Abstract
West Nile virus neuroinvasive disease (WNVND) manifests with meningitis, encephalitis, and/or acute flaccid paralysis. It represents less than 1% of the clinical syndromes associated with West Nile virus (WNV) infection in immunocompetent patients. Immunosuppressive therapy is associated with increased risk of WNVND and worse prognosis. We present a patient with WNVND during therapy with rituximab, and a review of the literature for previous similar cases with the goal to describe the clinical spectrum of WNVND in patients treated specifically with rituximab. Our review indicates that the most common initial complaints are fever and altered mental status, brain magnetic resonance imaging often shows bilateral thalamic hyperintensities, and cerebrospinal analysis consistently reveals mild lymphocytic pleocytosis with elevated protein, positive WNV polymerase chain reaction, and negative WNV antibodies. Treatment is usually supportive care, with intravenous immunoglobulins (IVIG) plus corticosteroids and WNV-specific IVIG also used. The disease is usually fatal despite intervention. Our patient’s presentation was very similar to prior reports, however demonstrated spontaneous improvement with supportive management only. WNVND is a rare and serious infection with poor prognosis when associated with rituximab therapy. Diagnosis is complicated by absent or delayed development of antibodies. The presence of bilateral thalamic involvement is a diagnostic clue for WNVND. There is insufficient evidence to recommend the use of corticosteroids or IVIG.
Similar content being viewed by others
References
Goates C, Tsuha S, Working S, Carey J, Spivak ES (2017) Seronegative West Nile virus infection in a patient treated with rituximab for rheumatoid arthritis. Am J Med 130:e257–e258. https://doi.org/10.1016/j.amjmed.2017.01.014
Honig A, Karussis D (2014) Delayed-onset flaccid paralysis related to West Nile virus reactivation following treatment with rituximab: a case report. BMC Res Notes 7:852. https://doi.org/10.1186/1756-0500-7-852
Huang C, Slater B, Rudd R, Parchuri N, Hull R, Dupuis M, Hindenburg A (2002) First isolation of West Nile virus from a patient with encephalitis in the United States. Emerg Infect Dis 8:1367–1371. https://doi.org/10.3201/eid0812.020532
Levi ME, Quan D, Ho JT, Kleinschmidt-Demasters BK, Tyler KL, Grazia TJ (2010) Impact of rituximab-associated B-cell defects on West Nile virus meningoencephalitis in solid organ transplant recipients. Clin Transpl 24:223–228. https://doi.org/10.1111/j.1399-0012.2009.01044.x
Malan AK, Stipanovich PJ, Martins TB, Hill HR, Litwin CM (2003) Detection of IgG and IgM to West Nile virus. Development of an immunofluorescence assay. Am J Clin Pathol 119:508–515. https://doi.org/10.1309/WJJ7UE42DFHTTF1X
Mawhorter SD, Sierk A, Staugaitis SM, Avery RK, Sobecks R, Prayson RA, Procop GW, Yen-Lieberman B (2005) Fatal West Nile virus infection after rituximab/fludarabine-induced remission for non-Hodgkins lymphoma. Clin Lymphoma Myeloma 6:248–250. https://doi.org/10.3816/clm.2005.n.053
Morjaria S, Arguello E, Taur Y, Sepkowitz K, Hatzoglou V, Nemade A, Rosenblum M, Cavalcanti MS, Palomba ML, Kaltsas A (2015) West Nile virus central nervous system infection in patients treated with rituximab: implications for diagnosis and prognosis, with a review of literature. Open Forum Infect Dis 2:ofv136. https://doi.org/10.1093/ofid/ofv136
Papa A, Anastasiadou A, Delianidou M (2015) West Nile virus IgM and IgG antibodies three years post- infection. Hippokratia 19:34–36
Petersen LR, Brault AC, Nasci RS (2013) West Nile virus: review of the literature. JAMA 310:308–315. https://doi.org/10.1001/jama.2013.8042
Robinson RL, Shahida S, Madan N, Rao S, Khardori N (2003) Transient parkinsonism in West Nile virus encephalitis. Am J Med 115:252–253. https://doi.org/10.1016/S0002-9343(03)00291-2
Winston DJ, Vikram HR, Rabe IB, Dhillon G, Mulligan D, Hong JC, Busuttil RW, Nowicki MJ, Mone T, Civen R, Tecle SA, Trivedi KK, Hocevar SN (2014) Donor-derived West Nile virus infection in solid organ transplant recipients: report of four additional cases and review of clinical, diagnostic, and therapeutic features. Transplantation 97:881–889. https://doi.org/10.1097/TP.0000000000000024
Yeung MW, Shing E, Nelder M, Sander B (2017) Epidemiologic and clinical parameters of West Nile virus infections in humans: a scoping review. BMC Infect Dis 17:609. https://doi.org/10.1186/s12879-017-2637-9
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Owens, M., Choe, L., Rivera, J.E. et al. West Nile virus neuroinvasive disease associated with rituximab therapy. J. Neurovirol. 26, 611–614 (2020). https://doi.org/10.1007/s13365-020-00854-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13365-020-00854-z