Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Sep 6, 2020; 8(17): 3797-3803
Published online Sep 6, 2020. doi: 10.12998/wjcc.v8.i17.3797
Cauda equina arachnoiditis – a rare manifestation of West Nile virus neuroinvasive disease: A case report
Marija Santini, Ivana Zupetic, Klaudija Viskovic, Juraj Krznaric, Marko Kutlesa, Vladimir Krajinovic, Vlatka Lovrakovic Polak, Vladimir Savic, Irena Tabain, Ljubo Barbic, Maja Bogdanic, Vladimir Stevanovic, Anna Mrzljak, Tatjana Vilibic-Cavlek
Marija Santini, Juraj Krznaric, Marko Kutlesa, Vladimir Krajinovic, Department for Intensive Care Medicine and Neuroinfectology, University Hospital for Infectious Diseases “Dr Fran Mihaljevic”, Zagreb 10000, Croatia
Ivana Zupetic, Department of Radiology, University Clinical Hospital Center, Clinic for Traumatology, Zagreb 10000, Croatia
Klaudija Viskovic, Department of Radiology and Ultrasound, University Hospital for Infectious Diseases “Dr Fran Mihaljevic”, Zagreb 10000, Croatia
Vlatka Lovrakovic Polak, Department of Infectious Diseases, General County Hospital Karlovac, Karlovac 47000, Croatia
Vladimir Savic, Department of Poultry Center, Laboratory for Virology and Serology, Croatian Veterinary Institute, Zagreb 10000, Croatia
Irena Tabain, Maja Bogdanic, Tatjana Vilibic-Cavlek, Department of Virology, Croatian Institute of Public Health, Zagreb 10000, Croatia
Ljubo Barbic, Vladimir Stevanovic, Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, Zagreb 10000, Croatia
Anna Mrzljak, Department of Medicine, University Hospital Merkur, Zagreb 10000, Croatia
Anna Mrzljak, Tatjana Vilibic-Cavlek, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
Author contributions: Santini M was the patient’s infectious disease physician, made the concept of the case report and wrote the original draft; Zupetic I and Viskovic K provided, analyzed and interpreted the imaging findings; Krznaric J, Kutlesa M, Krajinovic V and Lovrakovic-Polak V were the patient’s infectious disease physicians and contributed to manuscript drafting; Barbic Lj, Bogdanic M, Stevanovic V and Mrzljak A reviewed the literature and contributed to manuscript drafting; Vilibic-Cavlek T, Savic V and Tabain I performed the microbiological analyses and interpretation and contributed to manuscript drafting. All authors approved the final version of the manuscript.
Supported by Croatian Science Foundation, Project No. IP 2016-06-7456 CRONEUROARBO; European Union’s Horizon 2020 Research and Innovation Programme, No. 653316.
Informed consent statement: The study was approved by the Ethics Committees of the University Hospital for Infectious Diseases “Dr Fran Mihaljevic” and the Croatian Institute of Public Health.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Marija Santini, MD, PhD, Assistant Professor, Department for Intensive Care Medicine and Neuroinfectology, University Hospital for Infectious Diseases "Dr Fran Mihaljevic", School of Medicine, University of Zagreb, Zagreb 10000, Croatia. marijasantini.ms@gmail.com
Received: February 26, 2020
Peer-review started: February 26, 2020
First decision: April 21, 2020
Revised: May 10, 2020
Accepted: August 14, 2020
Article in press: August 14, 2020
Published online: September 6, 2020
Abstract
BACKGROUND

Data regarding the neuroradiology features of the West Nile virus neuroinvasive disease (WNV NID) is rather scarce. To contribute to the knowledge of the WNV NID, we present a patient with a combination of encephalitis and acute flaccid paresis, with cauda equina arachnoiditis as the main magnetic resonance (MR) finding.

CASE SUMMARY

A 72-year-old female patient was admitted due to fever, headache and gait instability. During the first several days she developed somnolence, aphasia, urinary incontinence, constipation, and asymmetric lower extremities weakness. Cerebrospinal fluid analysis indicated encephalitis. Native brain computed tomography and MR were unremarkable, while spinal MR demonstrated cauda equina enhancement without cord lesions. Virology testing revealed WNV IgM and IgG antibodies in serum and cerebrospinal fluid, which confirmed acute WNV NID. The treatment was supportive. After two months only a slight improvement was noticed but cognitive impairment, loss of sphincter control and asymmetric inferior extremities weakness remained. The patient died after a month on chronic rehabilitation.

CONCLUSION

Cauda equina arachnoiditis is a rare, but possible neuroradiological feature in acute flaccid paresis form of WNV NID.

Keywords: West Nile virus, Central nervous system infection, Cauda equina, Magnetic resonance, Neuroinvasive disease, Case report

Core tip: Data regarding neuroradiology features of the West Nile virus neuroinvasive disease is scarce and cauda equina arachnoiditis is rare. We discuss a case of West Nile virus encephalitis and acute flaccid paresis of the lower extremities, with cauda equina arachnoiditis with focus on diagnostic management.