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West Nile Neuroinvasive Disease Presenting as Elsberg Syndrome

Hawkes, Maximiliano A., MD*; Toledano, Michel, MD; Kaufmann, Timothy J., MD, MS; Rabinstein, Alejandro A., MD*

doi: 10.1097/NRL.0000000000000189
Case Report/Case Series

Introduction: Elsberg syndrome (ES) is a rarely recognized cause of cauda equina syndrome and lower thoracic myelitis, mainly linked to reactivation, or occasionally primary, infection with herpes simplex virus type 2. West Nile virus neuroinvasive disease is rarely considered in the differential diagnosis of patients with ES.

Case Report: A 63-year-old man with pancreatic cancer in remission and polymyalgia rheumatica on low-dose prednisone presented with a 10-day history of low-back pain and a viral-type illness with low-grade fever, nausea, and vomiting. Days later, he developed left leg monoparesis, neurogenic bladder, and bowel. Magnetic resonance imaging of the lumbar spine revealed a hyperintense signal abnormality within the central spinal cord and conus medullaris with mild swelling of the conus. Cells, proteins, and glucose in cerebrospinal fluid were 67/mm3, 70 mg/dL, and 58 mg/dL, respectively. Serology was positive for West Nile virus IgM. Nerve conduction studies and electromyography showed an acute motor neurogenic process affecting left lumbosacral segments.

Conclusions: West Nile virus neuroinvasive disease is an uncommon condition that should be considered in patients with ES. Determining the etiology of ES in the acute setting may avoid unnecessary diagnostic investigations and treatments.

*Division of Critical Care Neurology

Departments of Neurology

Neuroradiology, Mayo Clinic, Rochester, MN

The authors declare no conflict of interest.

Reprints: Maximiliano A. Hawkes, MD, 200 First Street Southwest, Rochester, MN 55905. E-mail:

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