22 July 2021
: Case report 
Unusual Movement Disorders and Atypical Magnetic Resonance Imaging (MRI) Findings in Patients with West Nile Encephalitis: Case Reports of 2 Patients with Evidence of Clinical and Imaging Resolution with IVIG
Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment, Patient complains / malpractice, Rare disease, Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathology
Irfan S. Sheikh1ABCDEF*, Ehad Afreen1AF, Ajaz Sheikh1ADEDOI: 10.12659/AJCR.932215
Am J Case Rep 2021; 22:e932215
Table 1. Demographics and Testing Results for Cases 1 and 2.
| Case 1 | Case 2 | |||
|---|---|---|---|---|
| Age | 34 | 57 | ||
| Sex | Male | Female | ||
| Symptoms | Constitutional symptoms (N/V, lethargy, low-grade fever and chills) Neuropsychiatric (somnolence, disinhibition) Movement disturbance (myoclonus, ataxia, and gait instability) Ocular manifestations (opsoclonus) Other: finger agnosia, prosopagnosia | Neuropsychiatric symptoms (confusion, agitation, combative behavior, aggressiveness, hallucinations, paranoia) Constitutional symptoms (fever, chills, headache) | ||
| CMV IgM | Negative | |||
| HIV | Negative | Negative | ||
| HSV 1 & 2 IgG | Negative | |||
| RT-QUIC | Negative | |||
| Heavy metals | Negative | |||
| CJD | Negative | |||
| DsDNA | Negative | Negative | ||
| CK | 792 | |||
| Lactate | 1.0 | 1.2 | ||
| Blood culture | Negative×3 | Negative×3 | ||
| WBC | 23.2 | 8.1 | ||
| UTox | Negative | Opiates, THC, BZ | ||
| Smooth muscle Ab titer | Negative | Negative | ||
| Lyme Dx IgM and IgG | Negative | Negative | ||
| SS-A/B Ab | Negative | Negative | ||
| Smith Ab | Negative | Negative | ||
| Scl-70 Ab | Negative | Negative | ||
| Jo 1 Ab | Negative | Negative | ||
| Anti-HCV | Negative | Negative | ||
| HBcAg IgM | Negative | Negative | ||
| HBsAg | Negative | Negative | ||
| Lyme IgG | >0.20 | Negative | ||
| Lyme IgM | Negative | Negative | ||
| Syphilis IgG | <0.2 | |||
| CRP | 2.3 | 6.0 | ||
| ESR | 12 | 50 | ||
| ANA | Negative | Positive | ||
| ANCA | Negative | Negative | ||
| Procalcitonin | <0.05 | <0.05 | ||
| Influenza PCR | Negative | Negative | ||
| GAD65 | Negative | |||
| Endomysial IgA | Negative | |||
| Tissue transglutaminase | Negative | |||
| IgA and IgG | ||||
| Legionella IgM & IgG | Negative | Negative | ||
| Stool O&P | Giardia | Negative | ||
| Cryptosporidium | Negative | |||
| CSF studies | Protein | 98 | 79 | |
| Gram stain | Negative | Negative | ||
| Culture | Negative | Negative | ||
| Neutrophils | 63 | 4 | ||
| Lymphocytes | 37 | 90 | ||
| Color | Colorless | Colorless | ||
| Clarity | Clear | Clear | ||
| RBC | 7 | 9 | ||
| Nucleated cells | 134 | 106 | ||
| Glucose | 64 | 57 | ||
| Meningitis panel | Negative | Negative | ||
| St. Louis encephalitis | Negative | |||
| Ab | ||||
| Oligoclonal band | Negative | Negative | ||
| Myelin basic protein | 1.65 | 3.90 | ||
| West Nile virus IgG | 0.90 | 0.45 | ||
| West Nile virus IgM | 7.10 | 8.97 | ||
| IgG index | 0.60 | 0.59 | ||
| JC virus | Negative | |||
| Cytology | No malignant cells, many polymorphous lymphocytes and occasional monocytes | No malignant cells | ||
| Mycoplasma PCR | Negative | |||
| Thyroid studies | Thyroglobulin AB | Negative | Negative | |
| Thyroperoxidase Ab | Negative | Negative | ||
| CSF VDRL | Negative | |||
| Lupus Ab | Cardiolipin | Negative | ||
| Mayo Clinic paraneoplastic Ab panel (ENC2 & PAC1) | Negative | Negative | ||
| Stroke workup | Lipid panel | Chol 127 | Chol 199 | |
| TG 116 | TG 198 | |||
| HDL 19 | HDL 42 | |||
| VLDL 23 | VLDL 40 | |||
| LDL 85 | LDL 117 | |||
| HbA1c | 5.4 | 6.1 | ||
| MRI head | Negative | |||
| Echocardiogram | EF 55%, no PFO | EF 60% | ||
| Carotid ultrasound | No flow limitation | |||
| Cancer workup | CA 19-9 | 27.3 | ||
| PSA | 0.51 | |||
| HCG-beta | <5 | |||
| LDH | 232 | |||
| Alpha-fetoprotein | 1.3 | |||
| CEA | 3.8 | |||
| Ab – antibody; ANA – antinuclear antibody; ANCA – antineutrophil cytoplasmic antibody; BZ – benzilate; CA – carbohydrate antigen; Chol – cholesterol; CJD – Creutzfeld-Jakob disease; CK – creatine kinase; CMV – cytomegalovirus; CRP – C-reactive protein; CSF – cerebrospinal fluid; CEA – carcinoembryonic antigen; DsDNA – double-stranded DNA; Dx – diagnosis; EF – ejection fraction; ESR – erythrocyte sedimentation rate; GAD65 – glutamic acid decarboxylase 65-kilodalton isoform; HbA1c –hemoglobin A1c; HBcAg – hepatitis B core antigen; HBsAg – hepatitis B surface antigen; HCG – human chorionic gonadotropin; HCV – hepatitis C virus; HDL – high-density lipoprotein; HSV – herpes simplex virus; IgA – immunoglobulin A; IgG – immunoglobulin G; IgM – immunoglobulin M; JC – John Cunningham; LDH – lactate dehydrogenase; LDL – low-density lipoprotein; MRI – magnetic resonance imaging; N/V – nausea and vomiting; O&P – ova and parasites; PCR – polymerase chain reaction; PFO – patent foramen ovale; PSA – prostate-specific antigen; RBC, red blood cell –; RT-QUIC – real-time quaking-induced conversion; TG – triglyceride; THC – tetrahydrocannabinol; UTox – urine toxicology; SS-A/B – Sjogren antibodies A/B; VDRL – Venereal Disease Research Laboratory; VLDL – very-low-density lipoprotein; WBC, white blood cell. | ||||