JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
West Nile Virus in a Pregnant Woman with Acquired Immune Deficiency Syndrome
Karli Boggs, MD, Louise McLaughlin, MS, MPS, Ferney Moore, MD AndrewMontz, MD
BACKGROUND: To the best of our knowledge, this is the first reported case of a pregnant, human immunodeficiency virus (HIV) positive, acquired immunodeficiency deficiency (AIDS) patient with neuro-invasive West Nile Virus (WNV). The symptoms of WNV infection may be attributed to other central nervous system (CNS) syndromes associated with HIV/ AIDS, and a definitive diagnosis of WNV infection can be delayed, making the challenges associated with this patient of interest to the medical community. CASE: A 24-year-old pregnant patient with AIDS presented with a headache, nausea, vomiting, non-bloody diarrhea, and fever. During hospitalization, she became increasingly lethargic and somnolent. She endorsedmosquito bites three days prior to her hospitalization andher symptoms resolvedwith supportivemeasures. Cerebrospinal fluidwas positive for West Nile IgM and IgG antibodies.
CONCLUSION:WNV infection should be considered in the differential diagnosis of pregnant HIV/AIDS patients with CNS symptomology, especially in endemic areas.
INTRODUCTION
ritonavir. Azithromycin and sulfamethoxazole/trimethoprim were also initiated as prophylaxis against opportunistic infections. Onexam, sheappearedacutely ill,withdiminishedbreathsounds bilaterally and oral thrush. Neurological exam demonstrated intact cranial nerves II-XII with no sensory or motor deficits and no nuchal rigidity. Initial laboratory data revealed a WBC of 10.5 thou/uL, hemoglobin of 6 gm/dL and platelet count of 278 thou/uL. She was admitted to the intensive care unit and internal medicine, infectious disease, and maternal fetal medicine services were consulted. She was started on broad spectrum antibiotics including vancomycin, ceftriaxone, and ampicillin after blood and urine cultures were obtained. Azithromycin and sulfamethoxazole/trimethoprim were continued and fluconazole was added for her oral thrush. Zidovudine and acyclovir were also added to her treatment regimen. She was transfused two units of packed red blood cells secondary to her anemia and a chest x-ray and a head computed tomography scan were within normal limits. On hospital day two, the patient became increasingly lethargic and somnolent and began to complain of neck pain. A lumbar puncture was performed revealing clear cerebrospinal fluid with no xanthochromia and 36 nucleated cells (73% neutrophils, 19% lymphocytes, 0% eosinophils), glucose 40 mg%, and total
A pregnant patient is in a state of modulated immune response. 1 An immunocompromising condition such as HIV/AIDS creates a major diagnostic dilemma when she presents with central nervous system symptomology. Opportunistic CNS infections commonly seen in HIV/AIDS patients include toxoplasmosis and cryptococcal meningitis. These diseases may be associated with headache, fever, meningismus, altered level of consciousness, or focal neurologic deficits. 2 Since neuro-invasive manifestations of WNV and other arboviruses such as Dengue and Zika virus can present similarly to the previously stated opportunistic CNS infections, 3, 4 the differential diagnosis in immunocompromised patientswith this symptomcomplex becomesmore challenging. We present a case of a gravid patient with a clinical picture of AIDS-related encephalitis/meningitis ultimately diagnosed with WNV encephalitis.
CASE
A 24-year-old gravida 4 para 3 woman at 26 1/7 weeks gestation with HIV for 10 years presented with a chief complaint of headache along with nausea, vomiting, non-bloody diarrhea, and subjective fever for four days. Initial vital signs demonstrated a fever of 39.3 degrees Celsius, BP 96/53 mmHg, and tachycardia of 102 bpm. Fetal heart rate was 165 bpm. The patient admitted to being poorly compliant on antiretroviral therapy since her last pregnancy two year earlier. At her most recent HIV clinic visit, one week prior to this presentation, she had a CD4 count of 24 mm 3 and was started on lamivudine, zidovudine, darunavir, and
158 J La State Med Soc VOL 169 NOVEMBER/DECEMBER 2017
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