Confusion beyond the usual suspects

Acute confusion in older adults is frequently attributed to systemic infections, often delaying the recognition of central nervous system involvement. West Nile virus (WNV) is an emerging cause of viral encephalitis in Europe, particularly during summer and autumn. We report the case of an 82-year-old man admitted in late summer in Northern Italy with fever, agitation, and fluctuating confusion. Initial investigations suggested a systemic infection, and empirical antibacterial therapy was started. Persistent fever, sterile cultures, and ongoing cognitive fluctuations prompted lumbar puncture, which revealed lymphocytic pleocytosis and elevated protein levels consistent with viral meningoencephalitis. A detailed exposure history disclosed a recent mosquito bite. Serological testing showed WNV-specific IgM and IgG antibodies, and WNV RNA was detected by RT-PCR in blood and urine, confirming WNV neuroinvasive disease. The patient received supportive care and progressively recovered. This case highlights the importance of considering WNV encephalitis in older adults presenting with fever and acute confusion during mosquito season in Europe and underscores the critical role of epidemiological history in achieving timely diagnosis.