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Neurological Respiratory Failure Due to West Nile Virus Induced Phrenic Nerve Palsy
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A5328 - Neurological Respiratory Failure Due to West Nile Virus Induced Phrenic Nerve Palsy
Author Block: M. Rudrappa1, L. Kokatnur2; 1Pulmonary and Critical Care Medicine, Overton Brooks VA Medical center, Shreveport, LA, United States, 2Neurology, LSUHSC shreveport, shreveport, LA, United States.
The incidence of West Nile virus infection in United states is increasing in the recent time from its first description in 1999 AD. Although most cases are symptomatic, around 1% of patient develop noninvasive disease with case fatality rate of 10%. Acute flaccid paralysis of respiratory system strongly correlates with mortality in animal studies . We present a case of west Nile encephalitis with isolated phrenic nerve involvement without flaccid paralysis leading to terminal respiratory failure.
A 80 year old man was brought to the emergency room by his family with complaints of drowsiness. He was in his usual state of health a week back when he started having flue like illness with on and off fever, body ache, lethargy and generalized weakness. From the past 2 days, family noticed that he was getting more lethargic, sleepy and has not got out of bed at all. Chest x ray showed possible right lower lobe infiltrates and was admitted with the initial diagnosis of aspiration pneumonia. Despite appropriate antibiotics, his mental status continued to decline and next day became encephalopathic responding only to painful stimuli. ABG showed evidence of hypercapnic respiratory failure. Patient could not be weaned of the BIPAP. Despite being in compensated respiratory failure, patients continued to be lethargic. EEG did not show any seizure. Lumbar puncture showed elevated protein levels with lymphocyte predominate leukocytosis . Any interruption of BIPAP would lead to hypoxic hypercapnia respiratory failure. Although formal sleep study could not be done, interrogation of BIPAP machine showed no evidence of central or peripheral sleep apnea. Meanwhile, the routine CSF viral panel came back as positive for both Ig M and IgG West Nile Virus(WNV) antibodies. On further evaluation, patients wife revealed about their recent trip to El Salvador one month back. Patient did not showed any evidence of weakens of his extremities. Fluoroscopic examination for diaphragmatic movements and detailed pulmonary functions tests could not done in view of patients condition. Bedside ultrasound of thorax showed absent movements of both diaphragms with deep inspiration.
Although, WNV virus is known for neuroinvasive disease, phrenic nerve palsy leading to respiratory failure is rare, and only reported in one two cases in English literature. Physician should be wary of this rare complication. Our case also illustrates the increasing use of ultrasound in pulmonary medicine. Unlike sniff test, this can be done at bedside and without any radiation exposure.
Author Block: M. Rudrappa1, L. Kokatnur2; 1Pulmonary and Critical Care Medicine, Overton Brooks VA Medical center, Shreveport, LA, United States, 2Neurology, LSUHSC shreveport, shreveport, LA, United States.
The incidence of West Nile virus infection in United states is increasing in the recent time from its first description in 1999 AD. Although most cases are symptomatic, around 1% of patient develop noninvasive disease with case fatality rate of 10%. Acute flaccid paralysis of respiratory system strongly correlates with mortality in animal studies . We present a case of west Nile encephalitis with isolated phrenic nerve involvement without flaccid paralysis leading to terminal respiratory failure.
A 80 year old man was brought to the emergency room by his family with complaints of drowsiness. He was in his usual state of health a week back when he started having flue like illness with on and off fever, body ache, lethargy and generalized weakness. From the past 2 days, family noticed that he was getting more lethargic, sleepy and has not got out of bed at all. Chest x ray showed possible right lower lobe infiltrates and was admitted with the initial diagnosis of aspiration pneumonia. Despite appropriate antibiotics, his mental status continued to decline and next day became encephalopathic responding only to painful stimuli. ABG showed evidence of hypercapnic respiratory failure. Patient could not be weaned of the BIPAP. Despite being in compensated respiratory failure, patients continued to be lethargic. EEG did not show any seizure. Lumbar puncture showed elevated protein levels with lymphocyte predominate leukocytosis . Any interruption of BIPAP would lead to hypoxic hypercapnia respiratory failure. Although formal sleep study could not be done, interrogation of BIPAP machine showed no evidence of central or peripheral sleep apnea. Meanwhile, the routine CSF viral panel came back as positive for both Ig M and IgG West Nile Virus(WNV) antibodies. On further evaluation, patients wife revealed about their recent trip to El Salvador one month back. Patient did not showed any evidence of weakens of his extremities. Fluoroscopic examination for diaphragmatic movements and detailed pulmonary functions tests could not done in view of patients condition. Bedside ultrasound of thorax showed absent movements of both diaphragms with deep inspiration.
Although, WNV virus is known for neuroinvasive disease, phrenic nerve palsy leading to respiratory failure is rare, and only reported in one two cases in English literature. Physician should be wary of this rare complication. Our case also illustrates the increasing use of ultrasound in pulmonary medicine. Unlike sniff test, this can be done at bedside and without any radiation exposure.
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