West Nile Viral Meningitis in a Heart Transplant Recipient

Abstract

Introduction West Nile virus (WNV) infection is uncommon and can cause encephalitis or meningitis. The CDC reported 958 cases diagnosed in 47 continental states and Washington DC in 2019. Only one other case has been reported in San Diego County so far in 2020. WNV infection in solid organ transplant recipients is rare and typically presents as encephalitis, with few reported cases in orthotopic heart transplant (OHT) recipients. Here we describe a case of WNV meningitis in a patient 1-year post-OHT. Case Report A 53-year-old female with history of non-ischemic cardiomyopathy due to myocarditis underwent OHT at UC San Diego 1 year ago. Her postoperative course was complicated by 3R rejection and was treated with anti-thymocyte globulin and pulse dose steroids. She recovered well, however 11 months post-OHT she experienced insidious onset of nausea and vomiting. One month later she started to experience malaise, tremors and headaches so she presented to our emergency room. Her immunosuppression regimen at that time included tacrolimus 2 mg twice daily and mycophenolate mofetil 750 mg twice daily. She was febrile to 103°F so blood and sputum cultures were obtained, lumbar puncture (LP) was performed and broad-spectrum antibiotics were started. The LP demonstrated elevated opening pressures of 31 mmHg, pleocytosis and elevated glucose, however cerebrospinal fluid (CSF) cultures and PCR array were unremarkable. Antibiotics were discontinued after 48 hours of negative cultures. CSF and blood returned positive for anti-WNV IgM and IgG. Later in her admission she developed reactive polyarthralgia which was treated with a 5-day burst of oral prednisone. She was discharged after 9 days, but continued to experience nausea, vomiting and polyarthralgia. She was readmitted 2 weeks later (13 months after transplant) with worsening joint pain, nausea, vomiting and blurry vision. Ophthalmologic exam was notable for papilledema, and brain magnetic resonance imaging revealed ventriculomegaly. Repeat LP was notable for interval decrease in opening pressures (now 22 mmHg), and CSF serology remained positive for anti-WNV IgM and IgG. Serum WNV PCR was negative. Given the improvement in her opening pressures, she was managed supportively and discharged after 4 days on a longer prednisone taper for reactive arthritis. Summary Here we report a rare case of WNV meningitis in a recent OHT recipient whose condition improved with supportive care.