Maoist leader Janardan Sharma was referred to India for treatment of encephalitis. An important reason for referral as reported by the local papers was to determine the cause of illness in order to guide therapy. Encephalitis is the inflammation of the brain whereas meningitis is the inflammation of the plastic-like covering of the brain. The distinction is often naturally blurred.
Recently at Patan Hospital we studied encephalitic patients with fever and neurological changes, a common presentation of this illness. Equally common in Nepal is the fact that a microbiological diagnosis (what bug caused the illness?) is seldom made, limiting treatment to an educated guess. In order to rectify this situation and discover the pathogen (bug) causing the illness, we studied the cerebrospinal fluid (CSF) of these patients with fever and neurological problems. The CSF is the fluid that closely surrounds and bathes the brain and spinal cord. Hence findings in the CSF (more than the blood) accurately reflect the problems in the brain. To obtain CSF, a simple procedure called the lumbar puncture is carried out and is done multiple times a day in hospitals across Nepal.
Our preliminary results from a CSF sample of 87 patients with fever and neurological problems revealed that a group of viruses called the enterovirus were the prime culprits. This group has rarely been documented in the CSF here in Nepal probably because of a lack of PCR-based testing facilities. The good news is that enterovirus caused meningitis is usually self-limiting and has a good prognosis. The other causes of fever and neurological problems were the usual bacterial suspects causing meningitis for which there are effective antibiotics. An important cause from our population of patients was Japanese Encephalitis (JE) which has an effective and inexpensive Chinese vaccine for prevention. The disease (JE) is fraught with complications, so prevention (vaccine administration among other measures) is clearly a better option.
An elusive bug (see picture) that caused meningitis in our sample population was the tuberculosis bacteria. It is potentially treatable with effective drugs. A very important and consistent finding about TB meningitis (TBM) is the duration of illness. The longer the duration, TBM is more likely. Newspapers reported Sharma, the Maoist leader to be sick at home for a month when things suddenly took a turn for the worse. If there is an infectious origin to his problem, TBM is an important, epidemiology-based diagnosis to consider in the Nepali setting.