Question

After working at Piedmont Hospital in the ER for 40 years, LaTonia retired and finally had some time for herself. She had enjoyed her going-away party a lot, maybe a little too much. Two days later, she woke up feeling awful. She was burning up and had a nasty headache. As the day progressed, she became nauseous and started to vomit. When her granddaughter Denisha called her that night, LaTonia sounded confused and her speech was halting and slow. LaTonia also complained of muscle cramps. Denisha knew something was wrong and drove her grandmother to the emergency clinic. As the physician assistant on duty at the time you admit her and show her to a private room. After talking to LaTonia and Denisha, you discover she:

• Is up to date on the polio, meningococcal, PCV13, and tetanus vaccines
• Has not lost or gained weight recently, nor has she had a decrease in appetite over the last month
• Is taking medication for high cholesterol
• Has no family history of neurological disorders
• Has gone through menopause
• Has a slightly elevated temperature, but not a high fever
• Is not diabetic, HIV positive, or a recent organ transplant recipient
• Had attended a retirement party two days before
  • The party was in a gazebo at a park.
  • The park was near a lake where she used a paddle boat.
  • The party lasted from 11:00am to 1:00pm.
  • She ate a roast beef sandwich, potato salad, green bean salad, and banana pudding.

Because she has neurological symptoms, confusion and agitation, and muscle cramping, you suspect meningitis. You order a lumbar puncture to examine her CSF. The lab order includes the following tests on the CSF: an ELISA for West Nile virus, a Gram stain, culture methods, white blood cell count, and glucose level. When you return to her room after ordering these tests, you notice her eyelids are beginning to droop. You realize the tests you just ordered are not the most immediate concern.

1. As the physician assistant on duty, you have narrowed down the possible causes of LaTonia's illness. Why did it make sense to initially suspect West Nile virus?

2. Why did LaTonia's drooping eyelids change the differential diagnosis you had originally developed? What is your new working diagnosis?

Answer 1

1. West Nile virus (WNV) is an infectious disease and symptoms include fever, headache, body aches, disorientation etc. So that they suspect West Nile virus disease. Symptoms of motor nerve damage include weakness and muscle atrophy. The sensory nerve damage may cause numbness, tingling, burning pains. The nerves of the peripheral nervous system control motor responses and sensation, so symptoms of numbness or tingling, or inability to move a part of your body, may be the result of lupus affecting these nerves.

2. Damage to sympathetic autonomic fibres that run in the cervical portions of the spinal cord may lead to drooping of the eyelid (ptosis) and a smaller pupil on the same side as the injury (Horner syndrome).