Adverse Reactions Associated with Intravenous Immunoglobulin Administration in the Treatment of Neurological Disorders: A Systematic Review.

Intravenous immunoglobulin (IVIg), which is used to treat multiple neurological conditions, may be associated with serious adverse reactions. The individual neurological disease characteristics associated with adverse reactions, along with strategies to prevent and treat adverse reactions, are uncertain. A systematic review was conducted of the databases PubMed, Embase, and Cochrane Library to summarise studies that report adverse reactions of IVIg therapy in patients with neurological disease. There were 65 studies included in the review. The reported rates of adverse reactions vary widely, but the best evidence suggests rates between 25 and 34% per patient. Common adverse reactions include headache and laboratory abnormalities. Less common but serious adverse reactions included thromboembolic complications and anaphylaxis. Overall, there is a lack of high-quality comparative data to definitively determine if any specific neurological indications are associated with a higher risk of adverse reactions. However, individual neurological disease characteristics possibly associated with an increased likelihood of adverse reactions include limited mobility (as in certain neuromuscular conditions), paraproteinaemia (as in certain peripheral neuropathies), and cardiomyopathy (as in certain myopathies). There is limited evidence to support the effectiveness of prevention and treatment strategies, which may include modification to dose, reduced infusion rate, and premedication. Further studies regarding methods to prevent and treat IVIg-ARs in neurology patients are required.

Home infusions of natalizumab for people with multiple sclerosis: a pilot randomised crossover trial.

OBJECTIVE: The delivery of healthcare at home has expanded to intravenous infusions of monoclonal antibodies. A recently developed model of care for home infusions of natalizumab for people with relapsing-remitting multiple sclerosis was evaluated. This pilot study of home infusions of natalizumab and usual care (attendance in a hospital out-patients' clinic) compared safety, feasibility, patient satisfaction, effectiveness and costs. METHODS: In this randomised AB/BA crossover trial, 37 adults were randomised to usual care (n = 19) or home infusions (n = 18). After three infusions, patients crossed over to the alternate treatment for another three infusions. Patient safety outcomes and adherence, satisfaction, quality of life, disability and costs were compared. RESULTS: No adverse events were recorded from 207 infusions from 35 patients across both home and clinic infusions. There was no difference in adherence (p = 0.71) and infection rates (p = 0.84) between home and clinic settings. Satisfaction with "convenience" of home infusions was significantly greater (p = 0.008) but there were no differences in quality of life measures. Excluding pharmacy, costs were A$74 lower per infusion at home, including A$16 of patients" out-of-pocket costs. INTERPRETATION: There were no differences in safety and effectiveness between clinic and home infusions of natalizumab. The home infusions were shown to be feasible, more convenient and less expensive than usual care. Larger scale studies are required to verify these preliminary findings, particularly around safety and management of hypersensitivity adverse events in the home setting and for equivalence of clinical outcomes.

Developing a Model of Care for Home Infusions of Natalizumab for People With Multiple Sclerosis.

Natalizumab is an effective treatment for multiple sclerosis that requires 4-weekly infusions that are usually provided in hospital outpatient clinics. In this study, a model of care (MOC), an overarching design for the provision of a health care service, was developed to permit home infusions of natalizumab. The proposed new MOC comprised 9 dimensions, in addition to the central concept of patient-centered care at home. The new MOC is responsive to patient needs and prioritizes the nurse-patient therapeutic relationship. It provides practical examples of patient-centered care to guide clinical practice for this patient population in the home setting.

Cardio-embolic cerebellar stroke secondary to mitral valve chordae rupture as a delayed complication of a high-voltage electrical injury.

A 41-year-old farmer sustained a high-voltage electrical injury resulting in confusion, electrical burns and paroxysmal atrial fibrillation which spontaneously reverted to sinus rhythm after a few hours. Two weeks later he presented with a sudden onset of headache, unsteadiness, horizontal oscillopsia and paraesthesia in the right side of his face. Examination revealed nystagmus to the right, right-sided limb ataxia and a tendency to veer toward the right when walking. An MRI of the brain demonstrated an acute infarct of the right cerebellar hemisphere in the territory of the right posterior inferior cerebellar artery. A transesophageal echocardiogram showed a ruptured mitral valve chordae. This is the first report of a cardio-embolic stroke secondary to mitral valve chordae rupture as a delayed complication of high-voltage electrical injury. Although many mechanisms of direct cerebral electrical injury have been speculated, a cardio-embolic origin should not be overlooked as a cause of stroke secondary to high-voltage electrical injury.

MR findings in Murray Valley encephalitis.

Murray Valley encephalitis (MVE) is caused by a flavivirus related to West Nile and St. Louis encephalitis viruses. We report a case of MVE resulting in quadriplegia and respiratory failure. MR imaging demonstrated thalamic hyperintensity on T2-weighted images, with similar involvement of the red nucleus, substantia nigra, and cervical cord. These findings preceded serologic diagnosis and are similar to those of Japanese encephalitis. In the appropriate setting, thalamic T2 hyperintensity is suggestive of flavivirus infection.

A case of longitudinally extensive transverse myelitis (LETM): neuromyelitis optica.

Neuromyelitis optica (NMO), characterised by longitudinally extensive transverse myelitis (LETM), was previously thought to be a variant of multiple sclerosis. Transverse myelitis may be a manifestation of autoimmune connective tissue diseases and NMO is now recognised to be a humorally mediated autoimmune disease. We present a case of NMO associated with non-organ-specific autoantibodies and the absence of the characteristic NMO-IgG antibody. Our case provides an opportunity to review the diagnostic criteria of NMO and its distinction from other autoimmune and demyelinating conditions. We report successful treatment with plasmapheresis and rituximab in NMO-IgG-negative relapsing disease.