443 - When COVID isn’t the culprit: Unraveling a case of acute flaccid paralysis due to West Nile Virus

Case Diagnosis: Rare neurological presentation of West Nile Virus (WNV)

Case Description: A previously healthy 60 year old female presented with left-sided weakness after international travel. Brain and spine imaging were negative. Patient declined lumbar puncture. Workup revealed SARS-COV-2 positivity, deep venous thrombosis, and pulmonary embolism. Repeat brain imaging showed bilateral occipital cortex abnormalities and subarachnoid hemorrhage. Neurology diagnosed weakness from bilateral infarcts related to COVID-19; however, imaging and symptoms were incongruent. Inpatient rehabilitation admission exam showed absent left patellar and achilles reflexes and 0/5 strength in left lower extremity with no sensory changes. No motor recovery seen after three months. Electrodiagnostic testing showed acute motor axonopathy. Diagnosis thought to be acute motor axonal variant of Guillain Barre secondary to COVID-19, although atypical due to asymmetric presentation. Further blood work returned positive for WNV. Patient frustrated with mobility deficits. C-brace knee ankle foot orthosis was fitted for knee extensor weakness and foot drop with successful return to ambulation.

Discussions: This case highlights the importance of having a broad differential diagnoses for unusual presentations of paralysis and adds to the limited literature identifying WNV infection as cause for flaccid paralysis. Also, we emphasize the impact of proper assistive equipment prescription in increasing independence.

Conclusions: Case reports have shown WNV to cause neurological symptoms with few including acute flaccid limb paralysis. Of patients that received intravenous immunoglobulin, many regained strength in the affected limb. This patient's prolonged diagnostic work up alongside COVID-19 complications delayed treatment options. For patients with continued disability, the rehabilitation team is essential in facilitating functional recovery.