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Dual infection with West Nile virus and echovirus 9 in a patient with aseptic meningitis

The seasonality, clinical and laboratory features of West Nile virus (WNV) neuroinvasive infection overlap with those of enteroviruses. We present a case report on dual infection with WNV and echovirus 9 in a patient with aseptic meningitis. In August 2018, a 59-year-old woman with a history of arterial hypertension was hospitalized at the Clinic for Infectious Diseases on the third day of the illnesses. The disease was manifested by a daily fever up to 38.2°C, diffuse headaches and nausea without vomiting. On admission, her condition appeared severe. She was conscious, but she suffered from weakness and hypotonia. Neurologic examination revealed terminal neck stiffness. Routine laboratory parameters were normal. Cerebrospinal fluid (CSF) analysis showed pleocytosis (19x106 cells/L) with 53% mononuclear cells and elevated protein level (0.412 g/L). Electroencephalogram showed slow diffuse dysrhythmia. PCR of CSF for HSV 1/2, enteroviruses, CMV, EBV, B. burgdorferi and L. monocytogenes were negative. High titer of both WNV IgM (ratio 3.36 ; >1.1 positive) and IgG antibodies (142.81 RU/ml ; positive >22) of low avidity (avidity index 21% ; low <40%) in serum sample as well as equivocal IgG antibodies (18.86 RU/ml) in CSF sample indicated WNV infection. RT- PCR of CSF and urine was negative for WNV RNA. Echovirus 9 was isolated from a stool sample. IgG antibodies to echoviruses were found in a serum sample, while CSF was negative. The patient was initially treated with acyclovir, ampicillin and ceftriaxone intravenously (until the completion of virology results) with a supportive (antiedematous) therapy. From the third day of hospitalization, the patient was afebrile and without a headache. The patient was monitored during the three months and she recovered fully. The presented case of acute WNV meningitis occurring concurrent with echovirus 9 infection suggest possible co-infections. Due to the overlapping seasonal activity, differential diagnosis of neuroinvasive infections should include both WNV and enteroviruses.

West Nile virus ; Echovirus 9 ; aseptic meningitis

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