Ann Hematol (1993) 67:151-152 Annals of Letter to the editor Hematology 9 Springer-Verlag 1993 Two episodes of aseptic meningitis during intravenous immunoglobulin therapy of idiopathic thrombocytopenic purpura M. Mitterer 1, N. Pescosta 1, W. Vogetseder 2, M. Mair 1, and P. Coser ~ Department of Hematology, General Hospital Bozen, L. BOhlerstrasse, 1-39100Bozen, Italy 2 Institute for Hygiene, University of Innsbruck, F. Pregl Strasse 3, A-6020 Innsbruck, Austria Received 26 Jannuary 1993 Sir, Intravenous immunoglobulins (IVIG) are successfully applied in severe cases of idiopathic thrombocytopenic purpura (ITP) [2]. Although IVIG therapy is often well tolerated, it is sometimes accompanied by side ef- fects such as fever, chills, headache, vomiting, and even anaphylaxis. Up to this point, five cases of aseptic me- ningitis during IVIG therapy have been described [1, 3-5]. We report here for the first time on the continua- tion of IVIG therapy, despite persisting aseptic menin- gitis, in acute idiopathic thrombocytopenic purpura. A 4-year-old boy was admitted to our department because of multiple petechiae and purpura. His plate- let count was below 10 • 109/1; hemoglobin and white blood cell count were in the normal range. The patient exhibited no signs of viral infection. Collagen diseases were eliminated by laboratory examinations. Serum immunoglobulin levels were in the normal range. The diagnosis of ITP was made after bone marrow exami- nation, and IVIG therapy (Sandoglobulin 0.4g/kg body wt. per day) was then started. The therapy was interrupted on day 2 of the immunoglobulin adminis- tration, as the patient developed fever (39.4 ~C), chills, headache, and nuchal rigidity. During the following day, the patient developed severe headache and Ker- nig's sign. The platelet count at this time was 110000/ /xl. A computed tomographic scan of the head as well as fundoscopy were normal. Examination of the cere- brospinal fluid revealed an increased leukocyte count (2 • 109/1; 67% neutrophils and 33% lymphocytes), the protein content was 33 rag/1. No pathogens were de- tected in the cerebrospinal fluid, and bacterial and fun- gal cultures were negative. Therefore, the diagnosis of aseptic meningitis was made. After 2 days the patient recovered completely. Two weeks later the IVIG therapy was restarted with another gammaglobulin product (Globuman Ber- na, 0.4 g/kg body wt. per day) as the patient's platelet count had decreased to below 10 x 109/1. On the second day of therapy the patient developed the signs of asep- tic meningitis, but the therapy was continued because of the persistent low platelet count (15 000//~l) and the risk of life-threatening hemorrhage. Despite continued therapy, the meningeal symptoms disappeared on the fourth day of the IVIG therapy. The patient was then observed for 12 months. The platelet count remained in the normal range during this period. The reason for the rare occurrence of aseptic meningitis during IVIG therapy is still unknown. This severe side effect seems to be independent of the brand of gammaglobulin product used. In all cases, aseptic meningitis has ap- peared on the second or third day of IVIG therapy. In the case of Kato et al. [3], in which the IVIG therapy was combined with hydrocortisone therapy, aseptic meningitis occurred 2 days after the end of the com- bined therapy. Until now, in all cases of aseptic menin- gitis, therapy with immunoglobulins has always been interrupted. We have described here the first case in which IVIG therapy was continued (in the second cycle) despite persisting aseptic meningitis. There was no difference in the severity of the aseptic meningitis occurring in the first (interrupted) and second (continued) therapy cycle. Although aseptic meningitis is a rare severe side ef- fect of IVIG therapy, in all cases it was self-limiting within 3 days. In our case it was independent of inter- ruption or continuation of therapy. Correspondence to: M. Mitterer, Department of Hematology, General Hospital Bozen, 1-39t00 Bozen, Italy