1273 - West Nile Virus and Transverse Myelitis: The Role of Steroids, PLEX, and IVIG in an 80-Year-Old Patient

Case Diagnosis: 80 year old female with a history of coronary artery disease (CAD) who developed transverse myelitis in the setting of west nile encephalitis after a family vacation in Wisconsin.

Case Description: The patient presented with acute bilateral lower extremity weakness and confusion. A neurologic workup revealed signal hyperintensity spanning the spinal cord from T9 to the conus, without abnormal enhancement. Cerebrospinal fluid (CSF) analysis showed pleocytosis along with IgG and IgM antibodies against West Nile Virus. The patient was initially treated with two days of high-dose methylprednisolone, followed by plasma exchange (PLEX). However, the patient developed worsening confusion and lower extremity weakness leading to flaccid paralysis. She was then switched to intravenous immunoglobulin (IVIG), and after receiving four days of IVIG, the patient showed improvement in mentation; however, the flaccid paralysis of the lower extremities persisted.

Discussions: High-dose methylprednisolone is the first-line treatment for transverse myelitis (TM), with plasma exchange (PLEX) as a common second option if steroids are not effective. IVIG, which reduces inflammation and neutralizes autoantibodies, is generally reserved for patients with more severe presentations or those unresponsive to steroids and PLEX. In this patient, early rehabilitation remained key in improving functional recovery. She has shown gains in truncal support and upper body strength, making transfers easier. Short-term goals include self-administration of suppositories and self-catheterization, with continued efforts to improve mobility and independence. Continued monitoring will provide further insights into both her neurological and functional recovery.

Conclusions:

West Nile encephalitis is challenging to treat and can lead to significant functional decline. Despite pharmacological interventions, paralysis persisted in this case, highlighting limited evidence of IVIG efficacy in viral-induced TM. This underscores the need for further research into therapeutic approaches that combine immunomodulatory treatments with rehabilitation to improve functional outcomes in viral-induced neuroinflammatory conditions like TM.