Background:

In the summer of 2015, three prior solid organ transplant recipients developed meningoencephalitis suggestive of West Nile virus (WNV) infection in the Phoenix area with inconclusive testing. All 3 were diagnosed with Saint Louis Encephalitis (SLE).

Methods:

We retrospectively reviewed the clinical manifestations, management, and outcomes for 3 transplant recipients with confirmed SLE.

Results:

Most common symptoms: fever (3/3), rigors (3/3), diarrhea (2/3), headache (2/3), confusion (2/3). All patients were receiving Tacrolimus, Prednisone and Mycophenolate.

One patient died within 24 hours after his lumbar puncture confirmed meningoencephalitis. The remaining 2 patients were initiated on Interferon alpha 2b and IVIG therapy (INF+IVIG). Both patients also tested positive for WNV IgG and IgM by EIA; they were subsequently confirmed to have SLEV infection based on a positive IgM by MAC-ELISA and by Plaque reduction neutralization test (PRNT) at a reference lab. Clinical improvement was observed within 72 hours after initiation of INF+IVIG therapy. Both patients survived, had steady neurological improvement, and were discharged after a prolonged hospital stay.

Conclusion

SLE is an uncommon cause of neuro-invasive disease in the United States. The clinical manifestations of our 3 patients with severe SLE were similar to WNV neuroinvasive disease. Serological cross-reactivity between WNV and SLEV, and the lack of a commercially available serological assay for SLEV hinders an accurate diagnosis. A high index of suspicion, as well as confirmatory testing for SLEV by the Health Department should be sought in suspected cases of WNV neuroinvasive disease. At present, there is no FDA approved treatment for flaviviral neuroinvasive disease. Anecdotal reports and case series indicate varying success with a combination of IFN+IVIG in WNV neuroinvasive disease. The same regimen might be of value in the immunocompromised host with neuroinvasive SLEV infection; further study is warranted.

CITATION INFORMATION: Hartmann C, Qaqish I, Grys T, Vikram H, Seville M, Orenstein R, Kusne S, Blair J, Patron R. Neuro-invasive Saint Louis Encephalitis Virus (SLEV) Infection in Solid Organ Transplant Recipients in a Non-Endemic Area. Am J Transplant. 2016;16 (suppl 3).

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