Aseptic Meningitis Due to Intravenous Immunoglobulin Therapy That Resolved with Subcutaneous Administration

Abstract

Aseptic meningitis is a rare but well recognized severe complication of high-dose intravenous immunoglobulin (IVIG) therapy. We report the case of a 9-year-old female who presented with functional hypogammaglobulinemia and recurrent sinopulmonary infections refractory to antibiotic prophylaxis. She was started on replacement dose IVIG therapy that was complicated by the development of headache, nuchal rigidity, photophobia, fever, nausea, vomiting, and lethargy after most infusions. Clinical evaluation and two cerebrospinal fluid analyses were consistent with aseptic meningitis. Interventions such as slower rates, in-line filters, dilute preparations, manufacturer change, and pretreatment were largely ineffective. The addition of post-IVIG oral corticosteroids attenuated the severity of symptoms, but the patient's quality-of-life and school attendance continued to suffer. In light of a continued need for therapy, mounting intravenous access difficulties, and requirement for frequent high dose corticosteroids, a trial of subcutaneous immunoglobulin infusion was initiated. She has tolerated this therapy for more than 3 years without serious adverse effects or need for corticosteroids, and continues to achieve clinical benefit by this route. A recent rechallenge with IVIG resulted in recurrent symptoms. Disabling aseptic meningitis and severe headache are rare complications of replacement-dose IVIG. It is noteworthy that aseptic meningitis has been previously described for replacement IVIG therapy in only one other child, but the refractory nature of this side effect in the index case described is unique in the literature. Subcutaneous immunoglobulin infusion is an effective and well-tolerated alternative to IVIG, especially in the setting of recurrent aseptic meningitis. (Pediatr Asthma Allergy Immunol 2000;14[4]:323–327.