Ben Birkenfeld, MD
Physician
Hackensack Meridian JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
Lei Lin, MD
Attending
Hackensack Meridian JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
A 76-year-old male with history of bladder cancer presented to acute rehabilitation after neuroinvasive West Nile Virus (WNV) infection. He was hospitalized for diplopia, confusion and diffuse weakness, with findings of WNV IgM antibodies in the serum and CSF. During hospitalization, the patient developed atrial fibrillation, seizures, and respiratory failure requiring intubation. He received supportive treatment. When admitted to rehabilitation, the patient was debilitated due to a prolonged bed-bound state. After 11 days of therapy, he developed spontaneous left foot drop, but denied limb or joint compression. Nerve conduction studies and electromyography of the lower extremities revealed generalized sensorimotor peripheral polyneuropathy with superimposed left fibular/peroneal axonal neuropathy. The patient was fitted with a left ankle foot orthosis and received comprehensive therapies. He became independent with ADLs and ambulated with a cane, enabling discharge home with outpatient therapies.
Discussions:
WNV is relatively uncommon, with less than 1% of cases being classified as severe neuroinvasive disease. However, infections range in greatly in their outcomes. This patient experienced a neuroinvasive CNS infection that ultimately caused aberrancies in multiple organ systems. Notably, he demonstrated cranial nerve involvement, causing diplopia, and peripheral axonal neuropathy, causing left foot drop. These findings demonstrate the sinister course of neuroinvasive WNV given its unpredictable symptomatology and timing.  With proper evaluation and follow-up, patients’ functional deficits can be managed with therapies, orthotics, and assistive devices.
Conclusions:
WNV manifests with a wide spectrum of symptoms. Here, we describe a case of neuroinvasive WNV with cranial nerve involvement and sudden onset focal mononeuropathy that presented 11 days after hospitalization. Such pathology demonstrates the prolonged and severe impact neuroinvasive WNV has on both the central and peripheral nervous systems.
