Patel Anish, Potu Kalyan Chakravarthy, Sturm Tamera
Department of Internal Medicine, University of South Dakota Sanford School of Medicine.
S D Med. 2017 Mar;70(3):119-121.
Intravenous immunoglobulin (IVIG) is a commonly used and generally well-tolerated medication. Common side effects include flu-like symptoms such as fevers, headaches, myalgia, fatigue, and nausea. One of the more rare side effects is aseptic meningitis, with a reported incidence rate of around 0.067 percent of all IVIG infusions. In this paper, we describe a 47-year-old female patient with a history of myasthenia gravis who presented with a headache, neck pain, and neck stiffness while undergoing IVIG infusions for a myasthenia crisis. On admission day, the patient was afebrile with stable vital signs. A physical examination revealed nuchal rigidity and tenderness with no focal neurological deficits. Cerebrospinal fluid (CSF) cytology noted an elevated white blood cell (WBC) count of 1,138 cells/μL with a neutrophil predominance (96 percent). CSF red blood cell count was unremarkable at 1 cell/μL. The patient's IVIG infusions were stopped, suspecting chemical meningitis. Given the markedly elevated CSF WBC count with neutrophil predominance, she was started on vancomycin and ceftriaxone to also cover for bacterial meningitis. The patient's meningeal signs and symptoms significantly improved 24 hours after admission. Given the clear temporal relationship to IVIG administration and the rapid improvement of symptoms, IVIG-induced aseptic meningitis is strongly suspected. The patient's antibiotics were discontinued. Forty-eight hours after stopping IVIG and 24 hours after discontinuing antibiotics, her meningitis symptoms completely resolved with the use of analgesics alone. The patient was then discharged uneventfully. CSF viral and bacterial studies, including a gram stain and cultures, did not result in anything noteworthy. Our case presents an interesting diagnostic dilemma where drug-induced (IVIG) aseptic meningitis mimics bacterial meningitis clinically and on CSF analysis. The clear temporal relationship to IVIG administration and the rapid resolution of symptoms upon stopping the drug can aid in the diagnosis of this rare event and help doctors avoid the use of unnecessary antibiotic therapy.
静脉注射免疫球蛋白（IVIG）是一种常用且普遍耐受性良好的药物。常见副作用包括流感样症状，如发热、头痛、肌痛、疲劳和恶心。较为罕见的副作用之一是无菌性脑膜炎，据报道在所有IVIG输注中发生率约为0.067%。在本文中，我们描述了一名47岁患有重症肌无力病史的女性患者，在因重症肌无力危象接受IVIG输注时出现头痛、颈部疼痛和颈部僵硬。入院当天，患者体温正常，生命体征稳定。体格检查发现颈项强直和压痛，无局灶性神经功能缺损。脑脊液（CSF）细胞学检查显示白细胞（WBC）计数升高至1138个细胞/μL，以中性粒细胞为主（96%）。脑脊液红细胞计数为1个细胞/μL，无异常。怀疑化学性脑膜炎，停止了患者的IVIG输注。鉴于脑脊液白细胞计数显著升高且以中性粒细胞为主，开始使用万古霉素和头孢曲松以覆盖细菌性脑膜炎。入院24小时后患者的脑膜体征和症状明显改善。鉴于与IVIG给药有明确的时间关系且症状迅速改善，强烈怀疑为IVIG诱导的无菌性脑膜炎。停用了患者的抗生素。停止IVIG输注48小时后及停用抗生素24小时后，仅使用镇痛药她的脑膜炎症状就完全消失了。然后患者顺利出院。脑脊液病毒和细菌学检查，包括革兰氏染色和培养，未发现任何值得注意的结果。我们的病例呈现了一个有趣的诊断难题，即药物诱导（IVIG）的无菌性脑膜炎在临床和脑脊液分析上模拟细菌性脑膜炎。与IVIG给药明确的时间关系以及停药后症状迅速缓解有助于诊断这一罕见事件，并帮助医生避免使用不必要的抗生素治疗。
