Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 35

Table 2. Results of other laboratory tests Blood test Results Antimitochondrial antibody Absent Antinuclear antibodies Absent Coccidioides/Rocky Mountain spotted fever antibody Negative C-reactive protein <0. 3 Creatine kinase 24 Blood culture Negative Paraneoplastic panel Negative Enterovirus/herpes simplex virus Negative West Nile virus IgM Positive showed small bilateral pleural effusions and a small amount of free fluid in the pelvis but no signs of primary malignancy. Laboratory test results were remarkable for the presence of WNV immunoglobulin (Ig) M in the blood, with negative IgG and negative polymerase chain reaction results (Table 2). Although CSF WNV IgM titers were below the assay cutoff, they were in fact found to be present at low levels. CSF WNV IgM was tested after completion of intravenous immunoglobulin (IVIG) treatment and while on high-dose steroids. Based on the clinical presentation and these laboratory findings, the diagnosis of acute WNV meningoencephalitis was made. CSF and blood cultures drawn prior to antibiotics were without any growths. Prior to transfer to Baylor University Medical Center, the patient was started on broad-spectrum antibiotics and antiviral coverage with doxycycline, meropenem, vancomycin, and acyclovir but showed no signs of improvement. She was also started on gabapentin and diazepam for nystagmus symptom relief. Nausea and emesis were controlled with promethazine and ondansetron. Upon transfer, the patient was immediately started on IVIG with a total of 2 g/kg administered over 3 days. On day 2 of IVIG, she was started on intravenous methylprednisolone 125 mg twice a day, which was later transitioned to oral prednisone after 5 days. Within a couple of days of starting IVIG and intravenous steroids, her symptoms of nystagmus and ataxia showed visible improvement. On day 5, her symptoms of headache, nausea, vomiting, and nystagmus had improved significantly such that she was finally able to open her eyes and eat. On day 6, oral prednisone, memantine, and oxcarbazepine were started. Due to drowsiness, memantine and oxcarbazepine were discontinued fairly quickly after initiation. By day 10, the patient had full range of motion in all extremities, and OMS had nearly resolved to the untrained eye. The patient had become very deconditioned from being bedbound for nearly 2 weeks with poor nourishment, requiring inpatient rehabilitation. Over the course of a year, she has improved to the extent of being able to get groceries and take care of her children. Using her eyes for prolonged tasks will still cause her to be nauseated and worsen her headache. Although her opsoclonic-nystagmoid movements are not visible outside of ophthalmological evaluations, which do show small continued April 2014 movement not obvious to the naked eye, she does have difficulty with reading. She also has intermittent problems with urinary retention. DISCUSSION West Nile virus According to the Centers for Disease Control and Prevention, in 2012, there were 5674 WNV cases in the United States (4). Texas was particularly hit hard, with 1739 (32%) cases reported (3). Severe cases of neuroinvasive WNV were initially reported in 2002 and 2003 but have been increasing in frequency over the past several years. Just in 2012 alone, 2873 of the reported WNV cases were neuroinvasive, with 286 repor FV@