paralysis as a complication of neuroinvasive West Nile Virus Joel - - PowerPoint PPT Presentation

Neuropathy and ascending paralysis as a complication of neuroinvasive West Nile Virus

09.18.2019

Joel Shackson PGY-2, Internal Medicine

History of present illness

• 28 year old male without PMHx, who presented to clinic after several ED

visits for numbness in all 4 extremities, worst in the legs

• Symptoms initially began with a frontal headache. He then woke up next

morning with these neuropathic type symptoms

• It had progressed to subjective muscle weakness, worst in the legs, but also

in the arms. He complained his muscles felt “tight” along with the numbness/tingling

• Neuropathy workup ordered, with consideration for future EMG or more

aggressive workup if symptoms worsened

2 09.18.2019

History of present illness

• Came back for 1 week follow-up, didn’t get any labs done. Symptoms worse.

Weakness had progressed, legs worse than arms. Brought into exam room in a wheelchair. Falling at home. Foot drop with walking.

• Social: Smokes 1 PPD, no EtOH, occasional marijuana (later admitted to

methamphetamines as well)

• Other history: no recent exposure to animals, insects, chemicals, or recent
• travel. Patient works in landscaping.
• At this point, advised patient to go to the ED for further workup and

monitoring due to concerns for progression of weakness and respiratory compromise

3 09.18.2019

Review of systems

• Positive for fatigue, jaw pain, intermittent blurry vision, neck stiffness (he

thought related to recent injury), weakness, headaches

• No fevers, chills, nausea, vomiting, diarrhea, urinary symptoms. No preceding

viral syndrome.

4 09.18.2019

Physical exam

• BP 129/90, HR 105, Resp 18, SpO2 98%, Temp 98.6F
• A&O x3, somewhat uncooperative but mentating appropriately
• Respiratory status intact
• Negative Kernig and Brudzinski signs
• 3-4/5 strength in lower extremities, 5/5 strength in upper extremities
• CN II-XII intact, sensation intact, good pulses
• Weakness appears more pronounced distally (finger abduction, dorsiflexion,

plantarflexion)

• Reflexes: absent ankle jerks B/L. Reflexes present otherwise.
• Sensory: No clear length dependent temp/ vibration loss. Subtle

pseudoathetosis.

5 09.18.2019

Initial workup

• Extensive workup was ordered for a fairly broad differential that included

GBS, meningitis, myelitis, MS

• CT head, MRI head, LP (patient initially refused), ME panel, Lyme ELISA, West

Nile Ab, basic labs, ESR/CRP, STD testing, CK, procal, neuropathy labs, Copper, vitamin E, B1, ANA, SPEP/ UPEP

6 09.18.2019

Initial labs

Alk Phos 4.1 ALT 80 AST 44 Procal <0.10 CK 66 CRP <5.0 ESR 13

7 09.18.2019

138 102 28 4.0 29 0.76 85 14.8 43.6 359 8.6 TSH 2.029 Folate 15.3 B12 522 HIV neg HepC neg Utox +amphetamines

Imaging

• CT head wo: no acute process
• MRI cervical spine and brain: Grossly patent central canal. Mild foraminal
• narrowing. No abnormal enhancement. No cord lesions are identified.

Prominent retrocerebellar CSF space, possible arachnoid cyst.

8 09.18.2019

Lumbar puncture

CSF

• Protein 225.1
• Nucleated cells 2
• Glucose 74

Meningitis/Encephalitis panel: negative

9 09.18.2019

Hospital course

• Neurology decided to start IVIG due to concerns for Guillain-Barre syndrome
• Patient had slow, small improvements but continued with weakness and

neuropathic symptoms

• On day 4 of IVIG, his West Nile Ab sendout resulted (+) indicating

neuroinvasive West Nile Virus

• Completed last day of IVIG, was recommended to have IP rehab but decided

to be discharged to home with home PT, wheelchair

• Follow up with Neuro for possible EMG/NCT, consideration for PLEX

10 09.18.2019

West Nile Virus and potential complications, including neuroinvasive disease

• Single-stranded RNA virus primarily spread by mosquitoes (birds are primary

host)

• First found in the US in 1999
• 2,647 cases identified in the US last year, symptoms range from no reaction

to neuroinvasive disease to death (~1% of cases develop severe symptoms)

• Preliminary research suggests IVIG may be of benefit, although no good data

11 09.18.2019

Final thoughts

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309965/

12 09.18.2019