Rare ocular manifestation in a case of West Nile virus meningoencephalitis
A 40-year-old male presented with confusion, short-term memory loss, and unsteady gait for one month. He also complained of intermittent right facial numbness, diplopia, bilateral lower extremity numbness and weakness, and severe choking spells while coughing. The patient mentioned that when he had visited Ohio four weeks ago, a dead bird was found with West Nile virus infection. On examination, he was drowsy, but oriented to time, place, and person with mild maculopapular rash on his upper back, chest, and face. Cranial nerve examination revealed a subtle downbeating nystagmus. His motor strength, sensory exam, and deep tendon reflexes were normal. The cerebrospinal fluid (CSF) showed lymphocytic pleocytosis, while the remaining results were normal. The patient was started on empirical antibiotics, while the culture results were awaited. Magnetic resonance imaging (MRI) of the brain and complete spine were unremarkable. The patient had pronounced bilateral subconjunctival hemorrhage with progressive drowsiness the next day. West Nile IgM in the CSF was noted to be positive, while his mental status deteriorated and he required intubation within the next 24 hours. Electroencephalography (EEG) showed mild bicentral slowing, with no evidence of epileptiform discharges. An ophthalmology examination showed acute hemorrhagic conjunctivitis, conjunctival chemosis, and periorbital edema, with no chorioretinitis on fundoscopy (). Supportive management was continued with gradual improvement of his mental status.