Case report: Acquired periodic alternating nystagmus and vestibular weakness in West Nile virus encephalitis
Abstract
Background: West Nile virus (WNV) encephalitis is reported to cause “ataxia” in up to 31% of patients, and “vertigo” in up to 14% of patients. The mechanism of these symptoms is unclear.
The case: We report the case of a lady who contracted WNV encephalitis at age 74 years. When evaluated 15 months later she complained both of baseline unsteadiness, and of a fluctuating component of disequilibrium. Instrumented vestibular testing identified bilateral vestibular weakness (in a different pattern on each side). It also identified periodic alternating nystagmus (PAN), presumably acquired (rather than congenital). Acquired PAN has been observed in other encephalidites, but has not been previously reported in association with WNV encephalitis.
Conclusion: In this case, WNV encephalitis appears to have caused both vestibular weakness (likely accounting for the baseline unsteadiness) and periodic alternating nystagmus (likely accounting for the fluctuating disequilibrium).
1. Pepperell C, Rau N, Krajden S, Kern R, Humar A, Mederski B, et al. West Nile virus infection in 2002: morbidity and mortality among patients admitted to hospital in southcentral Ontario. CMAJ. 2003;168(11):1399-405.
2. Al-Hashimi I, Okon E. West Nile Virus: A Neglected Cause of Bell's Palsy? Cureus. 2024;16(6):e62486. [DOI:10.7759/cureus.62486]
3. Anninger WV, Lomeo MD, Dingle J, Epstein AD, Lubow M. West Nile virus-associated optic neuritis and chorioretinitis. Am J Ophthalmol. 2003;136(6):1183-5. [DOI:10.1016/s0002-9394(03)00738-4]
4. Ayça S, Akkoç G, Özdemir H, Selçuk-Duru HN. An unusual neurologic presentation of pediatric neuroinvasive West Nile virus infection: ophthalmoplegia. Turk J Pediatr. 2021;63(5):909-12. [DOI:10.24953/turkjped.2021.05.019]
5. Cunha BA, Eisenstein LE, Wirkowski E, Klein NH, Johnson DH. West Nile encephalitis relapse presenting with abducens and facial nerve palsies. Am J Med. 2006;119(6):e1-2. [DOI:10.1016/j.amjmed.2005.09.061]
6. Gilad R, Lampl Y, Sadeh M, Paul M, Dan M. Optic neuritis complicating west nile virus meningitis in a young adult. Infection. 2003;31(1):55-6. [DOI:10.1007/s15010-002-3039-4]
7. Hart J Jr, Tillman G, Kraut MA, Chiang HS, Strain JF, Li Y, et al. West Nile virus neuroinvasive disease: neurological manifestations and prospective longitudinal outcomes. BMC Infect Dis. 2014;14:248. [DOI:10.1186/1471-2334-14-248]
8. Koevary SB. Ocular involvement in patients infected by the West Nile virus. Optometry. 2005;76(10):609-12. [DOI:10.1016/j.optm.2005.08.015]
9. Rosenheck MS, Higham C, Sanzone K, Caprio C. New-onset Bell's palsy after neuroinvasive West Nile virus. BMJ Case Rep. 2022;15(7):e249770. [DOI:10.1136/bcr-2022-249770]
10. Ross JJ, Worthington MG. Bilateral sixth nerve palsy in West Nile meningoencephalitis. J Neuroophthalmol. 2004;24(1):97-8. [DOI:10.1097/00041327-200403000-00034]
11. Vaispapir V, Blum A, Soboh S, Ashkenazi H. West Nile virus meningoencephalitis with optic neuritis. Arch Intern Med. 2002 Mar 11;162(5):606-7. [DOI:10.1001/archinte.162.5.606-a]
12. Baloh RW, Honrubia V, Konrad HR. Periodic alternating nystagmus. Brain. 1976;99(1):11-26. [DOI:10.1093/brain/99.1.11]
13. DiBartolomeo JR, Yee RD. Periodic alternating nystagmus. Otolaryngol Head Neck Surg. 1988;99(6):552-7. [DOI:10.1177/019459988809900603]
14. Halmagyi GM, Rudge P, Gresty MA, Leigh RJ, Zee DS. Treatment of periodic alternating nystagmus. Ann Neurol. 1980;8(6):609-11. [DOI:10.1002/ana.410080611]
15. Isago H, Tsuboya R, Kataura A. A case of periodic alternating nystagmus: with a special reference to the efficacy of baclofen treatment. Auris Nasus Larynx. 1985;12(1):15-21. [DOI:10.1016/s0385-8146(85)80074-2]
16. Daroff RB. Periodic alternating nystagmus and the shifting null. Can J Otolaryngol. 1974;3(3):367-71.
17. Furman JM, Wall C 3rd, Pang DL. Vestibular function in periodic alternating nystagmus. Brain. 1990;113 (Pt 5):1425-39. [DOI:10.1093/brain/113.5.1425]
18. Jeong HS, Oh JY, Kim JS, Kim J, Lee AY, Oh SY. Periodic alternating nystagmus in isolated nodular infarction. Neurology. 2007;68(12):956-7. [DOI:10.1212/01.wnl.0000257111.24769.d2]
19. Oh YM, Choi KD, Oh SY, Kim JS. Periodic alternating nystagmus with circumscribed nodular lesion. Neurology. 2006;67(3):399. [DOI:10.1212/01.wnl.0000219818.35451.10]
20. DE Silva L, Cooper BP, McLeod JG. Periodic alternating nystagmus. Proc Aust Assoc Neurol. 1975;12:157-60.
21. Tsutsumi T, Ikeda T, Kikuchi S. Periodic alternating nystagmus caused by a medullary lesion in acute disseminated encephalomyelitis. Otol Neurotol. 2014;35(5):861-5. [DOI:10.1097/MAO.0000000000000344]
2. Al-Hashimi I, Okon E. West Nile Virus: A Neglected Cause of Bell's Palsy? Cureus. 2024;16(6):e62486. [DOI:10.7759/cureus.62486]
3. Anninger WV, Lomeo MD, Dingle J, Epstein AD, Lubow M. West Nile virus-associated optic neuritis and chorioretinitis. Am J Ophthalmol. 2003;136(6):1183-5. [DOI:10.1016/s0002-9394(03)00738-4]
4. Ayça S, Akkoç G, Özdemir H, Selçuk-Duru HN. An unusual neurologic presentation of pediatric neuroinvasive West Nile virus infection: ophthalmoplegia. Turk J Pediatr. 2021;63(5):909-12. [DOI:10.24953/turkjped.2021.05.019]
5. Cunha BA, Eisenstein LE, Wirkowski E, Klein NH, Johnson DH. West Nile encephalitis relapse presenting with abducens and facial nerve palsies. Am J Med. 2006;119(6):e1-2. [DOI:10.1016/j.amjmed.2005.09.061]
6. Gilad R, Lampl Y, Sadeh M, Paul M, Dan M. Optic neuritis complicating west nile virus meningitis in a young adult. Infection. 2003;31(1):55-6. [DOI:10.1007/s15010-002-3039-4]
7. Hart J Jr, Tillman G, Kraut MA, Chiang HS, Strain JF, Li Y, et al. West Nile virus neuroinvasive disease: neurological manifestations and prospective longitudinal outcomes. BMC Infect Dis. 2014;14:248. [DOI:10.1186/1471-2334-14-248]
8. Koevary SB. Ocular involvement in patients infected by the West Nile virus. Optometry. 2005;76(10):609-12. [DOI:10.1016/j.optm.2005.08.015]
9. Rosenheck MS, Higham C, Sanzone K, Caprio C. New-onset Bell's palsy after neuroinvasive West Nile virus. BMJ Case Rep. 2022;15(7):e249770. [DOI:10.1136/bcr-2022-249770]
10. Ross JJ, Worthington MG. Bilateral sixth nerve palsy in West Nile meningoencephalitis. J Neuroophthalmol. 2004;24(1):97-8. [DOI:10.1097/00041327-200403000-00034]
11. Vaispapir V, Blum A, Soboh S, Ashkenazi H. West Nile virus meningoencephalitis with optic neuritis. Arch Intern Med. 2002 Mar 11;162(5):606-7. [DOI:10.1001/archinte.162.5.606-a]
12. Baloh RW, Honrubia V, Konrad HR. Periodic alternating nystagmus. Brain. 1976;99(1):11-26. [DOI:10.1093/brain/99.1.11]
13. DiBartolomeo JR, Yee RD. Periodic alternating nystagmus. Otolaryngol Head Neck Surg. 1988;99(6):552-7. [DOI:10.1177/019459988809900603]
14. Halmagyi GM, Rudge P, Gresty MA, Leigh RJ, Zee DS. Treatment of periodic alternating nystagmus. Ann Neurol. 1980;8(6):609-11. [DOI:10.1002/ana.410080611]
15. Isago H, Tsuboya R, Kataura A. A case of periodic alternating nystagmus: with a special reference to the efficacy of baclofen treatment. Auris Nasus Larynx. 1985;12(1):15-21. [DOI:10.1016/s0385-8146(85)80074-2]
16. Daroff RB. Periodic alternating nystagmus and the shifting null. Can J Otolaryngol. 1974;3(3):367-71.
17. Furman JM, Wall C 3rd, Pang DL. Vestibular function in periodic alternating nystagmus. Brain. 1990;113 (Pt 5):1425-39. [DOI:10.1093/brain/113.5.1425]
18. Jeong HS, Oh JY, Kim JS, Kim J, Lee AY, Oh SY. Periodic alternating nystagmus in isolated nodular infarction. Neurology. 2007;68(12):956-7. [DOI:10.1212/01.wnl.0000257111.24769.d2]
19. Oh YM, Choi KD, Oh SY, Kim JS. Periodic alternating nystagmus with circumscribed nodular lesion. Neurology. 2006;67(3):399. [DOI:10.1212/01.wnl.0000219818.35451.10]
20. DE Silva L, Cooper BP, McLeod JG. Periodic alternating nystagmus. Proc Aust Assoc Neurol. 1975;12:157-60.
21. Tsutsumi T, Ikeda T, Kikuchi S. Periodic alternating nystagmus caused by a medullary lesion in acute disseminated encephalomyelitis. Otol Neurotol. 2014;35(5):861-5. [DOI:10.1097/MAO.0000000000000344]
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How to Cite
1.
Cherchi M. Case report: Acquired periodic alternating nystagmus and vestibular weakness in West Nile virus encephalitis. Aud Vestib Res. 2025;.
