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Abstract

Case Reports: In 2012 the US has seen the largest number of reported cases of West Nile Virus (WNV) [1]. Of note 54% of the cases have been neuro-invasive with risk factors including advanced age and immunosuppression [1]. Few cases of naturally transmitted WNV in transplant recipients have been reported and only one case of opsoclonus-myoclonus has been reported [2,3]. A 69 year-old male with past medical history significant for liver transplantation 6 years prior, on chronic immunosupression with tacrolimus, presented with a 2-week history of increasing fatigue, nausea, vomiting, diarrhea, fevers, and new onset tremor. Within 72-hours of admission he required intubation for airway protection due to decline in mental status. Physical exam prior to intubation revealed a Glasgow Coma Scale (GCS) of 13(E2M6V5), left hemiparesis, and opsoclonus-myoclonus. A lumbar puncture (LP) was performed revealing an elevated white blood cell count, red blood cell count and protein count and a normal glucose. Initial cerebrospinal fluid (CSF) studies were negative for Epstein-Barr Virus, Varicella Zoster Virus, Herpes and Cytomegalovirus, and JC virus by polymerase chain reaction, negative WNV immunoglobulins G and M and culture was negative. A brain MRI showed a non-enhancing hyperintensity of the right thalamus consistent with encephalitis. Mild diffuse encephalopathy was identified on electroencephalography without epileptiform changes. Over the course of several days the patient had waxing and waning mental status with GCS varying from 8T (E3M4V1T) to 11T. A repeat LP performed 4 days after the initial revealed positive immunoglobulins G and M for WNV. Supportive care was provided and as his mental status gradually improved to the point of extubation and transfer out of the intensive care unit. This case report will discuss the neuro-invasive features of WNV, the need to consider WNV in the differential of altered mental status in post-transplant patients given its re-emergence in the US, the need for timely CSF WNV testing, and the role of treatment with intravenous immunoglobulin to attenuate the central nervous system inflammatory response. 1. Centers for Disease Control and Prevention. a. (September 4, 2012). “CDC West Nile Virus Homepage.” Retrieved September 5, 2012, 2012, from http://www.cdc.gov/ncidod/dvbid/westnile/index.htm. 2. Kleinschmidt-DeMasters BK, Marder BA, Levi ME, et al. Naturally Acquired West Nile Virus Encephalomyelitis in Transplant Recipients: Clinical, Laboratory, Diagnostic, and Neuropathological Features. Arch Neurol. 2004;61(8):1210-1220. 3. Khosla, J. S., M. J. Edelman, et al. (2005). “West Nile virus presenting as opsoclonus-myoclonus cerebellar ataxia.” Neurology 64(6): 1095.