JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
DISCUSSION
protein 76mg%; gram stain was negative for microorganisms. At the recommendation of the infectious disease staff, the collected cerebrospinal fluid was sent for fungal cultures, HIV RNA, VDRL, CMV, WNV, arbovirus panel, and HSV PCR. Fetal evaluation by maternal fetal medicine revealed appropriate growth, normal amniotic fluid index, and normal anatomy. On hospital day three, the patient’s mental status began to improve. Thorough follow-up history and physical revealed multiple lesions on her lower extremities that the patient described as “mosquito bites.” On hospital day six, CSF, HSV, and bacterial cultures were all negative. Both serum and CSF West Nile IgM and IgG antibodies resulted positive. All antibiotics were discontinued. The patient continued to improve, and she was discharged home on hospital day seven at 27 1/7 weeks gestation. The patient underwent a successful induction of labor at 38 weeks gestation after zidovudine was administered. Her HIV viral load at delivery was 170 cpy/mL. She delivered a viable female infant weighing 5 lbs 7 oz with APGAR scores of 8 and 8. Her postpartum course was uncomplicated. At discharge, depot medroxyprogesterone acetate was given for contraception, and a long-acting reversible contraceptive was subsequently placed at her 6-week visit. In July 2016, the patient stated she was doing well and her 20-month old daughter exhibited no signs of adverse sequelae secondary to WNV or HIV.
A comprehensive search of the medial literature was undertak- en by the hospital’s medical librarian in PubMed, PubMed Cen- tral, Ovid, and EMBASE through August, 2016. Medical terms and text words were “West Nile virus” or “West Nile fever” and “HIV” or “human immunodeficiency virus” or “HIV infections” or “AIDS” and “pregnancy.” Ten reported cases of WNV neuro-inva- sive disease in HIV-positive patients were identified (Table 1). 3, 8-14 However, the association of neuro-invasiveWNV in a HIV pos- itive pregnant woman has not been previously reported, mak- ing this the first reported case. WNV is a single-stranded RNA flavivirus within the family of ar- boviruses transmitted to humans through the bite of an infect- ed mosquito. 5 Additional modes of infection have been docu- mented and include blood product transfusion, occupational exposure in laboratory workers, organ transplantation, breast- feeding, and transplacental transmission. 6 Although 80% of human infections with WNV are asymptomatic, the remaining 20% present with a mild flu-like illness which may include fever, headache, fatigue, myalgias, gastrointestinal symptoms and an erythematous macular rash. Less than 1% of the symptomatic population develops a neuro-invasive disease which manifests as an overlapping spectrum of meningitis, encephalitis, myelo- radiculitis, poliomyelitis, or acute flaccid paralysis similar to Guil- lain-Barre. 7 Among the immunocompetent population, 1 in 150 develop neuro-invasive disease 6, but in the immunocompro-
Table 1
YEAR
LOCATION
PRESENTING SYMPTOMS
AGE SEX LABS
OUTCOME
STUDY TYPE
AUTHOR
Discharged after five days, with resolution of symptoms
Headache, fever, neck stiffness, photophobia, and vomiting
Szilak and Minamoto
CD4 count 351 mm 3 +CSF WNV lgM
Case report
2000
Bronx, NY
38 F
Case series WNV encephalomyelitis and correlates these findings with a variety of clinical features, including illness duration and underlying medical condition. Case series WNV encephalomyelitis and correlates these findings with a variety of clinical features, including illness duration and underlying medical condition.
Not reported
Guarner et al.
AIDS
2002
Not reported
Not reported
51
M
Not reported
M
AIDS
Guarner et al.
2002
Not reported
Not reported
63
CD4 count <200mm 3 with TB
Not reported
Died 18 days after admission Improved rapidly and discharged after 3 days
Conference summary
M
Rimland et al.
2003
Not reported
50
CD4 count <200 cells/µL
Not reported
Fever, headache, confusion, feeling ‘slow’
Conference summary
M
Rimland et al.
2003
48
Case report
M
Not reported
Gyure
2005
Michigan
Died after 2 months
Confusion
69
Discharged although with right peripheral seventh cranial nerve palsy
CD4 count 128 cells/µL +CSF WNVlgM
Weakness, headache, and myalgia
J La State Med Soc VOL 169 NOVEMBER/DECEMBER 2017 159 Case report
M
Unzek et al.
2006
Ohio
45
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