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

B-cell depleting therapies are used for MS, autoimmune disorders, renal disease and hematological malignancies but increase infection susceptibility.

To describe two cases of enterovirus meningoencephalitis in patients receiving B-cell depleting therapy and review anti-CD20-associated cases, detailing diagnosis, treatment, and outcomes.

We present two cases, one with MS and one with minimal change disease, and review 40 additional anti-CD20 cases. Demographic, clinical, laboratory, neuroimaging, treatment, and outcomes were abstracted. Neuro-QoL measures were analyzed.

Our cases were diagnosed by CSF multiplex PCR and treated with IVIg; one also received methylprednisolone and pocapavir. Persistent sequelae included dysarthria, cognitive impairment, nystagmus, pain, and reduced Neuro-QoL scores. Of 42 cases, 34 were associated with rituximab and eight with ocrelizumab. CSF PCR or molecular testing detected enterovirus in 39 cases; three required alternative specimens/sites. IVIg or subcutaneous immunoglobulin (SCIg) was used in 36 cases, steroids in seven, fluoxetine in six, pocapavir in two, pleconaril in two, and ribavirin/favipiravir in one. Outcomes included recovery in 11, sequelae in 19, and death in 12.

Enterovirus infection in B-cell depleted patients may cause severe CNS involvement. CSF PCR aids diagnosis, though alternative specimens may be required. Early IVIg and investigational antivirals may be considered.