High-dose intravenous immunoglobulin in the treatment of rituximab-induced B- cell dysfunction complicated with enteroviral meningoencephalitis

Abstract

Background: Rituximab (chimeric anti- CD20 monoclonal antibody) is indicated for the treatment in various autoimmune diseases as well as B cell lymphoid malig- nancies. Treatment with rituximab in concert with chemotherapy or immunosup- pressive agents may induce the develop- ment of prolonged secondary hypogammaglobulinemia and it can lead to severe and opportunistic infections. We report a case of a patient with low-grade B-Cell non-Hodgkin‘s lymphoma compli- cated with enteroviral meningoencephalitis after treatment with rituximab, which was successfully managed with high-dose intra- venous immunoglobulin (hdIVIg). Case report: A 33-year-old woman with low-grade B-Cell non-Hodgkin‘s lym- phoma showed complete remission after 8 standard cycles of treatment with ritux- imab and radiotherapy. However, after 8 months of maintenance therapy with rituximab she developed symptoms typical for meningoencephalitis. Cerebrospinal fluid (CSF) examination showed lymphocy- tosis >1328 x10 6 /l, elevated total protein (4.3 g/l) and normal glucose levels (2.2 mmol/l). In the CSF enterovirus RNA was detected by polymerase chain reaction (PCR), other viral infections were excluded. Immunophenotyping of periph- eral blood lymphocytes showed significant reduction of B-cell population. Immunoglobulin (Ig) levels were low: IgG 6.18 g/l (reference range 7.9–16.4 g/l), IgA 0.96 g/l (0.7–4.4 g/l), IgM 1.69 g/l (0.4– 2.8 g/l). The patient received a 5-day course of hdIVIg (total 2 g/kg). Clinical symptoms of meningoencephalitis disap- peared within 2 weeks, whereas patient’s Ig levels have reached the normal range only after 2 months. However, the amount of B-cells remains continuously reduced. Conclusion: The hdIVIg therapy improved enteroviral meningoencephalitis symptoms in a patient with rituximab-induced [...].