title: Acute Neurological Illness in a Kidney Transplant Recipient Following Infection With Enterovirus-D68: An Emerging Infection?
abstract: We report the first case of enterovirus-D68 infection in an adult living-donor kidney transplant recipient who developed rapidly progressive bulbar weakness and acute flaccid limb paralysis following an upper respiratory infection. We present a 45-year-old gentleman who underwent pre-emptive living-donor kidney transplantation for IgA nephropathy. Eight weeks following transplantation, he developed an acute respiratory illness from enterovirus/rhinovirus that was detectable in nasopharyngeal (NP) swabs. Within 24 h of onset of respiratory symptoms, the patient developed binocular diplopia which rapidly progressed to multiple cranial nerve dysfunctions (acute bulbar syndrome) over the next 24 h. Within the next 48 h, asymmetric flaccid paralysis of the left arm and urinary retention developed. While his neurological symptoms were evolving, the Centers for Disease Control reported that the enterovirus strain from the NP swabs was, in fact, Enterovirus-D68 (EV-D68). Magnetic resonance imaging of the brain demonstrated unique gray matter and anterior horn cell changes in the midbrain and spinal cord, respectively. Constellation of these neurological symptoms and signs was suggestive for postinfectious encephalomyelitis (acute disseminated encephalomyelitis [ADEM]) from EV-D68. Treatment based on the principles of ADEM included intensive physical therapy and other supportive measures, which resulted in a steady albeit slow improvement in his left arm and bulbar weakness, while maintaining stable allograft function.
authors.affiliation: Department of Surgery and Medicine, Inova Transplant Center, Falls Church, VA.
authors.forename: R K
authors.initials: RK
authors.lastname: Wali
authors.affiliation: Department of Radiology, Inova Health System, Falls Church, VA.
authors.forename: A H
authors.initials: AH
authors.lastname: Lee
authors.affiliation: Department of Nephrology, George Washington School of Medicine, Washington, DC.
authors.forename: J C
authors.initials: JC
authors.lastname: Kam
authors.affiliation: Department of Surgery, Inova Transplant Center, Falls Church, VA.
authors.forename: J
authors.initials: J
authors.lastname: Jonsson
authors.affiliation: Department of Surgery, Inova Transplant Center, Falls Church, VA.
authors.forename: A
authors.initials: A
authors.lastname: Thatcher
authors.affiliation: Department of Infectious Disease, Inova Health System, Falls Church, VA.
authors.forename: D
authors.initials: D
authors.lastname: Poretz
authors.affiliation: Department of Infectious Disease, Inova Health System, Falls Church, VA.
authors.forename: S
authors.initials: S
authors.lastname: Ambardar
authors.affiliation: Department of Surgery, Inova Transplant Center, Falls Church, VA.
authors.forename: J
authors.initials: J
authors.lastname: Piper
authors.affiliation: Department of Medicine, Virginia Commonwealth University, Richmond, VA.
authors.forename: C
authors.initials: C
authors.lastname: Lynch
authors.affiliation: Department of Neurology, Inova Health System, Falls Church, VA.
authors.forename: S
authors.initials: S
authors.lastname: Kulkarni
authors.affiliation: Department of Neurology, Inova Health System, Falls Church, VA.
authors.forename: J
authors.initials: J
authors.lastname: Cochran
authors.affiliation: Department of Pulmonary and Critical Care, Inova Health System, Falls Church, VA.
authors.forename: S
authors.initials: S
authors.lastname: Djurkovic
mesh_terms: D000208:Acute Disease; D000328:Adult; D001927:Brain Diseases / Q000209:etiology*; D030016:Enterovirus D, Human / Q000472:pathogenicity*; D004769:Enterovirus Infections / Q000150:complications / Q000821:virology*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D007676:Kidney Failure, Chronic / Q000601:surgery* / Q000821:virology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D010264:Paraplegia / Q000209:etiology*; D011183:Postoperative Complications; D011379:Prognosis; D012307:Risk Factors; D066027:Transplant Recipients
keywords: Clinical research/practice; complication: infectious; diagnostic techniques and imaging: magnetic resonance imaging; encephalopathy; infection and infectious agents; infectious disease; kidney transplantation/nephrology; viral