IVIg-induced headache: prospective study of a large cohort with neurological disorders.

BACKGROUND: Intravenous immune globulin (IVIg) is frequently used in some neurological diseases and is also the first-line therapy in Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. We aimed to evaluate the frequency and characteristics of headaches, which is one of the most common side effects of IVIg treatment. METHODS: Patients who received IVIg treatment for neurological diseases were prospectively enrolled in 23 centers. Firstly, the characteristics of patients with and without IVIg-induced headaches were analyzed statistically. Then, patients with IVIg-induced headaches were classified into three subgroups determined by their history: no primary headache, tension-type headache (TTH), and migraine. RESULTS: A total of 464 patients (214 women) and 1548 IVIg infusions were enrolled between January and August 2022. The frequency of IVIg-related headaches was 27.37% (127/464). A binary logistic regression analysis performed with significant clinical features disclosed that female sex and fatigue as a side effect were statistically more common in the IVIg-induced headache group. IVIg-related headache duration was long and affected daily living activities more in patients with migraine compared to no primary headache and TTH groups (p = 0.01, respectively). CONCLUSION: Headache is more likely to occur in female patients receiving IVIg and those who develop fatigue as a side effect during the infusion. Clinicians' awareness of IVIg-related headache characteristics, especially in patients with migraine, may increase treatment compliance.

How to manage MuSK antibody-positive myasthenic crisis during pregnancy?

Myasthenia gravis (MG) is an autoimmune disease that is characterised by the formation of antibodies against acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. The course of the disease cannot be predicted during pregnancy. A subtype of MG with positive muscle-specific receptor tyrosine kinase (anti-MuSK) antibodies exhibits more localised clinical characteristics and a poor response to treatment compared with the disease subtype that involves positivity for acetylcholine receptor antibodies. Myasthenic crisis is more frequently observed in anti-MuSK-positive myasthenia patients. Anti-MuSK-positive myasthenic crisis management is very difficult and a risky situation during pregnancy. The reported case was 30 years old, female, 9 weeks pregnant and musk antibody positive. She stopped her treatment without asking her doctor because she was planning pregnancy in the 6-month period before her hospitalization. She was intubated for a long time in the intensive care unit due to myasthenic crisis and was very resistant to treatment. During this period, her pregnancy was terminated due to fetal anomaly. Plasmapheresis, IVIg and immunosuppressive treatments were applied. Our patient was discharged after a period of about 10 weeks. We share our treatment management.

Reversible Intracranial Cytotoxic Edema Associated with COVID-19: A Case Report.

BACKGROUND: It is well-known that COVID-19 causes pneumonia and acute respiratory distress syndrome, as well as pathological neuroradiological imaging findings and various neurological symptoms associated with them. These include a range of neurological diseases, such as acute cerebrovascular diseases, encephalopathy, meningitis, encephalitis, epilepsy, cerebral vein thrombosis, and polyneuropathies. Herein, we report a case of reversible intracranial cytotoxic edema due to COVID-19, who fully recovered clinically and radiologically. CASE REPORT: A 24-year-old male patient presented with a speech disorder and numbness in his hands and tongue, which developed after flu-like symptoms. An appearance compatible with COVID-19 pneumonia was detected in thorax computed tomography. Delta variant (L452R) was positive in the COVID reverse-transcriptase polymerase chain reaction test (RT-PCR). Cranial radiological imaging revealed intracranial cytotoxic edema, which was thought to be related to COVID-19. Apparent diffusion coefficient (ADC) measurement values in the magnetic resonance imaging (MRI) taken on admission were 228 mm2/sec in the splenium and 151 mm2/sec in the genu. During the follow-up visits of the patient, epileptic seizures developed due to intracranial cytotoxic edema. ADC measurement values in the MRI taken on the 5th day of the patient's symptoms were 232 mm2/sec in the splenium and 153 mm2/sec in the genu. ADC measurement values in the MRI taken on the 15th day were 832 mm2/sec in the splenium and 887 mm2/sec in the genu. He was discharged from the hospital on the 15th day of his complaint with a clinical and radiological complete recovery. CONCLUSION: Abnormal neuroimaging findings caused by COVID-19 are quite common. Although not specific to COVID-19, cerebral cytotoxic edema is one of these neuroimaging findings. ADC measurement values are significant for planning follow-up and treatment options. Changes in ADC values in repeated measurements can guide clinicians about the development of suspected cytotoxic lesions. Therefore, clinicians should approach cases of COVID-19 with CNS involvement without extensive systemic involvement with caution.