A 46-year-old man presented with increasing general weakness, fever and headache. He described a tick bite 2 weeks previously. Clinically, the patient had mild neck stiffness and psychomotor slowing. His body temperature was 39.5 °C. Magnetic resonance imaging (MRI) revealed normal findings for the meninges, brain and spinal cord. Cerebrospinal fluid showed lymphocytic pleocytosis (64 cell per µl, normal <4 per µl) and antibodies against tick-borne encephalitis virus (TBEV, antibody-specific index 4.3, normal < 1.2). Antibodies against Borrelia, herpes simplex and varicella zoster virus were normal. Over 5 days, the patient had persistent fever spikes with a marked malaise. On day 6, the patient reported new pain and paresthesia in the right shoulder girdle. He went on to develop prominent scapular winging on the right side (Fig. 1). We diagnosed an infection with TBEV associated with peripheral nerve damage and marked scapular winging. At a follow-up examination 5 months later, the scapular winging persisted. The patient continued to receive physiotherapy and low-dose pain medication with pregabalin.
Fig. 1
Right scapular winging due to an infection caused by TBEV
