Bilateral Diaphragmatic Paralysis in a West Nile Virus Patient: A Case Report

Abstract

Introduction

Certain viruses can have rare but potentially fatal neuroinvasive courses. In Tanzania, multiple endemic viruses within the arbovirus class can lead to direct central or peripheral neurologic system invasion. Recognition is critical to diagnose and treat patients with this feared complication. In this case report, we describe a patient with West Nile Virus who was diagnosed with diaphragmatic paralysis with the use of bedside ultrasound.

Case Report

A healthy 24-year-old presented to the Emergency Department due to nausea and vomiting. She was diagnosed with West Nile Virus meningoencephalitis. Due to altered mental status and respiratory distress, she was intubated. She improved with supportive cares. Despite cognitive and strength improvement, she continued to feel short of breath. She was extubated after 8 days, but quickly re-intubated within 24 hours due to respiratory distress. 

Diaphragm ultrasound showed minimal diaphragm excursion or thickening bilaterally. Cervical spine MRI showed abnormal enhancement involving bilateral anterior C4, C5, C6, C7, C8, T1 nerve roots. She was diagnosed with diaphragm paralysis secondary to West Nile Virus and she was treated with diaphragm exercise. 

She was discharged with a home ventilator after 6 weeks of hospitalization. She was eventually weaned from the ventilator at home and was able to return to all normal activities, graduated from university, and began a full-time job. 

Lessons Learned

This case highlights the importance of proper diagnosis of diaphragmatic paralysis and the incredible recovery that can be made once function of the diaphragm is recovered. Though MRI was helpful in diagnosis, ultrasound is an important diagnostic tool and serves as an accessible and affordable modality. Diagnosis in this case was critical to determine prognosis and direct treatment. 

Conclusion

Diaphragmatic paralysis is a rare but potentially deadly complication of a number of viral illnesses that are endemic to East Africa. Diagnosis has historically been difficult and likely underdiagnosed. Bedside ultrasound can be a useful, fast, and cost-effective way in diagnosing diaphragmatic paralysis or weakness in order to guide prognosis and treatment.