Although the majority of West Nile Virus (WNV) infections are asymptomatic, severe neurologic injury and death may occur. Immunosuppressed lung transplant recipients are potentially at higher risk. However, the probability of developing severe disease after exposure, the clinical presentations, and the outcomes for lung transplant recipients contracting WNV are not well known.
We report one case of community acquired WNV infection in a lung transplant recipient who survived severe meningoencephalitis but with permanent neuromuscular impairment. The patient was a 48 year old male 2.5 years post bilateral transplant for idiopathic pulmonary fibrosis on immunosuppression with tacrolimus, mycophenalate, and alternate day prednisone. He was a farmer in rural western Canada in a highly endemic area of WNV in the summer of 2003.
He initially presented with fever, malaise and headache, and over the course of 5 days went on to develop confusion, decreased level of consciousness, and coma. Investigations included a series of 4 computerized tomographic head scans over 23 days which were normal. MRI was not done because of loose sternal wires. Lumbar puncture showed a lymphocytic pleocytosis with mildly elevated protein and negative WNV IgM. Initial WNV IgM in blood 5 days afer onset of symptoms was negative but became positive 14 days after symptoms began. The patient remained comatose on life support for nearly 3 months before neurologic recovery began. He received no specific treatment except initial empiric therapy with intravenous acyclovir in case of Herpes simplex encephalitis, and withholding of immunosuppression for 1 week followed by reinstitution at lower dosages. One year after presentation he has normal mentation but continues to have severe muscle weakness and dyscoordination limiting mobiity. Lung function remains unchanged from baseline levels.
This case illustrates that lung transplant recipients even though immunocompromised, may recover from severe WNV meningoencephalitis.
This case also emphasizes that prolonged life support may be required and that recovery may be incomplete.
Dale Lien, None.