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

Igor Dumic, Bridget Glomski, Janki Patel, Terri Nordin, Charles W. Nordstrom, Lawrence J. Sprecher, Eric Niendorf, Amteshwar Singh, Kosana Simeunovic, Anand Subramanian, Oladapo Igandan, Danilo Vitorovic

USA Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA

Am J Case Rep 2021; 22:e929952 :: DOI: 10.12659/AJCR.929952

Available online: 2021-02-15, In Press, Corrected Proof

Publication in the "In-Press" formula aims at speeding up the public availability of the pending manuscript while waiting for the final publication.
The assigned DOI number is active and citable. The availability of the article in the Medline, PubMed and PMC databases as well as Web of Science will be obtained after the final publication according to the journal schedule

#929952

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 hypercapnic 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.

Keywords: Encephalitis, Tick-Borne; Immunoglobulins, Intravenous; Lyme Disease; Powassan virus, co-infection

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