An increasing number of disease-modifying therapies (DMTs) are being approved for treatment of multiple sclerosis (MS). Ocrelizumab is a humanized B cell-depleting monoclonal antibody, recently approved for relapsing and primary progressive MS. 1 Here, we present a patient with MS who developed an acute aseptic neutrophilic meningitis following ocrelizumab initiation.
Case PresentationA 54-year-old woman diagnosed with relapsing MS 5 years earlier was on fingolimod, but it was decided to switch to ocrelizumab because of a new cervical spinal cord lesion and clinical worsening. Before initiating ocrelizumab, her timed 25-foot walk (T25-FW) was 11.4 seconds, and the Expanded Disability Status Scale (EDSS) score was 6.5, the primary symptoms being left-sided weakness and left-hand tremors. Routine safety laboratory results were normal (table ). She received the first 300 mg ocrelizumab infusion without any immediate side effects. However, 10 days after the first ocrelizumab dose, the patient developed a severe, acute-onset frontal headache with episodic confusion, photophobia, and nonsensical slurred speech, which had lasted for 1 day on presentation to the hospital. On admission, body temperature was 99.4 F, and the patient was hemodynamically stable without meningismus. Blood tests showed neutrophilic leukocytosis and slight absolute bandemia (table ). A head CT, chest X-ray, and urinalysis were normal. Lumbar puncture (LP) revealed predominantly neutrophilic pleocytosis (9,789 white blood cells [WBCs], 88% polymorphonuclear cells), elevated protein (399.3 mg/dL), and low glucose (30 mg/dL) in the CSF (table ). A brain MRI showed multiple hemispheric white matter, brainstem, and cerebellar MS lesions without contrast enhancement that were unchanged compared with a scan 2.5 months prior. Empiric IV antimicrobial treatment with ampicillin, ceftriaxone, vancomycin, and acyclovir was initiated. CSF HSV, VZV, and JCV PCRs returned negative. The patient began to recover within 24-48 hours following admission. A repeat LP performed 3 days following the initial LP showed improved findings (255 WBCs, total protein 70 mg/dL, and glucose 46 mg/dL; table ). Blood and CSF bacterial and fungal cultures, cryptococcal antigen, and Lyme tests returned negative, and the antimicrobial treatments were terminated 10 days following admission. The patient improved with only mild headache at discharge 11 days following admission. The tetrad of profound neutrophilic meningitis with low glucose, rapid clinical recovery, completely negative infectious disease workup, and recently initiated new medication (ocrelizumab) suggested that the patient had a probable drug induced aseptic meningitis (DIAM).At the neurology outpatient control visit 23 days following discharge, her EDSS score and T25-FW were unchanged. Due to the risk of recurring DIAM, 2 it was decided not to rechallenge the
