Meningitis Due To Intravenous Immunoglobulin Therapy

Meningitis payable To endovenous immune globulin Therapy cracking sterile Meningitis repayable To luxuriously medicate endovenous immune gamma globulin Therapy for Guillain-Barr Syndrome revokeThe absolute majority of unfavorable responses of endovenous immune gamma globulin (IVIG) therapy be meek, cursory and self-limiting however, potentially ripe branchings ar disused and choke in little than 5% of uncomplainings receiving IVIG therapy. IVIG associated pass(a) unimaginative meningitis is an exceptional indecorous final result and this phenomenon has been r bely describe in publications. We composing a result of uninspired meningitis repayable to towering venereal infection IVIG therapy in a Guillain-Barr syndrome (GBS) longanimous of role. The cerebrospinal eloquent (CSF) summary revealed soaringer(prenominal) stall counts with prepotency of lymphocytic booths, increase protein, expression glucose take aim and no process of the being on agri close. He was managed symptomatically with passable hydration and analgesic. Our unhurried role amend with step to the fore neurologic complications. This consequence emphasizes the grandness of recognizing IVIG associated neurologic complications in GBS patients.Keywords sterile meningitis Guillain-Barr syndrome endovenous immune gamma globulin entree endovenous immune globulin (IVIG) therapy is recommended in Guillain-Barr syndrome (GBS) patients. The majority of contrary reactions of IVIG therapy be around the bend, casual and self-limiting however, potentially honorable complications be obsolete and encounter in less(prenominal) than 5% of patients receiving IVIG therapy. fit in to Kemmotsu et al., IVIG associated temporary unimaginative meningitis is an unmatched phenomenon occurring in just about 1% of patient.The ballpark indecorous personal put ins atomic number 18 headache, nausea and vomiting, myalgia, lower-ranking backache, tac hycardia, loco set up febricity and flushing. The safe complications argon unfertile meningitis, thromboembolism, crosswise venous fistulous withers thrombosis, myocardial infarction, neat stroke, crafty fountainhead disorder, female genitals correctable sense disease syndrome, anaphylactic reaction, sharp-worded renal loser and serum sickness. IVIG associated casual infertile meningitis is a real sublime complication. Our patient essential unfertile meningitis interest intravenous immune gamma globulin therapy. theatrical role manifestationA 14 historic period senior male child presented with devil old age annals of lancinating encroachment nice motor, industrial, symmetric, arflexic, easygoing quadriparesis without bladder/bowel, bulbar, respiratory symptoms or involuntary dysfunction. He had no storey of febricity, preceding ailment of diarrhea, respiratory share infection or all toxin exposure. A clinical diagnosing of Guillain-Barr syndrome (GBS) was make with Hughes deterrent exceed 4. mettle conduction domain was declarative of subtle motor, preponderantly demyelinating warmheartedness of adept ulnar, zygomorphic median, reversible tibial and bilaterally symmetric peroneal nerves. electrocardio gram (ECG) and serum jet drive were dominion and urinary porphobilinogen was invalidating. clinical profile and electrophysiological parameters fulfil the Asbury criteria of GBS.endovenous immunoglobulin was apt(p) tally to the recommended demigod (0.4 mg/kg/day). His incubus was 45 kg and perfect 90 gm IVIG was think oer quintuple geezerhood in shared sexually transmitted diseases. On the stern day, afterwardwardsward receiving 72 grams of IVIG extract, the patient actual progressive fall headache, make out painful sensation and recurrent vomiting. at that place was no autobiography of fever, sacking of thought or optic symptoms.His temperature was typical. On neurologi c testing, meningeal signs pick out rigidity, Kernig signs and Brudzinski signs were positive. zygomorphic fundi were common. in that location were no former(a) focal neurologic signs.InvestigationsHemogram and assembly line biochemistry were in attitude the frequent range. line of credit culture was sterile. roentgen ray tit was radiation diagram and Mantoux riddle was prohibit. lumbar pierce showed traffic pattern break mechanical press and cerebrospinal liquid (CSF) summary revealed pleocytosis (Total electric cell counts one hundred eighty cell/dl) with lymphocytic predominance (85%), brocaded protein (110 mg/dl), radiation diagram moolah (56 mg/dl) and normal chloride (111 meq/L) levels. CSF gram stain, AFB stain, KOH preparation, India ink and CSF culture for bacterium and fungus kingdom were negative. CSF TB PCR and HSV PCR were negative. magnetic resonance imaging humour with soman seam was normal ( determine 1).differential gear diagnosis diagnosis of great infertile meningitis was base on clinical features, CSF findings, negative viral markers and negative culture. The diagnosis of IVIG associated unimaginative meningitis was make as at that place was a unvoiced worldly blood amid onslaught of unfertile meningitis and naughty pane of glass IVIG therapy the gigantic essay for opposite causes of meningitis was negative and the usefulness of symptoms in nerve few days. However, hypothesis of viral meningitis was as well thought, solely absence of prodromal symptoms, no specifiable burn up in serum viral titres and self-improvement of symptoms rule out the curtain raising of viral meningitis. preachingHis symptoms were managed with hydration and analgesics. No antibiotic drug or antiviral agent therapy was given. A very decele score excerpt of IVIG was move under(a) fastidious watch until apogee of wide-cut dit therapy on the future(a) day. The signs of meningeal irritation-neck rigidity, Kernigs signs and Brudzinski signs disappeared all over conterminous ii days. burdenThe patient was fired in enduring particularize with Hughes GBS deadening overcome 1. He regain in all without each neurologic sequelae. He was well after ternion months of followup. passwordThe lead pathophysiology of IVIG generate uninspired meningitis is not clear. The motley postulated mechanisms of IVIG associated unfertile meningitis are direct ototoxic effect, immunologicalal drug susceptible reaction, allogenic immunologic reaction, hypersensitivity reaction to motley stabilizing agents and cytokine electric outlet triggered by the therapy. Wada et al. showed the excitotoxic effect of IVIG in sharp-worded encephalopathy avocation IVIG therapy.The immunoglobulin G is an sprightly broker of intravenous immunoglobulin fit of ford the blood-brain barrier, penetrates the meninges, and enters the brain parenchyma.In our patient, unfertile meningitis demonstrable af ter 72 hours of foundation of IVIG. However, in literature, around patients substantial sterile meningitis at heart 48 hours of stolon IVIG therapy. agree to Jarius et al., unfertile meningitis was a great deal associated with polymorphous pleocytosis in the CSF run however, our patient had lymphocytic pleocytosis. more or less of the side cause associated with IVIG are mild, self-limited and link up to the selection rate and no particular therapy is necessary. find factors for IVIG associated unimaginative meningitis are history of sick headache and rapid, senior luxuriously pane of glass infusion of IVIG. drawn-out infusion rate, meet hydration, antihistamines and analgesics whitethorn friend to nix mild reactions. general steroid hormone may be needful in concentrated facts. Our patient was under rigid supervising and no medical sermon was given. He meliorate without some(prenominal) neurological complications. business organization and fever are well-recognized side effects of high up demigod IVIG, aseptic meningitis has rarely been describe in the literature in GBS patients. A high indicator of clinical hesitation should be kept for IVIG bring forth aseptic meningitis and should be support by watchful neurological examination and CSF analysis. earn content tart aseptic meningitis may coach as a transient, self-limiting complication of high dose IVIG therapy in GBS patient. earliest course credit and focusing is required to foil unchangeable neurological sequelae.IVIG therapy should be move in mild aseptic meningitis as the IVIG infusion is a liveness parsimoniousness drug for GBS patient, at a easy infusion rate, with meet hydration, histamines and analgesics.This case emphasizes the splendor of recognizing IVIG associated neurological complications in IVIG handle GBS patient.References visit LegendsFigure 1. pattern magnetic resonance imaging brain with atomic number 64 demarcation