Nipah virus encephalitis (NiV encephalitis) is a zoonotic illness caused by the Nipah virus resulting in a severe and often fatal encephalitis.
As the virus is thought to be spread from pigs to humans, pig farmers and abattoir workers are at the highest risk of exposure 2. Several outbreaks of the disease has occurred in Malaysia, Singapore, Bangladesh and India 5.
On presentation the clinical features ranging from most common to least common include 2:
- altered level of consciousness
- focal neurological signs (e.g. cerebellar, segmental myoclonus)
- respiratory symptoms
However, the infection may also be asymptomatic in some patients.
Nipah virus is a single stranded RNA virus and a member of the paramyxovirus family and the Henipavirus genus. The Henipavirus genus includes two of the most lethal viruses known to man: Hendra and Nipah. The natural reservoir of the virus is the fruit bat 2. The incubation time from exposure to symptom onset is around 9 days 6. However, delayed onset of symptoms has also been reported more than 11 weeks after exposure 2. Most human cases are thought to be related to exposure to porcine hosts which can also be infected with the virus 2. However, direct bat-human transmission and human-human transmission have also been described 5.
Autopsies performed on confirmed cases of Nipah showed widespread endothelial damage and vasculitis. Surrounding the vasculitic areas were regions of microinfarction 1,3. The brain is the main organ affected, but the kidneys, heart and lungs also show evidence of viral infection 3.
The virus is detectable in the CSF through viral culture and nucleic acid amplification. Hendra virus IgM and IgG ELISA tests can also detect Nipah 2.
In cases of Nipah virus encephalitis, CT is usually unremarkable 3.
In one study, lesions on MRI were seen in 100% of cases of Nipah virus encephalitis 1. Typical appearances include 1,4,7:
- small discrete lesions, may range in number from 2 to >10
- appear round or as strips
- present in deep white matter cortex (44%), temporal lobe (30%), pons (22%), penducles (10%) 1
- may be present as large confluent areas
- absence of surrounding or generalized edema or mass effect
- T1 C+ (Gd): aforementioned lesions are non-enhancing
- T2/FLAIR: aforementioned lesions are hyperintense
- DWI: lesions have high diffusion signal
Treatment and prognosis
Treatment is largely supportive, often patients may require ICU admission for ventilation due to respiratory compromise. Antiviral therapy with ribavirin has been trialled, although its benefit is uncertain 2. Public health measures such as pig culling and banning the importation of infected pigs is also important 2.
The condition can be rapidly fatal progressing from the onset of symptoms to death on average in 6 days 6. In one study mortality was 32%, whilst 14% had lasting neurological deficit; only 50% experienced complete recovery 2. In survivors, lesions on follow-up MRI have been noted to resolve or diminish over time 4.
History and etymology
The virus is named after the Kampung Sungai Nipah village in Malaysia where the first outbreak occurred in 1998-1999 2.
- 1. Sarji SA, Abdullah BJJ, Goh KJ, Tan CT, Wong KT. MR Imaging Features of Nipah Encephalitis. (2012) American Journal of Roentgenology. 175 (2): 437-42. doi:10.2214/ajr.175.2.1750437 - Pubmed
- 2. Goh KJ, Tan CT, Chew NK, Tan PSK, Kamarulzaman A, Sarji SA, Wong KT, Abdullah BJJ, Chua KB, Lam SK. Clinical Features of Nipah Virus Encephalitis among Pig Farmers in Malaysia. (2009) The New England journal of medicine. 342 (17): 1229-35. doi:10.1056/NEJM200004273421701 - Pubmed
- 3. Lam SK, Chua KB. Nipah virus encephalitis outbreak in Malaysia. (2002) Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 34 Suppl 2: S48-51. doi:10.1086/338818 - Pubmed
- 4. Lim CC, Lee KE, Lee WL, Tambyah PA, Lee CC, Sitoh YY, Auchus AP, Lin BK, Hui F. Nipah virus encephalitis: serial MR study of an emerging disease. (2002) Radiology. 222 (1): 219-26. doi:10.1148/radiol.2221010499 - Pubmed
- 5. Ksiazek TG, Rota PA, Rollin PE. A review of Nipah and Hendra viruses with an historical aside. (2011) Virus research. 162 (1-2): 173-83. doi:10.1016/j.virusres.2011.09.026 - Pubmed
- 6. Hossain MJ, Gurley ES, Montgomery JM, Bell M, Carroll DS, Hsu VP, Formenty P, Croisier A, Bertherat E, Faiz MA, Azad AK, Islam R, Molla MA, Ksiazek TG, Rota PA, Comer JA, Rollin PE, Luby SP, Breiman RF. Clinical presentation of nipah virus infection in Bangladesh. (2008) Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 46 (7): 977-84. doi:10.1086/529147 - Pubmed
- 7. Lim CC, Sitoh YY, Hui F, Lee KE, Ang BS, Lim E, Lim WE, Oh HM, Tambyah PA, Wong JS, Tan CB, Chee TS. Nipah viral encephalitis or Japanese encephalitis? MR findings in a new zoonotic disease. (2000) AJNR. American journal of neuroradiology. 21 (3): 455-61. Pubmed
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Infections of the central nervous system
- classification by etiology
- Eastern equine encephalitis
- enterovirus rhombencephalitis
- flavivirus encephalitis
herpes virus family
- herpes simplex virus 1 (HSV-1) encephalitis
- herpes simplex virus 2 (HSV-2) encephalitis
- varicella zoster virus (VZV) encephalitis
- Epstein-Barr virus (EBV) encephalitis
- cytomegalovirus (CMV) encephalitis
- human herpesvirus 6 (HHV-6) encephalitis
- HIV CNS manifestations
- HTLV-1-associated myelopathy
- JC virus
- measles encephalitis
- Nipah virus (NiV) encephalitis
- rabies encephalitis
- CNS listeriosis (Listeria monocytogenes)
- CNS nocardiosis (Nocardia spp)
- CNS tuberculosis (Mycobacterium tuberculosis)
- Lyme disease (Borrelia burgdorferi)
- neurosyphilis (Treponema pallidum)
- Rocky Mountain spotted fever (Rickettsia rickettsii)
- cerebral amoebiasis
- cerebral malaria (Plasmodium falciparum)
- cerebral sparganosis (Spirometra mansonoides)
- neurocysticercosis (Taenia solium)
- neurohydatidosis (Echinococcus spp)
- neurotoxoplasmosis (Toxoplasma gondii)
- others or those with possible infectious etiologies
- classification by location
- classification by etiology