A Case of Neuroinvasive West Nile Virus(WNV) A. Karki1, A. Al-Nuaimi1, K. Mandal2, V. Patel3, U. Kulsum2, S. Sarkar2, J. Raynor2  Introduction: WNV meningoencephalitis can affect respiratory muscles and is associated with persistent flaccid paralysis and death as a complication. Persistent quadriplegia and respiratory failure may indicate poor prognosis. Case report: 69 years old male with history of hypothyroidism who was functionally independent presented with altered mental status. Patient was complaining of watery diarrhea for 5 days. On the day of admission, he was found lying on the floor, poorly responsive and febrile. There was no obvious focal sign, seizure activity, recent travel or sick contacts. Patient did not have any cough, dyspnea or dysuria. On physical examination, patient was poorly responsive was intubated and was admitted to ICU to rule out encephalitis. CT head was negative for any bleeding or infarction. Urine toxicology screen was negative. Labs were pertinent for acute kidney injury and rhabdomyolysis (Creatine kinase 7300 U/L). Chest x-ray showed right upper lobe pneumonia, so patient was started on broad spectrum antibiotics. Lumbar puncture showed lymphocytic pleocytosis (66%) with elevated protein(81 mg/dL) and glucose (82 mg/dL). Bacterial antigens and cultures were negative. Sputum culture was positive for Stenotrophomonas maltophilia and antibiotics were adjusted accordingly. CSF west Nile IgM was positive with a value of 4.96 (>1.1 is significant). EEG showed diffuse cerebral dysfunction. MRI brain showed high signal foci on T2/FLAIR images in the periventricular and subcortical white matter (Fig.1)Supportive care was continued. Patient failed multiple weaning trials due to poor mental status and flaccid muscle paralysis so tracheostomy and PEG tube were placed. Bronchoscopy and continuous chest PT was needed for clearing of copious secretions and relieving left lung collapse secondary to mucus plugging. Patient finished 14 days of appropriate antibiotics. Patient condition improved and was transferred to regular floor on a ventilator. Fig.1 Discussion: Spectrum of presentation in WNV infection varies from simple incoordination to debilitating paralysis and ventilator dependence. Neuroinvasive WNV should be in the differential diagnosis in patients presenting with acute onset of fever and altered mental status, especially if patients develop flaccid paralysis within few days of presentation. Patients with persistent flaccid paralysis usually succumb to death from aspiration pneumonia despite aggressive supportive care. Reference: West Nile virus-associated flaccid paralysis Sejvar JJ, Bode AV, Marfin AA, Campbell GL, Ewing D, Mazowiecki M, Pavot PV, Schmitt J, Pape J, Biggerstaff BJ, Petersen LR.. Emerg Infect Dis.