Acute flaccid paralysis due to West nile virus infection in adults: A paradigm shift entity
A 45-year-old man presented to us with high grade fever of 5 days duration, generalized weakness, twitching of both thighs and difficulty in walking of 1 day duration. He had grade 3 power in the right hip flexion and knee extension, absent deep tendon reflexes in both lower limbs and generalized fasciculations all over the body, including the facial muscles. Sensory examination was normal. MRI spine showed an ill-defined non-enhancing hyperintensity in the cervico-thoracic cord. CSF showed 246 cells, 80% polymorphs and 20% lymphocytes, with normal sugar and protein. CSF PCR panel for multiple organisms including WNV was negative. Routine blood investigations including erythrocyte sedimentation rate were normal. He was treated with acyclovir and antibiotics and made a near complete recovery. At follow up 3 weeks later, he complained with severe fatigue and occasional buckling at the right knee. The serum and CSF samples were positive for both JEV and WNV IgM antibodies by IgM capture ELISA (JEV IgM ELISA, NIV Pune and WNV IgM ELISA, InBiosinc. USA). However, the serum samples (three samples collected within 2 weeks of onset of CNS symptoms) on micro-neutralization assay showed significantly high titer of neutralizing antibodies to WNV (titer: 320) and undetectable neutralizing antibodies to JEV (titer <10) confirming the WNV etiology. Demographics are shown in [].