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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: 11] [Impact Index Per Article: 5.5] [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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Abstract
Purpose of Review West Nile virus (WNV) is an arbovirus transmitted by mosquitos of the genus Culex. Manifestations of WNV infection range from asymptomatic to devastating neuroinvasive disease leading to flaccid paralysis and death. This review examines WNV epidemiology and ecology, with an emphasis on travel-associated infection. Recent Findings WNV is widespread, including North America and Europe, where its range has expanded in the past decade. Rising temperatures in temperate regions are predicted to lead to an increased abundance of Culex mosquitoes and an increase in their ability to transmit WNV. Although the epidemiologic patterns of WNV appear variable, its geographic distribution most certainly will continue to increase. Travelers are at risk for WNV infection and its complications. Literature review identified 39 cases of documented travel-related WNV disease, the majority of which resulted in adverse outcomes, such as neuroinvasive disease, prolonged recovery period, or death. Summary The prediction of WNV risk is challenging due to the complex interactions of vector, pathogen, host, and environment. Travelers planning to visit endemic areas should be advised regarding WNV risk and mosquito bite prevention. Evaluation of ill travelers with compatible symptoms should consider the diagnosis of WNV for those visiting in endemic areas as well as for those returning from destinations with known WNV circulation.
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