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A 41-Year-Old HIV-Positive Man with Acute Onset of Quadriplegia after West Nile Virus Infection

Suzanna Connick Jamison, MD, MSN, Sarah R. Michaels, MSPH, Raoult Ratard, MPH, MD, MS, FACPM, Jon M. Sweet, MD, FACP, Bennett P. deBoisblanc, MD, FACP, FCCP, FCCM
Volume: 100 Issue: 10 October, 2007

Abstract:

Most cases of West Nile encephalitis virus (WNV) infection are asymptomatic. In cases where WNV is symptomatic, patients usually experience high fever of sudden onset, myalgia, headache, and gastrointestinal symptoms, accompanied by a macular erythematous rash in a quarter to half of cases. More severe infections manifest as a poliomyelitis. Immunocompromise and immune senescence confer an increased risk of severe central nervous system (CNS) infection. Patients with human immunodeficiency virus (HIV) infection are therefore more susceptible, but, because the symptoms of WNV infection may be attributed to other CNS syndromes common in HIV patients, it is likely that the presence of WNV infection is underdiagnosed and underreported. We present a patient with severe WNV infection who was found to be HIV positive, who also suffered hearing loss. Several key differences in the presentation of WNV infection and Guillain-Barré syndrome that have treatment implications are discussed.


Key Points


* West Nile Virus poliomyelitis syndrome most often presents with asymmetric muscle weakness, in contrast to Guillain-Barré, which presents with ascending paralysis and sensory symptoms.


* CSF analysis can help differentiate among West Nile Virus infection, bacterial meningitis, and Guillain-Barré.


* West Nile Virus infection may be underdiagnosed in the immunocompromised and elderly, whose debility may be attributed to their general clinical condition.


* Diagnosis of acute West Nile Virus infection requires detection of WNV IgM antibodies in acute and convalescent serum samples, or a single acute cerebrospinal fluid (CSF) sample, or by demonstrating a 4-fold rise in WNV IgG titer between acute and convalescent sera.

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