A 34-year-old woman with multiple sclerosis treated with ublituximab developed enteroviral meningoencephalitis, highlighting the risk of viral CNS infections with B-cell-depleting therapies.
Case Report (n=1)
Highlights the risk of opportunistic viral CNS infections, such as enteroviral meningoencephalitis, in MS patients receiving B-cell-depleting therapies like ublituximab.
Abstract Background Multiple Sclerosis (MS) patients receiving B-cell-depleting therapies such as Ublituximab are at increased risk for opportunistic and atypical infections. Viral central nervous system infections in this population may mimic MS relapse, posing a diagnostic challenge. We present the uncommon case of enterovirus meningoencephalitis in a patient being treated with Ublituximab for MS. HPI: A 34-year-old woman with relapsing-remitting MS on Ublituximab, with last infusion four months prior, presented with a six-day history of bifrontal headache and high-grade fever of 105 °F along with right lower extremity weakness. She reported nausea, vomiting, and malaise but denied photophobia, neck stiffness, or rash. She reported a sick contact with her son who had diarrhea. Physical examination demonstrated 4/5 strength in the right lower extremity, mild maxillary sinus tenderness, and no meningeal signs. Her condition rapidly progressed to confusion and lethargy, requiring ICU admission. Rapid influenza testing was positive for Influenza B. Lumbar puncture revealed lymphocytic pleocytosis (197/mm3), normal glucose (61mg/dl), and mildly elevated protein (84.5mg/dl); Cerebro-spinal Fluid (CSF) cultures were negative. MRI of the brain showed chronic demyelinating plaques consistent with MS, without new or enhancing lesions. Continuous EEG was negative for epileptiform discharges. Viral PCR of CSF was positive for enterovirus, consistent with viral meningoencephalitis. The patient was treated with Intravenous immunoglobulin (IVIG) and oseltamivir. Neurological status improved over several days with gradual resolution of confusion and lower extremity weakness. Discussion Enteroviral meningoencephalitis should be considered in patients presenting with headache, fever, and altered mental status.This case highlights the susceptibility of patients on anti-CD20 monoclonal antibodies to viral CNS infections. As monoclonal antibody treatments become more popular, clinicians should maintain a high degree of suspicion for opportunistic infections. Ublituximab was approved for treatment of relapsing MS in 2022. Although it has not been directly linked to enteroviral meningoencephalitis, this appears to be the first reported case. The mechanism of B cell depletion and observed hypogammaglobulinemia would plausibly increase susceptibility to viral CNS infections as seen with other anti-CD 20 agents. A 2021 case report and systematic review reported an improvement in survival among patients with similar characteristics. Nonetheless, IVIG has also been employed off-label for the management of secondary hypogammaglobulinemia, which motivated us to pursue this therapeutic approach in our case. Conclusion Enteroviral meningoencephalitis is a rare but serious complication in MS patients receiving B-cell-depleting therapy. Differentiating infection from MS relapse is crucial to ensure timely and appropriate management. This abstract is funded by: None
Paul et al. (Fri,) conducted a case report in Multiple Sclerosis and Enteroviral Meningoencephalitis (n=1). Ublituximab was evaluated. A 34-year-old woman with multiple sclerosis treated with ublituximab developed enteroviral meningoencephalitis, highlighting the risk of viral CNS infections with B-cell-depleting therapies.