PATIENT CASE - ACUTE VIRAL ENCEPHALITIS

History of Present Illness

N.C. is an 83 yo male who has made an appointment with his personal internal medicine physician
because a mosquito bite has caused the area around his right eye to swell. He received the bite
approximately 96 hours ago while camping in Rocky Mountain National Park in Colorado. Periorbital
edema has become progressively worse, now to the point where the right eye is swollen shut. The
patient also has a mild fever and a mild headache, both of which developed last evening.

Past Medical History

• 18 months S/P cadaveric renal transplantation
• ESRD secondary to DM type 1, diagnosed 10 years ago
• CAD
• COLD 6 yrs
• Asthma for as long as he can remember
• DM type 1 diagnosed at age 13

Medications
• Nitroglycerin SR 6.5 mg po Q 8h - CAD
• Nitroglycerin 0.4 mg SL PRN - CAD
• Theo-Dur 100 mg po BID – ASTHMA? COPD?
• Albuterol MDI 2 puffs QID PRN – ASTHMA? COPD?
• Atrovent MDI 2 puffs BID – COPD? ASTHMA?
• Cyclosporine 250 mg po BID – prevent organ rejection
• Prednisone 10 mg po QD - inflammation (swelling), severe allergies, asthma, kidney problem
• Mycophenolate mofetil 1500 mg po BID – to prevent kidney rejection
• Insulin: NPH insulin 16 units at breakfast and Lispro insulin according to the schedule in
Patient Case Table 37.1
Allergies
• Vancomycin (rash) – antibiotic MRSA
• Penicillin (rash, hives, and difficulty breathing) – antibiotic
• Sulfa-containing products (rash) – antibiotic, eye drops

Review of System
The patient is alert and oriented. He denies fatigue, body aches, tremors, skin rashes, neck
stiffness, muscle weakness, photophobia, and general malaise. His physician suspects that
N.C. has developed an arthropod-transmitted infection and refers him to both a neurologist
and infectious diseases specialist for immediate follow-up the next morning. He also
instructs the patient to take OTC ibuprofen for his fever and headache, to apply ice to the
swollen area around the eye to decrease the swelling, and to go directly to the urgent care
clinic if his condition worsens.

Vital Signs
• BP 140/95
• P 90 and regular
• RR 16 and unlabored
• T 99.4F
• HT 59
• WT 165 lbs

Physical Examination and Laboratory Tests

Gen
The patient is disoriented, pale, is manifesting mild tremors, and appears ill.

Skin
• Warm and pale
• No rash observed

HEENT
• PERRLA
• EOM intact
• Fundi reveal old laser scars bilaterally without hemorrhages and occasional hard exudates
bilaterally
• Ears and nose unremarkable with no bulging of TMs
• Mucous membranes dry
• Mild non-exudative pharyngitis present
• Wears dentures
Neck
• Thyroid normal
• Supple with no masses present LN
• Cervical and axillary lymph nodes are palpable (approximately 2 cm)
• Femoral lymph nodes are not palpable

CV
• PMI is normal and not displaced
• S 1 and S2 are normal without S3, S4, rubs, or murmurs
• Sinus tachycardia
• Carotid, femoral, and dorsalis pedis pulses are normal at 2
• No carotid, abdominal, or femoral bruits heard

Chest
• Lungs are CTA & P with no crackles or wheezes
• There is full excursion of the chest without tenderness

Abd
• Soft, NT, and without organomegaly or masses
• Bowel sounds are normal

Rect
• Anus normal
• No masses or hemorrhoids observed
• Stool is heme-negative

Ext
• No CCE
• Range of motion intact
• Feet are without ulcers, calluses, or other lesions

Neuro
• Disoriented
• Mild tremor in both hands
• DTRs are 2 bilaterally for biceps, brachioradialis, quadriceps, and Achilles
• (+) Kernig sign
• (+) Brudzinski sign
• Muscular strength 3/5 throughout
• Slightly decreased sensation to light touch in both feet (consistent with diabetic neuropathy
CBC
Significant lymphopenia
Lumbar Puncture Results
See Patient Case Table 37.2

MRI
Mild diffuse cerebral edema with no intra-cerebral bleeding

Enzyme Immunoassay with Plaque Reduction Neutralization Test

Positive for West Nile

Clinical Course
The next morning N.C. woke up confused and disoriented, with mild tremors. His headache was
also much worse. His wife drove him immediately to the urgent care clinic for evaluation.