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Thebault S, Gandelman S, Lane C, Kim EJ, Pileggi C, Zuroff L, Yamashita LD, Schindler MK, Chiu C, Wilson MR, Berger JR, Markowitz C, Bar-Or A, Fuller R, Brandstadter R, Pruitt AA, Jacobs DA. Severe Neuroinvasive West Nile Virus in Association With Anti-CD20 Monotherapy for Multiple Sclerosis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200154. [PMID: 37562975 PMCID: PMC10414775 DOI: 10.1212/nxi.0000000000200154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES The objective of this study was to report on the development of neuroinvasive West Nile virus (WNV) infection in the context of anti-CD20 monotherapy for multiple sclerosis (MS). METHODS This is a case series study. RESULTS In 2021-2022, we observed 4 cases of neuroinvasive WNV infection in our patient population of 2009 patients with MS on ocrelizumab, compared with a total of 46 cases of neuroinvasive WNV infection reported in Pennsylvania and 40 in New Jersey. Odds were 258 times that of the general population (95% confidence interval 97-691), χ2 p < 0.0001). All were women aged 41-61 years with variable disease duration, level of disability, and duration of anti-CD20 therapy. All presented in summer/early fall with fever, headache, and encephalopathy consistent with meningoencephalitis. Three patients had acute cerebellitis. Two had anterior nerve root involvement progressing to quadriparesis, and 1 developed refractory nonconvulsive status epilepticus. All required intubation and experienced significant morbidity. All had CSF pleocytosis. Two patients were WNV IgM positive in both the serum and CSF, 1 patient had positive serum IgM and CSF metagenomic next-generation sequencing (mNGS), while 1 had positive CSF mNGS with negative serum and CSF antibodies. DISCUSSION Neuroinvasive WNV infection can develop with anti-CD20 monotherapy in the absence of additional immunosuppression. WNV serologies may be negative in the setting of anti-CD20 treatment; in the appropriate clinical context, one should consider direct detection methods such as PCR or mNGS-based testing.
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Affiliation(s)
- Simon Thebault
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco.
| | - Stephanie Gandelman
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Camryn Lane
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Erin J Kim
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Caitlin Pileggi
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Leah Zuroff
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Luana D Yamashita
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Matthew K Schindler
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Charles Chiu
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Michael R Wilson
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Joseph R Berger
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Clyde Markowitz
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Amit Bar-Or
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Ryan Fuller
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Rachel Brandstadter
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Amy A Pruitt
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
| | - Dina A Jacobs
- From the Division of Multiple Sclerosis (S.T., S.G., C.L., E.J.K., C.P., L.Z., L.D.Y., M.K.S., J.R.B., C.M., A.B.-O., R.F., R.B., A.A.P., D.A.J.), Hospital of the University of Pennsylvania and Perelman School of Medicine; Division of Infectious Diseases (C.C.), Department of Medicine; and Weill Institute for Neurosciences (M.R.W.), Department of Neurology, University of California, San Francisco
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Kapadia RK, Staples JE, Gill CM, Fischer M, Khan E, Laven JJ, Panella A, Velez JO, Hughes HR, Brault A, Pastula DM, Gould CV. Severe Arboviral Neuroinvasive Disease in Patients on Rituximab Therapy: A Review. Clin Infect Dis 2023; 76:1142-1148. [PMID: 36103602 PMCID: PMC10011006 DOI: 10.1093/cid/ciac766] [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] [Received: 07/01/2022] [Revised: 09/02/2022] [Accepted: 09/09/2022] [Indexed: 11/12/2022] Open
Abstract
With increasing use of rituximab and other B-cell depleting monoclonal antibodies for multiple indications, infectious complications are being recognized. We summarize clinical findings of patients on rituximab with arboviral diseases identified through literature review or consultation with the Centers for Disease Control and Prevention. We identified 21 patients on recent rituximab therapy who were diagnosed with an arboviral disease caused by West Nile, tick-borne encephalitis, eastern equine encephalitis, Cache Valley, Jamestown Canyon, and Powassan viruses. All reported patients had neuroinvasive disease. The diagnosis of arboviral infection required molecular testing in 20 (95%) patients. Median illness duration was 36 days (range, 12 days to 1 year), and 15/19 (79%) patients died from their illness. Patients on rituximab with arboviral disease can have a severe or prolonged course with an absence of serologic response. Patients should be counseled about mosquito and tick bite prevention when receiving rituximab and other B-cell depleting therapies.
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Affiliation(s)
- Ronak K Kapadia
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Neurology, Department of Clinical Neurosciences, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - J Erin Staples
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Christine M Gill
- University of Iowa, Carver College of Medicine, Department of Neurology, Iowa City, Iowa, USA
| | - Marc Fischer
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Ezza Khan
- Hunterdon Infectious Disease Specialists, Flemington, New Jersey, USA
| | - Janeen J Laven
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Amanda Panella
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Jason O Velez
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Holly R Hughes
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Aaron Brault
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Daniel M Pastula
- Neuro-Infectious Diseases Group, Department of Neurology and Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Carolyn V Gould
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Krett JD, Beckham JD, Tyler KL, Piquet AL, Chauhan L, Wallace CJ, Pastula DM, Kapadia RK. Neurology of Acute Viral Infections. Neurohospitalist 2022; 12:632-646. [PMID: 36147750 PMCID: PMC9485684 DOI: 10.1177/19418744221104778] [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] [Indexed: 11/16/2022] Open
Abstract
As specialists in acute neurology, neurohospitalists are often called upon to diagnose and manage acute viral infections affecting the nervous system. In this broad review covering the neurology of several acute viral infections, our aim is to provide key diagnostic and therapeutic pearls of practical use to the busy neurohospitalist. We will review acute presentations, diagnosis, and treatment of human herpesviruses, arboviruses, enteroviruses, and some vaccine-preventable viruses. The neurological effects of coronaviruses, including COVID-19, are not covered in this review.
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Affiliation(s)
- Jonathan D Krett
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - J David Beckham
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Departments of Immunology & Microbiology, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Kenneth L Tyler
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Departments of Immunology & Microbiology, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Amanda L Piquet
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
| | - Lakshmi Chauhan
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
| | - Carla J Wallace
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Daniel M Pastula
- Department of Neurology and Division of Infectious Diseases, Anschutz Medical Campus, University of Colorado Neurosciences Center, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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