Five weeks following cadaveric renal transplant, a 66 year old female developed increasing lethargy, depressed mental status, and diffuse tremulousness. This was accompanied by fever and leukocytosis. Her neurologic exam progressed to the point of a comatose state with partial preservation of brainstem reflexes and flaccid limbs. Cerebrospinal fluid (CSF) profile revealed only moderate protein elevation. Serum West Nile Virus (WNV) IgM and IgG were found to be positive. CSF WNV IgG was also positive though CSF IgM was negative. MRI of the brain revealed sulcal and symmetric subcortical, periventricular, and basal ganglia T2/FLAIR hyperintensities along with progressive symmetric diffusion restriction of bilateral thalami and descending pontine motor tracts. In the context of a feasible mode of transmission via organ transplantation, consistent neurologic syndrome, and prior reports of CSF IgM negativity with autopsy-confirmed WNV encephalitis, a diagnosis of probable West Nile Virus encephalitis was made. The patient was treated with a five day course of IVIG and high dose methylprednisolone. Immunosuppressive medication was also reduced. There was no change in her exam within the first week after treatment. In accordance with the patient’s previously stated wishes, at this time comfort measures were pursued and the patient expired.

This case report supports accumulating documentation of West Nile Virus transmission via organ transplantation as well as the higher risk of neuroinvasive disease in transplant recipients. It provides a reminder that, although nonspecific, a range of atypical movements may be one of the few initial clues to the diagnosis of WNV encephalitis. It serves to emphasize the relatively early seroconversion to IgG, which can be seen even in subacute infection. Lastly, this case report posits the possibility of normal CSF white blood cell count in an immunosuppressed patient with WNV encephalitis.