Case Description: A 75-year-old man presented in August 2015 with sepsis and one day of confusion, fever of 104°F, a white blood cell count (WBC) of 19.80, and blood pressure of 204/91, in the setting of a recent admission for small bowel obstruction. On exam, he was only oriented to self with slurred speech, tongue and bilateral quadriceps fasciculations, cogwheel rigidity and tremor of bilateral upper arms, and dysmetria. He did not have skin changes, no meningeal signs, or visual problems. Initially, he was treated empirically for meningitis. Head computed tomography (CT), magnetic resonance imaging (MRI), abdominal CT, chest X-ray (CXR) were negative. He remained febrile and hypertensive for four days, with worsening Parkinson’s features. Blood and urine cultures were negative and antibiotics were stopped. Neurology started a Sinemet trial. Lumbar puncture (LP) revealed mild pleocytosis and no detectable WNV. On day six, his white blood cell count (WBC) resolved, blood pressures were under control, and defervesced-only with supportive care. All of his Parkinson’s symptoms resolved. On day seven, serum WNV IgM was positively elevated >5.00. One week later, he had seroconverted.
Discussion: The first case of WNV was isolated in 1937 in Uganda. This case report reminds us of the necessity to heighten public health awareness for WNV. It also portends the need for WNV surveillance in order to control disease spread. Our priorities need to shift toward early disease identification and implementation of control measures. Reporting databases like ArboNET are effective, however, as it currently stands, the onus of reporting lies in the hands of health care professionals. This leads to an underestimate of the actual disease prevalence and burden. Frequently, WNV cannot be detected in serum because the viremia is short lived and peaks before clinical symptoms are present. Case reports have documented that WNV can present as Parkinsonian symptoms including hypomimia, bradykinesia and postural instability. Persistent fever without a known source should initiate a search for the cause, and merits a thorough review of the patient’s social history. Treatment should be focused on supportive care while pending laboratory confirmation of WNV, and irrespective of imaging studies. Consistent with the literature, our patient did not have significant imaging findings. WNV can be a preventable disease if preventative measures are taken. Thus, the long-term sequelae of WNV, which include depression, fatigue, headaches, cognitive and muscular deficits, can be potentially avoided.
Nikki Duong and Alita Mishra