Abstract Details

Title West Nile encephalitis in a patient with initially negative CSF serology.

Topic Infectious Disease

Presentation(s) P4 - Poster Session 4 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-016

Objective To describe a case of West Nile encephalitis in a patient with negative serological tests in the CSF.

Background Infection with West Nile virus (WNV) can produce a range of clinical presentations, including severe encephalitis and flaccid paralysis. The detection of serum and CSF IgM antibodies to WNV is essential to confirming the diagnosis.

Design/Methods We describe here a patient with chronic lymphocytic leukemia (CLL) who presented with a syndrome suspicious for WNV encephalitis, but with initially negative CSF IgM for WNV.

Results An 82-year-old patient with a history of CLL was admitted to the hospital because of 2-3 days of generalized fatigue, frequent falls, weakness, progressively worsening altered mental state and fever. After admission, he continued to be febrile up to 104 degrees Fahrenheit. His mental status continued to decline, so he was intubated for airway protection. A Lumbar puncture showed lymphocytic pleocytosis and elevated protein, other viral test were negative, and a West-Nile assay showed a positive IgG with negative IgM. On exam, the patient followed minimal commands, his pupils were reactive to light and he had intact eye movements, but rest of brainstem reflexes were absent and his motor exam showed flaccid paralysis and areflexia. MRI brain was unremarkable. MRI total spine diffuse enhancement in multiple lumbar and thoracic nerve roots with no spinal cord abnormalities. An EMG showed an axonal polyneuropathy, motor worse than sensory. Due to a strong clinical suspicion, serum West Nile virus IgG and IgM were repeated and these returned positive, confirming the diagnosis.

Conclusions West Nile virus encephalitis is characterized by changes in mental status and flaccid paralysis. In this case, the initial negative CSF IgM titers, possibly secondary to this patient’s comorbid CLL, delayed the diagnosis which was later confirmed by serology.

Authors/Disclosures
Paul Sanmartin, MD PRESENTER	No disclosure on file
Jeremy Moeller, MD, FAAN (Yale University)	Dr. Moeller has received publishing royalties from a publication relating to health care.
Tara A. Kimbrough, MD (Ochsner Medical Center)	Dr. Kimbrough has nothing to disclose.

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