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De Felice ELT, Toti GF, Gatti B, Gualtieri R, Camozzi P, Lava SAG, Milani GP, Treglia G, Vanoni F, Bianchetti MG, Bernasconi GF, Terziroli Beretta Piccoli B, Lavagno C. Acute Aseptic Meningitis Temporally Associated with Intravenous Polyclonal Immunoglobulin Therapy: A Systematic Review. Clin Rev Allergy Immunol 2024; 66:241-249. [PMID: 38739354 PMCID: PMC11193830 DOI: 10.1007/s12016-024-08989-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 05/14/2024]
Abstract
An acute aseptic meningitis has been occasionally observed on intravenous polyclonal human immunoglobulin therapy. Since case reports cannot be employed to draw inferences about the relationships between immunoglobulin therapy and meningitis, we conducted a systematic review and meta-analysis of the literature. Eligible were cases, case series, and pharmacovigilance studies. We found 71 individually documented cases (36 individuals ≤ 18 years of age) of meningitis. Ninety percent of cases presented ≤ 3 days after initiating immunoglobulin therapy and recovered within ≤ 7 days (with a shorter disease duration in children: ≤ 3 days in 29 (94%) cases). In 22 (31%) instances, the authors noted a link between the onset of meningitis and a rapid intravenous infusion of immunoglobulins. Cerebrospinal fluid analysis revealed a predominantly neutrophilic (N = 46, 66%) pleocytosis. Recurrences after re-exposure were observed in eight (N = 11%) patients. Eight case series addressed the prevalence of meningitis in 4089 patients treated with immunoglobulins. A pooled prevalence of 0.6% was noted. Finally, pharmacovigilance data revealed that meningitis temporally associated with intravenous immunoglobulin therapy occurred with at least five different products. In conclusion, intravenous immunoglobulin may cause an acute aseptic meningitis. The clinical features remit rapidly after discontinuing the medication.
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Affiliation(s)
- Elisabetta L T De Felice
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Gabriel F Toti
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Beatrice Gatti
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Renato Gualtieri
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Pietro Camozzi
- Department of Anesthesia, Hôpital du Valais, Sion, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Treglia
- Clinic of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Federica Vanoni
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Institute of Pediatric of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Mario G Bianchetti
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Gianmaria F Bernasconi
- Family Medicine Institute, Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Benedetta Terziroli Beretta Piccoli
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland.
- Epatocentro Ticino, Lugano, Switzerland.
- Faculty of Life Sciences & Medicine, King's College London, King's College Hospital, London, UK.
| | - Camilla Lavagno
- Pediatric Emergency Department, University Children's Hospital Zurich, Zurich, Switzerland
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Aseptic Meningitis in Oral Medicine: Exploring the Key Elements for a Challenging Diagnosis: A Review of the Literature and Two Case Reports. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073919. [PMID: 35409601 PMCID: PMC8998084 DOI: 10.3390/ijerph19073919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 12/18/2022]
Abstract
Aseptic meningitis (AM) is a potentially severe and life-threatening disease characterized by meningeal inflammation, usually with mononuclear pleocytosis. It represents a challenging and controversial issue in medicine for multiple etiologies, classification, and difficult diagnosis in the face of nonspecific sets of signs and symptoms. In the area of interest of oral medicine, in specific clusters of patients, even if rare, the occurrence of aseptic meningitis can pose a diagnostic and management dilemma in the following potential etiologies: (i) systemic diseases with oral and meningeal involvement, which include Behçet’s disease and Sjögren syndrome; (ii) drug-induced aseptic meningitis; (iii) aseptic viral meningitis, mostly related to herpes simplex virus infection and hand, foot, and mouth disease, caused by enteroviruses. In this review, clinical manifestations, diagnostic methodologies, incidence, treatment, and prognosis for each of these clinical entities are provided. Furthermore, two illustrative case reports are described: a patient suffering from recurrent oral ulcers, in which a sudden onset of AM allows us to diagnose Neuro Behçet’s disease, and a patient affected by pemphigus vulgaris, manifesting a drug-induced AM. Exploring this complex clinical entity scenario, it is clear that an oral medicine specialist has a place on any multidisciplinary team in making such a challenging diagnosis.
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Graça L, Alves J, Nuak J, Sarmento A. Immunoglobulin-induced aseptic meningitis: a case report. BMC Neurol 2018; 18:97. [PMID: 30016937 PMCID: PMC6048768 DOI: 10.1186/s12883-018-1102-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immunoglobulin associated meningitis is a rare disease that mimics infectious meningitis. This is, to our knowledge, the first case of Immunoglobulin-associated meningitis described in a patient with Systemic Lupus Erythematosus and hypogammaglobulinemia secondary to Rituximab. CASE PRESENTATION A 46-year-old female with a past medical history of Systemic Lupus Erythematosus, presented with meningismus 36 h after first infusion of intravenous immunoglobulin. The cerebrospinal fluid analysis showed neutrophilic pleocytosis and hyperproteinorrachia. All microbiological tests were negative. The patient recovered remarkably fast without sequela after just five days of antibiotic therapy. CONCLUSION Systemic Lupus Erythematosus is a well-documented risk factor for aseptic meningitis associated with other drugs. Possibly, it is also a risk factor for Immunoglobulin associated meningitis. This diagnosis, although rare, should be considered in patients receiving Immunoglobulin since it is a self-limited condition and treatment is supportive.
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Affiliation(s)
- Luísa Graça
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4202-451, Porto, Portugal. .,Instituto Nacional de Engenharia Biomédica (INEB), Instituto de Inovação e Investigação em Saúde (I3S), Grupo de I&D em Nefrologia e Doenças Infecciosas, Porto, Portugal. .,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Joana Alves
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4202-451, Porto, Portugal.,Instituto Nacional de Engenharia Biomédica (INEB), Instituto de Inovação e Investigação em Saúde (I3S), Grupo de I&D em Nefrologia e Doenças Infecciosas, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Nuak
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4202-451, Porto, Portugal.,Instituto Nacional de Engenharia Biomédica (INEB), Instituto de Inovação e Investigação em Saúde (I3S), Grupo de I&D em Nefrologia e Doenças Infecciosas, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Sarmento
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4202-451, Porto, Portugal.,Instituto Nacional de Engenharia Biomédica (INEB), Instituto de Inovação e Investigação em Saúde (I3S), Grupo de I&D em Nefrologia e Doenças Infecciosas, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
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Infliximab-Induced Aseptic Meningitis in a Patient with Crohn's Disease. ACG Case Rep J 2018; 5:e48. [PMID: 29951563 PMCID: PMC6013687 DOI: 10.14309/crj.2018.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022] Open
Abstract
Infliximab is an anti-tumor necrosis factor α (TNFα) monoclonal antibody that treats moderate-to-severe Crohn’s disease. In rare cases, infliximab has been associated with drug-induced aseptic meningitis. We present a 46-year-old woman with migraines and inflammatory Crohn’s colitis treated with intravenous infliximab and methotrexate. She developed nuchal rigidity, photophobia, and headache 2 days after each of her infliximab infusions, with symptom resolution 1 week post-infusion. Her exam, imaging, and cerebrospinal fluid analysis were consistent with drug-induced aseptic meningitis. She discontinued infliximab and started vedolizumab with continued remission of her Crohn’s disease.
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Management of adverse events in the treatment of patients with immunoglobulin therapy: A review of evidence. Autoimmun Rev 2015; 15:71-81. [PMID: 26384525 DOI: 10.1016/j.autrev.2015.09.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/08/2015] [Indexed: 12/12/2022]
Abstract
Immunoglobulin (IG) therapy is actually used for a broad range of diseases including primary and secondary immunodeficiency disorders, and autoimmune diseases. This therapy is available for intravenous (IV) and subcutaneous (SC) administration. The efficacy of the IG therapy has been demonstrated in numerous studies and across different diseases. Generally, IG infusions are well tolerated; however some well-known adverse reactions, ranging from mild to severe, are associated with the therapy. The most common adverse reactions including headache, nausea, myalgia, fever, chills, chest discomfort, skin and anaphylactic reactions, could arise immediately during or after the infusion. Delayed events could be more severe and include migraine headaches, aseptic meningitis, haemolysis renal impairment and thrombotic events. This paper reviews all the potential adverse events related to IG therapy and establishes a comprehensive guideline for the management of these events. Moreover it resumes the opinions and clinical experience of expert endorsers on the utilization of the treatment. Published data were classified into levels of evidence and the strength of the recommendation was given for each intervention according to the GRADE system.
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Bharath V, Eckert K, Kang M, Chin-Yee IH, Hsia CC. Incidence and natural history of intravenous immunoglobulin-induced aseptic meningitis: a retrospective review at a single tertiary care center. Transfusion 2015; 55:2597-605. [PMID: 26095012 DOI: 10.1111/trf.13200] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/03/2015] [Accepted: 05/10/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aseptic meningitis is a rare but significant complication of intravenous immunoglobulin (IVIG) therapy. The majority of literature is limited to case reports, so the true incidence of this complication is uncertain. STUDY DESIGN AND METHODS A retrospective review of all cases of IVIG-associated adverse transfusion reactions was performed at London Health Sciences Centre (LHSC) from January 1, 2008, to December 31, 2013. All reported transfusion reactions were evaluated to identify cases of aseptic meningitis due to IVIG. All documented IVIG infusions and lumbar punctures performed during the study period were reviewed; patients with both interventions were identified and further chart review was performed to identify aseptic meningitis. RESULTS During our study period, 1324 unique patients received a total of 11,907 IVIG infusions (554,566 g) for various conditions. Eight cases of aseptic meningitis were identified, suggesting an overall incidence of 0.60% for all patients and 0.067% for all IVIG infusions. Patients presented with symptoms within 24 to 48 hours of the infusion and were treated with antibiotics initially. The reactions were self-limited, as symptoms self-resolved within 5 to 7 days. Treatment was supportive, with subsequent IVIG infusions likely requiring preinfusion medication or possibly a switch in product formulation. CONCLUSION This review of IVIG-induced aseptic meningitis over a 6-year period identifies a more robust estimate of incidence and risk of 0.60% and 0.067% for all patients and infusions, respectively. Given that this complication can mimic infectious meningitis and cause considerable morbidity, physicians need to be aware of this rare but important condition.
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Affiliation(s)
- Vighnesh Bharath
- Department of Medicine, London Health Sciences Centre, Victoria Hospital
| | - Kathleen Eckert
- Blood Transfusion Laboratory, London Health Sciences Centre, Victoria Hospital
| | - Matthew Kang
- Division of Hematology, Department of Medicine, London Health Sciences Centre, Victoria Hospital
| | - Ian H Chin-Yee
- Division of Hematology, Department of Medicine, London Health Sciences Centre, Victoria Hospital.,Canadian Blood Services, London, Ontario, Canada
| | - Cyrus C Hsia
- Division of Hematology, Department of Medicine, London Health Sciences Centre, Victoria Hospital
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Abstract
In addition to its U.S. Food and Drug Administration (FDA) approved conditions, immune globulin intravenous (IGIV) is now being used to treat a vast array of autoimmune disorders. Some of the reasons for this overall increase in the use of IGIV include its effectiveness and safety. Despite many years of safe use, side effects and adverse reactions still occur. Common and mild side effects associated with IGIV include: headache, malaise, nausea, low-grade fever, urticaria, arthralgias, and myalgia. These symptoms typically resolve within a few days after their onset. Although rare, the serious and potentially fatal side effects include: anaphylactic reactions, aseptic meningitis, acute renal failure, stroke, myocardial infarction, and other thrombotic complications. Many of these side effects have occurred in patients who have significant, underlying risk factors for the development of the event. Thus, it is vitally important that a thorough and comprehensive medical evaluation be performed on every patient who is being evaluated for potential IGIV therapy. This evaluation can, to some extent, significantly minimize the risk of these side effects. Careful, constant, and close monitoring by trained personnel during the infusion can also result in early detection of such events. Physicians should thoroughly discuss the risks and benefits of IGIV with patients who are being considered for this therapy.
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Abstract
Drug-induced aseptic meningitis (DIAM) is an important entity. This article reviews the literature on this rare idiosyncratic event which may occur after local or systemic drug administration. The data on this adverse reaction is predominantly collated from anecdotal case reports and case series.
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Affiliation(s)
- Susan Hopkins
- Royal Free Hospital, Department of Infection and Immunity, London, UK.
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Abstract
Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.
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Affiliation(s)
- S Jolles
- Division of Cellular Immunology, National Institute for Medical Research, London, England.
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Abstract
This article provides an overview of the clinically relevant complications of the main immunosuppressants currently used in the treatment of neurologic disorders with suspected or established immune etiology. The most serious complications are discussed in detail, including pathophysiology and preventative measures. An intimate knowledge of these complications proves helpful in the day to day practice of the neurologist supervising immunotherapy.
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Affiliation(s)
- H Machkhas
- Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA
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