West Nile Encephalitis presenting with fever, vertigo, and intention tremor progressing to neurogenic shock and death in Philadelphia area elderly gardener.

A 77 year old female smoker with history of Polymyalgia Rheumatica and Sarcoidosis presented to hospital with a two day history of fever, nausea, gait ataxia, and new bilateral intention tremor. After admission, she was noted to become rigid with features of parkinsonism and subsequently developed worsening weakness with inability to follow appendicular commands. MRI brain showed midbrain and thalamic infiltration, with CSF findings of markedly elevated WBC, elevated protein, and West Nile IgM. Her condition worsened over the following eleven days to include fulminant flaccid paralysis and neurogenic shock requiring ICU transfer despite empiric treatment with standard of care therapies. Worsening shock refractory to vasopressors, persisting GCS of 3, and rising lactate with acute renal failure prompted family and clinicians to pursue palliative measures. She died with family at bedside 13 days after admission.