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 Joel Shackson PGY-2, Internal Medicine 09.18.2019

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 14.8 138 102 28 85 8.6 359 4.0 29 0.76 43.6 Alk Phos 4.1 TSH 2.029 ALT 80 Folate 15.3 AST 44 B12 522 HIV neg Procal <0.10 HepC neg CK 66 Utox +amphetamines CRP <5.0 ESR 13 7 09.18.2019

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