Objective:

Enterovirus is a diverse group of viruses transmitted via direct contact that can cause a variety of conditions including life-threatening illnesses. Here, we report a case of chronic relapsing enteroviral encephalomyelitis in a patient with a history of polyangiitis granulomatosis who was being treated with rituximab to discuss his course of illness and selective treatments.

Background:

A 26-year-old male with history of polyangiitis granulomatosis on Rituximab every 6 months and enterovirus meningoencephalitis with perimyocarditis presented with progressive change in mentation, memory, difficulty performing tasks, and anxiety. He was found to have multiple, brief, generalized clustered seizures and cerebellar ataxia so started on Keppra, Vimpat, and Depakote. MRI brain w/wo contrast revealed increased T2 FLAIR signal in the pons, midbrain, anteromedial temporal lobes, and insula of the frontal lobes. Given his history he was empirically started on acyclovir and methylprednisolone. LP sent for mNGS testing and positive for Enterovirus consistent with Coxsackievirus B5. Temporal brain biopsy confirmed encephalitis. Due to minimal improvement, the patient was started on IVIG for a 5-day course. Though clinically improved, he unfortunately had multiple re-admissions due to recurrent neurocognitive decline. He continued monthly IVIG, but given ongoing deterioration, he started on a 14-day course of an investigational drug Pocapavir IV therapy for severe enterovirus encephalitis. He had some meaningful improvement with IVIG and Pocapavir in the acute setting but continued to have chronic decline to overall neurologic health.  

Design/Methods:

not applicable

Results:

not applicable

Conclusions:

Rituximab can cause profound B-cell deficiency and thus predispose people to enterovirus encephalitis. There is no current specific antiviral therapy for enterovirus. One study on chronic enteroviral meningoencephalitis in patients with agammaglobulinemia did show some potential promise with IVIg. A literature search was completed on enteroviral meningoencephalitis treated with Pocapavir in adults and only 2 cases were found.