NA

Here we report a case of a 63-year-old African American male with history of kidney and liver transplant on immunosuppressive therapy presented with fever and altered mentation. Initial exam revealed impaired orientation and higher cortical function but was otherwise unremarkable. CSF analyses demonstrated pleocytosis, elevated protein, and positive for WNV IgG and IgM. He then subsequently developed acute right hemiparesis during his hospital stay. EEG revealed bilateral frontal epileptiform discharges without evolving to seizure. MRI of the brain revealed restricted diffusion in the bilateral precentral gyri, particularly on the left side. MR angiography showed patent anterior and posterior circulation. His acute stroke is thought to be secondary to WNV-induced vasculitis. He was initiated with lacosamide and levetiracetam to prevent seizure and was started with intravenous steroids and intravenous immunoglobulin for treating WNE. He became more awake and was able to follow commands after the treatment with resolution of CSF pleocytosis. However, he remained bed-bound with inability to speak at the time of discharge.

Our case demonstrates unusual clinical presentations from West Nile Virus infection in a transplant recipient including vasculitis-associated stroke and bifrontal epileptiform activities.  The case illustrates that severe West Nile Encephalitis is associated with high morbidity and mortality. Recognition of West Nile encephalitis especially in transplant recipients is critical for guiding prompt management.