Japanese Encephalitis: A Case of Miraculous Recovery After 68 Days of ICU Admission in a 30 -Years-Old-Male

Japanese Encephalitis: A Case of Miraculous Recovery After 68 Days of ICU Admission in a 30 -Years-Old-Male | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Japanese Encephalitis: A Case of Miraculous Recovery After 68 Days of ICU Admission in a 30 -Years-Old-Male Bishal Budha, Ziyaul Haq Musalman, Sabin Thapaliya, Roshan Chaudhary, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7529089/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 10 You are reading this latest preprint version Abstract Background Japanese encephalitis is a disease of central nervous system caused by Japanese Encephalitis Virus (JEV), a flavi virus transmitted by culex mosquitoes. Only <1% of the infected people develop symptoms and among symptomatic cases, around 1/3 rd die and remaining 30-50% develop persisted neurological damage. Here, we present an unusual case of 30 years male with severe neurological manifestations requiring intubation and ICU admission for 68 days but miraculously recovering completely without any residual neurological deficits. Case Presentation We present a case of 30 years Male who presented with high grade fever, headache, vomiting which progressed to altered sensorium and decreased GCS requiring intubation. CNS infection was suspected based on presentation and diagnosis of JE was confirmed with CSF anti-JEV IgM ELISA however CNS imaging was not significant. He was managed in ICU for 68 days with supportive care, antibiotics for ventilator associated pneumonia and physiotherapy. On long term follow up on outpatient basis, he miraculously recovered fully with no neurological deficits despite severe manifestations on initial presentation. Conclusion This case presents an unusual outcome of JE. Although the prognosis of JE isn’t great, from this case we can say that despite severe presentation we can have favorable outcomes with supportive care and long-term physiotherapy. It’ll also be helpful while counseling the patient and patient parties on the prognosis of JE. Further research is required to update the outcomes in JE patients in current healthcare settings. Japanese Encephalitis Culex Mosquito Neurological Sequelae Neurological Recovery Case Report Introduction Japanese Encephalitis is a zoonotic infection caused by Japanese Encephalitis Virus (JEV), a flavivirus transmitted by mosquitoes, principally Culex tritaeniorhynchus. 1 It is endemic in south east Asia and around 51.9% population of Nepal are living in at risk areas. 2 It is more prevalent in regions where Culex mosquitoes breed, particularly in areas with paddy fields and standing water. Most patients who are infected remain asymptomatic. Only < 1% people develop flu like symptoms and among symptomatic cases around 1 in 250 develop severe disease; 33% die and around 30–50% develop persistent neurological damage. 3 Clinical features varies widely from febrile illness associated with headache to more severe manifestations like confusion, convulsions, neurological deficits which are often persistent, coma and death. 4 , 5 Here, we present a case of Japanese Encephalitis presenting with severe manifestation requiring 68 days of ICU admission but having full recovery over long term follow up and supportive care unlike usual cases. Case Presentation A 30-year-old male from rural Nepal, with rice cultivation and livestock farming nearby, presented to the Emergency department of a local hospital with a four days history of high-grade fever reaching 39 o C, associated with chills and rigor, multiple episodes of vomiting per day, and generalized, moderate-to-severe headache. On the fifth day of illness, he developed slurred speech and progressive decrease in responsiveness. There were no features of meningism, or any gastrointestinal or respiratory complaints. He had a 3.5 pack year of smoking history but no history of Diabetes, Hypertension or any chronic illness. Family history and allergy history was unremarkable. Due to deteriorating sensorium, he was intubated for airway protection following a decline in GCS and was managed in the ICU of nearby higher center for 20 days. Subsequently, referred to our tertiary care center for further evaluation and management. On initial assessment at our center, he was ill looking, with a tracheostomy tube in situ. His vital signs were: BP 140/100 mmHg, RR 20/minute, and HR 100 bpm. GCS was E 4 V T M 6 . Neurological examination was evident for asymmetrically decreased strength in all extremities; (MRC 3/5) in the right upper extremity and (4/5) in all other extremities. Reflexes were 2 + and Babinski was down going. He was able to follow commands. Sensation was intact and he had no signs of meningism or abnormal body movements. Pupils were round, regular and reactive to light. Systemic examination was unremarkable. He was admitted to ICU for further management. Before referring to our center, he had already been diagnosed with Japanese Encephalitis based on CSF findings: Anti-JE IgM positive, cell count 200/mm 3 (predominantly lymphocytes), glucose 62 mg/dl and protein 80 mg/dl. A non-contrast CT scan of Head was normal. Subsequent contrast-enhanced MRI Brain and Cervical spine was done which revealed few discrete and confluent T2 and FLAIR hyperintense foci in B/L periventricular white matter and centrum semiovale, likely non-specific foci of demyelination. During the hospital course, he developed hospital acquired pneumonia for which sputum culture and sensitivity was sent. Pseudomonas aeruginosa and Klebsiella pneumoniae were isolated sensitive to Meropenem and Piperacillin-tazobactum. Viral encephalitis was suspected based on initial presentation of high fever, headache, decreased responsiveness and motor deficits and the biochemical picture of CSF analysis which showed increased cells (predominantly lymphocytes), normal glucose and slightly increased protein. Given the epidemiological setting, Japanese Encephalitis (JE) was strongly considered, and the diagnosis was confirmed by detection of anti-JEV IgM antibody in CSF using ELISA, which also excluded other flavi-viral infections. Neuroimaging was performed to localize the site and extent of involvement and to rule out other etiologies like brain abscess, tumor, other viral encephalitis like HSV, EBV, CMV etc. PCR testing was not pursued due to financial constraints and the already established diagnosis of JE through ELISA. At referring center, he was empirically treated for suspected meningitis with intravenous fluids and broad spectrum antibiotics (Ceftriaxone 2gm twice daily and vancomycin 1gm twice daily). These were discontinued once CSF analysis confirmed JE. He required intubation for progressive worsening of consciousness, which was subsequently converted to tracheostomy on day 10. He remained in ICU for a total of 20 days before being transferred to our center. During his stay, he developed ventilator associated pneumonia which was managed with antibiotics. At our tertiary center, he was co-managed by Neurology and Infectious Disease team and admitted to ICU for total of 68 days. Management included intravenous fluids, multiple courses of antibiotics tailored to culture sensitivity (meropenem, levofloxacin, linezolid, doxycycline) for VAP, which gradually resolved, and Lacosamide (50 mg) for seizure prophylaxis. Hypertension was managed with amlodipine, losartan, and clonidine, along with other supportive measures. The tracheostomy tube was progressively downsized and eventually removed. Physiotherapy was initiated during hospitalization and continued on an outpatient basis following discharge. He was then followed up monthly for the first three months and subsequently at three-months intervals. At his most recent follow-up visit, clinical examination revealed no residual neurological deficits, with complete recovery of motor power in both upper and lower limbs. He reported no recurrent seizures, cognitive impairment, or other neurological complaints. Overall, he demonstrated full resolution of symptoms, indicating complete recovery from Japanese Encephalitis. Discussion Japanese Encephalitis(JE) is an inflammatory disease of Central Nervous System(CNS) caused by JEV, a flavivirus and is the most common cause of viral encephalitis in Asia. 6 It is a mosquito borne zoonotic infection and uses Culex tritaeniorhynchus as a vector for transmission which is common in paddy fields and water logged areas. 7 WHO estimates around 68,000 annual cases worldwide and it’s a major public health concern in Nepal. 7 The number of cases has significantly dropped after introduction of vaccine against JEV which is 95 to 99% effective. 7 Immunity starts getting weakened at around 25 years of age that’s why JE infection is getting more common in middle aged population now. 8 Only 0.1-1% of infected develop encephalitis and majority remain asymptomatic but still it remains a neurological disease with highest global burden due to its long term neurological sequelae. 9 Patient commonly presents fever, coryza, myalgias which then progresses to headache, vomiting, altered sensorium and seizures. Important neurological manifestation include generalized tonic-clonic seizures, focal seizures, parkinsonian syndromes, cranial nerve palsies, acute flaccid paralysis and behavioral abnormalities. 9 Our patient also presented with similar symptoms like fever, persistent headache, vomiting and later he had decreased responsiveness and dropping GCS requiring intubation. That’s why clinical suspicion of JE was high especially considering the epidemiological background. Detection of Anti JEV IgM antibodies using ELISA plays crucial role in diagnosis of JE. It should be tested in both blood and CSF but CSF one is more specific. In cases where CSF sample can’t be taken, diagnosis can be made using clinical and imaging features along with positive serum anti JEV IgM antibodies. 8 On early presentation, antibodies may be negative and should be repeated at a later date if clinical suspicion is high. It can also differentiate other flavivirus infections. Imaging of brain shows characteristic focal lesions in unilateral or bilateral thalamus, basal ganglia, brainstem which are hypodense in CT and hyperintense in T2 weighted imaging (T2WI) and FLAIR signals in MRI and in some cases obvious brain edema is seen. 8 MRI is more sensitive than CT scan. CSF PCR can also be done to detect or rule out other viruses like HSV, EBV, CMV etc. In our patient as well, CSF analysis was done which showed increased protein and cells (predominantly lymphocytes) and normal glucose which is typical of viral encephalitis. CSF anti JEV IgM was positive and thus the diagnosis was made. CT scan was normal and MRI showed nonspecific foci of demyelination. PCR was not done due to high cost and serum anti JEV IgM was not sent as CSF result already came out to be positive. There’s no specific treatment of JE. Treating high fever, raised ICP, seizures, preventing and managing complications are the mainstay of therapy. 8 Our patient was also initially empirically managed with acyclovir and Ceftriaxone but antibiotics were stopped after diagnosis of JE was made. Due to his poor GCS score (7/15), he was intubated and later tracheostomy was done on 10th day. He stayed in ICU for a total of 68 days during which he received supportive care, anti- seizure medications prophylactically, multiple antibiotics to treat ventilator associated pneumonia and antihypertensive for controlling high blood pressure. Physiotherapy was started early in ICU on and was continued over long term in outpatient visits. Tracheostomy was downsized and strapping was done before he was discharged. Around 30% of the symptomatic cases die and among the survivors 50% developed long term persistent neurological sequelae like frank motor deficits, fixed flexon deformity of arms, equine feet, cognitive and language impairment etc. 10 Although, the prognosis is not very good with JE, early intervention with supportive care, prevention and management of complication and long term follow up and physiotherapy can result in good recovery as seen in our patient who, despite having serious manifestations on initial presentation had a miraculous recovery over a duration of 1 year. Further research is required to update the prognosis of JE in present healthcare settings. Conclusion Our case underscores that, although Japanese Encephalitis carries a poor prognosis and may present with severe illness necessitating intubation and prolonged ICU care, a favorable outcome is still possible. Despite developing severe neurological manifestations, Our patient achieved complete recovery through supportive care, physiotherapy, and meticulous management of complications in a resource-limited setting. This emphasizes the need for cautious optimism when counseling patients and families regarding JE outcomes. However, further research is necessary to clarify long-term prognoses in JE patients at current healthcare environments. Abbreviations JE Japanese encephalitis CSF cerebrospinal fluid ICU Intensive care unit CT Computed tomography MRI Magnetic resonance imaging CNS Central nerve system Declarations Ethical Approval Not Applicable Consent for publication Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request Availability of data and materials Not applicable Competing Interests Not applicable Funding No funding received Authors' contributions BB: Writing editing and original draft preparation ZHM: Writing and editing ST: Study concept, manuscript supervisor RC, DA SS and DR: Literature review and revision of the manuscript. All authors were involved in manuscript drafting and revising and approved the final version Acknowledgements No acknowledgement References Lopalco PL, Biasio LR. Japanese Encephalitis can be devastating. Ann Ig Med Prev E Comunita . 2024;36(3):370-375. doi:10.7416/ai.2024.2616 Moore SM. The current burden of Japanese encephalitis and the estimated impacts of vaccination: Combining estimates of the spatial distribution and transmission intensity of a zoonotic pathogen. PLoS Negl Trop Dis . 2021;15(10):e0009385. doi:10.1371/journal.pntd.0009385 Guo H, Sun L, Shen X, Hu W. A Retrospective Study of the Clinical Characteristics of Japanese Encephalitis in Adults. J Integr Neurosci . 2022;21(5):125. doi:10.31083/j.jin2105125 Kumar R. Understanding and managing acute encephalitis. F1000Research . 2020;9:F1000 Faculty Rev-60. doi:10.12688/f1000research.20634.1 Basnet P, Singh PR, Pudasaini KR, Shrestha S, Kc A. A rare case of symmetric quadriplegia in a patient with Japanese encephalitis: a case report. Ann Med Surg . 2025;87(4):2430. doi:10.1097/MS9.0000000000003105 Yun SI, Lee YM. Japanese encephalitis: The virus and vaccines. Hum Vaccines Immunother . 2014;10(2):263-279. doi:10.4161/hv.26902 Sah R, Mohanty A, Rohilla R, et al. Japanese encephalitis prevalence and outbreaks in Nepal and mitigation strategies: an update on this mosquito-borne zoonotic disease posing public health concerns. Int J Surg . 2024;110(10):6822. doi:10.1097/JS9.0000000000000080 Guo H, Sun L, Shen X, Hu W. A Retrospective Study of the Clinical Characteristics of Japanese Encephalitis in Adults. J Integr Neurosci . 2022;21(5):125. doi:10.31083/j.jin2105125 Sharma R, Agarwal M, Saxena SK, et al. Clinical Characteristics and Differential Clinical Diagnosis of Japanese Encephalitis. In: Saxena SK, ed. Japanese Encephalitis: Epidemiology, Pathogenesis, Diagnosis, and Therapeutics . Springer Nature; 2025:85-101. doi:10.1007/978-981-97-5433-5_8 Solomon T, Dung NM, Kneen R, Gainsborough M, Vaughn D, Khanh VT. Japanese encephalitis. J Neurol Neurosurg Psychiatry . 2000;68(4):405-415. doi:10.1136/jnnp.68.4.405 Additional Declarations No competing interests reported. Supplementary Files CARE.pdf Cite Share Download PDF Status: Published Journal Publication published 12 Jan, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 05 Nov, 2025 Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviewers agreed at journal 09 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor assigned by journal 07 Oct, 2025 Editor invited by journal 16 Sep, 2025 Submission checks completed at journal 12 Sep, 2025 First submitted to journal 12 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e It is more prevalent in regions where Culex mosquitoes breed, particularly in areas with paddy fields and standing water. Most patients who are infected remain asymptomatic. Only\u0026thinsp;\u0026lt;\u0026thinsp;1% people develop flu like symptoms and among symptomatic cases around 1 in 250 develop severe disease; 33% die and around 30\u0026ndash;50% develop persistent neurological damage.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Clinical features varies widely from febrile illness associated with headache to more severe manifestations like confusion, convulsions, neurological deficits which are often persistent, coma and death.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHere, we present a case of Japanese Encephalitis presenting with severe manifestation requiring 68 days of ICU admission but having full recovery over long term follow up and supportive care unlike usual cases.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 30-year-old male from rural Nepal, with rice cultivation and livestock farming nearby, presented to the Emergency department of a local hospital with a four days history of high-grade fever reaching 39\u003csup\u003eo\u003c/sup\u003eC, associated with chills and rigor, multiple episodes of vomiting per day, and generalized, moderate-to-severe headache. On the fifth day of illness, he developed slurred speech and progressive decrease in responsiveness. There were no features of meningism, or any gastrointestinal or respiratory complaints. He had a 3.5 pack year of smoking history but no history of Diabetes, Hypertension or any chronic illness. Family history and allergy history was unremarkable. Due to deteriorating sensorium, he was intubated for airway protection following a decline in GCS and was managed in the ICU of nearby higher center for 20 days. Subsequently, referred to our tertiary care center for further evaluation and management.\u003c/p\u003e\u003cp\u003eOn initial assessment at our center, he was ill looking, with a tracheostomy tube in situ. His vital signs were: BP 140/100 mmHg, RR 20/minute, and HR 100 bpm. GCS was E\u003csub\u003e4\u003c/sub\u003eV\u003csub\u003eT\u003c/sub\u003eM\u003csub\u003e6\u003c/sub\u003e. Neurological examination was evident for asymmetrically decreased strength in all extremities; (MRC 3/5) in the right upper extremity and (4/5) in all other extremities. Reflexes were 2\u0026thinsp;+\u0026thinsp;and Babinski was down going. He was able to follow commands. Sensation was intact and he had no signs of meningism or abnormal body movements. Pupils were round, regular and reactive to light. Systemic examination was unremarkable. He was admitted to ICU for further management.\u003c/p\u003e\u003cp\u003eBefore referring to our center, he had already been diagnosed with Japanese Encephalitis based on CSF findings: Anti-JE IgM positive, cell count 200/mm\u003csup\u003e3\u003c/sup\u003e (predominantly lymphocytes), glucose 62 mg/dl and protein 80 mg/dl. A non-contrast CT scan of Head was normal. Subsequent contrast-enhanced MRI Brain and Cervical spine was done which revealed few discrete and confluent T2 and FLAIR hyperintense foci in B/L periventricular white matter and centrum semiovale, likely non-specific foci of demyelination.\u003c/p\u003e\u003cp\u003eDuring the hospital course, he developed hospital acquired pneumonia for which sputum culture and sensitivity was sent. \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e were isolated sensitive to Meropenem and Piperacillin-tazobactum.\u003c/p\u003e\u003cp\u003eViral encephalitis was suspected based on initial presentation of high fever, headache, decreased responsiveness and motor deficits and the biochemical picture of CSF analysis which showed increased cells (predominantly lymphocytes), normal glucose and slightly increased protein. Given the epidemiological setting, Japanese Encephalitis (JE) was strongly considered, and the diagnosis was confirmed by detection of anti-JEV IgM antibody in CSF using ELISA, which also excluded other flavi-viral infections. Neuroimaging was performed to localize the site and extent of involvement and to rule out other etiologies like brain abscess, tumor, other viral encephalitis like HSV, EBV, CMV etc. PCR testing was not pursued due to financial constraints and the already established diagnosis of JE through ELISA.\u003c/p\u003e\u003cp\u003eAt referring center, he was empirically treated for suspected meningitis with intravenous fluids and broad spectrum antibiotics (Ceftriaxone 2gm twice daily and vancomycin 1gm twice daily). These were discontinued once CSF analysis confirmed JE. He required intubation for progressive worsening of consciousness, which was subsequently converted to tracheostomy on day 10. He remained in ICU for a total of 20 days before being transferred to our center. During his stay, he developed ventilator associated pneumonia which was managed with antibiotics.\u003c/p\u003e\u003cp\u003eAt our tertiary center, he was co-managed by Neurology and Infectious Disease team and admitted to ICU for total of 68 days. Management included intravenous fluids, multiple courses of antibiotics tailored to culture sensitivity (meropenem, levofloxacin, linezolid, doxycycline) for VAP, which gradually resolved, and Lacosamide (50 mg) for seizure prophylaxis. Hypertension was managed with amlodipine, losartan, and clonidine, along with other supportive measures. The tracheostomy tube was progressively downsized and eventually removed. Physiotherapy was initiated during hospitalization and continued on an outpatient basis following discharge.\u003c/p\u003e\u003cp\u003eHe was then followed up monthly for the first three months and subsequently at three-months intervals. At his most recent follow-up visit, clinical examination revealed no residual neurological deficits, with complete recovery of motor power in both upper and lower limbs. He reported no recurrent seizures, cognitive impairment, or other neurological complaints. Overall, he demonstrated full resolution of symptoms, indicating complete recovery from Japanese Encephalitis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eJapanese Encephalitis(JE) is an inflammatory disease of Central Nervous System(CNS) caused by JEV, a flavivirus and is the most common cause of viral encephalitis in Asia.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e It is a mosquito borne zoonotic infection and uses \u003cem\u003eCulex tritaeniorhynchus\u003c/em\u003e as a vector for transmission which is common in paddy fields and water logged areas.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e WHO estimates around 68,000 annual cases worldwide and it\u0026rsquo;s a major public health concern in Nepal.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The number of cases has significantly dropped after introduction of vaccine against JEV which is 95 to 99% effective.\u003csup\u003e7\u003c/sup\u003e Immunity starts getting weakened at around 25 years of age that\u0026rsquo;s why JE infection is getting more common in middle aged population now.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOnly 0.1-1% of infected develop encephalitis and majority remain asymptomatic but still it remains a neurological disease with highest global burden due to its long term neurological sequelae.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Patient commonly presents fever, coryza, myalgias which then progresses to headache, vomiting, altered sensorium and seizures. Important neurological manifestation include generalized tonic-clonic seizures, focal seizures, parkinsonian syndromes, cranial nerve palsies, acute flaccid paralysis and behavioral abnormalities.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Our patient also presented with similar symptoms like fever, persistent headache, vomiting and later he had decreased responsiveness and dropping GCS requiring intubation. That\u0026rsquo;s why clinical suspicion of JE was high especially considering the epidemiological background.\u003c/p\u003e\u003cp\u003eDetection of Anti JEV IgM antibodies using ELISA plays crucial role in diagnosis of JE. It should be tested in both blood and CSF but CSF one is more specific. In cases where CSF sample can\u0026rsquo;t be taken, diagnosis can be made using clinical and imaging features along with positive serum anti JEV IgM antibodies.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e On early presentation, antibodies may be negative and should be repeated at a later date if clinical suspicion is high. It can also differentiate other flavivirus infections. Imaging of brain shows characteristic focal lesions in unilateral or bilateral thalamus, basal ganglia, brainstem which are hypodense in CT and hyperintense in T2 weighted imaging (T2WI) and FLAIR signals in MRI and in some cases obvious brain edema is seen.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e MRI is more sensitive than CT scan. CSF PCR can also be done to detect or rule out other viruses like HSV, EBV, CMV etc. In our patient as well, CSF analysis was done which showed increased protein and cells (predominantly lymphocytes) and normal glucose which is typical of viral encephalitis. CSF anti JEV IgM was positive and thus the diagnosis was made. CT scan was normal and MRI showed nonspecific foci of demyelination. PCR was not done due to high cost and serum anti JEV IgM was not sent as CSF result already came out to be positive.\u003c/p\u003e\u003cp\u003eThere\u0026rsquo;s no specific treatment of JE. Treating high fever, raised ICP, seizures, preventing and managing complications are the mainstay of therapy.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Our patient was also initially empirically managed with acyclovir and Ceftriaxone but antibiotics were stopped after diagnosis of JE was made. Due to his poor GCS score (7/15), he was intubated and later tracheostomy was done on 10th day. He stayed in ICU for a total of 68 days during which he received supportive care, anti- seizure medications prophylactically, multiple antibiotics to treat ventilator associated pneumonia and antihypertensive for controlling high blood pressure. Physiotherapy was started early in ICU on and was continued over long term in outpatient visits. Tracheostomy was downsized and strapping was done before he was discharged.\u003c/p\u003e\u003cp\u003eAround 30% of the symptomatic cases die and among the survivors 50% developed long term persistent neurological sequelae like frank motor deficits, fixed flexon deformity of arms, equine feet, cognitive and language impairment etc.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Although, the prognosis is not very good with JE, early intervention with supportive care, prevention and management of complication and long term follow up and physiotherapy can result in good recovery as seen in our patient who, despite having serious manifestations on initial presentation had a miraculous recovery over a duration of 1 year. Further research is required to update the prognosis of JE in present healthcare settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur case underscores that, although Japanese Encephalitis carries a poor prognosis and may present with severe illness necessitating intubation and prolonged ICU care, a favorable outcome is still possible. Despite developing severe neurological manifestations, Our patient achieved complete recovery through supportive care, physiotherapy, and meticulous management of complications in a resource-limited setting. This emphasizes the need for cautious optimism when counseling patients and families regarding JE outcomes. However, further research is necessary to clarify long-term prognoses in JE patients at current healthcare environments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eJE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eJapanese encephalitis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecerebrospinal fluid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive care unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral nerve system\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical Approval\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo funding received\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eBB: Writing editing and original draft preparation\u003c/p\u003e\n\u003cp\u003eZHM: Writing and editing\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;ST: Study concept, manuscript supervisor\u003c/p\u003e\n\u003cp\u003eRC, DA SS and DR: Literature review and revision of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors were involved in manuscript drafting and revising and approved the final version\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;Acknowledgements\u003c/p\u003e\n\u003cp\u003eNo acknowledgement\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLopalco PL, Biasio LR. Japanese Encephalitis can be devastating. \u003cem\u003eAnn Ig Med Prev E Comunita\u003c/em\u003e. 2024;36(3):370-375. doi:10.7416/ai.2024.2616 \u003c/li\u003e\n\u003cli\u003eMoore SM. The current burden of Japanese encephalitis and the estimated impacts of vaccination: Combining estimates of the spatial distribution and transmission intensity of a zoonotic pathogen. \u003cem\u003ePLoS Negl Trop Dis\u003c/em\u003e. 2021;15(10):e0009385. doi:10.1371/journal.pntd.0009385 \u003c/li\u003e\n\u003cli\u003eGuo H, Sun L, Shen X, Hu W. A Retrospective Study of the Clinical Characteristics of Japanese Encephalitis in Adults. \u003cem\u003eJ Integr Neurosci\u003c/em\u003e. 2022;21(5):125. doi:10.31083/j.jin2105125 \u003c/li\u003e\n\u003cli\u003eKumar R. Understanding and managing acute encephalitis. \u003cem\u003eF1000Research\u003c/em\u003e. 2020;9:F1000 Faculty Rev-60. doi:10.12688/f1000research.20634.1 \u003c/li\u003e\n\u003cli\u003eBasnet P, Singh PR, Pudasaini KR, Shrestha S, Kc A. A rare case of symmetric quadriplegia in a patient with Japanese encephalitis: a case report. \u003cem\u003eAnn Med Surg\u003c/em\u003e. 2025;87(4):2430. doi:10.1097/MS9.0000000000003105 \u003c/li\u003e\n\u003cli\u003eYun SI, Lee YM. Japanese encephalitis: The virus and vaccines. \u003cem\u003eHum Vaccines Immunother\u003c/em\u003e. 2014;10(2):263-279. doi:10.4161/hv.26902 \u003c/li\u003e\n\u003cli\u003eSah R, Mohanty A, Rohilla R, et al. Japanese encephalitis prevalence and outbreaks in Nepal and mitigation strategies: an update on this mosquito-borne zoonotic disease posing public health concerns. \u003cem\u003eInt J Surg\u003c/em\u003e. 2024;110(10):6822. doi:10.1097/JS9.0000000000000080 \u003c/li\u003e\n\u003cli\u003eGuo H, Sun L, Shen X, Hu W. A Retrospective Study of the Clinical Characteristics of Japanese Encephalitis in Adults. \u003cem\u003eJ Integr Neurosci\u003c/em\u003e. 2022;21(5):125. doi:10.31083/j.jin2105125 \u003c/li\u003e\n\u003cli\u003eSharma R, Agarwal M, Saxena SK, et al. Clinical Characteristics and Differential Clinical Diagnosis of Japanese Encephalitis. In: Saxena SK, ed. \u003cem\u003eJapanese Encephalitis: Epidemiology, Pathogenesis, Diagnosis, and Therapeutics\u003c/em\u003e. Springer Nature; 2025:85-101. doi:10.1007/978-981-97-5433-5_8 \u003c/li\u003e\n\u003cli\u003eSolomon T, Dung NM, Kneen R, Gainsborough M, Vaughn D, Khanh VT. Japanese encephalitis. \u003cem\u003eJ Neurol Neurosurg Psychiatry\u003c/em\u003e. 2000;68(4):405-415. doi:10.1136/jnnp.68.4.405 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Japanese Encephalitis, Culex Mosquito, Neurological Sequelae, Neurological Recovery, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-7529089/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7529089/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJapanese encephalitis is a disease of central nervous system caused by Japanese Encephalitis Virus (JEV), a flavi virus transmitted by culex mosquitoes. Only \u0026lt;1% of the infected people develop symptoms and among symptomatic cases, around 1/3\u003csup\u003erd\u003c/sup\u003e die and remaining 30-50% develop persisted neurological damage. Here, we present an unusual case of 30 years male with severe neurological manifestations requiring intubation and ICU admission for 68 days but miraculously recovering completely without any residual neurological deficits.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe present a case of 30 years Male who presented with high grade fever, headache, vomiting which progressed to altered sensorium and decreased GCS requiring intubation. CNS infection was suspected based on presentation and diagnosis of JE was confirmed with CSF anti-JEV IgM ELISA however CNS imaging was not significant. He was managed in ICU for 68 days with supportive care, antibiotics for ventilator associated pneumonia and physiotherapy. On long term follow up on outpatient basis, he miraculously recovered fully with no neurological deficits despite severe manifestations on initial presentation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case presents an unusual outcome of JE. Although the prognosis of JE isn’t great, from this case we can\u0026nbsp;say that\u0026nbsp;despite severe presentation we can have favorable outcomes with supportive care and long-term physiotherapy. It’ll also be helpful while\u0026nbsp;counseling\u0026nbsp;the patient and patient parties on the prognosis of JE. Further research is required to update the outcomes in JE patients in current healthcare settings.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Japanese Encephalitis: A Case of Miraculous Recovery After 68 Days of ICU Admission in a 30 -Years-Old-Male","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 05:24:47","doi":"10.21203/rs.3.rs-7529089/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-05T05:33:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T13:58:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"197975119109257354623378399143162879133","date":"2025-10-21T13:53:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T13:56:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160900813019415726126935236340781813667","date":"2025-10-09T07:16:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T05:38:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T11:01:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-16T05:51:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-12T13:52:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-09-12T13:19:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c76a1ca6-364d-48a7-a91d-ec178cc0a88d","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T16:45:04+00:00","versionOfRecord":{"articleIdentity":"rs-7529089","link":"https://doi.org/10.1186/s12879-026-12540-2","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-01-12 16:28:34","publishedOnDateReadable":"January 12th, 2026"},"versionCreatedAt":"2025-10-22 05:24:47","video":"","vorDoi":"10.1186/s12879-026-12540-2","vorDoiUrl":"https://doi.org/10.1186/s12879-026-12540-2","workflowStages":[]},"version":"v1","identity":"rs-7529089","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7529089","identity":"rs-7529089","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}