Anti-CD20 associated enterovirus meningoencephalitis: A narrative review with two illustrative cases

Figures

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  Figure 1.. Neuroimaging findings. Case 1 demonstrated a left cerebral peduncle lesion with T2-shinethrough (DWI hyperintense/ADC isointense; red arrow). Repeat imaging two weeks later demonstrated faint-contrast enhancement (red arrow). Follow-up imaging 5 months later showed a T2-weighted/FLAIR lesion with a T1-hypointensity compatible with a demyelinated lesion in the left cerebral peduncle. Case 2 showed cerebellar (right > left) T2-weighted/FLAIR hyperintensities (blue arrows) and faint leptomeningeal enhancement of the right > left IACs (white outlined arrows) on 7T MRI suggestive of labyrinthitis.

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  Figure 2.. Change in Neuro-QoL domain T-scores over time relative to encephalitis onset. Neuro-QoL T-scores are plotted by months from encephalitis onset, with the dashed vertical line indicating symptom onset at month 0. Circles represent Case 1 and triangles represent Case 2. Functional domains include cognition, upper and lower extremity function, social participation, and social satisfaction, where higher scores indicate better function. Symptom domains include anxiety, depression, fatigue, sleep disturbance, and stigma, where higher scores indicate greater symptom burden. Linear regression lines and β estimates are shown for Case 1, which had repeated pre- and post-encephalitis measures; asterisks indicate significant slopes (*p < 0.05). Case 2 had only two post-encephalitis measures and is shown descriptively. Following encephalitis, Case 1 had worse anxiety (β = 0.62, p = 0.04, Cohen's f2 = 1.47, η2 = 0.59) and upper extremity function (β = –0.93, p = 0.03, Cohen's f2 = 1.98, η2 = 0.66).

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  Figure 3.. Immune profiles relative to anti-CD20 therapy and enteroviral encephalitis in Case 1. (A) Immunoglobulin levels for Case 1 relative to B-cell therapy and enteroviral encephalitis. IgG (blue circles plotted on left y-axis) and IgM (purple triangles plotted on right y-axis) levels (mg/dL) relative to months from onset of initial encephalitis symptoms (x = 0, green vertical line) are shown. Initial (black dashed vertical line) and final (orange dot-dashed vertical line) dates of ocrelizumab are highlighted. The shaded blue area indicates IgG lab normal range 700–1600 mg/dL and the dotted purple line indicates the lower limit of normal for IgM (40–230). The peak IgG level, observed 0.9 months after encephalitis symptom onset, was observed 5 days after completion of a 5-day course of IVIg (2 g/kg total). (B) Peripheral immune cell counts relative to anti-CD20 therapy and outside of B-cell counts were observed. Changes in counts immediately following onset of encephalitis is likely attributable to high dose methylprednisolone.