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Cambodian Literature: From Angkor to Year Zero and Beyond

Photo: Sharon May, “Bayon, Cambodia” (2009)

It has been forty years since the black-clad Khmer Rouge marched into Phnom Penh during the Khmer New Year of April 1975 and evacuated the city, sending its inhabitants on foot to work and starve in labor camps in the countryside, initiating “Year Zero.” Literature, art, and religion were abolished. The Khmer language itself was changed. The ability to read and write, knowledge of a foreign language, even the wearing of eyeglasses, could get one killed. During the regime, between 1975 and ’79, nearly two million people—out of a population of only seven million—died of starvation, disease, torture, and execution. According to one estimate, less than one percent of intellectuals survived. Most estimate about ten percent of artists survived; the same applies to books. Out of six hundred librarians, only three remained. During the Khmer Rouge period the Buddhist monasteries—traditional repositories of learning and literature—were ransacked and converted to prisons. The National Library was used to raise pigs. In the words of activist Vannath Chea, “The arts are like women: the first to be degraded in poverty and war.”

Cambodia is a small heart-shaped country—about the size of the US state of Washington—set in between Thailand, Laos, Vietnam, and the Gulf of Thailand. In the northwest lies the great lake of the Tonle Sap, on whose edges rise the magnificent temples of Angkor. This civilization flourished between the ninth and fifteenth centuries, and recent archeological mapping has revealed that Angkor was in fact the largest pre-industrial city in the world. In 1863, Cambodia became a protectorate of France; it gained independence in 1953, only to become inadvertently caught up in the American war in Vietnam. The US heavily bombed Cambodia in the 1960s and ’70s, before the Khmer Rouge took over in 1975.

While Cambodia is famous for the “killing fields” of the Khmer Rouge and for the temples of Angkor, it is less known for its writing. Nevertheless, Cambodia possesses a rich literature—both oral and written—and had a thriving community of writers before the war. This issue includes examples of this material, rarely translated into English, from the Angkor era through the Khmer Rouge regime and afterward.

The earliest recorded writings in Cambodia are stone inscriptions in Sanskrit, dating back to the fifth century. We are fortunate to have a translation of one of these inscriptions, composed at the pinnacle of the Angkor era by Queen Indradevi, celebrated as one of Cambodia’s first known female poets. Her poem (c. 1190–1200 AD) was carved into the Great Stele of Phimeanakas. Indradevi’s words are brought to life by translator Trent Walker, who chants the queen’s Sanskrit in Khmer style.

By the fourteenth century, Khmer had replaced Sanskrit as the official language. Classical Khmer represents the metaphysical union between Indian Brahmin and native Khmer of Cambodia’s creation myths. It combines the multisyllabic vocabulary of Pali and Sanskrit with the largely monosyllabic, highly alliterative and onomatopoeic native vocabulary. Classical Khmer poetry has about fifty forms, using complex meters and intricate rhyme schemes.

The epics, composed in thousands of stanzas, could take days to chant. These classics were recorded between the fourteenth to nineteenth centuries. The most famous epic poem in Cambodia is the Reamker , the Cambodian version of the Indian Ramayana, which has been recited, sung, and danced in various forms for centuries. Other epic poems include Lpoek Angkor Vat (The Story of Angkor Wat), which celebrates the Angkor temples; the Jataka tales, stories of the former lives of the Buddha; and the Tum Teav, based on a seventeenth-century tragic love story, considered Cambodia’s Romeo and Juliet. The classic tale of separated lovers would become the subject of many of Cambodia’s later modern novels.

Modern Cambodian literature began to emerge in the early nineteenth century. Khmer poet and scholar Ukñā Suttantaprījā Ind (1859–1924) was a pivotal figure. His poem  Journey to Angkor Wat describes his travels to attend King Sisowath’s arrival at the Angkor temples in 1909. The manuscript represents a transitional period in literature, between “tradition” and “modernity.” Possibly commissioned by the King, it was discovered posthumously, and the first edition was published by the Buddhist Institute. In the excerpt translated here, the poet’s recounting of the river journey becomes a meditation on life, desire, and impermanence.

The Buddhist Institute, which printed Ukñā Suttantaprījā Ind’s famous Gatilok and other literature, became the nation’s first publisher in the early 1900s. Khmer-language newspapers and journals first appeared in the 1920s, although the first Khmer-owned and operated newspaper, Naggaravatta (Angkor Wat) did not appear until 1937. The first Khmer modern novel also appeared in the 1930s. A new Khmer term was invented for the novel, pralomlok, which means a story that is written to seduce the hearts of human beings. Many of these early works featured ill-fated lovers and contained moral and social critique. As was common for the era in Southeast Asia, and for writers such as Dickens and Tolstoy earlier in Europe, most novels were first serialized in newspapers or journals. Among the early novels still read today are The Waters of Tonle Sap by Kim Hak, The Tale of Sophat by Rim Kim, The Rose of Pailin by Nhok Them, and Wilted Flower by Nou Hach. Literature became linked with national identity, as quoted in the journal Kambuja Surya , “If its writing disappears, the nation vanishes.”

Following Cambodia’s independence in the mid-twentieth century, literacy, education and publication expanded. Songwriting became a literary form. This was the heyday of Cambodian rock and roll, the “golden” voice of Sinn Sisamouth, and a vibrant, sophisticated community of writers and intellectuals, fluent in both Khmer and French, who were creating new Khmer literature and national consciousness. This literary community was also threatened by censorship, disappearances, assassinations, the closing down of publications, and the war that was spilling over from neighboring Vietnam. After the 1970 coup, which deposed Prince Sihanouk, civil war ensued between the Khmer Republic and the Khmer Rouge.

Kham Pun Kimny, featured in this issue, wrote about urban and political life in a surreal, satirical style during this tumultuous time. He was one of the first writers Soth Polin hired for his newspaper Nokor Thom . “Crazy for Wandering” comes from Kham Pun Kimny’s collection, Control Yourself: Don’t Cry, Don’t Laugh—Philosophies of the Strange and Absurd. Not long after the book’s publication, he disappeared.

On April 17, 1975, less than four decades after the publication of Cambodia’s first novel, the flourishing of Cambodian literature and scholarship abruptly ended with the Khmer Rouge takeover. Writing of a personal nature was completely prohibited. To dare to write risked one’s life. The diary of Oum Sophany is one of the few personal accounts known to have been written while the Khmer Rouge were in power. Laura Jean McKay’s essay, “The Keeper,” featured in this issue, tells the story of Oum Sophany and quotes passages from her remarkable diary.

On January 7, 1979, Vietnamese-backed troops ousted the Khmer Rouge. The handful of artists and writers who survived found themselves in a shattered country. The nation’s infrastructure had been destroyed, and the land seeded with mines and unexploded ordnance. There was widespread poverty and illiteracy. In addition, writers faced censorship, years of lost education, and a lack of printing presses; spare parts, ink, and even paper were hard to come by.

Considering all this, it is surprising that anyone wrote at all. But people did, among them Oum Sophany. Almost as soon as the Khmer Rouge regime ended, a new literature began to appear: novels were handwritten, often in pencil, on the cheap graph-lined paper of student notebooks, then photocopied or recopied by hand and rented out by the day at market stalls. Many memoirs also have been published over the decades, both inside and outside of Cambodia.

As for the former generation of writers, we are fortunate to have the work of three who survived the war and continue to write: U Sam Oeur, Kong Bunchheoun, and Soth Polin.

U Sam Oeur began singing poems as a child while herding water buffalo and received his MFA from the Iowa Writers’ Workshop in 1968, after which he returned to Cambodia. He survived the Khmer Rouge years by feigning illiteracy and pretending at times to be deaf and dumb. “I could not speak,” he says. “Even though people asked, Are you deaf? Are you mute? I always shook my head. There were no words. Just work and work. No talking. No looking at anyone. No looking at the sky, nothing.” He translated Walt Whitman’s Leaves of Grass into Khmer and is one of the first Cambodian poets to write in free verse. He believed this break from the rigid structures of classical Khmer poetry was necessary in order to convey the sorrow of the war. Even so, he still chants his poetry in traditional Khmer style. In this issue he is featured chanting with rap artist praCh in a unique poetic collaboration. His prose piece, “Silkworms,” recalls a time in his youth when he helped his mother raise silkworms during the Japanese occupation of Cambodia from 1942 to 1943.

Kong Bunchheoun, born in Battambang province, began his long writing career as a novelist, playwright, poet, and lyricist in the 1950s in Phnom Penh. He escaped execution during the Khmer Rouge time thanks to a cadre who had read his novels and testified to his “profound sense of social justice.” He continues to be one of Cambodia’s most prolific writers. “The Shade of the Tenth Coconut Tree” is among the many songs he wrote for Sinn Sisamouth in the 1970s inspired by the Sangkae River.

Cambodia’s strong oral tradition of poetry and storytelling is carried on today by traditional artists such as the bluesy, improvisational chapey master Kong Nay, known as the Ray Charles of Cambodia, and by a younger generation of spoken-word and rap artists, among them praCh. Called “Cambodia’s first rap star” by Newsweek, praCh was born in Cambodian refugee camps at the end of the war. In the tracks featured in this issue, he collaborates with Master Kong Nay and poet U Sam Oeur. 

Soth Polin learned to read and write from his great-grandfather, the poet Nou Kan, and began writing novels, short stories and philosophical tales in the 1960s. He survived the Khmer Rouge because he had fled for refuge to Paris after a friend’s assassination in 1974; he lived in France for a decade before going to the U.S. “When you lose your country, you lose everything,” he said. “If you are a writer, you no longer have the echo of your readers.” In France, he survived by driving a taxi. He published one novel in French, The Anarchist , an excerpt of which is featured in this issue.

The devastation of the Khmer Rouge period continues to impact writers today. Writers still must contend with high illiteracy rates, lack of availability of books, lack of mentors, scarcity of publishers and the absence of a central publication distribution network. Some have turned to online publishing. Many self-publish their work, through photocopies or on Facebook and blogs. Others write video scripts and song lyrics. Government-sponsored literary prizes and nongovernmental organizations provide some support. The Nou Hach Literary Project publishes Nou Hach Literary Journal, conducts literary awards, and holds creative-writing workshops and conferences. PEN Cambodia also supports writers through workshops and publication. 

The Center for Khmer Studies is instrumental in Khmer scholarship. The Documentation Center of Cambodia (DC-Cam), under the direction of Youk Chhang, has gathered hundreds of thousands of documents, photos, films, and interviews, as well as published several books, including translations of world literature into Khmer, and the famous Tum Teav into English.

In addition, an increasing number of Cambodian filmmakers are making their mark, foremost among them award-winning Rithy Panh, who helped create the Bophana Center in Phnom Penh, which preserves Cambodia’s film, photographic and audio history. Named for Rithy Panh’s film Bophana: A Cambodian Tragedy , which tells the story of the forbidden love letters of Hout Bophana and Ly Sitha, the center also trains Cambodian filmmakers, many of whom have won awards in their own right. 

The resilience of Cambodian writers, past and present, cannot be overstated. The loss of family, friends, mentors, education, country, home—even of paper, printing presses, and ink—none have stopped Cambodians from pursuing the illusive, seductive and demanding vocation of writing. “I hope our art continues. I think it will survive,” Soth Polin says. “There will be another generation of writers. But right now, what we have lost is indescribable. Khun Srun, Hak Chhay Hok, Chou Thani, Kem Sat . . . They are gone . . . What we have lost is not reconstructable. An epoch is finished. So when we have literature again, it will be a new literature.” 

Some of the material in this essay was drawn from “In the Shadow of Angkor: A Search for Cambodian Literature” and author interviews that first appeared in In the Shadow of Angkor: Contemporary Writing from Cambodia (Manoa: An International Journal/University of Hawai‘i Press, 2004). 

© Sharon May. All rights reserved.

Sharon May researched the Khmer Rouge regime for Columbia…

Sky of the Lost Moon

The keeper: oum sophany, the anarchist.

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When a Nation Loses Its Literature

On the mekong review, and a burgeoning cambodian literary scene.

Not long before coming to Cambodia, I heard about a writer with triumphant dreams. The writer lived in a wooden stilt house shaded by mango and breadfruit trees, a house from where he could hear the rasp of the Mekong River’s spectral wonder. And on the terrace behind his house there was a magnificent view of the Mekong, where the Vietnamese-Australian writer could watch the days end warm and slowly, lingering with low-lying clouds until a sense of darkness haunted the riverbanks. During those unhurried nightfalls, the Mekong was a ghostly river, a sublime setting for the transmigration of souls and, of course, for fostering dreams. And while dreams in Cambodia are too often replete with ethical quandaries, Minh Bui Jones had a benevolent ambition: to start a literary journal full of local soul that would connect each of the countries through which the Mekong runs.

What made this dream so grand, so full of marvel and prodigy, was that despite the Mekong’s heat and history, its wars and brutalities, and how the taunt of its horizon could lead men to grandeur or ruin, there had never been an English-language literary journal aimed at chronicling and reviewing the literature of the Mekong region. [1]  As a phenomenon, that would make such a journal something wholly new. It would be a standalone monument to the region’s celebrated stories. And one day last October, the dream to start that journal flared up with sparks of meaning that allowed Bui Jones’s ambitions to catch fire and test the threshold of a new literary future.

It was a mildly temperate October day in the capital. The monsoon season had faded and gusts of southwesterly wind swept through the scattering of palm trees lining Street 29 in central Phnom Penh. Bui Jones, the dreamer, a 47-year-old former newspaperman and a sage editor, walked towards one of his regular haunts: a small café adorned with simple wooden tables and locally-sourced coffee. In the intimate interior of Feel Good Café, Bui Jones joined a table filled with a few friends—a guitarist, a writer, and a web developer—and over coffees they caught up with each other’s lives.

The guitarist was busy booking Khmer bands for upcoming concerts, the writer was putting together panels and readings, and the developer was out of a job after a local magazine had hastily shuttered. The trio of artists at the table, it turned out, also happened to be in the midst of developing the inaugural Kampot Writers & Readers Festival, and they had a proposition for Bui Jones.

The festival was being held in Kampot City, an ever-so-louche enclave set against a sleepy river at the foot of green hills a few hours south of Phnom Penh. It was meant to be a spirit-lifting event, a gateway to promote literacy in Cambodia while celebrating local arts and culture with readings and concerts and parties for anyone from  motodop   drivers to blotto backpackers to literati luminaries. The co-founders of the festival needed an experienced writer and editor with knowledge of Kampot to moderate a bookish discussion about the history of the province—essentially someone who could shoot the shit about “French protectorates and pirates and pepper plantations.”

When the trio eventually asked Bui Jones to host the discussion in Kampot, it was the first he had heard of the festival. For a few moments, the far-reaching raison d’être of the festival passed through his mind: to promote literacy and literature in Cambodia, to support novels and magazines in the Kingdom. It was in those moments at the Feel Good that Bui Jones first saw how the tide of his literary ambitions could flow through Kampot. There was an opportunity down in the southern province he had never imagined, and he realized this festival offered an ideal occasion to launch a literary journal. “The energy would be there, the publicity would be there, the buzz would be there,” he thought, and so his dream from years back began to take shape.

The dream grew as Bui Jones left the Feel Good Café, lounging in the back of a tuk-tuk as the driver embarked on the writer’s favorite route home: dashing east down Sihanouk Boulevard and slipping north past the park at Wat Bottom. At the palace walls, Bui Jones started working out the particulars of the magazine: “There would need to be an assistant editor, a designer, a commercial director,” he thought as the tuk-tuk turned toward the Riverside, gliding in the shadow of the Buddhist flags blowing above the Tonle Sap River. And then, in the strobe-light swirl of  motos  spinning around Wat Phnom, his mind ran with minutiae and money and mastheads, all before the tuk-tuk climbed the Japanese Friendship Bridge, heading towards the tranquility of the Mekong. Finally, stepping into the windswept glory of his home, Bui Jones thought, “It’s a ripe time for a literary rag. Timing is everything, and I’m already running out of time.”

Bui Jones became a man inspired, a man in hot pursuit of a righteous cause, busting his ass for an off-the-cuff literary magazine that needed to be conceived, written, designed, edited, funded, printed, and distributed in just four weeks to be launched in time for the Kampot Festival.

The next day Bui Jones aligned his team of dreamers. There was a 49-year-old veteran journalist and whip-smart wordsmith by the name of Rupert Winchester, an Englishman, who came onboard as the assistant editor. There was Oliver Cahalan, a British voluptuary of 32 who agreed to moonlight as the journal’s commercial director when he wasn’t working as a regional director for the Tribune Content Agency. And then there was Robert Starkweather, the web developer from the meeting at Feel Good, a 44-year-old American expat who had an extensive knowledge of Cambodia’s publishing industry.

When these men brought their expertise and artistic vision to the  Mekong  team, Bui Jones felt for the first time there was order and control in the journal’s conception. And so there ensued a race to publish the journal. Bui Jones hit it the hardest, pouring all his creativity into the magazine by commissioning a murderers’ row of esteemed academics and Cambodia-based journalists to write reviews and think pieces and letting the rhythm of longform essays about Henry Kissinger, cult-classic gossip columns, and rock ‘n’ roll set the tone of the journal’s initial issue.

A few weeks passed like this and myriad tasks upsurged like Mekong floodwater. There were always more words to read, more emails to send, more themes to discuss, more designs to scheme, more Angkors to drink at the end of more hot nights. That was the sweet trumpeting of a machine in progress, the sound of striving for greatness or something like it, the sting and hum of desire and urgency, the only reason Bui Jones, Cahalan, Starkweather, and Winchester got into this gamble: to enter a creative venture emotionally, to feel it all very intensely until the night when the deadline loomed.

And when that sun rose at the end of four weeks, on the sixth of November, the four men had a slick, artful beauty of a debut journal. They called the thing the  Mekong Review  and whisked it down to Kampot.

But this is not merely a story of one small and exceptional magazine’s genesis, nor is it the story of a short-lived one-hit wonder. This is also the story of what happened after the  Mekong Review  hit the shelves, and what is continuing to happen as the team prepares to release its third issue. It’s about how a city crawling with Western journalists, artists, and businessmen have turned the  Mekong Review  into a startling success, and how the journal has enlivened the discussion regarding the state of Khmer literature in contemporary Cambodia. It’s about how, as Minh Bui Jones likes to put it, “Timing is everything. A magazine has to be out there at a time when people are interested.” And so, in the end, it’s about how I went to Cambodia to see why now, more than any other time in recent history, is the time for the  Mekong Review  to prosper.

Let’s start with a party on a Saturday night. Everyone is here: writers and poets and journalists and aid workers, all sharing drinks in the wavering light; Americans, Australians, Brits, and Cambodians; Bui Jones, Cahalan, Starkweather, and Winchester. It’s late April, and over the past six months, following the launch in Kampot, the first two issues of the  Mekong Review  have sold over 1,300 copies in print. “It’s remarkable clearance for an English-language journal of its ilk in a country like Cambodia,” Bui Jones tells me. “I’ve been in the business for more than two decades and I’ve never come across anything like it.” The  Mekong  team is understandably thrilled. They are fresh-faced, they’re a bit drunk on their own joy and cans of Angkor, and they are suddenly planning to last for a year, maybe three—it’s hard to know what lies ahead. They were never expecting to make it past the first issue.

The party is being thrown to celebrate the literary journal’s initial success, to draw attention to the forthcoming third issue—which was released during the first week of May—and to thank contributors and donors for their support. The loft in which the party is held sits above a bistro that looks out onto Phnom Penh’s Street 240. After greeting the  Mekong  team, I take a long walk through the gathering, being introduced to writers and diplomats, and eventually making my way to a breezy set of stairs. A collection of writers is sitting in the balmy night near the entrance to the loft, beers at their side or wine glasses resting on their knees. I take a seat next to Phorn Bopha, a reporter and writer who, at 31, finds herself in a small tier of Cambodian authors who are writing sophisticated literature in English. [2]

With a deft and economic style, Phorn has provided crackling reportage for  The Cambodia Daily  and, more recently, for the Voice of America in Cambodia. She has been the target of an assassination attempt, won the International Women’s Media Foundation’s Courage in Journalism Award, and in 2012 her debut short story, “Dark Truths,” was published in an English-language anthology called,  Phnom Penh Noir . After finishing her drink in the stairway, Phorn steps into the party and, a few moments later, returns carrying a copy of the anthology.

I open the book at random, read a page, and flip to the table of contents. I’m pleased to find Phorn’s name listed among other local writers, like Suong Mak, an emerging young novelist, and Kosal Khiev, a once-jailed poet. Yet these three Cambodian authors comprised the entirety of the Khmer contribution to an anthology expressly devoted to their country’s capital city. Of the 15 authors anthologized in  Phnom Penh Noir , 11 were Western-born of non-Cambodian heritage. I recall an earlier conversation I had with Bui Jones, an exchange in which he mentioned how a few readers had inquired as to why there weren’t more Cambodian writers contributing to the  Mekong Review . I had to admit, I was surprised to learn that only one Khmer writer [3]  had contributed to the first two issues of a literary journal based in Phnom Penh. [4]  Inevitably, with the curious eye of a literary enthusiast, I began to wonder why.

Saturday nights in Phnom Penh weren’t always abounding in lavish literary parties attended by the intellectual set. Nearly 41 years ago to the day of the  Mekong  loft party, on April 17, 1975, Phnom Penh was invaded by the Khmer Rouge and emptied out, gutted like a river fish until it became a ghost town. The capital’s inhabitants were put on trains and sent to the countryside to work as farmers, setting in motion the groundwork for Pol Pot’s doomed vision of an agrarian Khmer society.

For four years the Khmer Rouge effectively eliminated all facets of Khmer arts and culture by killing virtually any person who could read, write, or displayed any semblance of intellectualism—for simply wearing glasses, a Cambodian could have been killed. Then in 1979, the Vietnamese army overthrew the Khmer Rouge, establishing a pro-Vietnamese People’s Republic of Kampuchea to control Cambodia, which led to 12 years of war between Vietnam and numerous Cambodian resistance groups. During this time, few works of literature made it into the public eye, and those that did were subject to strict state scrutiny and produced through state-run publishing houses. The Khmer Rouge era and the Cambodian-Vietnamese war officially ceased in October 1991, yet the cultural devastation wrought by the turmoil has continued to encumber Cambodia’s literary scene.

Nine years after the end of war, an American named Sharon May arrived in Cambodia to search the Kingdom for Khmer literature. Inspired by the cynicism of many skeptics, May spent several years translating contemporary works written by Cambodians, collecting pieces from refugee camps, and started to compile an anthology for  Mānoa , a literary journal published by the University of Hawaii Press. The result of her endeavors was  In the Shadow of Angkor , an anthology published in 2004 featuring essays, fiction, interviews, poetry, and even lyrics from a Khmer rap artist. In a review of the anthology published in  The Cambodia Daily , Thomas Beller—a longtime contributing editor at the  Daily  and a founder of the New York-based lit mag  Open City —acknowledged that the very existence of  In the Shadow of Angkor  was “a triumph,” but was quick to qualify his praise, adding, “But it is a complicated triumph.”

The rationale behind Beller classifying the “triumph” as “complicated” is that most of the anthologized stories “fail to achieve a presence and density of feeling, humor, or perception,” Beller says, and this failure “is where the defiant triumph of bringing together so many Khmer writers . . . runs into its limitation.” While Beller’s lukewarm assessment of  In the Shadow of Angkor  does not diminish the anthology’s achievement, it does, however, provide a baseline doctrine for why publications like the  Mekong Review  have not featured more work from Khmer authors. The work by many modern Khmer writers has failed to wholeheartedly impress the editors running these publications, editors who are seeking what Beller refers to as “craft and style” and the “sort of storytelling innovation, in which voice and character are primary.” Those inherent qualities of modern literature, he asserts, are mostly missing from contemporary Cambodian literature.

On a summery Monday evening, at the end of the Khmer New Year, I had dinner with Bui Jones at his stilt house on the Mekong. The setting sun threw blades of scarlet through the house’s airy, opened windows, and I asked him to describe the  Mekong Review ’s philosophy regarding the essays, stories, and poems the journal selects for publication. “The main driving concern is the quality of [a piece], the only thing we care about is whether it’s well-written, that it tells a good story, and whatever the author is trying to say is conveyed.” A few days later, at a lunch with Winchester, the associate editor emphasized the journal’s search for well-written essays and stories. “We obviously want [a piece] to be relatively high quality,” he said, “and we’re doing everything we can to be as inclusive as possible.” Near the end of our lunch, I raised the question of Cambodian writers and whether they would begin to appear more in the journal. “Absolutely, yes, of course. You know, we’re just trying to encourage people to be interested in books and literature. . .  We’re just trying to push things forward in the best way we know how. We don’t have an agenda. Anything anyone writes we would consider.”

Perhaps the most educational explanation for the dearth of Khmer writers featured in major literary publications comes from Sharon May herself. “Given Cambodia’s history, it’s unclear how long it will take to rebuild and fully establish a new Cambodian literature,” May says, writing to me by email from California where she is editing a new anthology of Cambodian literature for  Mānoa . “The extent of the catastrophe of the war in Cambodia and its continuing effects through succeeding generations, inside and outside of the country, cannot be underestimated. Cambodia has undergone trauma to its people, culture and literature to an extent few countries in the modern world have experienced. . .  The educational system, publishing infrastructure, literacy and libraries still have not recovered.”

And yet, despite Cambodian literature existing in a present-day purgatory suspended between the oppressive wars of its past and a story-rich future, contemporary Khmer writers continue to persevere and endure adversity. “Cambodians have displayed remarkable resolve and ingenuity in the face of huge challenges,” says May. “That inventive spirit in the face of overwhelming odds continues in the new generation of writers today, who are exploring many subjects and forms of storytelling and poetry.” The feeling presented by May is that in the years to come contemporary Khmer talents will emerge and, “In the meantime, those of us who believe in the vitality of the arts should do everything we can to support, train, and build community among Cambodian writers.” And for May, Bui Jones and the  Mekong  team are demonstrating their belief in the vitality of Khmer arts: “the  Mekong Review  is part of the process of recovery and re-creation of literature in Cambodia. It’s an exciting development in promoting transnational literary dialogue and international community. I expect we’ll see many more contemporary Cambodian writers publishing in the near future as the word gets out.”

In the days following my dinner with Bui Jones, I flitted around Phnom Penh for the better part of a week and, in a way, I got the word out. I spread the word not by advertising or canvassing, but simply by bringing copies of the  Mekong Review  to lunches and drinks I’d scheduled with Khmer writers and the like. On my literary crawl across downtown, I had lime juice with Yeng Chheangly, coffee with Sok Chanphal, beers with a circle of poets,  sach moan chhar  with Heng Sreang, and in between I swapped emails with Phina So and Dr. Teri Yamada. At each meeting I would ask the writers if they were familiar with the  Mekong Review , what they thought of it, and whether the writers believed they, or any of their literary friends, could write for the journal.

Most of Cambodia’s bright, young writers spend their days working a job unrelated to their literary ambitions. After laboring as a farmer in Kandal Province, Yeng Chheangly earned a degree in management and started working for a telecom company in Phnom Penh. As a poet, the 27-year-old has been awarded the second-place prize [5]  in the Nou Hach Literary Association Competition, an association started as a non-governmental organization to support the development of modern Cambodian literature. When I slide the second issue of the  Mekong Review  across a café table, it takes Yeng a moment to recognize the journal. “I used to hear people talk about it, but I never saw it. I should read this. I should buy this.” When I tell Yeng the issue is for him to keep, he smiles warmly and flips a page, discovering Ocean Vuong for the first time. In the day’s fading light, the young Khmer poet reads “Aubade with Burning City” with a concentrated fondness and high regard.

In many respects, Phina So is a saint and a savior, and she might just be the person who can help Khmer literature flourish. As the head of the Women Writers Committee—a charter of PEN Cambodia—Phina So writes and edits anthologies featuring stories with strong, smart female protagonists aimed at empowering Khmer women to overcome hardship. Her ambitions are mindful of the challenges to encouraging literary development in Cambodia. Specifically, So has an all-encompassing wish list of what should be done to improve the climate for Khmer writers that includes: establishing a creative writing school; calling for urgent and strict implementation of copyright law; imploring the government “to allocate sufficient funding to promote writing and reading” through grants that support residency and exchange programs; for the Ministry of Culture and Fine Arts to host an annual writing competition; [6]  and for the government to “promote and guarantee freedom of expression” in literature while also promoting a respectable public image of writers.

At the Kampot Writers and Readers Festival, Phina So held a panel with Bopha Phorn to discuss the current state of Khmer women’s literature. As a speaker at the festival, So was in Kampot when the  Mekong Review  was launched and she was therefore aware of the journal when I asked her how well known it was among Khmer writers. “I believe the  Mekong Review  is not yet known to many [Khmer] writers, especially the older generation,” she said before bringing up the language barrier facing many Khmer writers. “I believe that there are capable writers out there that can produce quality work in English. However, the confidence, time constraints, and the pressure of their ‘full-time’ jobs might be obstacles.” Yeng Chheangly echoes So’s lament regarding the difficulties of Khmer writers producing English-language literature. “The point is that the translation is very hard for me.” Ultimately though, like So, Yeng remains optimistic when I ask him whether contemporary Cambodians are producing work that could appear in influential literary journals. “Yes, I think maybe so. It would be good because young writers keep writing silently.”

The most decorated young writer in Cambodia today is Sok Chanphal. Modest, congenial, and soft-spoken, the 32-year-old has an inquisitive air, always listening to the world around him. In 2013, Sok was presented with the S.E.A. Write Award, a regional award given annually to a writer from each country in ASEAN, the Association of Southeast Asian Nations. It’s the region’s most prestigious literary award and, by winning the honor, Sok was the first Cambodian to be presented with the award in five years—ASEAN nations are not required to give the award annually, and Cambodia has not presented the award to any writer since presenting it to Sok. Over coffee, I give Sok a copy of the  Mekong Review  and for several minutes he flips through the pages with interest. When I ask whether Sok believes he and other Khmer writers could contribute to the journal, he hesitates for a few moments. “Yes, but I’m not sure about it. . .  In Cambodia, people don’t feel pride in their [work]. . .  I’m so worried about it because as I grow older and I become part of the [literary] society, the people around me are almost, like, they just don’t have any career goals.” He trails off for a moment, stealing a glance at the waters of the Tonle Sap River. “This is why I worry about Cambodia. I am 32, but I feel very young in knowledge and I start to worry. I wish we could have more knowledge and we could do something for our country to develop.”

Dr. Teri Yamada, a professor of Asian Studies at California State University, Long Beach, is another advocate supporting the development of modern Cambodian literature. Since 2002, during her summers away from academia, Yamada has been running the Nou Hach Literary Association in Phnom Penh as a non-governmental organization to “foster greater literacy” and to help Cambodian literature “recover from the excesses of the Khmer Rouge era.” Later this spring, the association will publish  Modern Cambodian Literature , the second volume in an anthology series featuring English translations of contemporary writing from Khmer authors and Cambodian Americans. The association also publishes the  Nou Hach Literary Journal  annually, which has featured work in Khmer and English from writers like Yeng Chheangly and Sok Chanphal.

In Yamada’s effort to encourage young Cambodians to embark on literary pursuits, she has also been presenting awards to emerging writers for more than a decade. To the delight of Yamada, many of the past winners of the competition have gone on to publish their own books, write screenplays, and receive other esteemed awards. One of those success stories belongs to Sok Chanphal.

In October 2012, a few years after Sok won the Nou Hach Literary Association Competition for short fiction, Yamada was contacted by the  Mekong Review’s  Rupert Winchester, who had recently returned from the S.E.A. Write Awards in Bangkok. Winchester was covering the awards for the  Phnom Penh Post  when an organizer of the event mentioned how it had been years since Cambodia had honored one of its writers. The organizer asked Winchester if he could explore the possibilities of awarding a Khmer writer for the 2013 ceremony, and he willingly began the pursuit. Back in Phnom Penh, Winchester got in touch with Yamada and the duo proceeded to set up a committee along with Heng Sreang, the longtime president of PEN Cambodia. A year later, the committee selected Sok Chanphal to receive Cambodia’s S.E.A. Write Award, in large part due to his publications and exposure from the Nou Hach Association.

Given Yamada and Winchester’s considerable involvement with the S.E.A. Write committee, I was surprised to learn the committee has neglected to award a Khmer writer since 2013. When I inquire as to why no writer has received Cambodia’s annual award in three years, Winchester suggests that Heng Sreang has wrested control of the committee and effectively stymied its initial progress. Over lunch one afternoon, I ask Sreang about the matter. “We don’t really have a ‘best’ writer that could be given an award,” he says. “It’s hard to establish an award when really we have no writer who can collect it, so I’m reluctant to do that. People push me a lot, but I’m afraid that there will be conflict.” I listened with a kind of fretful awe. It seemed like a startling confession to make for a man holding arguably the highest-ranking literary position in the country, especially considering the entire aim of the organization he runs is to promote literature in Cambodia. A few days later, I tell Winchester about Sreang’s comments and Winchester tiredly guffaws, saying, “That man has screwed up the awards. I don’t want to have a full on coup d’état, but it’s crossed my mind once or twice. I think a Khmer woman should have a chance to run PEN Cambodia.” By and large, the SEA Write committee debacle appears to be an illustration of how Cambodia’s literary intentions never quite seem to land in the right place.

Yamada declines to comment on that matter, though when I ask her about the  Mekong Review , she is more than willing to speak. “I think the  Mekong Review  is a wonderful idea,” she tells me by email from Long Beach, mentioning how it “provides a good model” for Khmer writers who might be interested in starting their own literary journals. This notion of influencing young Khmer writers is a point Bui Jones also feels strongly about. “What you hope [the  Mekong Review ] does for aspiring writers—or anyone,” he says, “is that it inspires them to great stuff, that they want to reach up to that level.” But Yamada remains cautious regarding the reality of homegrown Cambodian literary journals, asserting that, “the problem with 99 percent of the [Khmer] writers I know is the cost of publication. I know of no wealthy writers in Cambodia who could back the cost of publishing a  Mekong Review ; nor do I see the type of entrepreneurial spirit required to seek ad revenue among those writers I know at present. They are busy trying to survive.”

More and more though, as the hostilities of the past fade into the rearview, Khmer writers are starting to find time to tell their stories through self-published works. In May 2015, Chheangly and his Khmer writing circle produced a zine called, “De Zine,” which, despite its photocopied construction, is an intimately created work of care and consideration featuring 20 pages of poems, flash fiction, and art. It is uninhibitedly amateur, but contains the sort of anarcho-punk aesthetic that came to define zines of a certain era. It’s precisely the sort of ingenuity one hopes to see from writers with limited access and resources. And that, to me, is a testament to the lasting influence a literary association like Nou Hach can have on writers in Cambodia. As young Khmer writers gradually discover the mechanisms through which they can tell their stories, the country’s literature will only grow richer and writers who once expressed their voice through self-published zines can soon contribute as well to top-notch literary magazines like the  Mekong Review . It’s not a transition that will be accomplished swiftly, but Cambodian writers are stepping out of the shadows and becoming a part of their country’s artistic community.

Let’s go back to that Saturday night loft party. Everyone is still there, though the lights are a little dimmer, the drinkers a little drunker. Several small groups have assembled around the loft—on the balcony, at the top of the stairway, in the parlor room—everyone buzzing and chattering away. Eventually I take another long walk through the crowd, recalling Bui Jones’s avowal that, “A magazine has to be out there at a time when people are interested.” And it’s when I’m in the throes of the writers and their seamless sense of community that I can recognize how genuinely interested everyone is in the  Mekong Review’s  continued survival.

It’s true that the spirit of a literary magazine requires an abundance of homegrown passion, and the reverence on display in the loft on nights like this is why the  Mekong Review  can thrive in Phnom Penh. The social scene here contains a trace of Tangier in the 1950s, when the American author Paul Bowles began to bring global awareness to local Moroccan writers while his apartment served as a hub for carefree literary gatherings. Even more so, these  Mekong Review  parties contain a trace of Tribeca in the late 90s, when the magazine  Open City  would throw legendary “rent parties” in Robert Bingham’s [7]  apartment, showcasing an indomitable literary spirit. And so I make my way across the loft in Phnom Penh, listening to the breathless enthusiasm that has turned the  Mekong Review  into an unlikely magazine of the moment:

Bui Jones is telling me how he’s thrilled to have commissioned Emma Larkin of  Finding George Orwell in Burma  fame to write a piece for the fourth issue, and how he’s now working on getting Bopha Phorn to contribute a story; and oh, there’s Chath Pier Sath, a Khmer poet Bui Jones wants to speak with and he’s off; and then Bopha Phorn is saying how she’s planning to write a novel, something perhaps set against the backdrop of pastoral Cambodia; and a few moments later Jay Raman, the Public Affairs Officer at the U.S. Embassy, tells me how the  Mekong Review  is now on reserve at the library in the embassy’s Information Resource Center for curious Cambodians to read; and out on the stairway Wayne McCallum, the writer from the Feel Good, is talking to Robert Starkweather about how they plan to enrich and improve this year’s Kampot Writers and Readers Festival, where the  Mekong Review  will celebrate its one-year anniversary; and on the balcony, writer Sebastian Strangio is talking about his latest book, the nonfiction tour-de-force,  Hun Sen’s Cambodia ; and next to him is William Bagley, the purchasing officer at Monument Books—Southeast Asia’s preeminent independent bookstore—who’s telling me how there’s a remarkable thirst for the  Mekong Review  because the region has been yearning for a magazine that’s “on a literary mission.”

And the  Mekong Review , after its initial success,  is  on a literary mission. After being embraced by its audience in Phnom Penh, and after realizing the journal’s potential for becoming a major cultural force, the editors are bent on taking the  Mekong Review  to new heights by expanding its reach to new cities. Out on the stairway Winchester tells me how arrangements are being made for the journal to be distributed in cafés and galleries in Siem Reap, Saigon, and Hanoi, and how they soon hope to establish a presence in Bangkok, Singapore, and Yangon. Regarding distribution, Cambodia is a land of the hustle and do-it-yourself exporting, where established trade routes are unrealistic for small-press journals and where any acquaintance with a plane ticket is a potential magazine courier. So when I mention to Bui Jones and Winchester that I have plans to meet a few former colleagues in Myanmar the following week, their interest is sufficiently piqued. As the party slowly wanes, we make plans for me to transport thirty copies of the third issue to an art gallery in Yangon.

Time slides away and heat lightning is blanketing the sky every half-minute, illuminating the clouds above the loft where only a few guests remain. The rains have still not come to relieve the country of its drought, and dust blows through the silver light of the distant boulevard where locals laugh at little tables, the smell of frying ginger peppering the night. I think of how the  Mekong Review  is not a curative for Cambodia’s lost literary legacy, but how it can certainly aid in registering Khmer literature on the global radar. Over time, I know its pages will undoubtedly feature more contemporary Cambodian voices. The third issue features a poem from emerging Cambodian-American writer Sokunthary Svay, Bui Jones and Winchester frequently give guest lectures at the city’s universities to encourage students to write and submit stories, Winchester is currently spearheading the search for a Khmer writer to represent Cambodia at this year’s S.E.A. Write Awards, and it seems likely that the winner’s work will appear in the journal. Still, even with these forward-looking developments in the works, more outreach can surely take place to move the narrative of Khmer literature forward; and if a literary journal like the  Mekong Review  can use its influence to help develop Khmer literature, it will generate a magazine and a literary scene that is ultimately more rewarding.

Successful literary magazines are rare and fleeting, but for as long as the  Mekong Review  can last, the journal will surely serve to expand Phnom Penh’s repertoire of great writers, bringing together the expat and Khmer literary scenes when it can: at writers festivals, at awards ceremonies, at loft parties on Saturday nights. I gather the sense that Bui Jones, Cahalan, Starkweather, and Winchester will remember this time fondly, a time when they had their eyes on the pulsing horizon, chronicling the cultural shift of a region as its literature was being reborn as something thoroughly new. And whatever happens to the  Mekong Review —whether it lasts a year or two or three—it will always be connected to the literary lore of a Kingdom grasping to find its modern voice.

[1]  Other literary magazines covering Asia exist— Asia Literary Review ,  Eastlit ,  LONTAR ,  Asian Review of Books —but none are specifically tailored to the Greater Mekong Subregion of Cambodia, Laos, Myanmar, Thailand, and Vietnam.

[2]  A note on Khmer names: in Cambodia, a person’s name typically appears with the surname first, followed by a given name. In more recent times, some Cambodians prefer their names to be written to align with Western conventions, with the given name first, followed by the surname. Names in this article appear according to each individual’s preference. When referring to a person by one name, their surname is used.

[3]  The Cambodian writer is Soth Polin, whose contribution to the  Mekong Review  was an excerpt from his well-praised 1996 novel,  The Anarchist , which was originally published in French. By most accounts, Polin now drives a taxi in Seattle.

[4]  While only one Khmer writer contributed to the first two issues, writers of Burmese and Vietnamese heritage also contributed.

[5]  In 2013, when Chheangly won the second-place prize, no poet was awarded the first-place prize.

[6]  The Ministry of Culture and Fine Arts does currently host one writing contest, however, as Phina So points out, the prize of $200 for a novel of 200 pages or more with only a possibility of publication is entirely inadequate.

[7]  Bingham also happens to have written  Lightning on the Sun , one of the classic Western novels set in Cambodia.

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Women and Political Leadership in Cambodia - Literature Review

This review considers literature in English on women and leadership in Cambodia. It was undertaken in 2018 in preparation for the Public Perceptions of Women as Leaders research to be conducted by Cambodian women’s rights organisations in partnership with International Women’s Development Agency (IWDA). The focus of the literature is on women and political leadership; however, women’s activity in social and economic spheres is also of interest. The review was updated in October 2019 to reflect changes.

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One of the reasons the Democratic Kampuchea regime was more brutal than other communist regimes may partly originate from the grandeur of the Angkorian era in the Khmer Rouge’s (KR) megalomaniac, utopian imagination. Was this modelled on an illusory future or on an imagined past? Even before the KR seized power, they managed to fashion a bizarre amalgam of royalty, revolution, and past glory through the propaganda trip made by Norodom Sihanouk to Angkor in March 1973. Soon after seizing power on April 17, 1975 they organized a three-day victory celebration within the precincts of Angkor Wat temple and spared the conservation team in the evacuation of Siem Reap. Angkor and the greatness of its past civilization entered the revolutionary rhetoric and fed the megalomania of the leaders. More specifically, the revolutionaries were convinced that Angkor owed its prosperity to the achievements of their forebears who were believed to have blanketed the entire territory with an intricate irrigation network. The “hydraulic city”––a term introduced in the 1960s by the French archaeologist at Angkor, Bernard-Philippe Groslier––had become a hydraulic country. During the KR foreign visitors were granted visits to Angkor Wat and Angkor Thom, as well as visits to some of the grand reservoirs and dams built during the regime. These, along with the Potemkin villages erected in the area, served to eclipse the immense suffering of the populace. Democratic Kampuchea became a laboratory experiment for a form of revolutionary neo-colonialism that has its roots in the West––a Marxism-Leninism revised by Lenin, Stalin, and later, Mao. The KR period became an ugly caricature of the “civilizing mission” and used an incoherent jumble of ideas borrowed from the West.

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“Our race lived in cities over which my dynasty, my family, reigned, while your forebears were wandering westwards seeking lands where their barbarity could feed itself” (translated H.L.), original text: “Notre race [aryenne] habitait les villes sur quoi régnait ma dynastie, ma famille, alors que vos aïeux erraient vers l‘ouest cherchant des terres où leur barbarie pût se nourrir.”

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The Lyon Police Laboratory was founded in 1910 by my grandfather, Edmond Locard.

According to art historian Danielle Guéret, what everyone believes––namely, that the towers of Angkor Wat are represented on the Cambodian flag––is not quite true. The five towers represent Mount Meru, the residence of the gods: The central tower represents Çiva, the supreme deity, who is superior to all other gods, flanked by Brahma on his right and Vishnu on his left.

Editor’s note: In 2006 Peter Fröberg Idling published the Swedish book Pol Pot’s Smile. A Swedish Travel through Cambodia of the Red Khmer (published in German in 2013). Here, the author describes in detail how the four travelers became victims of perfectly staged Khmer Rouge propaganda.

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Locard, H. (2015). The Myth of Angkor as an Essential Component of the Khmer Rouge Utopia. In: Falser, M. (eds) Cultural Heritage as Civilizing Mission. Transcultural Research – Heidelberg Studies on Asia and Europe in a Global Context. Springer, Cham. https://doi.org/10.1007/978-3-319-13638-7_9

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ពិនិត្យឡើងវិញ, រៀនសាឡើងវិញ [c are the top translations of "review" into Khmer. Sample translated sentence: How can we benefit from reviewing the way Jehovah saved the Israelites? ↔ តើ យើង អាច ទទួល ប្រយោជន៍ អ្វី ពី ការ ពិចារណា អំពី របៀប ដែល ព្រះ យេហូវ៉ា បាន សង្គ្រោះ ជន ជាតិ អ៊ីស្រាអែល?

A second or subsequent reading of a text or artifact. [..]

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• Published: 10 May 2024

Severe fever with thrombocytopenia syndrome with central nervous system symptom onset: a case report and literature review

• Dawei Shan 1 ,
• Weibi Chen 1 ,
• Gang Liu 1 ,
• Huimin Zhang 1 ,
• Shuting Chai 1 &
• Yan Zhang 1  

BMC Neurology volume  24 , Article number:  158 ( 2024 ) Cite this article

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Severe fever with thrombocytopenia syndrome (SFTS) is a natural focal disease transmitted mainly by tick bites, and the causative agent is SFTS virus (SFTSV). SFTS can rapidly progress to severe disease, with multiple-organ failure (MOF) manifestations such as shock, respiratory failure, disseminated intravascular coagulation (DIC) and death, but cases of SFTS patients with central nervous system (CNS) symptoms onset and marked persistent involuntary shaking of the perioral area and limbs have rarely been reported.

Case presentation

A 69-year-old woman with fever and persistent involuntary shaking of the perioral area and limbs was diagnosed with SFTS with CNS symptom onset after metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) and peripheral blood identified SFTSV. The patient developed a cytokine storm and MOF during the course of the disease, and after aggressive antiviral, glucocorticoid, and gamma globulin treatments, her clinical symptoms improved, her laboratory indices returned to normal, and she had a good prognosis.

This case gives us great insight that when patients with CNS symptoms similar to those of viral encephalitis combined with thrombocytopenia and leukopenia are encountered in the clinic, it is necessary to consider the possibility of SFTS involving the CNS. Testing for SFTSV nucleic acid in CSF and blood (mNGS or polymerase chain reaction (PCR)) should be carried out, especially in critically ill patients, and treatment should be given accordingly.

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Severe fever with thrombocytopenia syndrome (SFTS) is a natural focal disease transmitted mainly by tick bites, and the causative agent is a novel Bunyavirus, also known as SFTS virus (SFTSV), belonging to the Phenuiviridae family and the Bandavirus genus, which was first isolated from patient serum by the Chinese Centre for Disease Control and Prevention in 2010 [ 1 ]. The main features of SFTS include fever, thrombocytopenia, leukopenia and gastrointestinal symptoms, and in severe cases, patients may present with multiple‑organ failure (MOF) symptoms such as shock, respiratory failure, disseminated intravascular coagulation (DIC) and death, with a mortality rate of 5–30% in East Asia [ 2 , 3 ]. SFTS may also present with central nervous system (CNS) involvement, which can severely affect the patient’s disease progression and prognosis and is manifested by seizures, psychiatric symptoms, cognitive impairment, and disorders of consciousness [ 4 , 5 ]. However, reports of patients who present with CNS symptoms as the first symptom and with marked persistent involuntary shaking of the perioral area and limbs are rare.

A 69-year-old female patient was admitted to the hospital with fever for 4 days, involuntary shaking around the mouth and limbs for 3 days, and mental abnormalities for 1 day. The patient was admitted to the emergency department of another hospital 4 days before admission because of fever, where her body temperature reached 38.7 °C and she showed poor mental status, less talking, a loss of appetite, but no headache, vomiting, and limb twitching. A routine blood examination showed a white blood cell (WBC) count of 2.28 × 10 9 /L and a platelet count of 165 × 10 9 /L. When given a cooling infusion for symptomatic treatment, her body temperature would temporarily return to normal. Three days before admission, she experienced persistent involuntary trembling around the mouth and lips, as well as trembling of the tongue and extremities. The trembling of the lips, mouth, and both distal upper limbs was especially bothersome and was aggravated by emotional excitement and accompanied by slurred speech. Two days before admission, she had persistent fever, with a body temperature up to 39.6 °C, and the effect of antipyretic drugs was not good. A routine blood examination performed in another hospital showed a WBC count of 1.78 × 10 9 /L and a platelet count of 81 × 10 9 /L, which was significantly decreased compared with the count from the previous examination. One day prior to admission, the patient experienced babbling, restlessness, irritability, and a decline in time and place orientation and calculation power.

The patient had a many-year history of hypertension, diabetes mellitus and hyperlipidaemia; denied a history of working and living in hilly, forested and mountainous areas and travelling; denied a recent history of mosquito bites; and reported a history of close contact with a pet dog in the last month.

Neurological examination after admission showed that the patient had normal arousal but had unclear speech, hyperactivity, irritability. Her time and place orientation and calculation power decreased. The patient was uncooperative in the pharyngeal reflex examination, and involuntary tongue twitching could be seen when the tongue was stretched out. The remaining cranial nerve examination did not show any abnormalities. Perioral and limb involuntary shaking was obvious and persistent, especially in the perioral area and distal part of both upper limbs. Bilateral tendon reflexes were symmetrical, bilateral pathological signs were negative, and meningeal irritation signs were negative.

On admission, viral encephalitis was considered, and intravenous acyclovir antiviral therapy (0.5 g, q8h) was empirically administered. A comprehensive examination revealed that the patient had MOF: (1) Her platelet count further decreased to 63 × 10 9 /L (normal: 100–300 × 10 9 /L), toxic granules were seen in some granulocytes of the peripheral blood smear, and heterogeneous lymphocytes accounted for 21% of the total. (2) She had impaired liver function with elevated liver enzymes (alanine aminotransferase (ALT), 76 IU/L (normal: 5–40 IU/L); aspartate aminotransferase (AST), 188 IU/L (normal: 8–40 IU/L); and gamma-glutamyl transpeptidase (γ-GT), 177 IU/L (normal: 7–50 IU/L)), which was treated with magnesium isoglycyrrhizinate injection and vitamin C for liver protection. (3) She had acute myocardial injury, with an increased heart rate of > 120 beats/minute and markedly elevated myocardial enzyme and B-type natriuretic peptide levels (myoglobin, 299 ng/mL (normal: 25–58 ng/mL); troponin T, 209 ng/L (normal: 0–14 ng/L); and B-type natriuretic peptide, 9,355 pg/mL (normal: 0-125 pg/mL)). Electrocardiograms (ECGs) showed various atypical manifestations, such as short PR intervals; atrial premature, mild ST-segment depression in leads V2V3; and T-wave changes in multiple leads. Cardiac ultrasound showed a normal left ventricular ejection fraction but abnormal segmental motion of the left ventricular wall, biventricular diastolic insufficiency and a small amount of pericardial effusion. Coenzyme Q10 and trimetazidine were given to improve myocardial energy metabolism, and fluid intake and output were closely monitored. (4) The patient had a bacterial infection of the lungs, combined with type I respiratory failure, which were treated with tracheal intubation and mechanical ventilation immediately to assist respiration and antibiotic antimicrobial therapy. The patient did not have prolonged hypoxic injury. (5) She had impaired renal function, with elevated blood urea nitrogen (BUN) (17.33 mmol/L) (normal: 1.7–8.3 mmol/L) and urinary protein. We administered measures to ensure fluid intake and without the use of nephrotoxic drugs. (6) She had impaired pancreatic function, with elevated lipase (56.5 U/L) (normal: 5.6–51.3 U/L); we administered acid-suppressing drugs to inhibit pancreatic secretion and reduce the load and damage to pancreatic tissue. (7) She had abnormal coagulation, with a prolonged prothrombin time (PT) and thrombin time (TT) (15.7 s (normal: 11–15 s) for PT and 22.6 s (normal: 14–21 s) for TT), decreased fibrinogen (1.8 g/L) (normal: 2–4 g/L), and markedly elevated plasma D-dimer (9.01 µg/mL) (normal: 0.01–0.5 µg/mL) and fibrinogen degradation products (FDPs) (28.36 µg/mL) (normal: 0–5 µg/mL). (8) A thrombus had formed in her right peroneal vein and the intermuscular veins of the right and left calves, for which low molecular heparin anticoagulation was given. (9) Her muscle enzyme profiles were variably elevated (creatine kinase (CK), 335 IU/L (normal: 24–195 IU/L); lactate dehydrogenase (LDH), 1347 IU/L (normal: 109–245 IU/L); and alpha-hydroxybutyrate dehydrogenase (α-HBDH), 645 IU/L (normal: 72–182 IU/L)), correlating with inflammatory response-mediated organ damage. (10) The patient experienced a cytokine storm, with significantly increased inflammatory factors (ferritin > 1500 ng/mL (normal: 11-306.8 ng/mL), interleukin (IL)-6 = 49.88 pg/mL (normal: 0–20 pg/mL), IL-8 = 45.99 pg/mL (normal: 0-21.4 pg/mL), and IL-10 = 25.67 pg/mL (normal: 0-5.9 pg/mL), interferon (IFN)-α = 9.76 pg/mL (normal: 0-7.9 pg/mL), and IFN-γ = 18.7 pg/mL (normal: 0-17.3 pg/mL)) in serum (Table  1 ). (11) Finally, the patient showed an electrolyte balance disorder, as evidenced by hypernatremia (154 mmol/L) (normal: 135–145 mmol/L), hyperchloremia (119 mmol/L) (normal: 96–108 mmol/L), hypocalcaemia (1.92 mmol/L) (normal: 2.03–2.67 mmol/L), and hypophosphatemia (0.54 mmol/L) (normal: 0.84–1.65 mmol/L), and treatments included calcium supplementation, phosphorus supplementation, nasal administration of plain water, and a reduction of sodium and chlorine intake.

Lumbar puncture was performed on the second day after admission (Table  2 ). Cerebrospinal fluid (CSF) was colourless and clear, with a pressure of 190 mmH 2 O (normal: 80–180 mmH 2 O) and a WBC count of 3 × 10 6 /L. CSF cytology showed scattered lymphocytes and a few mononuclear cells. The glucose level and protein counts were normal, chloride was slightly elevated (134 mmol/L) (normal: 118–128 mmol/L), immunoglobulins (Ig) were slightly elevated (IgA, 1.03 mg/dL (normal: 0-0.2 mg/dL); IgM, 0.22 mg/dL (normal: 0-0.2 mg/dL); and IgG, 6.68 mg/dL (normal: 0.48–5.86 mg/dL)), and CSF cytokine levels of IL-6 (27.46 pg/mL) (normal: 0–20 pg/mL) and IL-8 (546.93 pg/mL) (normal: 0-21.4 pg/mL) were elevated. CSF was negative for an autoimmune encephalitis antibody profile (NMDAR, CASPR2, AMPAR1, AMPAR2, LGI1, GABABR, DPPX, and IgLON5), neuroparaneoplastic syndrome antibody profile (Hu, Ri, Yo, CV2, Amphiphysin, GAD65, PNMA2, Recoverin, SOX1, Titin, Tr, and Zic4), and CNS demyelination antibody profile (AQP4, GFAP, MBP, and MOG). Metagenomic next-generation sequencing (mNGS) showed that the number of sequences of a novel Bunyavirus of the Bandavirus genus was 59 in the blood and 12 in the CSF. We also excluded acute febrile illnesses by serum and CSF mNGS, such as dengue fever, chikungunya fever, EB virus infection, renal syndrome hemorrhagic fever, and rickettsial disease.

A diagnosis of SFTS that started with symptoms of CNS and encephalitis due to a novel Bunyavirus was considered based on the patient’s clinical presentation and laboratory test results. With immediate effect, acyclovir was adjusted to the broad-spectrum antiviral drug Foscarnet sodium (3 g, q8h); intravenous infusion of dexamethasone (10 mg qd for five days) and intravenous immunoglobulin (IVIG) (0.4 g/kg for five days) were administered to regulate immune function and inhibit the cytokine storm; nifedipine and benidipine hydrochloride were given to reduce the viral-induced calcium inflow to inhibit viral replication, reduce the viral load and increase the platelet count; clonazepam (1 mg, q8h) was given to relieve the patient’s obvious symptoms of involuntary shaking; and adequate symptomatic supportive therapy was given to ensure adequate calorie and protein intake and to maintain water, electrolyte, blood glucose and acid‒base balance.

After 3 days of hospitalization, the patient’s platelet and WBC counts began to rise gradually and returned to normal levels. After 5 days of hospitalization, the patient’s involuntary shaking and psychiatric symptoms were less severe than before, but compliance with activities was still poor, and her cognitive level still had not returned to normal. After 11 days of hospitalization, the lung infection was better than before, and ventilator withdrawal training was started. After 12 days of hospitalization, cranial magnetic resonance imaging (MRI) was performed, which showed slightly high signals in the bilateral anterior temporal lobe, temporal lobe hook gyrus, insular cortex, and bilateral thalamus on fluid attenuated inversion recovery (FLAIR) and diffusion weighted imaging (DWI) (Fig.  1 a-f). After 13 days of hospitalization, a blood sample was negative for novel Bunyavirus nucleic acid. After 16 days of hospitalization, her condition was significantly better than before, she could perform activities as instructed and answer questions correctly, her time and place orientation returned to normal, and her cognitive level was better than before. A electroencephalogram (EEG) was performed, and a full-lead low-wave amplitude state was observed (Fig.  2 ). After 17 days of hospitalization, the ventilator was completely withdrawn, and the tracheal tube was removed. A repeat lumbar puncture 3 weeks after hospitalization showed a pressure of 110 mmH 2 O, a WBC count of 4 × 10 6 /L, a normal protein count, a slightly elevated glucose level (5.19 mmol/L, compared with a glucose of 7.9 mmol/L over the same period), a slightly elevated chlorine level (130 mmol/L), and a return of Ig to normal. The levels of cytokines IL-6 (4.35 pg/mL) and IL-8 (96.17 pg/mL) decreased significantly compared with the previous levels, and the levels of whole-blood cytokines returned to the normal range (IL-6, 12.22 pg/mL; IL-8, 4.62 pg/mL; IL-10, 1.27 pg/mL; IFN-α, 0 pg/mL; and IFN-γ, 1.14 pg/mL) in serum (Table  1 ). No further novel Bunyaviruses were detected by mNGS of the CSF. Meanwhile, MOF gradually recovered, and liver, heart, lung, kidney, pancreas and coagulation function; the muscle enzyme profile; inflammatory factors; and electrolyte levels gradually returned to normal levels.

After antiviral therapy, immunotherapy, life support and symptomatic treatment, the patient’s vital signs were stable 3 weeks after admission, with clear speech and normal higher cortical function to perform tasks correctly on command. The muscle strength of all four limbs was grade 5, muscle tone was normal, bilateral tendon reflexes existed symmetrically, an ataxia test was normal, bilateral pathological signs were negative, and meningeal irritation signs were negative. She was discharged from the hospital in 23 days after admission. The patient was followed up 1 month after she was discharged from the hospital and is now back to her normal living conditions, with normal functioning of the higher cortex, the ability to take care of herself, and the ability to perform all of the activities she regularly engages in.

Cranial MRI of the patient 12 days after admission. Bilateral anterior temporal lobe (a and d) , temporal lobe leptomeningeal gyrus (a and d) , insular cortex (b and e) , and bilateral thalamus (c and f) FLAIR and DWI sequences with slightly high signals

Sixteen-lead resting-state EEG of the patient 16 days after admission. Simultaneous display an EEG record in monopolar and bipolar montages. A low-amplitude state can be seen in all leads. (a) monopolar montage EEG, (b) bipolar montage EEG

Discussion and conclusions

SFTS is an infectious disease caused by SFTSV infection. The epidemic period is mainly in May-August, and SFTSV is mainly transmitted by tick bites to humans. In recent years, interpersonal and human-animal transmission has also been found. An epidemiological survey of SFTS found that 48% of the patients had had close contact with their pets within two weeks of the onset of the disease [ 6 ]. The general population is susceptible, with a higher risk of infection in residents living in areas such as hills, mountains and forests and in people who spend time outdoors. In this case, SFTSV was isolated from blood and CSF. There was no history of tick bites or travel in the wild, but there was a history of close contact with a pet dog within the past month, and we hypothesized that the infected dog might have been the source of SFTSV in this patient.

The pathogenesis of CNS involvement in SFTS patients is unclear. Previous studies have demonstrated that Bunyaviruses have neurological properties of attack, and Park et al. found viral transcripts of novel Bunyaviruses in the brain and spinal cord of an aged model ferret. It is hypothesized that novel Bunyaviruses also involve the CNS, with consequent symptoms [ 7 ]. Possible mechanisms by which SFTSV attacks the CNS include direct invasion, cytokine storms, and impaired immune function. Kaneko et al. [ 8 ] performed an autopsy on a patient with SFTS with rapid CNS involvement, and the pathological findings revealed a massive infiltration of macrophages with high haematoxylin content and inflammatory cells around the microvessels of the cerebral pontine, fibrin deposition in the vessels, and focal degenerative lesions in some neuronal cells. In a variety of brain tissues, positive SFTSV nucleocapsid protein antigens were observed in the immunoblasts infiltrating the vascular lumen, suggesting that SFTSV can invade the CNS directly for disease development. The availability of agents that recognize these antigens also suggest immunoassays are possible and available for serodiagnosis. For example, serum enzyme linked immunosorbent assay or immunofluorescence to determine SFTSV antigens and antibodies have been used for clinical diagnosis [ 9 ]. Several studies [ 10 , 11 , 12 , 13 , 14 , 15 ] have found that the blood levels of several cytokines, including IFN-α, IFN-γ, IL-6, IL-8, IL-10, tumour necrosis factor (TNF)-α, and monocyte chemotactic protein (MCP)-1, are elevated in patients with SFTS, and IL-8 and MCP-1 levels in the CSF are significantly higher than the blood of those who present with CNS symptoms [ 10 ], suggesting that a cytokine storm may increase vascular permeability and prompt SFTSV to cross the blood‒brain barrier (BBB) and invade the CNS. SFTSV was found in the CSF of this patient, suggesting that the virus had invaded the patient’s CNS. The patient’s blood levels of IL-6, IL-8, IL-10, IFN-α, and IFN-γ were markedly elevated compared with normal ranges; IL-6 and IL-8 were elevated in the CSF; and CSF IL-8 levels were significantly higher than the blood levels, which was consistent with the results of a previous study [ 10 , 11 , 12 , 13 , 14 , 15 ], further suggesting that the cytokine storms induced by multiple elevated cytokines may increase BBB vascular permeability and contribute to the SFTSV invasion of the CNS. In patients with SFTS complicated by neurological involvement, protein and glucose levels in the CSF are normal and that an increase in leukocytes in the CSF may be uncommon. However, in the case of a high suspicion both on a clinical and epidemiological level in countries where the infection exists, in these patients the search for MCP-1 and IL-8 in the CSF and serum is indicated and CSF viral RNA detection are recommended.

According to the course of infection, SFTS can be divided into four periods: the incubation period, the febrile period, the MOF period, and the recovery period [ 1 , 2 , 3 , 16 ]. Patients with SFTS can present with neurological symptoms, which usually appear approximately 5 days after the onset of the disease (Table  3 ) and are often regarded as a complication of SFTS, which has been referred to as SFTS-associated encephalopathy/encephalitis (SFTSAE) [ 10 ]. SFTSAE mainly manifests as headache, seizures, mental abnormality, irritability, limb convulsions, cognitive impairment, and impaired consciousness, with an incidence of approximately 19.1-57.02% [ 4 , 5 , 11 , 17 ]. Most patients with SFTSAE develop impaired consciousness, such as coma, before their condition is taken seriously, which leads to a poor prognosis for the patients [ 4 , 18 ]. Most clinicians rely on the clinical manifestations to make the clinical diagnosis. SFTSV has rarely been isolated from CSF. We screened studies and case reports of SFTS with CNS involvement and found no reports of disease onset with CNS symptoms such as marked persistent involuntary shaking of the perioral area and extremities. In this case, the patient first presented with fever, followed by persistent involuntary tremors of the perioral area and limbs and mental behavioural abnormalities such as rambling, irritability and agitation; furthermore, the whole-genome sequence of SFTSV was found by mNGS of blood and CSF. The case reported here is a case of SFTS with CNS symptoms onset, accompanied by perioral and extremity persistent involuntary shaking, which has not been previously reported in the literature. It has been reported in the literature that SFTS patients can have tremors of limbs and muscles [ 8 , 17 , 19 ], but most of them occurred in the middle and late stages of the disease, and the tremor amplitude was small. In this case, the patient had large-amplitude involuntary shaking of the limbs that was persistent and intensified during agitation, which immediately attracted the clinician’s attention. An additional movie file shows this in more detail [see Additional file 1 ]. However, the specific underlying mechanism is not clear, and a description of similar symptoms of viral encephalitis and an analysis of the underlying mechanism have not been found before; therefore, further studies are needed. The course of the disease in this patient was consistent with the general pattern, with the clinical experience of the febrile period, the MOF period, and the recovery period. The febrile period lasted approximately 4 days, followed by MOF involving the liver, heart, lungs, kidneys, and pancreas, and then the recovery period began approximately 2 weeks after the disease onset, with clinical symptoms gradually returning to normal.

There are fewer reports on neurological-related ancillary investigations (CSF, cranial imaging, and EEG) in SFTS patients with CNS involvement, and we analyse this because SFTS patients rarely start with CNS symptoms and go directly to the neurology department and because such patients are generally more severely ill, making it difficult for them to cooperate in completing the relevant investigations. In a few previous studies, lumbar puncture CSF tests in SFTS patients with CNS symptoms were mostly normal, with few abnormal changes in leukocyte counts, sugars and proteins [ 10 , 20 ]. Park et al. [ 10 ] analysed head imaging and EEG in a series of SFTS patients presenting with CNS symptoms, and no new focal lesions were seen on imaging in any of the brain parenchyma, suggesting that the imaging was not specific and that the EEG in the majority of the patients showed a slow-wave background rhythm (δ-θ), a common feature of encephalitis/encephalopathy. In this patient, two lumbar punctures were performed successively, and no CSF leukocyte abnormalities were observed in any of them either; it was presumed that SFTSV infection was less likely to involve the meninges. We performed cranial MRI and EEG on the patient 12 and 16 days after admission, respectively, and slightly high signals were observed in the bilateral anterior temporal lobes, temporal lobe hook gyrus, insular cortex, and bilateral thalamus in the FLAIR and DWI sequences of cranial MRI, all of which were consistent with the general imaging manifestations of viral encephalitis and were presumed to be related to viral invasion. In addition, we should consider the similarities and differences between the above MRI changes and cortical laminar necrosis associated with hypoxia or hypotension. We found that both had MRI high signals distributed along the cortex. However, this patient’s cranial MRI showed cortical high signals only in FLAIR and DWI sequences, and no abnormal signal was found in T1WI, which was the most obvious difference from cortical laminar necrosis. Furthermore, the patient did not show hypotension or significant hypoxic injury, so the changes on cranial MRI were more likely to be inflammatory changes of viral encephalitis and less relevant to cortical laminar necrosis. The background rhythm of the EEG was an α rhythm, and the whole leads were in low amplitude, which was different from previous studies [ 10 ]. It was presumed that the patient’s brain inflammation had tended to recover at that time, but the suppression of cortical function was remained.

There are no specific drugs for the treatment of CNS symptoms in SFTS, and symptomatic supportive treatment is the mainstay. In vitro and ex vivo studies have found that nifedipine or benidipine hydrochloride can inhibit SFTSV replication, reduce viral load, increase platelet counts, and reduce morbidity and mortality, as confirmed in a retrospective clinical study [ 21 , 22 ]. Glucocorticoids can inhibit the cytokine storms caused by the overproduction of cytokines and reduce patient mortality [ 12 , 13 , 23 ], and a Japanese report documented that three SFTS patients with impaired consciousness recovered without any neurological sequelae after short-term glucocorticoid treatment. However, the authors also suggested that the dosage should be minimized and the duration of administration should be shortened to inhibit cytokine storms and provide systemic benefit, rather than high doses or prolonged use, to avoid side effects [ 24 ]. Gamma globulin, which triggers complement activation and viral neutralization and influences the differentiation process of Schwann cells to increase their regenerative potential [ 25 ], has been used to treat other virus-induced encephalitides and can be used for the treatment of CNS symptoms in SFTS. Two successful cases of combined glucocorticoid and IVIG therapy were reported in Korea [ 26 ]. Two case reports documented that plasma exchange therapy reduced cytokine levels but not viral load, presumably making plasma exchange more effective at an early stage [ 27 , 28 ]. However, these are case reports, and the findings should be confirmed by large-scale randomized controlled studies. In this case, the patient was given the broad-spectrum antiviral drug foscarnet sodium, intravenous infusion of dexamethasone and IVIG to regulate the immune function of the body and inhibit the inflammatory storm, nifedipine and benidipine hydrochloride to inhibit viral replication and reduce the viral load, and other symptomatic treatments. The patient’s clinical manifestations and laboratory indicators gradually improved.

The prognosis of patients with SFTS is related to numerous factors, and studies have shown that advanced age; significant elevations in ALT, AST, CK, CK-MB, LDH, γ-GT, and BUN; low platelet count; persistent lowering of blood calcium; and the presence of CNS symptoms are all important influences that can lead to a poor prognosis [ 29 , 30 , 31 , 32 , 33 , 34 ]. Most of these are commonly used to monitor cardiac, hepatic and renal function, and significant abnormalities in their results indicate more severe organ damage and dysfunction. In addition, there is a statistically significant difference in serum viral copy number between deceased and non-dead patients. The mean viral copy number was higher in deceased patients than in surviving patients, and patients with higher copy numbers had higher mortality rates [ 35 , 36 ]. It was shown that the serum viral load detected by polymerase chain reaction (PCR) on admission was higher in SFTSAE patients than in non-encephalitis patients [ 11 ]. The above suggests a relationship between patient serum number of SFTSV RNA copies and encephalitis CNS symptoms and mortality in SFTS patients. CNS symptoms are often considered to be associated with fatal outcomes in patients with SFTS [ 33 ], and early diagnosis and treatment of neurological symptoms can help reduce mortality. Advanced age; long intervals between onset and admission; comorbid diabetes mellitus or subcutaneous haemorrhage; pulmonary rales; low platelet count; elevated neutrophil percentages and LDH, CK, and C-reactive protein (CRP) levels; and decreased chloride concentrations are significantly associated with the development of CNS symptoms and should be taken into consideration in clinical practice [ 11 , 17 ]. We believe that changes in platelet count and CK-MB should be monitored in patients with SFTSAE. As shown in previous, decreased platelet counts and high CK-MB levels are risk factors for poor prognosis in patients with SFTS. The presence of encephalitis is evidence of a more critical condition. Monitoring changes in platelet counts may provide an initial indication of the direction of the patient’s regression. It has been found that in cardiac enzyme profiles, patients presenting with CNS symptoms have elevated CK levels earlier than LDH and AST levels, and elevated liver enzyme levels later than cardiac enzymes [ 17 ]. Therefore, early monitoring of CK-MB levels may have a predictive effect on the development of CNS symptoms in patients. Although the mortality rate of SFTS patients presenting with CNS symptoms is significantly higher [ 11 ], several studies have found [ 11 , 37 , 38 ] that the long-term prognosis of surviving patients is good, with no obvious sequelae after active treatment. In this case, the patient’s laboratory indicators were consistent with the factors leading to a poor prognosis, and the CNS symptoms were prominent, suggesting that the condition was critical, but with timely administration of treatment, the patient’s condition eventually returned to normal.

In summary, we report a case of SFTS in a patient who started with CNS symptoms accompanied by marked persistent involuntary perioral and extremity shaking, and the whole-genome sequence of SFTSV was found by mNGS of both serum and CSF (It is important to note that hospitals where mNGS analysis is unavailable should use real-time fluorescent quantitative PCR to detect SFTS-specific nucleic acids in serum and CSF.). This has given us great insight into the fact that SFTS should be considered a possible cause when patients present with common CNS symptoms of viral encephalitis, such as mental behavioural abnormalities, convulsions, and cognitive deficits, or rare symptoms, such as persistent involuntary shaking of the perioral area and limbs in the rare case of this patient, combined with thrombocytopenia and leukopenia. Prompt lumbar puncture examination for SFTSV should be performed, and appropriate treatment should be given aggressively to reduce mortality.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

severe fever with thrombocytopenia syndrome

severe fever with thrombocytopenia syndrome virus

multiple-organ failure

disseminated intravascular coagulation

central nervous system

metagenomic next-generation sequencing

cerebrospinal fluid

alanine aminotransferase

aspartate aminotransferase

gamma-glutamyl transpeptidase

electrocardiogram

blood urea nitrogen

prothrombin time

thrombin time

fibrinogen degradation products

creatine kinase

lactate dehydrogenase

alpha-hydroxybutyrate dehydrogenase

interleukin

immunoglobulin

intravenous immunoglobulin

magnetic resonance imaging

fluid attenuated inversion recovery

diffusion weighted imaging

electroencephalogram

tumour necrosis factor

monocyte chemotactic protein

blood-brain barrier

severe fever with thrombocytopenia syndrome -associated encephalopathy/ encephalitis

polymerase chain reaction

C-reactive protein

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This project was supported by National Key Research and Development Program of China (2020YFC2005403), and by China Association for Promotion of Health Science and Technology (JKHY2023001).

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Dawei Shan and Yan Zhang contributed to the conception and design of the manuscript. Dawei Shan collected the data and drafted the manuscript. Yan Zhang, Weibi Chen, Gang Liu, Huimin Zhang and Shuting Chai reviewed and modified the manuscript. All authors contributed to manuscript revision and read and approved the final submitted version.

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12883_2024_3664_MOESM1_ESM.mp4

Supplementary Material 1. File name: Additional file 1. File format: mp4. Title of data: Video of patient with persistent involuntary shaking of the perioral area and limbs. Description of data: We took this video on day 2 after the patient was admitted to the hospital. The patient develops persistent involuntary shaking of the perioral area and limbs, especially in the perioral area and distal limbs, which is aggravated by agitation and is accompanied by slurred speech.

Supplementary Material 2. CARE Checklist of information to include when writing this case report.

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Shan, D., Chen, W., Liu, G. et al. Severe fever with thrombocytopenia syndrome with central nervous system symptom onset: a case report and literature review. BMC Neurol 24 , 158 (2024). https://doi.org/10.1186/s12883-024-03664-6

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Alice Munro, Nobel literature winner revered as short story master, dead at 92

FILE - Canadian author Alice Munro poses for a photograph at the Canadian Consulate’s residence in New York on Oct. 28, 2002. Munro, the Canadian literary giant who became one of the world’s most esteemed contemporary authors and one of history’s most honored short story writers, has died at age 92. (AP Photo/Paul Hawthorne, File)

FILE - Canadian author Alice Munro is photographed during an interview in Victoria, B.C. Tuesday, Dec.10, 2013. Munro, the Canadian literary giant who became one of the world’s most esteemed contemporary authors and one of history’s most honored short story writers, has died at age 92. (Chad Hipolito/The Canadian Press via AP, File)

FILE - Nobel Prize-winning Canadian author Alice Munro attends a ceremony held by the Royal Canadian Mint where they unveiled a 99.99% pure silver five-dollar coin in Victoria, B.C., on March 24, 2014. Munro, the Canadian literary giant who became one of the world’s most esteemed contemporary authors and one of history’s most honored short story writers, has died at age 92. (Chad Hipolito/The Canadian Press via AP, File)

FILE - Writer Alice Munro attends the opening night of the International Festival of Authors in Toronto on Wednesday Oct. 21, 2009. Munro, the Canadian literary giant who became one of the world’s most esteemed contemporary authors and one of history’s most honored short story writers, has died at age 92. (Chris Young/The Canadian Press via AP)

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Nobel laureate Alice Munro, the Canadian literary giant who became one of the world’s most esteemed contemporary authors and one of history’s most honored short story writers, has died at age 92.

A spokesperson for publisher Penguin Random House Canada said Munro, winner of the Nobel literary prize in 2013, died Monday at home in Port Hope, Ontario. Munro had been in frail health for years and often spoke of retirement, a decision that proved final after the author’s 2012 collection, “Dear Life.”

Often ranked with Anton Chekhov, John Cheever and a handful of other short story writers, Munro achieved stature rare for an art form traditionally placed beneath the novel. She was the first lifelong Canadian to win the Nobel and the first recipient cited exclusively for short fiction. Echoing the judgment of so many before, the Swedish academy pronounced her a “master of the contemporary short story” who could “accommodate the entire epic complexity of the novel in just a few short pages.”

Munro, little known beyond Canada until her late 30s, also became one of the few short story writers to enjoy ongoing commercial success. Sales in North America alone exceeded 1 million copies and the Nobel announcement raised “Dear Life” to the high end of The New York Times’ bestseller list for paperback fiction. Other popular books included “Too Much Happiness,” “The View from Castle Rock” and “The Love of a Good Woman.”

Over a half century of writing, Munro perfected one of the greatest tricks of any art form: illuminating the universal through the particular, creating stories set around Canada that appealed to readers far away. She produced no single definitive work, but dozens of classics that were showcases of wisdom, technique and talent — her inspired plot twists and artful shifts of time and perspective; her subtle, sometimes cutting humor; her summation of lives in broad dimension and fine detail; her insights into people across age or background, her genius for sketching a character, like the adulterous woman introduced as “short, cushiony, dark-eyed, effusive. A stranger to irony.”

Her best known fiction included “The Beggar Maid,” a courtship between an insecure young woman and an officious rich boy who becomes her husband; “Corrie,” in which a wealthy young woman has an affair with an architect “equipped with a wife and young family"; and “The Moons of Jupiter,” about a middle-aged writer who visits her ailing father in a Toronto hospital and shares memories of different parts of their lives.

“I think any life can be interesting,” Munro said during a 2013 post-prize interview for the Nobel Foundation. “I think any surroundings can be interesting.”

Disliking Munro, as a writer or as a person, seemed almost heretical. The wide and welcoming smile captured in her author photographs was complemented by a down-to-earth manner and eyes of acute alertness, fitting for a woman who seemed to pull stories out of the air the way songwriters discovered melodies. She was admired without apparent envy, placed by the likes of Jonathan Franzen, John Updike and Cynthia Ozick at the very top of the pantheon. Munro’s daughter, Sheila Munro, wrote a memoir in which she confided that “so unassailable is the truth of her fiction that sometimes I even feel as though I’m living inside an Alice Munro story.” Fellow Canadian author Margaret Atwood called her a pioneer for women, and for Canadians.

“Back in the 1950s and 60s, when Munro began, there was a feeling that not only female writers but Canadians were thought to be both trespassing and transgressing,” Atwood wrote in a 2013 tribute published in the Guardian after Munro won the Nobel. “The road to the Nobel wasn’t an easy one for Munro: the odds that a literary star would emerge from her time and place would once have been zero.”

Although not overtly political, Munro witnessed and participated in the cultural revolution of the 1960s and ‘70s and permitted her characters to do the same. She was a farmer’s daughter who married young, then left her husband in the 1970s and took to “wearing miniskirts and prancing around,” as she recalled during a 2003 interview with The Associated Press. Many of her stories contrasted the generation of Munro’s parents with the more open-ended lives of their children, departing from the years when housewives daydreamed “between the walls that the husband was paying for.”

Moviegoers would become familiar with “The Bear Came Over the Mountain,” the improbably seamless tale of a married woman with memory loss who has an affair with a fellow nursing home patient, a story further complicated by her husband’s many past infidelities. “The Bear” was adapted by Sarah Polley into the 2006 feature film “Away from Her,” which brought an Academy Award nomination for Julie Christie. In 2014, Kristen Wiig starred in “Hateship, Loveship,” an adaptation of the story “Hateship, Friendship, Courtship, Loveship, Marriage,” in which a housekeeper leaves her job and travels to a distant rural town to meet up with a man she believes is in love with her — unaware the romantic letters she has received were concocted by his daughter and a friend.

Even before the Nobel, Munro received honors from around the English-language world, including Britain’s Man Booker International Prize and the National Book Critics Circle award in the U.S., where the American Academy of Arts and Letters voted her in as an honorary member. In Canada, she was a three-time winner of the Governor’s General Award and a two-time winner of the Giller Prize.

Munro was a short story writer by choice, and, apparently, by design. Judith Jones, an editor at Alfred A. Knopf who worked with Updike and Anne Tyler, did not want to publish “Lives of Girls & Women,” her only novel, writing in an internal memo that “there’s no question the lady can write but it’s also clear she is primarily a short story writer.”

Munro would acknowledge that she didn’t think like a novelist.

“I have all these disconnected realities in my own life, and I see them in other people’s lives,” she told the AP. “That was one of the problems, why I couldn’t write novels. I never saw things hanging together too well.”

Alice Ann Laidlaw was born in Wingham, Ontario, in 1931, and spent much of her childhood there, a time and place she often used in her fiction, including the four autobiographical pieces that concluded “Dear Life.” Her father was a fox farmer, her mother a teacher and the family’s fortunes shifted between middle class and working poor, giving the future author a special sensitivity to money and class. Young Alice was often absorbed in literature, starting with the first time she was read Hans Christian Andersen’s “The Little Mermaid.” She was a compulsive inventor of stories and the “sort of child who reads walking upstairs and props a book in front of her when she does the dishes.”

A top student in high school, she received a scholarship to study at the University of Western Ontario, majoring in journalism as a “cover-up” for her pursuit of literature. She was still an undergraduate when she sold a story about a lonely teacher, “The Dimensions of a Shadow,” to CBC Radio. She was also publishing work in her school’s literary journal.

One fellow student read “Dimensions” and wrote to the then-Laidlaw, telling her the story reminded him of Chekhov. The student, Gerald Fremlin, would become her second husband. Another fellow student, James Munro, was her first husband. They married in 1951, when she was only 20, and had four children, one of whom died soon after birth.

Settling with her family in British Columbia, Alice Munro wrote between trips to school, housework and helping her husband at the bookstore that they co-owned and would turn up in some of her stories. She wrote one book in the laundry room of her house, her typewriter placed near the washer and dryer. Flannery O’Connor, Carson McCullers and other writers from the American South inspired her, through their sense of place and their understanding of the strange and absurd.

Isolated from the literary center of Toronto, she did manage to get published in several literary magazines and to attract the attention of an editor at Ryerson Press (later bought out by McGraw Hill). Her debut collection, “Dance of the Happy Shades,” was released in 1968 with a first printing of just under 2,700 copies. A year later it won the Governor’s General Award and made Munro a national celebrity — and curiosity. “Literary Fame Catches City Mother Unprepared,” read one newspaper headline.

“When the book first came they sent me a half dozen copies. I put them in the closet. I didn’t look at them. I didn’t tell my husband they had come, because I couldn’t bear it. I was afraid it was terrible,” Munro told the AP. “And one night, he was away, and I forced myself to sit down and read it all the way through, and I didn’t think it was too bad. And I felt I could acknowledge it and it would be OK.”

By the early ’70s, she had left her husband, later observing that she was not “prepared to be a submissive wife.” Her changing life was best illustrated by her response to the annual Canadian census. For years, she had written down her occupation as “housewife.” In 1971, she switched to “writer.”

Over the next 40 years, her reputation and readership only grew, with many of her stories first appearing in The New Yorker. Her prose style was straightforward, her tone matter of fact, but her plots revealed unending disruption and disappointments: broken marriages, violent deaths, madness and dreams unfulfilled, or never even attempted. “Canadian Gothic” was one way she described the community of her childhood, a world she returned to when, in middle age, she and her second husband relocated to nearby Clinton.

“Shame and embarrassment are driving forces for Munro’s characters,” Atwood wrote, “just as perfectionism in the writing has been a driving force for her: getting it down, getting it right, but also the impossibility of that.”

She had the kind of curiosity that would have made her an ideal companion on a long train ride, imagining the lives of the other passengers. Munro wrote the story “Friend of My Youth,” in which a man has an affair with his fiancee’s sister and ends up living with both women, after an acquaintance told her about some neighbors who belonged to a religion that forbade card games. The author wanted to know more — about the religion, about the neighbors.

Even as a child, Munro had regarded the world as an adventure and mystery and herself as an observer, walking around Wingham and taking in the homes as if she were a tourist. In “The Peace of Utrecht,” an autobiographical story written in the late 1960s, a woman discovers an old high school notebook and remembers a dance she once attended with an intensity that would envelop her whole existence.

“And now an experience which seemed not at all memorable at the time,” Munro wrote, “had been transformed into something curiously meaningful for me, and complete; it took in more than the girls dancing and the single street, it spread over the whole town, its rudimentary pattern of streets and its bare trees and muddy yards just free of the snow, over the dirt roads where the lights of cars appeared, jolting toward the town, under an immense pale wash of sky.”

This story has been updated to correct the title of “The Beggar Maid.”