Robin Trotman, DO Case Conference

1
Robin Trotman, DOCase Conference

• October 4, 2004
• A Case of Possible/probable/presumptive/not West
  Nile Virus
• Viral Encephalitis diagnostics

2
Presentation

• 57yo wm presented to an OSH ED with fevers and
  altered mental status. VS _at_ OSH ED 120/82, 100,
  respirations 40, temp 101.9 rectally.
• Fever started at about 24h prior to presentation.
  Due to MSC he was intubated at OSH and
  transferred to WFU.
• They were vacationing at the beach during this
  time and on the way home he started to become
  confused and having fevers again. At about 430
  p.m. on the day of presentation, he was taken to
  the emergency department for fevers and
  confusion.
• He complained of having aches all over his body
  as well as a headache. No diarrhea, no history
  of bug bite at the beach, denies any sick
  contacts, no nausea or vomiting. There is a
  history of a tick bite approximately one to two
  weeks ago, unknown duration of exposure and no
  symptoms.

3
Presentation

• Past Medical History
• 1. S/PL4-5 status post laminectomy in 7/98.
• 2. HX of EtOH abuse, last drink approximately
  2-3 years ago.
• 3. History of tobacco abuse, last cigarette use
  two to three years ago.
• 4. Peripheral vascular disease with neuropathy.
• Medications
• 1. Amitriptyline 100 mg p.o. daily.
• 2. Methocarbamol 750 mg two in the morning and
  two in the evening.
• 3. Vitamin B, vitamin E and an enteric coated
  aspirin.
• Allergies
• 1. Morphine and Codeine.
• Family History
• 1. Positive for cancer, diabetes and lung
  disease.
• Social History

4
Presentation

• 150/63, pulse 86, temperature 100.9 rectally,
  SpO2 100, _at_14/min.
• General Rigors, shaking his head side to side
  and chewing on ETT. Ativan 2 mg given, the
  patient within minutes stopped shaking and is
  able to respond to commands fully.
• Skin No rashes, left wrist has a healing wound
  with scab. Stasis dermatitis in his lower
  extremities bilaterally.
• Eyes Pupils 2 mm, nonreactive to light.
• ENT No lymphadenopathy, no carotid bruits.
• Chest Rhonchi bilaterally.
• Cardiovascular regular, no murmurs
• Abdomen Tight tympani in all four quadrants.
  NT to palp. No HSM
• Lymphatic No lymphadenopathy.
• Musculoskeletal Muscles are tight and some
  shivering.
• Neurologic deep tendon reflexes in the upper
• extremities are 2 bilaterally. Deep tendon
  reflexes in the lower
• extremities 1 bilaterally.
• Psychiatry minimally responsive

5
Admit Labs
Segs-80 Lymph-12 Monos-9
14
5
140
40
14
142
101
126
3.3
26
1.1
ALP-63 Bili-1 Alb-2.5 Ca-8.4 AST/ALT-28/18 CPK-343
UA/EDS-neg
AG15
Micro BCX-neg UCx-neg
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Hospital Course

• Admitted to MICU
• Extubated the following day
• Transferred to floor, LP results from OSH were
  all negative.
• Treated with Keflex for cellulitis on hand
• Discharged to home 7 days after presentation.

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Follow up

• CXR/Head CT/Brain MRI all negative
• Lyme EIA negative
• ANA and ANCA negative
• Tox screens negative
• OSH CSF parameters wnl and sterile at DC from WF

8
Follow up

• Meningoencephalitis panel obtained from WF
  showed
• 8/23(HD1) IgG 132 IgM positive
  interpretation presumptive for recent WNV inf
  or related virus
• At this point he needs confirmatory CSF PCR(
  which may be negative, CSF IgG, or increase in
  IgG titer in convalescent sera.
• 9/9 Convalescent serum showed WNV IgG and IgM
  titers of 164.
• 9/20 Convalescent serum ordered and pending.
• Deleted from the Arboviral cases report Friday.

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West Nile Virus

• West Nile Virus first recognized as human ds in
  Israel in 1957.
• Flaviviridae family, lineage 1.
• 3-14d incubation period and 3-6 days of symptoms.
• Enzootic life cycle-birds and culicine mosquito
• lt1 develop encephalitis
• First US Case in 1999
• Cohen and Powderly, 2nd ed.
• Peterson, et al., West Nile VirusA primer for
  the Clinician. Annals 2004

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West Nile Virus

• Analysis of the experience in Illinois during
  2002-884 cases with 66 attributable deaths.
• 1/3 required hospital admission
• 60 days to recovery back to normal and was not
  statistically different in older and younger
  patients
• Cohen and Powderly, 2nd ed.
• Watson et al. Clinical Characteristics and
  Functional Outcomes of West Nile Fever. Annals
  2004

12
Huang, Cinnia, et al. Multiple-Year Experience in
Diagnosis of Viral Central Nervous System
Infections with a Panerl of PCR Assays for
Detection of 11 Viruses. CID Sept 1 2004.

• Enteroviruses were found most commonly, then HSV
• CMV detected in CSF of immunocompromised
• Doing PCR on CSF with proteingt45 and Nuc WBCgt5
  cells/mm3.
• In another study by Tang et al CID 1999, defined
  these breakpoints
• In this study, 84 of the pts who had PCR done
  met these criteria. Of the positive PCR pts, 96
  met the criteria. Of the 4 of positive PCRs
  that did not meet the criteria, 15/18 were
  Enteroviruses, and 2 were WNV.
• Best time for PCR detection is within the first 2
  days of symptom onset. Then less than 10
  detection rate after 2 weeks.
• Their conclusions Enterovirus and HSV PCR is
  standard of care, their data were consistent with
  previous findings of WNV PCR sensitivity of 60.
• California subgroup arboviruses up to 90
  sensitivity