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General Rehabilitation

(Kiosk 1) A Case of West Nile Encephalitis Complicated by Orthostatic Hypotension in the Acute Inpatient Rehabilitation Setting

Friday, November 17, 2023
8:00 AM – 9:15 AM CT

    Primary Author(s)

  • Tarek Almaleh, DO (he/him/his)

    PGY-3
    Good Samaritan Hospital Medical Center PM&R Program
    Astoria, New York

    • Co-Author(s)

  • CK

    Chi Lam Kwok, DO

    Medical Student
    New York Institute of Technology College of Osteopathic Medicine
    Rego Park, New York

  • MS

    Michael G. Schloss, DO

    PGY-3
    Good Samaritan Hospital Medical Center PM&R Program
    Rockville Centre, New York

  • LS

    Lauren Stimler-Levy, MD

    Rehabilitation Attending covering Mercy Medical Center acute inpatient rehabilitation
    Parkway Pain Care and Rehab P.C.
    North Bellmore, New York

Case Diagnosis: We present a rare case of West Nile Encephalitis (WNE) complicated by orthostatic hypotension (OH) in an acute inpatient rehabilitation (AR) setting.

Case Description or Program Description: A 73-year-old female presented to the emergency department with hypotension, altered mental status, and fevers. She was diagnosed with WNE, which was confirmed by positive West Nile IgG/IgM on cerebrospinal fluid analysis. Once stabilized, the patient was transferred to AR for ongoing functional optimization. The patient experienced persistent OH, limiting her participation in physical and occupational therapy. Medications were reviewed and the patient was started on a treatment regimen of nightly intravenous fluid hydration, compressive garments, Florinef and Midodrine, which was maintained throughout the hospitalization.

Setting: Inpatient Rehabilitation

Assessment/Results: 15/26 of the patient's total therapy sessions were limited due to severe OH. With the institution of appropriate medical management, the frequency of OH-limiting therapy sessions was significantly reduced during the final week of the patient's hospitalization. The patient was discharged to subacute rehabilitation.

Discussion (relevance): West Nile Virus is the leading cause of mosquito-borne disease in the United States. To our knowledge, there remains limited literature on OH secondary to WNE, but some studies have reported an incidence of up to 22%. The severe dysautonomia experienced by this subset of patients can also sometimes present as cardiac dysrhythmia, which should be noted. Because only a small subset of patients with WNE will develop OH, clinicians may not readily recognize this association. OH negatively impacted our patient's therapy sessions, slowed their functional recovery and ultimately may have adversely affected their final discharge disposition.

Conclusions: As the incidence of WNE continues to rise in the United States, more patients will require AR during their recovery. Clinicians should remain cognizant that those who have been diagnosed with WNE should be screened for OH and cardiac dysrhythmias to prevent complications and help prioritize functional recovery during AR.