Title : Rare presentation of West Nile virus Encephalitis
Abstract:
We present a case of West Nile Virus Encephalitis .West Nile fever is an infection by the West Nile virus, which is typically spread by mosquitoes. WNV is one of the Japanese encephalitis antigenic serocomplex of viruses.In about 80% of infections people have few or no symptoms. Here we present a case of sepsis and identifying west Nile Virus
Mr S,76 year old male, known case of Bronchial asthma, Type 2 Diabetes Mellitus, Systemic Hypertension,old cerebrovascular accident came with complaints of fever of two days duration- low grade in nature, intermittent and not associated with chills/rigor. Bystanders gave history of reduced food intake and reduced response since yesterday evening.No history of cough ,vomiting ,loose stools . On Examination:He was tachypneaic ,had tachycardia and hypotension and other system examination were in normal limits and CNS system examination revealed Rigidity in Neck , Clasp knife rigidity on both upper limbs, reflexes brisk on all four limbs,plantar- flexor bilateral.
Initial blood investigations revealed elevated inflammatory markers, thrombocytopenia. Chest X-RAY showed hyperinflated lungs. In view of poor oral intake and altered sensorium he was started on Ryles tube feeding. He was started on IV antibiotics -Ceftriaxone and Azithromycin, antipyretics and other supportive management. Patient had worsening of his sensorium and appeared to be in gasping state. The bystanders were explained in detail regarding present condition and need for intubation, consent was obtained for the same, all queries explained in detail and he was Intubated and mechanically ventilated. Neurology consultation was sought and had advised CT/ MRI BRAIN showed no acute intra or extra-axial bleed, small hypodensities in left high frontal region – possible old ischemic insult and chronic small vessel ischaemic changes.
In view of recurring fever associated with neck rigidity, Lumbar Puncture was done for CSF analysis to rule out meningitis. LP showed features of Viral Meningitis with 420 cells (Lymphocytes -97 ,monocyte -1), Protein-191 and sugar-88. He was started on IV antiviral (Acyclovir), CSF Meningitis panel, TB panel, Serum Influenza virus, Paraneoplastic panel, Lyme, GAD 65were negative. His Widal test was found to be positive for salmonella typhi H (1:80). Bronchoscopy and BAL done on 19/4/23 and culture showed presence of Staphylococcus aureus (MSSA) and Urine culture showed Klebsiella. IV antibiotics were optimized according to ID advice. Patient was improving :---->On CPAP Mode- 30% FiO2 and was extubated . After 2 days patient was awake, conscious on NP - 2L O2 and obeying commands and was planned for shift out from ICU. , But patient condition worsened, he was drowsy, with non-vocalizing, pooling secretions, not moving limbs, tremors (+), no spontaneous eye opening and continuous fever spikes. Repeat lab parameters showed worsening of renal functions and AKI. Medications were optimized.Patient was reintubated in view of poor sensorium and had Myoclonic jerks (+) ? seizure and was started in Inj.Levipil and Fentanyl infusion.
Neurology review was taken, EEG showed mild delta waves, he was started on Midazolam .Repeat MRI (27/4)- was stable to slightly more prominent FLAIR hyperintensities in the sub cortical white matter of the left frontal lobe along the middle frontal and the posterior frontal gyrus, and right anterior centrum semiovale. Better appreciated restricted diffusion in the dependant portions of the occipital horn of the lateral ventricles which may represent an element of ventriculitis. In view of his worsening renal functionand reduced urine output, Nephrology consultation was sought and he was initiated on Hemodialysis on 29/4/23 .
Repeat Lumbar puncture done on 29.04.2023 showed TC 107 (1 Neutrophil, 99 Lymphocytes) with protein124 and sugar 124. and after 2 days , Serum West Nile IgM turned positive. Infectious Disease review was obtained and antibiotics and antivirals were stopped. . He was started on Syndopa plus and showed good improvement. TRODAT + PET CT brain showed significant dopaminergic transporter abnormalities seen in bilateral putamen (right >left) with mildly reduced dopaminergic transporter abnormality seen in left caudate and global hypometabolism in brain. He was tracheostomized . Gradually, he was weaned off to portable ventilator. Physiotherapy was initiated. Now he is better, conscious, oriented, tremors+, on T piece and overnight BiPAp. He was transferred to Physical Medicine and Rehabilitation for further care.
Audience takeaway:
West Nile virus encephalitis (WNE) is the most common neuroinvasive manifestation of WNND .We present a case of sepsis and like to emphasis on how important as a clinician its to keep going until the right cause is found .
The goal of this case presentation is for learners to be better able to diagnose and manage West Nile virus (WNV) disease participants will:
Have increased knowledge regarding the
Transmission of WNV
Prevention of WNV infection
Have greater competence related to
Clinical management of WNV disease
Demonstrate greater confidence in their ability to
Diagnose WNV infection
Diagnose West Nile virus infection based on:
Signs and symptoms
History of possible exposure to mosquitoes that can carry West Nile virus
Laboratory testing of blood or spinal fluid
Treatment:No vaccine or specific medicines are available for West Nile virus infection. Antibiotics do not treat viruses. Rest, fluids, and over-the-counter pain medications may relieve some symptoms.
In severe cases, patients often need to be hospitalized to receive supportive treatment, such as intravenous fluids, pain medication, and nursing care.
