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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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Young CC, LaRovere KL, Newhams MM, Kucukak S, Gertz SJ, Maddux AB, Halasa NB, Crandall H, Kong M, Fitzgerald JC, Irby K, Randolph AG, Campbell AP, Son MBF. Clinical Course Associated with Aseptic Meningitis Induced by Intravenous Immunoglobulin for the Treatment of Multisystem Inflammatory Syndrome in Children. J Pediatr 2023:113372. [PMID: 36870559 DOI: 10.1016/j.jpeds.2023.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/15/2022] [Accepted: 01/11/2023] [Indexed: 03/06/2023]
Abstract
Aseptic meningitis is a rare but potentially serious complication of intravenous immunoglobulin (IVIG) treatment. In this case series, meningitic symptoms following IVIG initiation in patients with multisystem inflammatory syndrome were rare (7/2,086 [0.3%]). However, they required the need for additional therapy and/or readmission.
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Affiliation(s)
- Cameron C Young
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA; Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston MA, USA
| | - Angela P Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Muacevic A, Adler JR, Chan KYW, Yeung HMR. Immunoglobulin-Induced Aseptic Meningitis in Juvenile Dermatomyositis: A Case Report. Cureus 2022; 14:e31808. [PMID: 36579229 PMCID: PMC9780508 DOI: 10.7759/cureus.31808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
Aseptic meningitis is a known but unusual serious adverse effect of intravenous immunoglobulin (IVIG). It usually resembles infectious meningitis, which makes its diagnosis challenging. In this report, we present the case of a five-and-a-half-year-old Chinese girl with juvenile dermatomyositis (JDM) who presented with signs of meningismus 21 hours after the initiation of IVIG infusion. Her blood work at diagnosis showed neutrophilia and lymphopenia. The cerebrospinal fluid (CSF) analysis demonstrated neutrophilic pleocytosis, hyperproteinorrachia, and normoglycorrhachia. All microbiological tests were negative. The child fully recovered within 72 hours without neurological sequelae. IVIG-induced aseptic meningitis remains a diagnosis of exclusion. Although it is rare, pediatricians should be aware of this complication and avoid unnecessary investigations or treatment.
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Intravenous Immunoglobulin-Induced Aseptic Meningitis—A Narrative Review of the Diagnostic Process, Pathogenesis, Preventative Measures and Treatment. J Clin Med 2022; 11:jcm11133571. [PMID: 35806861 PMCID: PMC9267278 DOI: 10.3390/jcm11133571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022] Open
Abstract
Intravenous immunoglobulins (IVIGs) are widely used in the treatment of numerous diseases in both adult and pediatric populations. Higher doses of IVIGs usually serve as an immunomodulatory factor, common in therapy of children with immune thrombocytopenic purpura. Considering the broad range of IgG applications, the incidence of side effects in the course of treatment is inevitable. Aseptic meningitis, an uncommon but significant adverse reaction of IVIG therapy, can prove a diagnostic obstacle. As of April 2022, forty-four cases of intravenous immunoglobulin-induced aseptic meningitis have been reported in the English-language literature. This review aims to provide a thorough overview of the diagnostic process, pathophysiology, possible preventative measures and adequate treatment of IVIG-induced aseptic meningitis.
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Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version). Pediatr Int 2014; 56:135-58. [PMID: 24730626 DOI: 10.1111/ped.12317] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/04/2014] [Indexed: 12/14/2022]
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Kemmotsu Y, Nakayama T, Matsuura H, Saji T. Clinical characteristics of aseptic meningitis induced by intravenous immunoglobulin in patients with Kawasaki disease. Pediatr Rheumatol Online J 2011; 9:28. [PMID: 21917158 PMCID: PMC3189389 DOI: 10.1186/1546-0096-9-28] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 09/14/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Aseptic meningitis is a serious adverse reaction to intravenous immunoglobulin (IVIG) therapy. We studied the clinical characteristics of patients with acute Kawasaki disease (KD) who developed IVIG-induced aseptic meningitis. METHODS A retrospective analysis of the medical records of patients with KD who developed aseptic meningitis after IVIG treatment was performed. RESULTS During the 10-year period from 2000 through 2009, among a total of 384 patients with Kawasaki disease, 4 (3 females and 1 male; age range, 19-120 months) developed aseptic meningitis after IVIG. All 4 developed aseptic meningitis within 48 hours (range, 25-40 hours) of initiation of IVIG. The analyses of cerebrospinal fluid (CSF) revealed elevated white blood cell counts (22-1,248/μL) in all 4 patients; a predominance of polynuclear cells (65%-89%) was noted in 3. The CSF protein level was elevated in only 1 patient (59 mg/dL), and the glucose levels were normal in all 4 patients. Two patients were treated with intravenous methylprednisolone; the other 2 children were observed carefully without any special therapy. All patients recovered without neurological complications. CONCLUSIONS In our patients with Kawasaki disease, aseptic meningitis induced by IVIG occurred within 48 hours after initiation of IVIG, resolved within a few days, and resulted in no neurological complications, even in patients who did not receive medical treatment.
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Affiliation(s)
- Yasushi Kemmotsu
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Toho University, Tokyo 143-8541, Japan.
| | - Tomotaka Nakayama
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Toho University, Tokyo 143-8541, Japan
| | - Hiroyuki Matsuura
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Toho University, Tokyo 143-8541, Japan
| | - Tsutomu Saji
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Toho University, Tokyo 143-8541, Japan
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García Norniella B, Morán Poladura M, Fernández Díaz M, Fernández Fernández E, Suárez Castañón C. [Aseptic meningitis secondary to intravenous immunoglobulin treatment in Kawasaki disease]. An Pediatr (Barc) 2011; 75:79-80. [PMID: 21420919 DOI: 10.1016/j.anpedi.2010.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 11/05/2010] [Accepted: 11/08/2010] [Indexed: 11/19/2022] Open
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Jarius S, Eichhorn P, Albert MH, Wagenpfeil S, Wick M, Belohradsky BH, Hohlfeld R, Jenne DE, Voltz R. Intravenous immunoglobulins contain naturally occurring antibodies that mimic antineutrophil cytoplasmic antibodies and activate neutrophils in a TNFα-dependent and Fc-receptor–independent way. Blood 2007; 109:4376-82. [PMID: 17264299 DOI: 10.1182/blood-2005-12-019604] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Intravenous immunoglobulin (IVIg) preparations are increasingly used for therapy of several neuroimmunologic diseases. IVIg therapy is considered safe, although serious side effects like aseptic meningitis, cerebral vasospasm, or ischemic encephalopathy have been reported. These side effects are frequently associated with neutrophilic pleocytosis in the cerebrospinal fluid (CSF), suggesting a neutrophil-mediated mechanism. To elucidate the potential role of neutrophil activation, we analyzed IVIg preparations from 5 different commercial sources for the presence of antineutrophil cytoplasmic antibody (ANCA)–like immunoglobulins against ethanol-fixed peripheral-blood neutrophils, purified human antigens, and a panel of human and nonhuman tissues. All IVIg batches tested (n = 13) contained atypical ANCAs (IgG titer up to 1:2048, IgA up to 1:512). Moreover, all preparations were capable of inducing hydrogen peroxide production in TNFα-primed human neutrophils, with a significant correlation (P < .005) between atypical ANCA titers in IVIg preparations and neutrophil activation. Fc-mediated binding and activation was ruled out by the use of IVIg-F(ab′)2 fragments. Our findings strongly suggest that in vivo activation of TNFα-primed neutrophils by atypical ANCAs of IVIg may contribute to the side effects of IVIg therapy and for the first time demonstrate that the activation of neutrophil granulocytes by IVIg occurs in an Fc receptor (FcR)–independent, hence antigen-dependent, way.
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Affiliation(s)
- Sven Jarius
- Institute of Clinical Neuroimmunology, Ludwig Maximilians University, Munich, Germany
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Obando I, Duran I, Martin-Rosa L, Cano JM, Garcia-Martin FJ. Aseptic meningitis due to administration of intravenous immunoglobulin with an unusually high number of leukocytes in cerebrospinal fluid. Pediatr Emerg Care 2002; 18:429-32. [PMID: 12488836 DOI: 10.1097/00006565-200212000-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ignacio Obando
- Division of Pediatric Emergency Medicine, Hospital Meterno-Infantil Carlos Haya, Malaga, Spain.
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Abstract
Kawasaki disease is a systemic vasculitis of unknown aetiology that has been reported worldwide since its initial description in Japanese children. The most significant sequelae of acute Kawasaki disease are related to the inflammation of small to medium sized arteries and, in particular, the development of coronary artery aneurysms. Because the aetiology is unknown, pharmacological therapy is nonspecific and directed towards modulation of the inflammatory response and inhibition of platelet activation with the aim of preventing coronary artery aneurysms. In the US, the recommended treatment for Kawasaki disease in the acute phase is a single, high dose of intravenous gammaglobulin (2 g/kg) and high dose aspirin (80 to 100 mg/kg/day). Use of this regimen has resulted in a significant decrease in the incidence of coronary artery abnormalities. Although the American Heart Association currently recommends high dose aspirin, moderate doses are used in Japan and the optimal dose of aspirin is not known. There has been renewed interest in the use of corticosteroids in the treatment of acute Kawasaki disease: however, their precise role remains unclear. Newer antiplatelet agents have also shown some promise in the treatment of patients with coronary artery aneurysms. Long term pharmacological therapy consists primarily of anticoagulation in patients with persistent coronary artery abnormalities. In this review, current recommendations for pharmacological therapy in Kawasaki disease are reviewed and some of the controversies in management of this disease, including management of patients who do not respond to initial therapy and the role of corticosteroids in the acute setting, are outlined.
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Affiliation(s)
- R V Williams
- Department of Pediatrics, Division of Cardiology, University of Utah and Primary Children's Medical Center, Salt Lake City 84113, USA.
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