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| CASE REPORT |
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| Year : 1984 | Volume
: 32
| Issue : 1 | Page : 45-47 |
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Bicker staffs encephlitis following acute haemorrhagic conjunctivitis
SP Dhir, VP Munjal, IS Jain
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
S P Dhir
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 6500665 
How to cite this article:
Dhir S P, Munjal V P, Jain I S. Bicker staffs encephlitis following acute haemorrhagic conjunctivitis. Indian J Ophthalmol 1984;32:45-7 |
Acute haemorrhagic conjunctivitis is usually considered to be a benign condition, but various ocular as well as neurological complications have been described. Recently two cases of optic neuritis and one case with 6th nerve palsy has been reported.[1] The aim of this paper is to put on record a case who developed multiple cranial nerve palsies following an attack of acute haemorrhagic conjunctivitis.
| Case report | |  |
S.K (A-83656) 29 years old male contracted acute haemorrhagic conjunctivitis and the following day he developed upper respiratory tract infection. After 4 days he noted nasal twang in his voice and regurgitation of fluids through the nose. In the next two days he developed diplopia, drooping of the upper lids, heaviness in the head and vertigo. Diplopia remained for two days and then his eyes became fixed, and diplopia disappeared. When we saw this case in our clinic. He was quite ill looking, but was alert on stimulation. He complained of heaviness in the head and giddiness. Ocular examination revealed moderate ptosis with good LPS action, he could lift the eye lids when asked to look up [Figure - 1][Figure - 2]. His visual acuity was 6/0 in the right eye and 6/6 in the left eye. The eye balls were fixed in the central position, there was no eye movement present in any direction. there was no significant change in anterior segment accept fixed and dilated pupils in both the eyes, right pupil was bigger than the left. Fundi were normal in both eyes. The visual fields were full. Neurological examination revealed; normal higher functions, there was partial involvement of IX and X cranial nerves in the form of bilateral palatal palsy with poor gag reflex. All other cranial nerves were normal. There was no sensory or motor deficit anywhere in the body. Laboratory investigations showed: Hb 13.50 gm%, TLC 6800 per cmm. with differential count of Polymorphs 64%, Lymphocytes 34%, ESR 10 mm, 1st hour by Westergren's method, blood sugar 113 mg %, Blood urea 30 mg%, Total serum proteins 6.6 mg% and differential proteins with albumin 3.8 mg%, globulins 2.8 mg% and albumin-globulin ratio 1.4. X-ray skull lateral and basal views were normal, CSF showed normal pressure, clear with no cells on microscopic examination. Biochemistry of CSF revealed: proteins 40 mg% Globulins nil, glucose 94mg%, chloride 107 meq. per litre. The patient was put on oral prednisolone 40 mg daily. After two days, he started showing improvement in the form of change in voice and decrease in ptosis. Five days later his pupils were reacting well to light but the anisocoria persisted. There was gradual improvement in the next few days, he complained of uncrossed diplopia, there was right convergent squint and movements improved in all the directions. On the 8th day of admission he developed infranuclear seventh nerve palsy on the right side. C.S.F. examination was repeated after 13 days, which showed no significant change. Patient gradually, recovered completely over a period of 3 months [Figure - 3].
| Discussion | | |
Bickerstaff and Cloake published 4 cases in 1951[2] of a benign form of brainstem encephalitis and another group of similar cases was published by the same authors in 1957.[3] Subsequently there has been many case reports of similar nature. Marn[4] described a similar case and used the title Bickerstaff's encephalitis, this has been perpetuated by Jablowski[5] in his Illustrated Dictionary of Eponymic Syndrome's. Our case showed most of the features described by Bickerstaff.[6]
The time between conjunctivitis and onset of neurological symptoms was between 1-3 weeks in the cases reported during the last epidemic (1973) by Wadia et al.[7] Our case developed neurological symptoms four days after the conjunctivitis. This may suggest that encephalitis was due to viraemia and not as result of immune complexes when Luxe some time to develop. Various case reports of neurological complication following an attack of acute haemorrhagic conjunctivitis[2],[7],[8] indicate that the involvement is mainly of the motor system, the sensory nerves are spared, and secondly the recovery is usually complete. The role of systemic steroid is yet to be proved. Our case showed good early recovery but he developed VII nerve palsy while on steroid therapy. This indicates that steroids do not prevent the progress of the disease, but may have a role to shorten the course of the disease.
| Summary | | |
One case of Bickerstaff's encephalitis following an attack of acute haemorrhagic conjunctivitis is reported. There was involvement of III, IV, VI, IX and X cranial nerves. While on systemic steroids patient, developed VII nerve palsy on the right side. Patient showed good recovery.
| References | | |
| 1. | Alexander T.A and Thomas Anna, 1981, Ind Ophthalmol. 29; 35.  |
| 2. | Bickerstaff, E.R- and P.C.P., Cloake, 1951, Brit.Med. Jr., 2: 77. |
| 3. | Bickerstaff, ER., 1957, Brit. Med. Jr. 1: 1384 |
| 4. | Maran, A.G.D., 1966, J. Laryng, 80: 520. |
| 5. | Jablowski, S., 1969, Illustrated Dictionary of Eponymic Syndromes and Diseases and their Synonyms, Philadelphia. Pa., Saunders. |
| 6. | Bickerstaff, E.R, Handbook of clinical Neurology, Vol. 34, 1978, Elsevier/North-Halland Biomedical Press. Amsterdam, The Netherland, P.P. 605-609. |
| 7. | Wadia, N:H., and Irani, P.F., 1973, Lancet, 1: 350 |
| 8. | Saxena, RC., Bhatia, M. and Chaturvedi, U.C.,1972. Oriental Archs. Ophthalmol. 10: 253. |
[Figure - 1], [Figure - 2], [Figure - 3]
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