Aseptic meningitis following intravenous immunoglobulin therapy of common variable immunodeficiency.

Dear Sir,

We read with great interest the case report on “Aseptic meningitis following intravenous immunoglobulin (IVIG) therapy of common variable immunodeficiency (CVID)” published in JPN by Kaarthigeyan et al. and have following comments to offer:

“Enterovirus (EV) associated meningitis is one of the most common cause of meningitis in patients with CVID.[1] In the present case, patient presented with severe headache, vomiting, fever, neck stiffness, and an episode of generalized tonic-clonic seizures suggesting central nervous system (CNS) infection as a cause of meningitis rather than IVIG induced aseptic meningitis. This is further strengthened by raised total leucocyte counts with lymphocytic predominance.

Rudge et al.[1] conclude that EVs are a major cause of the diverse CNS symptoms and signs in patients with CVID. EVs cause a wide variety of diseases that range from non-specific viral illness to mild infections of herpangina and hand, foot, and mouth disease to potentially serious diseases such as myopericarditis, meningitis, myelitis, and neonatal sepsis.[2] Laboratory confirmation of EV associated neurologic disease is typically performed by polymerase chain reaction PCR of cerebro spinal fluid (CSF) samples because of the greater sensitivity and rapid turnaround time, compared with culture.[3] For enteroviral associated neurologic disease, the sensitivity of EV-PCR of CSF samples is reported to be 76-100%.[3] There may be clinical circumstances, in which testing of other specimens (blood, urine, or skin vesicle) may also be useful for diagnosing the enteroviral infections.[4] Magnetic resonance imaging is the cranial imaging of choice in an acute meningoencephalitis and at times computed tomography of the head may be normal.