Dengue encephalopathy or dengue hemorrhagic fever (DHF) with neurological involvement was once considered to be one of the rarer presentations of this infectious agent. In recent years, many such clinical cases have been reported, though they still remain isolated. We hereby report a case of confirmed dengue fever with features of encephalopathy with previously unreported cranial magnetic resonance imaging findings suggestive of extensive involvement of the bilateral cerebellar region, brainstem, and thalami along with peculiar rim enhancement but normal cerebrospinal fluid analysis.

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BackgroundRheumatoid arthritis (RA) is an autoimmune inflammatory arthritis driven by an inflammatory cascade of different cytokine families. IL-23/Th17 axis cytokine (IL-23, IL-17) has been studied as a key pathway for disease development and its association with disease severity, joint erosion and functional outcome [1], but the data supplementing to support the hypothesis is lacking and conflicting. Also, there is a paucity of data on the role of IL-23/Th17/IL-17 axis cytokines in an Indian subset of patients.ObjectivesThe objective was to find the correlation between serum cytokines (IL-17, IL-23) and clinical parameters of Rheumatoid arthritis patients, e.g., disease activity (DAS28) and functional status.MethodsThis cross-sectional observational study was conducted in General Medicine OPD from 2021 to 2022. ACR/EULAR 2010 classification criteria was used to diagnose RA. Eighty-four consecutive RA patients were recruited after taking consent. Serum IL-17 and IL-23 levels were measured by the ELISA method. Clinical and laboratory parameters, DAS28-ESR, and HAQII were recorded. Data were analyzed to find the correlation between cytokine and disease parameters, and compare cytokine levels in different subgroups.ResultsThe study showed a higher proportion of females than males (n=76,90.5% vs n=8,9.5%). 14.28%(n=12) cases were elderly RA. 90.5% were taking cDMARDs, whereas 48.8% (n=41) were steroid users. Majority of cases, 57.14% (n=48) had high disease activity, whereas 25% (n=21) had moderate disease activity. Cases achieved remission was 5.95%. The median value of serum IL-17 and IL-23 were 103.72 pg/ml (IQR=39.91-524.13) and 981.87 pg/ml (IQR=793.25-1205.0), respectively.Swollen joint count, but not tender joint count, correlated positively with both IL-17 and IL-23 levels (rs=0.229, p=0.036;rs=0.098, p=0.016, respectively). Among the inflammatory marker, only CRP correlated positively with IL-23 (rs=0.269, p=0.014). Both IL-17 and IL-23 levels showed an insignificant, weak positive correlation with the disease activity DAS28 (rs=0.183, p=0.097 &rs=0.125, p=0.259), respectively. There was no difference in IL-17 and IL-23 levels among the disease severity group (p=0.130 & p=0.215). It was also noted that IL-17 was positively correlated with IL-23 (rs=0.221, p=0.044). Among the cytokines, only IL-23 had shown a statistically positive correlation with functional status (HAQII) (rs=0.284, p=0.009).IL-23 level differed significantly between males and females (p=0.013). Also, advanced RA had higher IL-17 level than early RA (p=0.028). Neither IL-17 nor IL-23 level showed any difference between the subgroup e.g., age (younger RA vs elderly RA), obesity (obese vs nonobese), DMARDs or steroid (user vs naïve), serology status (RF+ vs RF- & CCP+ vs CCP-).ConclusionSerum IL-17 levels were high in advanced RA as compared to early RA. Both IL-17 and IL-23 correlated positively with the swollen joint count. Only IL-23 was directly correlating with CRP and functional status. Both IL-17 and IL-23 had a weak, insignificant positive correlation with disease activity, and there was no difference in cytokines level among severity classes. Even cDMARD/steroid use did not affect the cytokines level.IL-17 receptor activation triggers transformations of acute synovitis to chronic persistent arthritis [2]. IL-23/IL-17 may be a factor for advanced/erosive disease develoment, which need further research. Hence, blocking IL-23 and IL-17 at an early stage may diminish IL-17 activity, retard the progression to chronic inflammatory arthritis and advanced disease.References[1]Lubberts E. The IL-23-IL-17 axis in inflammatory arthritis. Nat Rev Rheumatol. 2015 Jul;11(7):415-29.[2]Lubberts E, Schwarzenberger P, Huang W, Schurr JR, Peschon JJ, van den Berg WB, Kolls JK. Requirement of IL-17 receptor signaling in radiation-resistant cells in the joint for full progression of destructive synovitis. J Immunol. 2005 Sep 1;175(5):3360-8.AcknowledgementsWe thank Dr.Amit Mishra for helping in data analysis.Disclosure of InterestsNone Declared.