“Double Trouble”: Severe Meningoencephalitis Due to Borrelia burgdorferi and Powassan Virus Co-Infection Successfully Treated with Intravenous Immunoglobulin

Abstract

Patient: Male, 76-year-old Final Diagnosis: Powassan virus encephalitis Symptoms: Confusion • fever • respiratory distress Medication: Immunoglobulin • ceftriaxone Clinical Procedure: — Specialty: Infectious Diseases • General and Internal Medicine • Neurology Objective: Rare co-existance of disease or pathology Background: Powassan virus (POWV) is an emerging tick-borne flavivirus transmitted to humans by ticks. While infection is asymptomatic in some people, others develop life-threatening encephalitis with high mortality rates. Co-infection between POWV and Borrelia burgdorferi is rare despite the fact that both pathogens can be transmitted through the same tick vector, Ixodes scapularis. It is unclear if co-infection leads to more severe clinical presentation and worse outcome. Case Report: A 76-year-old Wisconsin man was admitted for meningoencephalitis complicated by hypoxemic and hyper-capnic respiratory failure requiring endotracheal intubation. The patient had no known tick bites but lived in a heavily wooded area. Extensive work-up for infectious, autoimmune, and paraneoplastic causes was positive for Borrelia burgdorferi and Powassan virus infection (POWV). Following treatment with ceftriaxone for neuroborreliosis and supportive care for POWV infection, the patient failed to improve. Intravenous immunoglobulins (IVIG) were started empirically, and the patient attained gradual neurological improvement and was successfully extubated. Conclusions: Treatment for POWV infection is supportive, and at this time there are no approved targeted antivirals for this disease. At this time, it remains unclear if co-infection with 2 pathogens leads to a more severe clinical presentation and higher mortality. In the absence of contraindications, IVIG might be beneficial to patients with POWV infection who are not improving with supportive care.

Human Co-Infections between Borrelia burgdorferi s.l. and Other Ixodes-Borne Microorganisms: A Systematic Review

“…To our best knowledge, this study is the first systematic review of human co-infections by TBMs. This latter fills a data gap underlined by Henningsson et al in 2021 [ 55 ].…”

A comprehensive neurological perspective on tick-borne flaviviruses, with emphasis on Powassan virus

“…When POWV RNA is detected, the pathological and molecular findings imply a combination of direct viral-induced CNS neuronal damage along with broad-ranging lymphocytic inflammation and microgliosis involving the leptomeninges and brain tissue. 20 It is essential for medical practitioners to remain attentive in identifying these signs, particularly in regions like the USA with documented POWV prevalence. Recognizing exposure to ticks is pivotal in facilitating the diagnosis.…”

The Consumption of Raw Goat Milk Resulted in TBE in Patients in Poland, 2022 “Case Report”

“…Only patients with severe encephalitis should be empirically treatment with intravenous acyclovir and antibiotics until herpes and bacterial infections are ruled out, but our patients did not meet these criteria [ 39 ]. Similarly, for the previously mentioned Powassan virus infection, treatment is usually supportive, but in the one described case of Borrelia burgdorferi and POWV co-infection, improvement of the patient’s condition was achieved by empiric intravenous immunoglobulin (IVIG) inclusion in the treatment [ 11 ]. In our study, both patients denied being bitten by ticks, and the symptoms were strictly related to the consumption of raw goat milk.…”

“…The average percentage of Ixodes ricinus tick infections with TBEV ranges from 0.1 to 2.5%, depending on the gender and developmental stage of the tick [ 10 ]. Two other flaviviruses transmitted by ticks from the Ixodes genus ( I. scapularis and I. cookie ) belong the Powassan virus (POWV), which is responsible for infections in North America [ 11 ].…”