Case Presentation: A 78-year-old male, ambulatory, independent in ADLs with a medical history of atrial fibrillation and diffuse large B cell lymphoma in remission presented to the Emergency Department (ED) for fever, malaise, and cough. The patient was found to be Influenza A positive and was discharged from the ED with Tamiflu. The patient reported complete resolution of symptoms, but was called back to the ED 4 days later when blood cultures resulted positive for Kocuria marina. He was admitted for monitoring and repeat blood cultures were sent (which were ultimately no growth indicating initial positive had been a contaminate). While awaiting repeat blood cultures, the patient sustained a mechanical fall. Exam immediately post fall revealed bilateral lower extremity pain and decreased strength. Hip and pelvis x-rays were obtained and showed no fracture or dislocation. On exam the following morning, the patient was noted to have significant loss of strength, urinary retention, and decreased rectal tone. MRI cord compression was done, which showed diffuse cord signal abnormality with slight cord expansion extending from C7 down to the conus medullaris. Findings were consistent with longitudinally extensive transverse myelitis (TM). Repeat Influenza A testing was negative. Lumbar puncture results showed elevated WBC and protein and the patient was started on methylprednisolone followed by plasma exchange without any symptomatic improvement. Although repeat imaging showed near-complete resolution of cord swelling, the patient did not have symptomatic improvement. He was discharged to a rehabilitation facility and continues to have paraplegia and urinary retention.
Discussion: Influenza A is a rare trigger for TM, a serious inflammatory disorder of the spinal cord. Although most cases are monophasic, persistent disability and/or relapse can occur in patients with specific risk factors. Older age, infectious antecedents, rapid onset, and peripheral nervous system involvement are all associated with poor prognosis. Our patient had all of these risk factors and despite early diagnosis, good functional status at baseline and rapid resolution of cord swelling on imaging after treatment, he continues to suffer persistent neurologic deficits.
Conclusions: Influenza is a globally prevalent acute respiratory infection. It is often characterized by an abrupt onset of upper respiratory symptoms and systemic symptoms such as malaise and myalgias with most individuals recovering within 3-7 days. However, some patients can develop severe post-viral illnesses that result in life changing outcomes. In our case, the patient’s typical resolution of influenza symptoms followed by a rapid neurologic decline prompted us to investigate a rare post-influenza complication.