Case Presentation:
The patient is a 33‐year‐old white woman with dermatomyositis who was well until she awoke one night with a severe frontal and bibasilar headache associated with neck stiffness, bilateral eye and neck pain on movement, chills, nausea, and vomiting. She noted that her 2‐year‐old son had had a mild viral illness recently. The patient's current medications include prednisone, mycophenolate, and hydroxychloroquine; she received her first dose of intravenous immune globulin (IVIG) the previous afternoon. She had no history of opportunistic infections. On physical examination, the patient was afebrile with normal vital signs. She was alert and oriented. There were no focal neurological abnormalities. Extraocular movement was painful but not limited. Her neck was supple but painful on passive and active flexion. She had plethora of her face and upper chest but no other rashes. She had bilateral MCP joint Gottron's papules. The remainder of the exam was unremarkable. A lumbar puncture yielded slightly turbid, colorless, clear fluid, with 295 RBC/μL and 2425 WBC/μL (93% neutrophils). A CSF gram stain showed many neutrophils, few monocytes, and no organisms. Glucose was 37 mg/dL, and protein was 208 mg/dL. Serum WBC count was 3.2. Head CT revealed no significant abnormalities. Patient was placed on vancomycin, ceftazidime, acyclovir, and dexamethasone. Isolation precautions were initiated, and immune modulating agents were held. The patient's headache gradually resolved. CSF gram stain, cultures, viral antigen serologies were negative at 48 hours. Antibiotics were stopped, and immunomodulators were resumed. The patient was discharged home with a presumed diagnosis of IVIG‐related aseptic meningitis. A repeat LP done the next day when she was reevaluated for a post‐LP headache showed no WBCs and no organisms on gram stain or culture.
Discussion:
Since its introduction in 1952, IVIG has increasingly been used for many conditions. Common “mild' side effects include headaches, fatigue, nausea, and vomiting. Aseptic meningitis is infrequently reported and typically develops within the first 24‐48 hours of IVIG infusion. CSF analysis shows leukocyte pleocytosis and elevated protein and IgG concentrations. Symptoms usually resolve without sequelae within 3 to 5 days. Corticosteroids do not appear to be protective. Recurrent symptoms usually develop on rechallenge with IVIG.
Conclusions:
Aseptic meningitis related to IVIG administration is an uncommon but well‐recognized phenomenon. The temporal relationship between drug administration and symptoms suggests the diagnosis. Hospitalists must be aware of this condition, as most patients receiving IVIG will have some form of immune compromise; however, a lack of awareness of this condition could lead to inappropriate use of antibiotics and hospital resources.
Author Disclosure:
T. S. Hamieh, none; D. Pierre, none; M. Rabbat, none; C. Whinney, none.