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West Nile Virus and Conversion Disorder

TO THE EDITOR: West Nile virus (WNV) arrived in North America in 1999, when it first appeared in the New York City area. Only 20% of all cases are symptomatic, with only the most severe cases (<1%) demonstrating neurologic manifestations, including encephalitis, meningitis, and acute flaccid paralysis.^1,2 Because of these complications, there is a possibility of misdiagnosing WNV infection as a psychiatric illness. Here, we report a case of WNV infection referred to the Psychiatry Department as a possible case of conversion disorder.

Case Report

"Ms. A," a single, 19-year-old African American woman, was admitted to the Obstetrics and Gynecology (OB/GYN) unit of a teaching hospital in her eighth month of pregnancy after presenting with unilateral paralysis of her right leg and foot. A routine examination, including a complete blood count, electrolytes, urea, liver and thyroid function tests, urinalysis, and a noncontrast CT scan of the head were all negative. An initial diagnosis of neurological deficit secondary to compression of the sciatic nerve was made; however, repeated maneuvering of her posture, as well as a Neurology consultation, did not indicate involvement of the sciatic nerve.

A psychiatric consult was called to rule out conversion disorder. On psychiatric evaluation, Ms. A had no presenting symptoms and denied any previous psychiatric history. She described her mood as euthymic, without any suicidal ideation. There was no evidence of psychosis such as delusions or hallucinations and no evidence of mania or any anxiety disorders. Ms. A denied any history of sexual or physical trauma, as well as any current stressors. She showed concern about her current condition and did not demonstrate the classic belle indifference. She denied any current use of alcohol or drugs.

A mental status examination revealed Ms. A to be calm and cooperative, but worried about her "disability." Her speech was spontaneous and normal in rate, tone, and volume. Her affect was full-ranged, and she had no delusions, hallucinations, or cognitive abnormalities. Her insight and judgment were adequate.

The fact that Ms. A did not have any current or previous stressors and the fact that she was psychiatrically asymptomatic argued against a diagnosis of conversion disorder. We therefore recommended to the primary treatment team to investigate Ms. A more aggressively. After further testing, Ms. A was positively confirmed for WNV infection.

Ms. A eventually delivered a baby boy via vaginal birth and was subsequently referred to the outpatient infectious disease clinic for follow-up care.

Discussion

Although most WNV infections are asymptomatic, associated clinical symptoms typically begin with sudden onset of fever, headache, and myalgia that are often accompanied by gastrointestinal symptoms, as well.^1,3 Fewer than 1% of cases demonstrate neurologic manifestations, most often encephalitis, meningitis, and acute flaccid paralysis.¹ Because its clinical onset is nonspecific, diagnosis of WNV infection must be confirmed through laboratory findings, namely, development of WNV-specific neutralizing antibody or detection of IgM in serum or cerebrospinal fluid.³

In cases where WNV-associated acute flaccid paralysis has been observed, presentation is abrupt and asymmetric, ranging from paralysis of a single limb to complete quadriplegia. Although the complete pathogenesis of WNV-associated acute flaccid paralysis is not known, it is believed to affect primarily the anterior-horn motor neurons.^1,2

Because WNV can be complicated, with acute asymmetric paralysis, it is not surprising that a psychiatric consultation was obtained to rule out conversion disorder. WNV has spread widely in both geographic distribution and number of reported cases since its first appearance in the United States in 1999.⁴ It is thus expected that more patients will present with paralysis with the potential for being misdiagnosed as conversion disorder. Psychiatrists, family physicians, and internists should be aware that WNV has increased in prevalence over recent years and may be mistaken for a psychiatric condition such as conversion disorder.

REFERENCES

1. Saad M, Youssef S, Kirschke D, et al: Acute flaccid paralysis: the spectrum of a newly recognized complication of West Nile virus infection. J Infect 2005; 51:120–127[CrossRef][Medline]
2. Li J, Loeb JA, Shy ME, et al: Asymmetric flaccid paralysis: a neuromuscular presentation of West Nile Virus infection. Ann Neurol 2003; 53:703–710[CrossRef][Medline]
3. Campbell GL, Marfin AA, Lanciotti RS, et al: West Nile virus. Lancet Infect Dis 2002; 2:519–529[CrossRef][Medline]
4. Center for Disease Control and Prevention: West Nile Virus (http://cdc/gov/ncidod/dvbid/westnile/index.htm)

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Alao, A. O. Articles by Chung, C. Search for Related Content PubMed Citation Articles by Alao, A. O. Articles by Chung, C. Primary Care Somatoform Disorders Syndromes Secondary to General Medical Disorders

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