Working Diagnosis:
West Nile Virus infection with viral myositis, encephalopathy, and SIADH

Treatment:
Hyponatremia and confusion worsened, and she required hospitalization. Hypertonic saline was used to correct her hyponatremia. CT Head showed mild cerebral atrophy, and CT L-spine showed degenerative disc disease with L4/L5 disc protrusion.

Outcome:
At 1 year, post infection she is able to jog on indoor track, but due to problems with post infectious spatial orientation and tendency of getting lost, she was not able to participate in solo trail running

Author's Comments:
For outdoor athletes who present with myalgia, fever, and episodic confusion, consider the differential diagnosis of West Nile Virus infection. Outdoor sports such as trail running can increase exposure to such vector borne diseases. Humans typically acquire West Nile virus through a bite from an infected adult mosquito of the Culex species. In the U.S.A this virus is maintained in an enzootic mosquito-bird-mosquito cycle (4). It is important to wear long sleeve shirts and pants, and the use of mosquito repellent to minimize exposure (3). Clinical management for West Nile Virus is supportive, and most individuals recover completely (3,4). Symptoms such as fatigue, confusion, and muscle pain can persist for weeks to months or longer (3,4).

Editor's Comments:
In each case presentation, it is important to keep in mind the patient's possible exposures. In outdoor athletes, zoonotic disease such as West Nile Virus should be included in the differential. Older age increases the risk for WNV encephalitis.

References:
1. Alli A, Ortiz JF, Atoot A, Atoot A, Millhouse PW. Management of West Nile Encephalitis: An Uncommon Complication of
West Nile Virus. Cureus. 2021;13(2):e13183. Published 2021 Feb 6. doi:10.7759/cureus.13183
2. Goldsmith C. Details - public health image library(phil). Centers for Disease Control and Prevention.
https://phil.cdc.gov/Details.aspx?pid=2290. Accessed March 16, 2022.
3. West Nile Virus Prevention. Centers for Disease Control and Prevention.
https://www.cdc.gov/westnile/prevention/index.html. Published December 7, 2020. Accessed October 25, 2021.
4. West Nile Virus Transmission Cycle. Mayo Clinic-West Nile virus transmission cycle Print.
https://www.mayoclinic.org/diseases-conditions/west-nile-virus/multimedia/west-nile-virus-transmission-cycle/img-
20006044. Accessed March 16, 2022

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