Tick-borne encephalitis

Last revised by Arlene Campos on 7 May 2024

Tick-borne encephalitis (TBE), a zoonotic disease, occurring as a result of tick-borne encephalitis virus (TBEV) infection, is a recognized flavivirus encephalitis and an increasingly considered differential diagnosis globally 1

Tick-borne encephalitis is endemic to Asian, eastern European, Baltic, and Nordic countries 2. The number of confirmed tick-borne encephalitis cases in Europe specifically has increased by almost 400% in decades, with a reported annual incidence of 10,000-12,000 3,4. Infection rate peaks over the summer months, with higher risk associated with outdoor activity, particularly in woodland areas.

Initial symptoms following infection with European tick-borne encephalitis virus subtypes are often biphasic in nature and will typically occur within 14 days. These include marked pyrexia, myalgia, fatigue and vomiting. Following a short asymptomatic period, the pyrexia returns with signs of central nervous system involvement. This may manifest as one or more of:

Cranial nerve involvement has been reported 5

Less commonly, there is no asymptomatic period i.e. the infection is monophasic in presentation: this is frequently seen with the more aggressive Far Eastern subtype.

Tick-borne encephalitis virus is in the mammalian tick-borne flavivirus group of Flaviviridae, which are single-stranded RNA viruses. There are three subtypes of tick-borne encephalitis viruses, the most virulent being the Far Eastern subtype 2

Ticks of the Ixodidae family act as the vector transmitting tick-borne encephalitis virus to mammalian hosts 3

Imaging is consistent with inflammation of the involved central nervous system anatomy, which is of broad etiology. However, tick-borne encephalitis has a few anatomical predilections on MRI that may aid in developing a differential diagnosis, along with positive IgM and IgG serology 5

  • T1: involvement of the meninges may be more pronounced in the cerebellar folia and the basal cisterns

  • T2/FLAIR/DWI: ​focal or diffuse hyperintensities within the thalami, basal ganglia, cerebellum and anterior horns of the spinal cord

Of note, contrast medium enhancement is rare.

There is currently no treatment for tick-borne encephalitis and vaccination is encouraged. Although the risk of death is small, long term neurological sequelae - mainly gait disturbance - occur in approximately half of patients and may persist for several years 6.

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