Rapidly progressive neurologic decline and morbilliform rash presenting in a patient with lymphoma

A 67-year-old male with past medical history of mantle cell lymphoma and atrial fibrillation presented with a truncal rash, bilateral lower extremity weakness, and confusion. Within three days of presentation, his condition rapidly deteriorated with the onset of diffuse flaccid paralysis, aphasia, and severe alteration in mental status. Initial results from serum studies, lumbar puncture, magnetic resonance imaging, and electroencephalogram were not diagnostic. However, on the ninth day after initial presentation, the West Nile Virus (WNV) immunoglobulin M antibody returned positive from the cerebrospinal fluid. West Nile Virus encephalitis is endemic worldwide, and is the most common viral encephalitis in the United States. WNV presents in a variety of ways, and the recognition by physicians is crucial due to the estimated 2- 12% mortality rate and significant longterm morbidity of neuroinvasive disease. The initial management and long term prognosis are points of ongoing research. This case represents a particularly profound example of neuroinvasive WNV. Our patient made a significant recovery after his initial presentation with aggressive supportive care, however still suffers from bilateral lower extremity weakness more than a year later.

Download Full-text

Performance Characteristics of an In-House Assay System Used To Detect West Nile Virus (WNV)-Specific Immunoglobulin M during the 2001 WNV Season in the United States

Clinical and Diagnostic Laboratory Immunology ◽

10.1128/cdli.10.1.177-179.2003 ◽

2003 ◽

Vol 10 (1) ◽

pp. 177-179 ◽

Cited By ~ 4

Author(s):

Harry E. Prince ◽

Wayne R. Hogrefe

Keyword(s):

West Nile Virus ◽

The United States ◽

Immunoglobulin M ◽

Enzyme Linked Immunosorbent Assay ◽

Screening Assay ◽

West Nile ◽

Elisa System ◽

Igm Elisa ◽

Specific Immunoglobulin ◽

Control And Prevention

ABSTRACT During the 2001 U. S. West Nile virus (WNV) season, 163 specimens were reactive in an in-house WNV-specific immunoglobulin M (IgM) screening enzyme-linked immunosorbent assay (ELISA) and were referred to either the Centers for Disease Control and Prevention or the appropriate state public health laboratory (CDC/SPHL) for additional testing. CDC/SPHL supplied results for 124 specimens that could be further evaluated in-house: 70 specimens were nonreactive in the CDC/SPHL WNV-specific IgM screening assay, and 54 specimens were reactive. These specimens were used to evaluate a modified in-house WNV-specific IgM ELISA that incorporated background subtraction to identify nonspecific reactivity and thus improve assay specificity. Of the 70 CDC/SPHL nonreactive samples, 49 (70%) were nonreactive in the modified ELISA; of the 54 CDC/SPHL reactive samples, 51 (94%) were reactive in the modified ELISA. Confirmatory studies performed by CDC/SPHL indicated that 38 CDC/SPHL screen-reactive specimens represented true WNV infection; all 38 specimens were reactive in the modified in-house WNV-specific IgM ELISA. These findings demonstrate that an in-house ELISA system for WNV-specific IgM effectively identifies patients with WNV infection.

Download Full-text

Immunoglobulin G Avidity in Differentiation between Early and Late Antibody Responses to West Nile Virus

Clinical and Vaccine Immunology ◽

10.1128/cvi.13.1.33-36.2006 ◽

2006 ◽

Vol 13 (1) ◽

pp. 33-36 ◽

Cited By ~ 33

Author(s):

Janet L. Fox ◽

Stuart L. Hazell ◽

Leslie H. Tobler ◽

Michael P. Busch

Keyword(s):

United States ◽

New York ◽

West Nile Virus ◽

The United States ◽

Immunoglobulin M ◽

West Nile ◽

Marked Rise ◽

Igm Antibodies ◽

Igg Avidity ◽

Igg Level

ABSTRACT In 1999 West Nile virus (WNV) surfaced in the United States in the city of New York and spread over successive summers to most of the continental United States, Canada, and Mexico. Because WNV immunoglobulin M (IgM) antibodies have been shown to persist for up to 1 year, residents in areas of endemicity can have persistent WNV IgM antibodies that are unrelated to a current illness with which they present. We present data on the use of IgG avidity testing for the resolution of conflicting data arising from the testing of serum or plasma for antibodies to WNV. Thirteen seroconversion panels, each consisting of a minimum of four samples, were used. All samples were tested for the presence of WNV IgM and IgG antibodies, and the avidity index for the WNV IgG-positive samples was calculated. Panels that exhibited a rise in the WNV IgM level followed by a sequential rise in the WNV IgG level were designated “primary.” Panels that exhibited a marked rise in the WNV IgG level followed by a sequential weak WNV IgM response and that had serological evidence of a prior flavivirus infection were designated “secondary.” All samples from the “primary” panels exhibited low avidity indices (less than 40%) for the first 20 to 30 days after the recovery of the index sample (the sample found to be virus positive). All of the “secondary” samples had elevated WNV IgG levels with avidity indices of ≥55%, regardless of the number of days since the recovery of the index sample. These data demonstrate that it is possible to differentiate between recent and past exposure to WNV or another flavivirus through the measurement of WNV IgG avidity indices.

Download Full-text

Evaluation of an Enzyme Immunoassay for Detection of Immunoglobulin M Antibodies to West Nile Virus and the Importance of Background Subtraction in Detecting Nonspecific Reactivity

Clinical and Vaccine Immunology ◽

10.1128/cvi.00480-06 ◽

2007 ◽

Vol 14 (6) ◽

pp. 665-668 ◽

Cited By ~ 11

Author(s):

Mindy L. Rawlins ◽

Erica M. Swenson ◽

Harry R. Hill ◽

Christine M. Litwin

Keyword(s):

West Nile Virus ◽

Sensitivity And Specificity ◽

Background Subtraction ◽

False Positive ◽

The United States ◽

Immunoglobulin M ◽

West Nile ◽

Capture Elisa ◽

Subtraction Procedure ◽

Positive Results

ABSTRACT Since the introduction of West Nile virus (WNV) in the United States in 1999, several assays have become commercially available to detect antibodies against WNV. Capture enzyme-linked immunosorbent assays (ELISAs) for the detection of WNV-specific immunoglobulin M (IgM) have been approved by the Food and Drug Administration for clinical testing and are available from Focus Diagnostics and PanBio, Inc. The Focus Diagnostics IgM capture ELISA utilizes a background subtraction protocol in order to detect nonspecific reactivity due to rheumatoid factor, heterophile antibodies, or other interfering substances. A background subtraction procedure is not currently recommended for the PanBio IgM capture ELISA. In previous experiments, we determined the agreement, sensitivity, and specificity of the PanBio first-generation IgM capture ELISA compared to an immunofluorescence assay and the Centers for Disease Control and Prevention's IgM capture ELISA. The PanBio assay has since been reformulated to improve the specificity of the assay. We evaluated the reformulated PanBio assay with and without an antigen subtraction procedure and compared the results to the Focus IgM capture ELISA. Agreement, sensitivity, and specificity of the PanBio assay were, respectively, 85%, 95%, and 76% without the subtraction protocol and 94%, 95%, and 93% with the subtraction protocol. In general, when the subtraction protocol was applied to the PanBio IgM capture ELISA, there was a reduction in some, but not all, false-positive results. We suggest that all WNV IgM assays be standardized with a procedure such as background subtraction to eliminate nonspecific reactivity that may cause false-positive results.

Download Full-text

Evaluation of a Diagnostic Algorithm Using Immunoglobulin M Enzyme-Linked Immunosorbent Assay To Differentiate Human West Nile Virus and St. Louis Encephalitis Virus Infections during the 2002 West Nile Virus Epidemic in the United States

Clinical and Diagnostic Laboratory Immunology ◽

10.1128/cdli.11.6.1130-1133.2004 ◽

2004 ◽

Vol 11 (6) ◽

pp. 1130-1133 ◽

Cited By ~ 22

Author(s):

Denise A. Martin ◽

Amanda Noga ◽

Olga Kosoy ◽

Alison J. Johnson ◽

Lyle R. Petersen ◽

...

Keyword(s):

United States ◽

West Nile Virus ◽

Immunosorbent Assay ◽

Diagnostic Algorithm ◽

The United States ◽

Encephalitis Virus ◽

Immunoglobulin M ◽

Enzyme Linked Immunosorbent Assay ◽

Virus Infections ◽

West Nile

ABSTRACT A diagnostic algorithm was developed to differentiate between human infections of West Nile virus (WNV) and St. Louis encephalitis virus (SLEV) using positive-to-negative (P/N) ratios derived from the immunoglobulin M capture enzyme-linked immunosorbent assay (MAC-ELISA). To validate this algorithm, we tested 1,418 serum and cerebrospinal fluid (CSF) samples from confirmed WNV and SLEV infections collected during the WNV epidemic of 2002 in the United States. WNV P/N-to-SLEV P/N ratios (W/S ratios) were calculated and used to identify the infecting virus. These results were compared to results from the plaque reduction neutralization test (PRNT), which is currently the standard assay used to discriminate between closely related flavivirus infections. If the W/S ratio was ≥1, the predictive value positive (PNP) for WNV was 97.8%, where 95% of flavivirus cases were due to WNV infection and only 3.7% of specimens would require PRNT to differentiate WNV from SLEV infection. Use of the W/S ratio as part of the testing algorithm to interpret MAC-ELISA results generates reportable probable cases quickly, alleviating the need for PRNT in most instances.

Download Full-text

Two Case Reports of Neuroinvasive West Nile Virus Infection in the Critical Care Unit

Case Reports in Infectious Diseases ◽

10.1155/2012/839458 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Edgardo M. Flores Anticona ◽

Hadeel Zainah ◽

Daniel R. Ouellette ◽

Laura E. Johnson

Keyword(s):

Critical Care ◽

West Nile Virus ◽

Lower Extremity ◽

Mental Status ◽

Critical Care Unit ◽

Disease Process ◽

Care Providers ◽

West Nile ◽

Lower Extremity Weakness ◽

Csf Analysis

We describe the clinical course of two cases of neuroinvasive West Nile Virus (WNV) infection in the critical care unit. The first case is a 70-year-old man who presented during summer with mental status changes. Cerebrospinal fluid (CSF) analysis revealed pleocytosis with lymphocyte predominance. WNV serology was positive in the CSF. His condition worsened with development of left-sided weakness and deterioration of mental status requiring intensive care. The patient gradually improved and was discharged with residual left-sided weakness and near-complete improvement in his mental status. The second case is an 81-year-old man who presented with mental status changes, fever, lower extremity weakness, and difficulty in walking. CSF analysis showed pleocytosis with neutrophil predominance. WNV serology was also positive in CSF. During the hospital stay his mentation worsened, eventually requiring intubation for airway protection and critical care support. The patient gradually improved and was discharged with residual upper and lower extremity paresis. Neuroinvasive WNV infection can lead to significant morbidity, especially in the elderly. These cases should be suspected in patients with antecedent outdoor activities during summer. It is important for critical care providers to be aware of and maintain a high clinical suspicion of this disease process.

Download Full-text

Physical Therapist Examination, Evaluation, and Intervention for a Patient With West Nile Virus Paralysis

Physical Therapy ◽

10.1093/ptj/86.6.843 ◽

2006 ◽

Vol 86 (6) ◽

pp. 843-856 ◽

Cited By ~ 5

Author(s):

Nancy H Miller ◽

David J Miller ◽

Joanna L Goldberg

Keyword(s):

West Nile Virus ◽

Physical Therapist ◽

Single Point ◽

The United States ◽

Assistive Device ◽

Full Time ◽

West Nile ◽

Lower Extremity Weakness ◽

Disease Case ◽

Practice Approach

Abstract Background and Purpose. The incidence of West Nile virus (WNV) has increased in the United States since 1999. A small percentage of people with WNV develop West Nile neuroinvasive disease (WNND) with encephalitis and flaccid paralysis. The purpose of this report is to describe the physical therapist management and outcomes for a patient with WNND and the therapist’s efforts to use an evidence-based practice approach in the management of a patient with this disease. Case Description. The patient was an active 55-year-old woman in excellent health who became acutely ill with asymmetrical lower-extremity weakness. The physical therapist reviewed the available literature, consulted with medical and physical therapist experts and the patient, and elected to use a poliovirus “period of recovery” approach combining intensive strengthening and monitoring of fatigue. Outcomes. The patient progressed from an initial nonambulatory status to ambulation with a single-point cane at week 18 after onset of symptoms. She began to ambulate without an assistive device by week 20. The patient returned to work part-time by week 22 and full-time by week 43. Discussion. These outcomes demonstrate the recovery of a patient with WNND after an intensive strengthening program.[Miller NH, Miller DJ, Goldberg JL. Physical therapist examination, evaluation, and intervention for a patient with West Nile virus paralysis. Phys Ther. 2006;86:843– 856.]

Download Full-text

Detection of West Nile Virus (WNV)-Specific Immunoglobulin M in a Reference Laboratory Setting during the 2002 WNV Season in the United States

Clinical and Diagnostic Laboratory Immunology ◽

10.1128/cdli.10.5.764-768.2003 ◽

2003 ◽

Vol 10 (5) ◽

pp. 764-768 ◽

Cited By ~ 17

Author(s):

Harry E. Prince ◽

Wayne R. Hogrefe

Keyword(s):

West Nile Virus ◽

Serum Sample ◽

The United States ◽

Immunoglobulin M ◽

Enzyme Linked Immunosorbent Assay ◽

Reference Laboratory ◽

Sample Collection ◽

Serum Samples ◽

West Nile ◽

Specific Immunoglobulin

ABSTRACT Between 1 June and 31 December 2002, 30,677 serum samples and 4,554 cerebrospinal fluid (CSF) samples were tested for West Nile virus (WNV)-specific immunoglobulin M (IgM) by an in-house enzyme-linked immunosorbent assay (ELISA); 1,481 serum samples (4.8%) and 345 CSF samples (7.6%) were positive for WNV IgM. Positive samples were forwarded to public health service laboratories (PHSLs) for further testing. PHSLs supplied results from their WNV IgM ELISAs for 654 samples; 633 (97%) were positive. PHSLs supplied WNV plaque reduction neutralization test results for 128 samples; 123 (96%) were positive. WNV IgM seroconversion and seroreversion trends were evaluated for 749 patients who each provided two serum samples that were tested during the study period. Of 574 patients whose first serum sample was IgM negative, 41 (7%) seroconverted (the second serum sample was IgM positive); of 175 patients whose first serum sample was IgM positive, 22 (13%) seroreverted (the second serum sample was IgM negative). The seroreversion rate was directly proportional to the time between serum sample collection; whereas only 1% of patients whose sera were collected <20 days apart showed seroreversion, 54% of patients whose sera were collected >60 days apart showed seroreversion. Conversion and reversion trends for CSF were evaluated for 68 patients. Of 54 patients whose first CSF specimen was IgM negative, 9 (17%) converted; none of 14 patients whose first CSF specimen was IgM positive reverted. Concomitant detection of WNV IgM in serum and CSF was assessed for 1,188 patients for whom paired serum and CSF specimens were available; for all 130 patients for whom IgM was detectable in CSF, IgM was also detectable in serum. These findings show that an in-house WNV IgM ELISA accurately identifies patients with WNV infection, document WNV IgM conversion and reversion trends, and demonstrate that WNV IgM detection in CSF is accompanied by WNV IgM detection in serum.

Download Full-text

338. Analysis of Etiologies of Aseptic Meningitis within a Nation-Wide Hospital Network

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.533 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S239-S239

Author(s):

Arunmozhi S Aravagiri ◽

Scott Kubomoto ◽

Ayutyanont Napatkamon ◽

Sarah Wilson ◽

Sudhakar Mallela

Keyword(s):

United States ◽

West Nile Virus ◽

Aseptic Meningitis ◽

Epidemiologic Study ◽

The United States ◽

Positive Test ◽

Diagnostic Tools ◽

West Nile ◽

Varicella Zoster ◽

The Us

Abstract Background Aseptic meningitis can be caused by an array of microorganisms, both bacterial and non-bacterial, as well as non-infectious conditions. Some etiologies of aseptic meningitis require treatment with antibiotics, antiviral, antifungals, anti-parasitic agents, immunosuppressants, and or chemotherapy. There are limited diagnostic tools for diagnosing certain types of aseptic meningitis, therefore knowing the differential causes of aseptic meningitis, and their relative percentages may assist in diagnosis. Review of the literature reveals that there are no recent studies of etiologies of aseptic meningitis in the United States (US). This is an epidemiologic study to delineate etiologies of aseptic meningitis in a large database of 185 HCA hospitals across the US. Methods Data was collected from January 2016 to December 2019 on all patients diagnosed with meningitis. CSF PCR studies, and CSF antibody tests were then selected for inclusion. Results Total number of encounters were 3,149 hospitalizations. Total number of individual labs analyzed was 10,613, and of these 262 etiologies were identified. 23.6% (62) of cases were due to enterovirus, 18.7% (49) due to HSV-2, 14.5% (38) due to West Nile virus, 13.7% (36) due to Varicella zoster (VZV), 10.5% (27) due to Cryptococcus. Additionally, we analyzed the rate of positive test results by region. Nationally, 9.7% of tests ordered for enterovirus were positive. In contrast, 0.5% of tests ordered for HSV 1 were positive. The southeastern United States had the highest rate of positive tests for HSV 2 (7% of tests ordered for HSV 2 were positive). The central United States had the highest rate of positive test for West Nile virus (11% of tests ordered for West Nile were positive). The northeastern region and the highest rate of positive tests for varicella zoster (18%). Table 1: Percentage of positive CSF tests (positive tests/tests ordered) Table 2: Lists the number of HIV patients and transplant patients that had positive CSF PCR/serologies Figure 1: Percentage of positive CSF tests in each region Conclusion Approximately 40% of aseptic meningitis population had treatable etiologies. A third of the Cryptococcus meningitis population had HIV. Furthermore, enteroviruses had the majority of cases within the US, which are similar to studies done in other parts of the world. Disclosures All Authors: No reported disclosures

Download Full-text