Monkeypox virus (MPV) is an orthopox virus in the Poxviridae family that is currently of international concern. It is endemic to Central and Western Africa with two known viral clades. Various African rodents and primates are likely the natural reservoirs. Zoonotic transmission occurs by direct contact with infected animals (e.g., bites, scratches, slaughtering). Human to human transmission occurs through close contact with infected persons (e.g., respiratory droplets, skin-on-skin, or sexual contact) or fomites. Classically, human MPV disease first has a febrile prodrome with lymphadenopathy followed by a diffuse maculopapular to vesiculopustular skin/mucosal lesion eruption. In the current 2022 outbreak, which is primarily affecting men who have sex with men (MSM) currently, the febrile prodrome may be absent and skin/mucosal lesions may be isolated to the genital and anal regions. Rarely, MPV likely has the potential to be neuroinvasive based on animal models, previous case series, and preliminary reports currently under investigation. Even though neurologic manifestations of human MPV infection are rare, given the sheer numbers of increasing cases throughout the world, neurologists should be prepared to recognize, diagnose, and treat potential neuroinvasive disease or other neurologic symptoms.

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With increasing use of rituximab and other B-cell depleting monoclonal antibodies for multiple indications, infectious complications are being recognized. We summarize clinical findings of patients on rituximab with arboviral diseases identified through literature review or consultation with the Centers for Disease Control and Prevention. We identified 21 patients on recent rituximab therapy who were diagnosed with an arboviral disease caused by West Nile, tick-borne encephalitis, eastern equine encephalitis, Cache Valley, Jamestown Canyon, and Powassan viruses. All reported patients had neuroinvasive disease. The diagnosis of arboviral infection required molecular testing in 20 (95%) patients. Median illness duration was 36 days (range, 12 days–1 year) and 15/19 (79%) patients died from their illness. Patients on rituximab with arboviral disease can have a severe or prolonged course with an absence of serologic response. Patients should be counseled about mosquito and tick bite prevention when receiving rituximab and other B-cell depleting therapies.