Emma Spilsted, MD
Doctor
ECU Health
Greenville, North Carolina, United States
Bailey Pechner, DO
Medical Student
Campbell University
Sanford, North Carolina, United States
Matthew Parker, MD
Attending Physician
ECU Health
Greenville, North Carolina, United States
West Nile Virus causing acute ascending flaccidity and LE pain, diagnosed via lumbar puncture
Case Description: 45-year-old Caucasian woman with well controlled multiple sclerosis (MS) presented to the emergency department with acute bilateral lower extremity flaccid paralysis. Initially thought to be an acute MS flair, she was started on a five-day course of plasmapheresis while further diagnostic workup was conducted. MRI of the brain and cervical spine were largely stable. On day 5 serologic testing confirmed IgG/IgM positive WNV and plasmapheresis was discontinued. She was moved to acute inpatient rehabilitation to focus on intensive therapy. Initial physical exam showed signs of lower motor neuron disease with bilateral asymmetric flaccid paralysis of lower extremities, diminished reflexes, and patchy areas of reduced sensation. She began multidisciplinary treatment with OT, PT, and psychologic therapy and quickly began improving. Strength testing improved from 0-2/5 strength in LE to 3-4/5 within 2 days. She otherwise received predominantly symptomatic care including multi-modal pain medication to help with cramping and spasms.
Discussions:
This case demonstrates the difficulties of diagnosis and management of WNV and the significant impact IPR can have in patient recovery. Among the sequelae of WNV, flaccid paralysis is a rare and poorly understood process which makes identification and treatment a challenge. Current limited data shows improvements to strength can continue up to 6 months to a year after onset, although outcomes can vary widely. While immunotherapies such as IVIG and plasmapheresis are available for GBS, there are no current recommendation guidelines for treatment of WNV – associated flaccid paralysis (poliomyelitis-like syndrome). Symptomatic management is key, including intensive therapy targeted towards increasing patient strength and mobility.
Conclusions:
West Nile Virus itself is a self limiting disease, without treatment. Timely transition to IPR for intensive therapy positively impacted this patients recovery, and should be considered when future cases arise.
