158 Infection 33 · 2005 · No. 2 © URBAN & VOGEL Tick-Borne Encephalitis in Friuli Venezia Giulia, Northeastern Italy Tick-borne encephalitis (TBE) is an infectious zoo- notic disease occurring in so-called natural foci present in many European countries, rarely encountered in Italy [1, 2]. Ixodes ricinus is the dominant hard tick vector of the European subtype of TBE virus. In Italy, it represents the main vector of the infection that may be sub-clinical in 70–95% of cases [3]. We report the first confirmed au- tochtonous case of TBE in Friuli Venezia Giulia (FVG). On July 28, 2003, a 36-year-old female was admitted to the Department of Neurology at the Hospital of Udine complaining of fever (39 °C), headache, vomiting, pain in the shoulders, and neck stiffness, which had begun 24 h before. On physical examination, neck stiffness, paralysis of upper limbs more prominent on the left side and shoulder girdle, and weakness on the left leg were detected. The comput- erized tomography scan of the brain was normal. Lumbar puncture (LP) was performed and disclosed a clear fluid, WBC count of 343 cells/mm 3 (300 polymorphonuclear cells), a glucose level of 48 mg/dl and a protein level of 900 mg/dl. She had never been vaccinated against yellow fever or Japanese encephalitis and she had not traveled outside It- aly over the last 12 months. On July 5–6, 2003, she spent the weekend in a rural area of the northeastern Alps in FVG (near Moggio – Chiusaforte) and she reported a tick bite during a walk through dense vegetation. About 2 weeks later, she had fever (37.5 °C) and flu-like symptoms of 3- day duration. She was otherwise well until July 26, 2 days before the first hospital admission. An electromyography revealed critical illness neurop- athy with severe damage to the bilateral brachial plexus, more relevant on the left side with a distal gradient. The MRI of the cervical spine showed an increased signal on T2-weighted images of the spinal cord anterior horns of the vertebrae cervicales C4-C6. Another LP was performed on August 18, and serological tests for viruses that cause neurological diseases were performed on paired serum and CSF samples. The result of enzyme immunoassay for the quantitative detection of specific IgG and IgM antibodies to the TBE virus in serum and CSF showed the presence of specific IgM (6.8 and 4.8 index, respectively; normal value < 1) and IgG (49 and 48 U/ml, respectively; normal value < 5). The result was later confirmed with hemagglutination inhibition antibody test and neutralization assay by a refer- ence center [2]. The patient was discharged home with a diagnosis of meningoencephalomyelitis form of TBE com- plicated by diplegia of the upper limbs, more evident on the left side. The emergence and recognition of an increasing num- ber of new TBE cases in Europe in recent years highlights the significance of this zoonosis as a public health problem of growing importance [4, 5]. The clinical features of our case were typical, but the area in which it occurred was not considered endemic; this in turn entailed low clinical suspicion index and delays in diagnosis. Presently this re- gion is only reported as an area of endemicity for Lyme borreliosis, and not for TBE [6]. In Italy, the first clinical case of TBE was documented in 1975 in Tuscany [7]. Since then, sporadic cases have been reported particularly in the northeast provinces (Trentino- Alto Adige and Veneto) [8]. During the years 1995–2001, the number of cases of TBE increased, with a total of 102 indigenous TBE cases recorded. By comparing the median number of TBE cases per year recorded in the period 1975– 1991 and in the period 1992–2001, a 10-fold increase in the incidence of the TBE can be calculated [1]. Infection Correspondence A. Beltrame (corresponding author) Clinic of Infectious Diseases, Dept. of Clinical and Morphological Research, School of Medicine, University of Udine, V. Colugna n° 50, 33100 Udine, Italy; Phone: (+39/0432) 5593-54, Fax: -60, e-mail: anna.beltrame@med.uniud.it A. Beltrame, L. Scudeller, F. Cristini, G. Rorato, P. Viale Clinic of Infectious Diseases, Dept. of Clinical and Morphological Research, School of Medicine, University of Udine, Udine, Italy B. Cruciatti, G.L. Gigli Dept. of Neurology, Hospital of Udine, Udine, Italy M. Ruscio Microbiology Dept., Hospital of S. Daniele, S. Daniele, Italy Received: August 23, 2004 • Revision accepted: March 1, 2004 Infection 2005; 33: 158–159 DOI 10.1007/s15010-005-4109-1