Aimee Abbott-Korumi, DO
Physical Medicine and Rehabilitation Resident
JFK Johnson Rehabilitation Institute
Sewell, New Jersey, United States
Lei Lin, MD
Attending
Hackensack Meridian JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
Esha Patel, DO
Resident Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
Ben Birkenfeld, MD
Resident
Hackensack Meridian JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
A 61 year old male with no known past medical history presented with generalized weakness, profound fatigue, lymphadenopathy, transient rash, fever, and subsequent left lower extremity (LLE) weakness and neuropathy. Recent travel to the west coast and mosquito exposure were noted. MRI revealed T2 FLAIR signal alterations in the parietal/occipital lobes, and nonspecific signal changes at T11 and T12, with nerve root enhancement of the cauda equina on repeat imaging. Lumbar puncture revealed leukocytosis, lymphocytic predominance, and mildly elevated protein. CSF testing was positive for West Nile virus (WNV) IgM > 5, consistent with West Nile encephalomyelitis. Electromyography showed LLE axonal damage without acute demyelination. He was treated with intravenous immunoglobulin. Two weeks later, he developed mental status changes and facial droop. CT Head and CTA were negative; Bell's Palsy secondary to WNV was suspected. He received a 5-day course of IV steroids and was stabilized for inpatient rehabilitation.
Discussions:
WNV, a flavivirus endemic to the US, is the leading cause of mosquito borne illness in the country. While most infections are asymptomatic, about 30% present with symptoms, with those in their 60s to 80s at higher risk for central nervous system (CNS) involvement. Neuroinvasive disease accounts for 95% of WNV-related deaths. BP is a facial nerve paralysis often linked to viral infections, most commonly Herpes Simplex Virus. However only a few case studies have documented BP associated with WNV.
Conclusions:
Flavivirus related BP is rare, with only two WNV and one Dengue case reported. This case illustrates neuro-invasive WNV leading to LLE weakness, neuropathy, and Bell's Palsy. Without approved WNV treatments and recurring outbreaks in the US, it remains a significant public health concern, necessitating further research into the epidemiology, clinical manifestations, and potential treatments for neuro-invasive WNV.
