Derek A. Fox, MD
Resident Physician
Emory University
Atlanta, Georgia, United States
Gavin Ajami, MD
PGY3 PM&R Resident
Emory
Atlanta, Georgia, United States
Kymbreana Coley, MD
Attending Physician
Emory University
Atlanta, Georgia, United States
A 54-year-old female presented with one week of diffuse non-pruritic rash followed by fevers, arthralgias, and progressive bilateral lower extremity weakness. Physical exam noted asymmetric bilateral lower extremity weakness, hyporeflexia and a normal sensory exam. CSF analyzed from a lumbar puncture demonstrated elevated protein, pleocytosis, elevated West Nile Virus IgM. CSF cultures were negative. MRI spine revealed T2 weighted cord signal hyperintensity from C4-C7 and from T7 to the conus medullaris, most intense in the anterior horns. Negative inspiratory force (NIF) was -24cm H2O, but she maintained adequate oxygenation saturations on room air. She was treated with plasmapheresis and intravenous steroids for 5 days, halting progressive motor weaknes and improving NIF. During early hospitalization, she developed significant lower body neuropathic pain and urinary retention. She was admitted to acute inpatient rehab with the anticipation of discharging home at the wheelchair level.
Discussions:
This case highlights a rare presentation of West Nile Virus (WNV), as well as an interesting manifestation of the underlying pathology. Compared to the handful of cases reported in the literature on this condition, the feature of markedly decreased NIF is uncommon. Significant respiratory weakness here may be attributed to the involvement of diaphragmatic, intercostal, and abdominal musculature innervation, as evidenced by C4-C7 and T7-conus medullaris spinal cord signal enhancement on MRI.
Conclusions:
Due consideration of WNV and other viral infectious processes should be given to patients presenting with progressive asymmetric bilateral lower extremity weakness with preceding prodromal symptoms. The disease’s potential to impair respiratory function could be fatal. Early identification and treatment are crucial for prevention of more severe neurologic involvement. Although guidelines for treatment aside from supportive care have not been established, usage of intravenous steroids, IVIG, and plasmapheresis have been reported effective for halting disease progression and improving neurologic function.
