Disseminated enterovirus infection treated with intravenous immunoglobulin in a patient on maintenance ocrelizumab for multiple sclerosis

We present a case of a woman in her 40s with disseminated enterovirus infection in the setting of maintenance therapy with ocrelizumab for relapsing-remitting multiple sclerosis. The patient originally presented with fever, bilateral lower limb swelling and hypoalbuminaemia. She subsequently developed a productive cough and diarrhoea, and a viral respiratory multiplex panel detected rhino/enterovirus. Despite supportive care, the patient continued to deteriorate with persistent high-grade fevers and progressive derangement of her liver biochemistry. Repeat viral respiratory multiplex testing failed to detect rhino/enterovirus and, therefore, she was investigated for a fever of unknown origin. However, initial extensive special investigations identified no alternate infective, inflammatory or malignant cause. On further testing, enterovirus RNA was detected by specific monoplex nucleic acid amplification test (NAAT) in whole blood, stool and from a targeted enterovirus nasopharyngeal swab. The patient was eventually treated with intravenous immunoglobulin, which led to marked clinical and biochemical improvement.