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Patient With Severe Headache After IV Immunoglobulin

Federal Practitioner. 2022 December;39(12)a:487-489 | doi:10.12788/fp.0342
December 15, 2022|Federal Practitioner
Capt Christopher Russo, MD, USAF;LT Kenneth Dalton, MD, USN;Loran Grant, HM2, USN;Noelle Enos;2d Lt Andrew Evans, USAF
Author and Disclosure Information

Capt Christopher Russo, MD, USAFa; LT Kenneth Dalton, MD, USNa; Loran Grant, HM2, USNa; Noelle Enosb; 2d Lt Andrew Evans, USAFc
Correspondence: Christopher Russo (chrisrusso1991@gmail.com)

aWalter Reed National Military Medical Center, Bethesda, Maryland
bUniversity of South Florida, Tampa
cUniformed Services University of the Health Sciences, Bethesda, Maryland

Author disclosures

The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Ethics and consent

Written informed consent was obtained from the patient reported in this case.

The patient’s history, physical examination, vital signs, imaging, and lumbar puncture findings were most concerning for drug-induced aseptic meningitis (DIAM) secondary to her recent IVIG infusion. An algorithm can be used to work through the diagnostic approach (Figure 2).3,4

Given the patient’s absence of other etiology, her recent use of IVIG, and neutrophilic pleocytosis on LP (30% segmented neutrophils), a diagnosis of IVIG-induced aseptic meningitis was supported.5 Other affirmative findings on LP include clear CSF and normal CSF glucose.6 The patient’s normal protein (33 mg/dL) is lower than most other case reports of DIAM, though, an elevated protein is not needed for diagnosis when other findings are consistent.6,7

Immediate and delayed adverse reactions to IVIG are known risks for IVIG therapy. About 1% to 15% of patients who receive IVIG will experience mild immediate reactions to the infusion.6 These immediate reactions include fever (78.6%), acrocyanosis (71.4%), rash (64.3%), headache (57.1%), shortness of breath (42.8%), hypotension (35.7%), and chest pain (21.4%).1 For a delayed adverse reaction, < 1% of patients are expected to experience IVIG-associated DIAM, though certain patient factors, such as patients with a history of migraines, hypertension, and dehydration are thought to increase this risk.6

IVIG is an increasingly used biologic pharmacologic agent used for a variety of medical conditions. This can be attributed to its multifaceted properties and ability to fight infection when given as replacement therapy and provide immunomodulation in conjunction with its more well-known anti-inflammatory properties.8 The number of conditions that can potentially benefit from IVIG is so vast that the American Academy of Allergy, Asthma and Immunology had to divide the indication for IVIG therapy into definitely beneficial, probably beneficial, may provide benefit, and unlikely to provide benefit categories.8 As the use of IVIG increases, more patients become susceptible to IVIG-associated DIAM, and it is important for clinicians to have the diagnosis on their differential.

For treatment of IVIG-associated DIAM, most cases are self-limiting and will resolve with supportive therapy within 2 to 3 days, which was the outcome in our patient’s case.6 Fluids should be given to assist with resolution of headache along with conservative pain control with acetaminophen. IVIG-associated DIAM is known to recur, and subsequent IVIG infusions should be monitored carefully. Slowing of subsequent IVIG infusion, ensuring hydration, pretreatment with acetaminophen, and use of antihistamines have been shown to be helpful for preventing subsequent episodes.5,9 Our patient made a full recovery with supportive care and was discharged after 48 hours of observation.

Conclusions

We encourage heightened clinical suspicion of DIAM in patients who have recently undergone IVIG infusion and present with meningeal signs (stiff neck, headache, photophobia, and ear/eye pressure) without any evidence of infection on physical examination or laboratory results. With such, we hope to improve clinician suspicion, detection, as well as patient education and outcomes in cases of DIAM.

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