Management of aseptic meningitis secondary to intravenous immunoglobulin

Editor—Picton and Chisholm describe a case of aseptic meningitis related to high dose intravenous immunoglobulin diagnosed on the basis of eosinophils in the cerebrospinal fluid.¹ This adverse effect varies in presentation from a transient headache after the infusion to vomiting, photophobia, neck stiffness, and severe headache. The timing of symptoms may be delayed by up to seven days, though most occur within 48 hours after the treatment.² The symptoms are not always recurrent, particularly with the milder forms. The mechanism is not understood, and any interventions are empirical.

Several measures are helpful in managing those patients who have an ongoing requirement for high dose intravenous immunoglobulin. When starting treatment we use a slow rate and a dilute solution of immunoglobulin. The first dose (of 2 g/kg total) is given over five days at a 3% solution—that is, 0.4 g/kg/day not faster than 6 g per hour. This approximates more closely the infusion rate and dilution usually given as replacement for hypogammaglobulinaemia, where complications such as aseptic meningitis are much less frequent. When the initial treatment has been uncomplicated the next infusion of 2 g/kg can be given over three days and if successful then reduced to a two day administration time. The concentration may also be increased to 12%, reducing nursing time to change the bottles. The patient needs to be encouraged to maintain a good fluid intake.

If symptoms occur over the first 48 hours of treatment with high dose intravenous immunoglobulin it is possible to use paracetamol alone or with codeine as premedication and to tailor the rate of subsequent infusions. In addition, prehydration and the use of an antihistamine—for example, cetirizine, which may influence eosinophil migration in addition to blocking H₁ receptors—has been helpful in some patients.

Recognition of aseptic meningitis as an adverse reaction of high dose intravenous immunoglobulin is important as it may be treated effectively in many patients, allowing the continuation of treatment. Computed tomography and lumbar puncture may be avoided, particularly when high dose intravenous immunoglobulin is used for one of its many unlicensed indications (accounting for 60% of its use) in a setting of limited experience with this form of treatment.