Download West Nile Encephalitis Associated with Recurrent Strokes Initial

West Nile Encephalitis Associated with Recurrent Strokes
Kate Hoppock DO, Timothy Mikesell DO, Ashwini Peruri MD, Lynn Klassman
Advocate Lutheran General Hospital
MRA Carotids wo/w Contrast: Stenoses at
the origins of the cervical internal carotid
arteries bilaterally. Diffuse diminished
caliber of the cervical left internal carotid
artery. Very poor filling/nofilling of bilateral
M1 segments.
Introduction:
In 2012 the CDC reported 5,674 cases of
West Nile Virus (WNV) infections in the
United States, 56% classified as
neuroinvasive disease. As of July 2013, 31
cases of WNV were reported with 35%
classified as neuroinvasive disease. This
case report is of a man with acute ischemic
strokes associated with WNV and is aimed at
raising awareness of this rare association.
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MRI Brain WO/W Contrast: Extensive
infarctions in both hemispheres anteriorly
mostly and moderate infarctions in the left
cerebellum. Within the frontal infarctions are
scattered small foci of blood products.
Initial Presentation:
58 year old male brought to the ED complaining of a
severe headache, neck stiffness, and confusion. Pt was
in usual state of health until 1 week prior to admission
after returning from a hiking trip in Wisconsin. The
patient initially developed a headache, neck stiffness,
intermittent nausea with no emesis and subsequently
developed fevers and difficulty with balance. Upon
questioning he did recall a mosquito bite to the neck
during one of his hikes, but did not recall any other insect
bites. Patient denied any rashes, extremity numbness,
tingling, or weakness, changes in vision, chest pain,
dyspnea, abdominal pain, vomiting, or diarrhea on initial
presentation. His past medical history was significant for
a pituitary adenoma s/p resection in 2007 as well as HTN
and DM controlled without medications
On initial physical exam, the patient was febrile, nonfocal, but was noted to have difficulty with coordination
and gait. CT without contrast brain was negative for
acute changes and lumbar puncture was unrevealing
demonstrating a modest pleocytosis. Emperic antibiotics
and antivirals were started along with high dose steroids
and a work up was initiated. On day 3 of his
hospitalization, the patient developed subtle right arm
weakness and right facial droop, prompting further
imaging. MRI brain revealed numerous punctate
infarctions in both hemispheres along the distribution of
the middle cerebral artery along with an MRA head/neck
demonstrating narrowing at the carotid terminus
bilaterally suggestive of an emboli or vascular
abnormality. A comprehensive “young stroke workup”
was then pursued.
IR Carotid Cerebral Angiogram: Lack of
normal visualization and contrast
opacification of the distal internal carotid
arteries--concerning for vasculitis.
Figure 1. First MRI of admission: MRI brain wo/w contrast--Numerous punctate regions of acute
cerebral infarctions involving the cerebral hemispheres bilaterally in the middle cerebral artery
distribution.
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Cardioembolic: Transthoracic and transesophageal
echo were negative for endocarditis.
Hypercoaguable: Normal protein S and C,
antithrombin III, thrombin, fibrinonogen, factor 7,
plasminogen, lupus anticoagulant, cryoglobulin,
MTHFR, phosphatidylserine, beta-2 glycoprotein,
cardiolipin.
On the day of the biopsy, Serum and CSF were
found to be positive for CSF WNV Ab IgM
Given the patient’s grave prognosis, artifical
support was withdrwan and the patient passed
away 12 days after presentation. Final autopsy
results demonstrated “acute encephalitic
changes, pancortical vascular congestion and
edema, along with left cerebellar infarction.
WNV has previously been implicated as causing
meningitis, encephalitis, and demyelinating
neuropathies. Based on review of the literature, this
is the second case report of WNV associated with a
stroke. Detection and sharing of WNV associated
ischemic stroke cases will potentially lead to the
development of treatment strategies to decrease the
morbidity of this neuroinvasive disease.
References
Infectious: Negative for hepatitis, HIV, HSV, Lyme
disease, varicella, RPR, T. pallidum, EBV, CMV.
Blood cultures remained negative. WNV serologies
from CSF and Serum were still pending.
During work up the patient was treated with
methylpredisone 1 g daily x 3 days and continued
on Acyclovir until HSV serologies were negative.
Emperic antibiotics were discontinued as no source
was identified. Patient continued to deteriorate and
imaging was again repeated.
Brain, right frontal leptomeninges, right frontal,
right frontal subcortex all demonstrated benign
tissue without specific pathologic changes.
Brain, right frontal: Benign cortical tissue
with ischemic changes
**The biopsies were essentially normal on
histopathology. There were focal ischemic
changes, but lacked increased chronic
inflammation, perivascular chronic inflammation,
neuronophagia, or evidence of CNS angiitis.
Conclusion:
Work Up:
Autoimmune: No abnormalities including ANA, RF,
MPO, lupus anticoagulant panel, C3, C4, CRP,
Pathologic Diagnosis:
1.Kanagarajan K, Ganesh S, Alakhras M, et al. West Nile Virus
Infection Presenting as Cerebellar Ataxia and Fever: Case
Report. Southern Medical Association 2003;96 vol.6: 600601
Figure 2. Second MRI: MRI brain wo/w contrast--Extensive infarctions in both hemispheres
anteriorly.
Given the patients rapid decline, and unknown
etiology, the decision was made to obtain a tissue
diagnosis and cerebral and leptomeningeal biopsies
were obtained. After the procedure, the patient
remained on mechanical ventilation and did not
regain consciousness.
2.CDC. West Nile Virus Disease and Other Arboviral Diseases
United States, 2011. MMWR 2012;61; 510-514
3.Carson PJ, Konewko P, Wold KS et al. Long-Term Clinical
and Neuropsychological Outcomes of West Nile Virus
Infection. Clinical Infectious Diseases 43 (6);723-730
4.Alexander J, Lasky A, et al, Stroke Associated with Central
Nervous System Vasculitis After West Nile Virus Infection.
Journal of Child Neurology 2006; 21:623-625
5.Gilden D, Lipton H, Wolf, et al. Two patients with Unusual
Forms of Varicella-Zoster Virusc Vasculopathy. New England
Journal of Medicine 2002; 347:1500-1503