The epidemiology, clinical presentation, and predictors of severe Tick-borne encephalitis in Lithuania, a highly endemic country: A retrospective study of 1040 patients

Abstract

Introduction: In recent decades, the incidence of Tick-borne encephalitis (TBE) has been increasing and posing a growing health problem because of the high costs to the healthcare system and society. The clinical manifestations are well studied but there is a lack of research analyzing the severity of the disease.

Objective: The aim of this study was to analyze the epidemiology and clinical presentation of severe TBE, to identify the predictors for a severe disease course, and also predictors for meningoencephalomyelitic and severe meningoencephalitic/encephalitic forms.

Methods: A retrospective study was conducted in the Center of Infectious Diseases and the Center of Neurology at Vilnius University Hospital Santaros Klinikos in the years 2005-2017 to describe the clinical and epidemiological features of TBE in adults.

Results: 1040 patients were included in the study. A total of 152/1040 (14.6%) patients had a severe course. The highest proportion of severe cases, reaching 41.2%, was reported in the 70-79 year-old age group. A total of 36/152 (23.7%) severe patients presented meningoencephalomyelitis. Myelitic patients were older, were frequently infected in their living areas, and usually reported a monophasic disease course compared with severe meningoencephalitic/encephalitic patients. Severe meningoencephalitic/encephalitic patients, compared with non-severe meningoencephalitic/encephalitic, were older, less often noticed the tick bite, and often had a monophasic course. The sequelae on discharge were observed in 810/1000 (81%) of patients.

Conclusions: The prognostic factors associated with a severe disease course and severe meningoencephalitic form are: older age, comorbidities, a monophasic course, a fever of 40˚C and above, CRP more than 30 mg/l, CSF protein more than 1 g/l, delayed immune response of TBEV IgG, pathological findings in CT. Age above 60 years, presence of CNS disease, bulbar syndrome, pleocytosis 500x106/l and above, and delayed immune response of TBEV IgG are predictors of the most severe myelitic form.

Fig 1. Clinical and disease course forms of Tick-borne encephalitis.

E–encephalitis, M–meningitis, ME–meningoencephalitis, Myelitis–meningoencephalomyelitis.

Fig 2. Annual incidence of Tick-borne encephalitis (n = 1040).

Fig 3. Seasonal incidence of Tick-borne encephalitis (n = 1040).

Fig 4. Neurological signs of Tick-borne encephalitis.

(A) Neurological signs of severe and non-severe TBE. (B) Neurological signs of severe myelitic and severe meningoencephalitic/encephalitic forms of TBE. (C) Neurological signs of severe and non-severe meningoencephalitic/encephalitic forms of TBE. *p<0.05, **p≤0.01, ***p<0.0001.