from the begining of general infectious symptoms, and the first day of neurological symptoms. Two patients had confusion, disorientation and hallucinations, two patients had somnolence and sopor, and two patients had tremor. During first two days of treatment, all patients had raised body temperature in range from 37.2º C to 38.3º C. Cerebrospinal fluid analysis in all patients spoke in favor of serous meningitis. The number of leukocytes (mainly lymphocytes) ranged from 10 to 517 x106/L, there was a moderate protein elevation and marginal lactate elevation. Glucose and chlorides were within normal range. All patients had EEG changes dysrithmic, diffuse or laterally. CT scan of the brain was normal in two patients, two patients had diffuse brain atrophy, and one had chronic vascular lesions. MRI scan of the brain in two patients was normal. Patients were treated with anti-edematous therapy with infusion 10% Mannitol and 10% Dextrose and other symptomatic therapy. Clinical signs improved within 5 days of treatment. Hospitalization lasted 2-3 weeks. All patients were discharged without neurological sequelae.Keywords: West Nile virus infection; meningoencephalitis; Eastern Slavonia; Croatia.UDK UDK 616-022.1(497.5)Original scientific paperReceived:   7 June 2013Accepted: 18 September 201382Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaINTRODUCTIONAbout 80% of West Nile virus (WNV) infections are asymptomatic. Most WNV infections are mild and often clinically unapparent.  Approximately 20% of those infected develop a generally mild illness (West Nile fever). The incubation period is thought to range from 3 to 14 days [1,2,3]. Symptoms generally last 3 to 6 days.The mild form of WNV infection as a febrile illness of sudden onset often accom-panied by: malaise, headache, anorexia, myalgia, nausea, rash, vomiting, lympha-denopathy, eye pain [4,5,6]. Symptoms occurring among patients hospitalized with severe disease include: fever, gastrointestinal symptoms, weakness, severe neurolo-gical disease. A minority of patients with severe disease developed a maculopapu-lar or morbilliform rash involving the neck, trunk, arms, or legs [7]. Approximately 1 in 150 infections will result in severe neurological disease [7]. The most significant risk factor for developing severe neurological disease is advanced age [1].Neurological presentations include: encephalitis, meningoencephalitis, menin-gitis, West Nile poliomyelitis, acute flaccid paralysis, ataxia, extrapyramidal signs, optic neuritis, cranial nerve abnormalities, polyradiculitis [4,5,8]. Encephalitis is more commonly reported than meningitis.Signs and symptoms of neurological diseases include: high fever, severe headac-he, stiff neck, disorientation or confusion, sopor or coma, tremors or muscle jerking, lack of coordination, convulsions, pain, partial paralysis or sudden weakness [9,10]. Signs and symptoms of West Nile fever usually last a few days, but signs and symp-toms of encephalitis or meningitis can linger for weeks, and certain neurological effects, such as muscle weakness, may be permanent. Myocarditis, pancreatitis, and fulminant hepatitis have been rare described [11].MATERIALS AND METHODSFive patients with serologically confirmed West Nile virus infection and  me-ningoencephalitis were analysed, according to following criteria shown in the ta-ble: age, sex, place of residence, personal anamnesis, tick bite, swimming in sta-gnant water, period of disease before hospitalization, highest body temperature, headache, vomiting, duration of neurological symptoms before hospitalization, photophobia, neck stiffnes, neurological  symptoms, white blood cell count, platelet count, laboratory information on levels of alanine aminotransferase, aspartate ami-notransferase, gamma-glutamyl transferase and urea, liquor white blood cell count, electroencephalography, CT and MRI scan of the  brain, serological tests (ELISA - Enzyme-linked immunosorbent assay test).83Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaRESULTS AND DISCUSSIONData on our patients are shown in following six tables, sorted according to diffe-rent criteria. Table 1. Details from personal anamnesis in patients Patient Age (in years) SexPlace of residence Personal anamnesisTick biteSwimming in stagnant water 1. D.M. 48 F Budimci Vertigo - -2. S.K. 77 F Vukovar Hypertension - -3. P.B. 76 M Belišće Stroke, hypertension - -4. R.V. 48 F Kuševac   - - -5. V.S. 65 M PetrijevciHypertension,chr. radiculopathy,stroke- -Table 2. General symptoms in patientsPatient Period of disease before hospitalization (in days)Highest body temperature Headache Vomiting1. D.M. 4 38 ºC + +2. S.K. 3 38,5 ºC + -(Nausea)3. P.B. 3 38 ºC + -(Nausea)4. R.V. 5 38,3 ºC + +5. V.S. 6 38,5 ºC + +84Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaTable 3. Neurological symptoms of patientsPatientDuration of neurological symptoms before hospitalization (in days)Photophobia Neck stiffness Neurological symptoms 1. D.M. 1. + + Apathy, somnolence, sopor 2. S.K. 1. + + Anxiety, irritability, hallucination 3. P.B. 1. - - Anxiety, irritability hallucination, tremor 4. R.V. 1. + + Apathy, somnolence 5. V.S. 1. - - Tremor Table 4. Blood analysis data         PatientWhite blood cell count 3,4 – 9,7 x109/L Platelet count 158 – 424x109/LAST (11-38 U/l)ALT (12-48 U/l)GGT (11-55 U/l)Urea2,8-8,3 mmol/L1. D.M. 5,0 214 AST 64, ALT 99, GGT 42 5,5 2. S.K. 11,0   190  AST 37, ALT 80, GGT 49 12 3. P.B. 5,1   143 Normal AST and ALT,  GGT 94 13,24. R.V. 14,1  187 Normal value 6,2 5. V.S. 3,5  84  AST 51, ALT 65, GGT 41 5,885Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaTable 5. Diagnostic tests usedPatients/Lumbar puncture done on day Liquor white blood cell count x106/L Electro-encephalography (EEG)CT and MRI Scan of the brain 1. D.M.14 .day 10 (ly 100%) Diffuse dysrithmic CT scan of the brain - normal 2. S.K.1. day517 (ly 15, mono 3, neutro 82 % ) Unilateral dysrithmic CT scan of the brain - diffuse brain atrophy 3. P.B.2. day120 (ly 26, mono 9, neutro 65% ) Difusse dysrithmicCT scan of the brain - diffuse brain atrophy MRI scan of the brain - Normal4. R.V.1. day272 (ly 74, mono 19, neutro 16 %) Unilateral dysrithmic CT scan of the brain - normal 5. V.S.12. day17 (ly 75, mono 23, neutro 2%) -MR of the brain - chronic vascular lesion Table 6. Serological test resultsPatientsDay of disease when serum sample was taken ELISA Positive >1,1 RU/mLIgMELISAPositive >22 RU/mLIgG1. D.M. 21. 1,7 1322. S.K. 15. 3,3 403. P.B. 6. 3,2 Neg4. R.V. 13. 4,1 1255. V.S. 8. 3,5 Neg86Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaAll patients were residents of different settlements from eastern Slavonia. Pa-tients ranged in age from 48 to 77 years.  Most of them had some chronic illness. Three of these patients were treated in Neurology; two of them due to the stroke, and third because the vertigo. During first two days of treatment, all patients had raised body temperature in range from 37.2º C to 38.3º C. Patients were admited to the hospital on the 4th to 6th day from the beginning of general infectious symptoms, and the first day of neurological symptoms. Two patients had confusion, disorien-tation and hallucinations, two patients had somnolence and sopor, and two patients had tremor. All of them had headache and most of them vomiting. Three patients had photophobia and neck stiffness. One had leukopenia, two thrombocytopenia and three elevated aminotransferase levels. Cerebrospinal fluid analysis in all patients spoke in favor of serous meningitis. The number of leukocytes (mainly lymphocytes) ranged from 10 to 517 x106/L. All patients had EEG changes dysrithmic, diffuse or laterally. CT scan of the brain was normal in two patients, two patients had diffuse brain atrophy, and one had chronic vascular lesions. MRI scan of the brain in two patients was normal. Serum samples were collected 6th to 21th day of illnes, and  in all patients West Nile virus was proved to be cause, serologically (ELISA IgG and IgM positive).CONCLUSIONDuring August and September of the year 2012th there were 5 patients with me-ningoencephalitis treated at Clinic of Infective Diseases, Osijek University Hospital Centre. In all of them West Nile virus was confirmed to be cause, serologically (ELI-SA IgG and IgM positive). These are the first confirmed cases of West Nile encepha-litis in Eastern Slavonia, Croatia (Budimci, Vukovar, Belisce, Kusevac, Petrijevci).We showed clinical manifestations, neurological symptoms and certain labo-ratory tests in first patients with West Nile virus meningoencephalitis in Eastern Slavonia, Croatia.  Patients were treated with anti-edematous therapy with infusion 10% Mannitol and 10% Dextrose and other symptomatic therapy. Clinical signs improved within 5 days of treatment. Hospitalization lasted 2-3 weeks. All patients were discharged without neurological sequelae. From now on, in differential diagnosis of patients with acute meningoencepha-litis occuring during warmer months, West Nile virus infection must be taken in consideration.87Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaReferences[1]  Campbell G, Marfin A, Lancioti R, Gubler D. West Nile virus. Lancet Infect Dis. 2002;2:519–29.[2]  Murray S, Weir E. West Nile virus. CMAJ. 2005;173:484.[3]  West Nile virus encephalitis -NY. Centers for Disease Control and Prevention. Mor-bidity and Mortality Weekly Report. MMWR. 1999;48:944–6.[4] Petersen LR. Clinical manifestations and diagnosis of West Nile virus infection. http://www.uptodate.com/ index. Accessed Sept. 5, 2012.[5] Ferri FF. Ferri’s Clinical Advisor 2013: 5 Books in 1. Philadelphia, Pa.: Mosby Else-vier; 2012. [6]  West Nile virus and other arboviral diseases - United States, 2011. Centers for Dis-ease Control and Prevention. Morbidity and Mortality Weekly Report. MMWR. 2012;61:510. [7]  Hubalek Z, Halouzka J. West Nile fever - a reemerging mosquitoborne viral disease in Europe. Emerg Infect Dis. 1999;5:643–50.[8]  Glass J, Samuels O, Rich M. Poliomyelitis due to West Nile virus. N Engl J Med. 2002;347:1280-1281. [9]  Watson J, Pertel P, Jones R, et al. Clinical characteristic and functional outcomes of West Nile fever. Ann Intern Med. 2004;141:360–5.[10]  Weiss D, Carr D, Kellachan J, et al. Clinical findings of West Nile virus infection in hos-pitalized patients, New York and New Jersey, 2000. Emerg Infect Dis. 2001;7:654–8.[11]  Lichtensteiger CA, Heinz-Taheny K, Osborne TS, Novak RJ, Lewis BA, Firth ML. West Nile virus encephalitis and myocarditis in wolf and dog. Emerg Infect Dis. 2003;9:1303–06. SažetakKlinička obilježja infekcije virusom zapadnog Nila kod ljudi u HrvatskojTijekom kolovoza i rujna 2012. godine u Klinici za infektologiju KBC-a Osijek liječeno je pet bolesnika s meningoencefalitisom, u kojih je serološki (ELISA IgG i IgM pozitivni) dokazan virus zapadnog Nila. To su prvi dokazani slučajevi meningoencefalitisa uzrokova-nog virusom zapadnog Nila u istočnoj Slavoniji (Budimci, Vukovar, Belišće, Kuševac, Petri-jevci). Bolesnici su bili u dobi od 48 do 77 godina. Tri su se bolesnika godinu prije liječila na neurologiji: dva zbog cerebrovaskularnog inzulta, a treći zbog vertiginoznog sindroma. Hospitalizirani su od četvrtog do šestog dana prisutnih općih infektivnih simptoma, a prvog dana prisutnog poremećaja svijesti. Smetenost, dezorijentiranost i halucinacije imala su dva bolesnika. Somnolencija i sopor bili su prisutni također kod dva bolesnika, a kod dva boles-nika bio je prisutan i tremor.  88Rad 517. Medical Sciences, 39 (2013) : 81-88Lj. Perić et al: Clinical aspects of West Nile virus infections in humans in CroatiaPovišenu temperaturu svi su bolesnici imali prva dva dana liječenja i ona je iznosila od 37,2 ºC do 38,3 ºC. U svih je bolesnika nalaz likvora govorio u prilog seroznog meningitisa. Broj leukocita (pretežno limfocita) varirao je od 10 do 517 x106/L. Prisutna je bila umjerena proteinorahija i granično povišene vrijednosti laktata. Glukoza i kloridi bili su u granicama normale. U svih bolesnika EEG je bio dizritmički promijenjen, difuzno ili postranično. CT mozga bio je uredan kod dva bolesnika, kod dva bolesnika bila je prisutna difuzna atrofija mozga, a kod jednog kronična vaskularna lezija. Nalaz MR-a mozga kod dva bolesnika bio je uredan. Uz antiedematoznu terapiju (infuzije 10% manitola i 10% dekstroze) i drugu simptomatsku terapiju, unutar pet dana liječenja uslijedilo je poboljšanje. Bolničko liječenje trajalo je 2 – 3 tjedna. Svi su otpušteni bez neuroloških posljedica.Ključne riječi: infekcija virusom zapadnog Nila; meningoencefalitis; istočna Slavonija; Hrvatska.Corresponding author: Danijel Šimašek E-mail: bentonbenton@net.hr

Klinička obilježja infekcije virusom zapadnog Nila kod ljudi u Hrvatskoj

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