Introduction: Following natural disasters such as hurricanes, cases of West Nile neuroinvasive disease (WNND) have been shown to increase. Early-season hurricanes (June–July) are particularly associated with elevated WNV transmission in affected areas.
Description: A 56-year-old female with CKD, type II diabetes, hypertension, and recent deceased-donor kidney transplant (1 month prior) presented with fever, altered mental status, and diarrhea just days after Hurricane Beryl. Her immunosuppression included mycophenolate, prednisone, and letermovir.
Over six days, her condition rapidly worsened, developing flaccid paralysis in all extremities and loss of airway protection requiring intubation. MRI of the brain and spine revealed T2 hyperintensities in the pons, thalami, and spinal cord (Figures 1–3). Due to her altered mental status and recent transplant, extensive infectious workup was initiated with blood, urine, and CSF studies—all initially negative. She was empirically started on doxycycline, zosyn, and acyclovir.
Twelve days after symptom onset, WNV IgM returned positive (2.1; cutoff >1.11), with negative IgG, confirming acute infection. Given her rapid neurologic decline, immunosuppressive medications were stopped. She was treated with investigational IVIG for five days followed by corticosteroids, without improvement.
Due to persistent paralysis and ventilator dependence, a tracheostomy and PEG tube were placed. Repeat MRIs at one and two months post-diagnosis showed progressive disease with new areas of hyperintensity (Figures 4–5). Over three months, she had modest neurological improvement and was weaned to trach collar, though with minimal recovery of motor or cognitive function. She was transferred to a skilled nursing facility for long-term rehabilitation.
Discussion: Early-season hurricanes and immunosuppression are significant risk factors for WNND. This case highlights the devastating consequences of WNV infection in immunocompromised patients following a natural disaster. It also raises an important question: should solid organ transplants be delayed during early hurricane season in high-risk regions? Education and preventive mosquito measures are critical for transplant recipients in hurricane-prone areas.
