BMJ Case Reports 2017; doi:10.1136/bcr-2017-220799
  • Unusual presentation of more common disease/injury

Brainstem encephalitis and acute polyneuropathy associated with hepatitis E infection

  1. Craig Heath1
  1. 1Institute of Neurosciences, Queen Elizabeth University Hospital, Department of Neurology, Glasgow, Glasgow, UK
  2. 2The West of Scotland Specialist Virology Centre, Glasgow Royal Infirmary, Glasgow, Glasgow, UK
  1. Correspondence to Dr Craig Heath, craigheath{at}
  1. AD and KL contributed equally.

  • Accepted 23 August 2017
  • Published 11 September 2017


A 59-year-old man presented with feverish illness. His Glasgow Coma Scale was 15, had reduced visual acuity in the left eye with partial left ptosis and mild left hemiparesis with an extensor left plantar. Over 48 hours, he accrued multiple cranial nerves palsies and progressed to a flaccid paralysis necessitating admission to an intensive care unit.

Cerebrospinal fluid (CSF) study showed 20 lymphocytes and raised protein. Viral and bacterial PCRs were negative. Samples for Lyme, blood-borne viruses, syphilis and autoantibodies were also negative. MRI brain showed T2 abnormalities within the brainstem. Nerve conduction studies revealed an acute motor and sensory axonal neuropathy pattern of Guillian Barre Syndrome (GBS). The patient was treated for both infective and inflammatory causes of brainstem encephalitis and GBS.

Retrospective studies confirmed the presence of hepatitis E virus (HEV) RNA in CSF and serum studies showed positive HEV IgG and IgM prior to intravenous infusion. After 3 months of intensive rehabilitation, the patient was discharged home walking with a frame.


  • Contributors All authors contributed to the original draft and were actively involved in the revision.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog

Navigate This Article