Rhombencephalitis caused by West Nile fever virus

Abstract

In the past, West Nile fever has manifested as a systemic illness involving acute fever, myalgia, headache, lymphadenopathy, and maculopapular rash. 2 However, in 1 to 40% of cases there has been infection of the neuroaxis, including encephalitis, meningitis, myelitis, radiculopathy, and peripheral neuropathy. 3,4 We describe an adolescent with West Nile encephalitis with brainstem manifestations.Case report. A healthy 15-year-old boy presented with a 3-day history of fever, headache, vomiting, and confusion. Recent history was remarkable for multiple insect bites while living in the Bronx and during a visit to Rhode Island in July 1999. History was negative for immunosuppression, systemic illness, rashes, vaccinations, trauma, or drug use. The patient was hospitalized in the Bronx on September 5, 1999. Pertinent laboratory investigations included abnormal CSF results, with 98 white blood cells/mm 3 , 498 red blood cells/mm 3 , protein count of 84 mg/dL, and glucose count of 65 mg/dL. The differential showed 8% polymorphonuclear cells, 86% lymphocytes, and 6% monocytes. The Center for Disease Control and Prevention documented an elevated immunoglobulin M (IgM) count in the high positive category for West Nile virus in the CSF and blood. Serum Lyme titer was negative, and no other serology workup was performed. Hematologic and blood chemistries were normal. Before the diagnosis, sedimentation rate and antinuclear antibody tests were not ordered. A CT scan of the brain was normal. No electrophysiologic studies were performed. During the hospitalization, the patient required a nasogastric tube, as he was unable to swallow.Six weeks postadmission, the patient was seen in a pediatric neurology clinic. He had bifacial weakness, depressed gag reflex, and tongue fasciculations. Also, there was bilateral appendicular and truncal ataxia. The tendon reflexes were mildly increased, with the right side greater than left. One month later, he improved with a more ellicitable gag reflex, less ataxia, a decrease in tongue fasciculations, less drooling, better swallowing, and efficient feeding. Brain MRI at that time was normal. Six months after the illness, neurologic examination was normal.

West Nile Virus Disease in Children, United States, 1999–2007

“…2,9,[11][12][13][14][15][16] In the early 1980s, WNV was isolated from the brains of 3 children who died of encephalitis within the same state in India. 23 During an unusual outbreak in Sudan in 2002, all 31 of the probable cases identified were among children Ͻ13 years of age, with most cases in those aged Յ5 years.…”

“…10 Although immunocompromised children seem to be at a higher risk of developing severe disease, 6 many of the severe cases described in the literature occurred in previously healthy children. 3,5,[11][12][13]15,16 Other host factors that may increase the risk of WNND in children are unknown.…”

Electroencephalography Findings in Adult Patients with West Nile Virus--Associated Meningitis and Meningoencephalitis

“…WNF outbreaks in different parts of the world have been reported with increasing frequency in the past few years. However, these studies have mainly presented epidemiological and clinical data [9][10][11][12][13][14][15][16][17]. Only a small number of clinical studies and single case reports describe the EEG findings for patients with WNV-associated meningitis or encephalitis.…”

West Nile Virus Encephalitis in a Child with Left‐Side Weakness

“…A 15-year-old boy presented with fever, confusion, cranial nerve deficits, ataxia, and brisk tendon reflexes, which are consistent with a rhomboencephalitis. CNS imaging findings were normal at presentation and 1 month later [7]. Mild neurologic findings lingered for several months after hospital discharge.…”