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Abstract: SA-PO1126

West Nile Virus: A Peculiar Cause of Fever and Encephalopathy in a Transplant Patient

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Swanson, Kurtis J., UW Health, Madison, Wisconsin, United States
  • Aziz, Fahad, UW Health, Madison, Wisconsin, United States
  • Parajuli, Sandesh, UW Health, Madison, Wisconsin, United States
Introduction

West Nile Virus (WNV) is an uncommon viral encephalitis. Here we describe an unusual presentation of WNV encephalitis in a kidney transplant recipient.

Case Description

65 year old woman with ESKD due to fibrillary glomerulonephritis, recurrent UTIs, T2DM s/p living related donor kidney transplant with basiliximab induction, CMV -/+, EBV -/+, no PRA/DSA maintained on standard triple immunosuppression who presented with fever, dysuria. On presentation she was febrile, tachycardic, normotensive, and with normal mentation. She recently was treated for multi-drug resistant E. Coli UTI, but had persistent symptoms, positive UA and started on empiric pipercilin-tazobactam. Urine culture grew the same E. Coli. Blood cultures remained negative. She was narrowed to ceftriaxone. Despite appropriate coverage, she remained febrile, weak, and developed a dense hypoactive delirium. She developed dysarthria prompting Neurology consultation and head imaging, which were unremarkable. Over days, her mental status did not improve and exam changed with new spasticity/hyperreflexia. A lumbar puncture was performed, showing lymphocytosis and CSF WNV IgM positivity via ELISA testing with an index value of 9.73 (1.1 or greater suggestive of WNV) . With this diagnosis, her immunosuppression was reduced to azathioprine/prednisone along with 1 dose of IVIG. Over days, her delirium resolved. She had a prolonged course of rehabilitation. Her graft function remained stable throughout her illness.

Discussion

West Nile Virus is a rare disease associated with marked neurological sequelae including weakness often lasting months. Diagnosis is often challenging, as manifestations can be non-specific and involve multiple organ systems. A high index of suspicion and thorough neurologic evaluation are key to diagnosis. CSF IgM is a useful test, specific for neuroinvasive WNV as IgM does not cross the blood brain barrier. Interpretation can be difficult as it usually takes 4-10 days to manifest. Interestingly, it can persist for 12 months i.e. may represent prior infection in some cases. Aside from insect repellent, no other preventative measures or directed therapies exist to quell this infection, which ultimately requires supportive care. West Nile Virus is a key differential diagnosis in the transplant patient with encephalopathy and its recognition is vital to guiding prognosis and management.