To describe the unique occurrence of ischemic stroke in association with West Nile meningoencephalitis.

A 67 year old woman with significant history of pigeon exposure presented to the hospital as a stroke alert with acute onset of right sided facial droop, right sided weakness, in association with low back pain and lethargy. Patient was febrile with leukocytosis, significantly encephalopathic, and in respiratory distress warranting intubation. CT angiogram of the head and neck was unrevealing. Subsequent MRI of the brain showed a medial left frontal acute infarct. Lumbar puncture revealed 351 nucleated cells, 61 lymphocytes, normal glucose, and protein of 98. A myriad of infectious studies were performed and WNV IgM, IgG in CSF returned positive. Serum Chlamydia psittici IgM was positive. However, CSF studies for C.Psittici were negative. She was treated with Doxycycline for Chlamydia Psittacosis and started on IVIG for her WNV. Her mental status significantly improved and she was discharged to a rehabilitation facility.

Our patient presented as a stroke alert with encephalopathy, acute right sided facial droop and hemiparesis. The degree of patient’s encephalopathy appeared to be out of proportion to the patient’s ischemic stroke size and location and was an important clue that prompted further investigation, as did her interesting epidemiologic risk factors. The occurrence of stroke as a complication of WNV is extremely rare with only a handful of case reports reported to date .It is important to keep CNS infections such as WNV in mind while evaluating toxic appearing elderly patients with stroke symptoms.