Case report on SARS-CoV-2 misdiagnosis: West Nile virus meningoencephalomyelitis in patients with SLE

A fatal case of West Nile Virus (WNV) meningoencephalomyelitis – incorrectly diagnosed as COVID-19 – was reported in an Egyptian woman with a long history of systemic lupus erythematosus (SLE) and stage 4 lupus nephritis, according to a study published in The American Journal of Tropical Medicine and Hygiene.

The 63-year-old patient was presented to Luigi Sacco Hospital in Milan, Italy after testing positive for SARS-CoV-2 RNA by real-time polymerase chain reaction (PCR; performed on a nasopharyngeal swab). She had lived in the metropolis of Milan last year and had not returned to Egypt since arriving. The patient had received immunosuppressive therapy with azathioprine and steroids since 1999, had a history of type 2 diabetes mellitus and severe coronary artery disease.

One day before the COVID-19 diagnosis, the patient was admitted to another hospital emergency room with complaints of a 4-day history of malaise, fever, abdominal pain, and diarrhea. Blood tests showed mild leukocytosis, thrombocytopenia, and increased serum creatinine levels. The patient was empirically treated with intravenous ceftriaxone (2 g / d) and taken to the hospital.

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When the patient was admitted on August 8, 2020, the patient’s vital functions were in the normal range, she did not require oxygen supplementation and she appeared to be cognitively intact despite the language barrier. Later that night, she developed confusion and excitement which was interpreted as delirium.

The following day the patient developed a high fever (up to 39 ° C) with persistent confusion. Neurological consultation indicated gross tremors and myoclonus of the extremities. However, a computed tomography scan of the brain did not reveal any intracranial abnormalities. After a lumbar puncture, the cerebrospinal fluid was notable for pleocytosis, a glucose concentration of 62 mg / dl and a protein concentration of 1080 mg / l.

Nasopharyngeal swabs for SARS-CoV-2 detection were taken on August 8th, 9th and 10th, all of which were negative for the viral RNA. On August 11, the patient deteriorated neurologically and was intubated and taken to the intensive care unit. Negative PCR results for SARS-CoV-2 indicated COVID-19 in a convalescence phase.

A second lumbar puncture was not possible due to a worsening of the thrombocytopenia (47,000 / µl). In addition, the electroencephalogram results showed epileptic activity and general slowing with diffuse irregular delta activity with arrhythmic waves.

A WNV virus serology and a PCR on blood and urine were then requested. Immunoglobulin (Ig) M and IgG anti-WNV were positive in blood and urine samples. After a neurological reassessment, a diagnosis of WNV was made on August 13; Despite supportive therapy, the patient died 6 days later in the intensive care unit.

The case report authors noted that the patient may have been convalescing from COVID-19, but her rapid clinical deterioration raised concerns about possible central nervous system infections and the possible occurrence of neuropsychiatric lupus.

“While the diagnosis of WNV encephalitis should always be kept in mind, our patient’s initial diagnosis of COVID-19 was misleading and may have contributed to delayed diagnosis due to strict hospital isolation measures imposed for such patients,” the authors wrote. “Indeed, we can speculate that our patient’s death would have been classified as a consequence of SARS-CoV-2 if the diagnosis of WNV had not been made.”

The authors added that despite the increasing reports of neurological complications associated with SARS-CoV-2 infection, it is imperative to maintain a high index of suspicion for other infections during the COVID-19 pandemic.


Schiuma M., Pezzati L., Ballone E. et al. Case Report: A fatal case of West Nile Virus meningoencephalomyelitis in a woman with systemic lupus erythematosus originally mistakenly diagnosed as SARS-CoV-2 infection. Am J Trop Med Hyg. Published online March 29, 2021. doi: 10.4269 / ajtmh.21-0041

This article originally appeared on Rheumatology Advisor

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