Multiple Sclerosis Accepted: 15 May 2016 Receiving Tysabri

Iranian Journal Letter to Editor of Neurology Iran J Neurol 2016; 15(3): 175-176

Bacterial meningitis in a patient

Received: 10 Mar 2016 with multiple sclerosis Accepted: 15 May 2016 receiving Tysabri

Abdorreza Naser Moghadasi1, Soroor Advani2, Shiva Rahimi2

1 Multiple Sclerosis Research Center, Neuroscience Institute, Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2 Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

Keywords lesions (Figure 1-A) with no evidence of PML or Bacterial Meningitis; Multiple Sclerosis; Tysabri HSE encephalitis. Meningeal enhancement was seen after the injection of the contrast medium (Figure 1-B).

The most important adverse effect of natalizumab is progressive multifocal leukoencephalopathy (PML).1 Apart from PML, there are reports of other cerebral infections including herpes simplex encephalitis (HSE)2,3 and cryptococcal meningitis4 in the literature. The patient was a 29-year-old woman, a known case of multiple sclerosis (MS) for at least 5 years. She was treated using natalizumab since 6 month before. She was under treatment with prednisolone 1 g daily for 5 days for optic neuritis, which was 2 weeks before the onset of symptoms of meningitis. Approximately three days before visiting the neurologist, a continuous headache in the left temporal lobe was developed. Figure 1. Periventricular lesions confirming the The patient was febrile at that time as well. diagnosis of multiple sclerosis (MS) in the FLAIR MRI Besides, two days before this, she had started view (A). Meningeal enhancement was seen after ciprofloxacin for treatment of a urinary gadolinium injection (B) tract infection. An investigation for the John Cunningham The patient underwent a lumbar puncture. (JC) virus was negative. The brain magnetic Simple analysis of the cerebrospinal fluid (CSF) resonance imaging (MRI) showed periventricular showed the following: white blood cell

http://ijnl.tums.ac.ir 6 July (WBC) = 350 (55% lymphocytes and 45% marked clinical benefits in patients with MS, there polymorphonuclear cells); red blood cell is an occasional cause of fetal adverse effects like (RBC) = 20; protein = 150 mg/dl; glucose = 37 PML and HSE. 5 These mechanisms might have mg/dl; and concomitant blood sugar = 155 facilitated the development of meningitis in our mg/dl. Other routine tests including blood patients as well. biochemistry and complete blood cells (CBC) This case report introduces a different were all normal. probable complication of natalizumab in a patient Considering the patient’s condition and her with MS. As mentioned above, natalizumab can CSF profile, treatment with ceftriaxone, cause infection in brain and it is not limited to vancomycin, and acyclovir was started. Since HSE and PML. It should be considered that in polymerase chain reaction (PCR) assay for HSE-1 every patient receiving any drugs with the and 2 was negative, acyclovir was stopped and potential to alter the immunity of the brain, high other antibiotics were continued with a diagnosis suspicion of opportunistic infections is one of the of partially treated bacterial meningitis. The most important points in the patient’s follow-up. 6 patient’s headache and fever also subsided. Other investigations including PCR of the CSF Conflict of Interests for tuberculosis, cryptococcus, and human The authors declare no conflict of interest in this immunodeficiency virus (HIV) were all negative. study. CSF culture and smear were negative, which could be due to the previous administration of Acknowledgments ciprofloxacin. The most probable diagnosis was We acknowledge all the patients participated in partially treated bacterial meningitis in this study. consideration of CSF analysis and other investigations as well as the patient’s response to treatment. How to cite this article: Naser Moghadasi A, Advani S, Through targeting the α-4 integrin, Rahimi S. Bacterial meningitis in a patient with multiple sclerosis receiving Tysabri. Iran J Neurol natalizumab prevents activated T lymphocytes 5 2016; 15(3): 175-6. from entering the brain. However, despite its

References 1. Kornek B. An update on the use of 3. Shenoy ES, Mylonakis E, Hurtado RM, multifocal leukoencephalopathy and other natalizumab in the treatment of multiple Venna N. Natalizumab and HSV disorders caused by JC virus: clinical sclerosis: appropriate patient selection meningitis. J Neurovirol 2011; 17(3): features and pathogenesis. Lancet Neurol and special considerations. Patient Prefer 288-90. 2010; 9(4): 425-37. Adherence 2015; 9: 675-84. 4. Valenzuela RM, Pula JH, Garwacki D, 6. Haghighi S, Seyed Ahadi M, Naser 2. Fine AJ, Sorbello A, Kortepeter C, Cotter J, Kattah JC. Cryptococcal Moghadasi A. Cryptococcal meningitis in Scarazzini L. Central nervous system meningitis in a multiple sclerosis patient a human immunodeficiency virus- herpes simplex and varicella zoster virus taking natalizumab. J Neurol Sci 2014; negative patient with rheumatoid arthritis. infections in natalizumab-treated patients. 340(1-2): 109-11. Iran J Neurol 2016; 15(2): 106-8. Clin Infect Dis 2013; 57(6): 849-52. 5. Tan CS, Koralnik IJ. Progressive

176 Iran J Neurol 2016; 15(3) Naser Moghadasi et al.

http://ijnl.tums.ac.ir 6 July