SESSION TITLE: Infectious Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Acute flaccid paralysis has a wide array of differentials ranging from infectious or noninfectious etiologies and requires a thorough history, physical examination, and radiological assessment. We present a case of an elderly woman with fevers and acute flaccid paralysis found to be West Nile Poliomyelitis.
CASE PRESENTATION: 80 year-old woman with history of coronary artery disease status post bypass and pacemaker, hypertension, diabetes mellitus, and chronic kidney disease initially presented with weakness, fatigue, and failure to thrive. She was found to have a urinary tract infection, admitted and started on intravenous antibiotic treatment. Over the course of the next few days, she developed persistent high grade fevers associated with vomiting, decline in mental status, respiratory distress and hypoxia. She was transferred to the intensive care unit for further management, and required intubation and mechanical ventilation. Her antibiotic regimen was broadened to cover for possible aspiration pneumonia versus meningitis. Neurologic exam revealed flaccid paralysis involving the right upper and right lower extremities and hypoactive deep tendon reflexes. Computed tomography (CT) scan of the brain did not demonstrate any acute intracranial abnormalities, and MRI was not done given pacemaker in situ. Lumbar puncture was performed and cerebrospinal fluid (CSF) results were equivocal, with no evidence of bacterial meningitis or herpes simplex virus encephalitis, and cultures all remained negative. Eventually, viral encephalitis screening of the CSF returned positive for west nile virus immunoglobulin M antibodies. She was treated with supportive care, requiring tracheostomy placement and ultimately discharged to a nursing home.
DISCUSSION: West Nile virus is a mosquito-borne flavivirus that is known the affect the two extremities of age, the young and the elderly. It is also more commonly seen in seen in HIV positive, organ transplant, and pregnant patients. The mode of transmission is mainly by the Culex species of mosquitos. Other documented modes of transmission include transplantation of infected organs, vertical transmission via intrauterine route, and via human milk. Most infections are asymptomatic or subclinical with patients reporting headaches, myalgias, arthralgias or gastrointestinal symptoms. Neuroinvasive disease occurs in less than 1% of infections and may present as meningitis, encephalitis or acute flaccid paralysis. Long term outcomes of West Nile encephalitis have shown morbidity and mortality rates of up to 20% with lasting implications. Patients may have movement disorders and extrapyramidal involvement for months to years. West Nile encephalitis with acute flaccid paralysis is known as West Nile Poliomyelitis, as in our patient. Mortality has been noted to be greater that 50%. Treatment is supportive only, and focuses more on prevention of disease.
CONCLUSIONS: In conclusion, West Nile encephalitis is an important clinical entity in the differential of acute onset of asymmetric flaccid paralysis. It holds a high morbidity and mortality rate and no specific curative treatment. It also has long term psychiatric effects, notably anxiety, memory loss, and chronic fatigue which should be concurrently addressed with other general supportive measures.
Reference #1: Sejvar, J. et al. Neurologic manifestations and outcome of West Nile Virus Infection. JAMA, 2003 July 23; 290(4):511-5
Reference #2: Jeha LE, et al. West Nile virus infection: a new acute paralytic illness. Neurology 2003 July8;61(1): 55-9
Reference #3: Hughes, J. et al. The Long-term Outcomes of Human West Nile Infections. Emerging infections. 2007:44 (June 15)
DISCLOSURE: The following authors have nothing to disclose: George Juan, Ruchi Bansal, Ivan Wong, Saleem Shahzad
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