The patient is a 78 year old male with a history of ischemic cardiomyopathy status-post orthotopic heart transplant on tacrolimus and mycophenolic acid, who presented to the emergency department with 4 days of nausea, vomiting and watery diarrhea. He was found to have a fever to 101.7 but otherwise vital signs were stable. Physical examination was remarkable for a thin-appearing male, mildly drowsy and with tenderness to palpation over the epigastric region, but otherwise unremarkable. He had a mild leukocytosis, and was started on vancomycin and piperacillin-tazobactam. Diagnostic studies included blood cultures, stool culture, Clostridium difficile toxin PCR, and Rotavirus antigen immunoassay, and Norovirus PCR. He was found to have campylobacterin the stool and his antibiotic regimen was narrowed to levofloxacin; however, he continued to have worsening diarrhea as well as confusion while on antibiotics. Given this presentation, assay for West Nile Virus (WNV) serologies was sent which revealed detection of IgM. Lumbar puncture also revealed IgM in the CSF. The patient then became more tachycardic, tachypneic, and obtunded with concerns for worsening sepsis; the patient was thus transferred to the ICU and intubated. He developed a global flaccid paralysis over several days. Because of his tenuous status, he was treated with intravenous immunoglobulin (IVIG) for West Nile encephalitis. He received a tracheostomy after prolonged intubation. He slowly regained neurological function, and was able to track with his eyes and make slight movements in his extremities. He was discharged with plans for intense rehabilitation.
West Nile Virus is endemic and is the leading cause of arthropod-borne encephalitis in the United States, with the vast majority of transmission from mosquitoes. The most common clinical manifestations of WNV can be separated into two broad categories: West Nile fever, a viral syndrome which can be indistinguishable from the flu; and West Nile Neuroinvasive disease, which includes meningitis and encephalitis. Neuroimaging is oftentimes unremarkable. The incidence of long-term sequelae is more common for neuroinvasive disease, with poorer functional and physical prognosis including limb weakness and decreased activity. As this case demonstrates, the sequelae can be more severe, especially in those who are immunocompromised. Treatment is supportive, and although IVIG has demonstrated activity in vitro, its efficacy in the clinical setting is yet unclear.
It is important for clinicians to recognize West Nile Virus as a possible etiology in those presenting with flu-like symptoms, especially in patients with signs of altered mental status. Immunocompromised patients are especially susceptible. Prevention should be emphasized as the treatment for this disease is largely supportive.
To cite this abstract:Pan D, Fernandes S. West Nile Neuroinvasive Disease in a Patient with Orthotopic Heart Transplant. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 719. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/west-nile-neuroinvasive-disease-in-a-patient-with-orthotopic-heart-transplant/. Accessed May 22, 2019.