1517: Ebv Strikes the Nerve: A Rare Case of Ebv Ganglionitis Treated With Plasma Exchange

Introduction: Ebstein-Barr virus (EBV) is a herpesvirus that typically causes self-limited illness, which may trigger neurological complications, especially in immunocompromised individuals, including meningitis, encephalitis, and radiculitis. We present a diagnostically challenging case of EBV-associated ganglionitis in an elderly patient on infliximab (IFX) for Crohn’s disease (CD), initially mimicking cauda equina syndrome (CES) and Guillain-Barré syndrome (GBS), successfully treated with plasma exchange (PLEX). Description: A 70-year-old male with hypertension, benign prostatic hyperplasia, and CD on IFX presented with two weeks of worsening fatigue, ambulatory dysfunction, and new-onset urinary and fecal incontinence. He endorsed perianal and bilateral plantar numbness, poor appetite, weight loss, and generalized weakness. Initial labs were unremarkable. Given the presentation, there was high clinical suspicion for CES. Cervical and thoracic spine imaging showed patchy myelomalacia and demyelination; lumbar MRI revealed no cauda equina/cord compression, disc bulging, or significant degeneration. The patient continued to have lower extremity sensory and motor deficits with fecal incontinence. A trial of intravenous immunoglobulin was initiated for presumed GBS, though autonomic dysfunction was atypical, and he showed minimal improvement. Due to immunosuppression from IFX, EBV was suspected; CSF PCR was positive. He was transferred to the intensive care unit (ICU) and treated for presumed EBV ganglionitis with PLEX and acyclovir, plus high-dose solumedrol for lumbar arachnoiditis likely causing sacral radiculopathy and neurologic bowel and bladder. He tolerated five sessions of PLEX without complications, with subsequent neurological improvement and resolution of incontinence. Discussion: This case highlights the diagnostic complexity of neurologic decline with sacral involvement in immunocompromised patients. The absence of CES radiographic evidence and atypical features of GBS prompted further evaluation. Though rare, EBV ganglionitis should be considered in the immunosuppressed and elderly population presenting with lumbosacral radiculopathy. Early antiviral and immunotherapy may lead to recovery, highlighting the importance of ICU management in complex neuroinfectious cases.