Case Presentation:
A 40-year-old-male with history of diabetes type 1 and renal transplant on immunosuppression presents with 2 weeks of weakness, anorexia, and cough. Initial exam revealed temperature 102.8 but was otherwise normal. He was started on empiric broad-spectrum antibiotics. Two days after admission, he was found obtunded and dysarthric. He suffered an aspiration event for which he had to undergo endotracheal intubation. CT Head and MRI Brain were non-specific. Lumbar puncture was consistent with a lymphocytic predominant pleocytosis and high protein. West Nile Virus IgM was elevated to 3.13. He was diagnosed with West Nile Virus encephalitis and his immunosuppression was held. Patient received intravenous immunoglobulin (IVIG) with significant improvement of his neurological status 24 hours after infusion. Extubation was attempted, however failed due to an aspiration event. Patient was noted to have weak cough and gag reflexes and pulmonary hygiene was done to augment clearance of secretions. A second dose of IVIG was given after which further neurologic improvement was observed. Weak cough and gag reflexes persisted, but he tolerated pressure support ventilation with no evidence of fatigue. He was considered high risk for aspiration and tracheostomy was performed. He was weaned quickly to tracheostomy collar and sent to medical floor for ongoing management. After much improvement of his weakness, immunosuppression was re-started.
Discussion:
West Nile Virus (WNV) is an arbovirus which causes neuroinvasive disease in less than 1% of those infected. This renal transplant recipient presented with decline in mental status as well as muscular and bulbar weakness. Special care should be taken in patients who present with bulbar symptoms, since there may be an increased risk of aspiration. Early tracheostomy allows for airway protection and expedited liberation from the ventilator. This patient’s immunosuppression was held when he clinically deteriorated. IVIG was administered after diagnosis was confirmed which lead to an improvement in mental status but persistent bulbar weakness.
Conclusions:
To our knowledge, this is the first reported case of WNV encephalitis with bulbar weakness in a solid organ transplant recipient. These patients should be weaned off the ventilator with caution. Early tracheostomy should be considered. This allows for early liberation from the ventilator, participation in physical therapy, and time for recovery of cough and gag reflexes. Holding immunosuppression in the transplant recipient is thought to improve chances of recovery in WNV encephalitis. The risk and benefits of withdrawing immunosuppressive agents (including allograft failure) should be taken into context of disease presentation. Multiple case studies suggest role for IVIG in treatment of West Nile Virus, suggesting the importance of humoral immunity in clearing infection.