Page 140 - TBE_Book_V2_2019

Chapter 7: TBE in special situations

severe encephalitis. Finally, the patient rheumatic diseases before initiating rituximab
survived with several months of reconvales- and can be recommended if the clinical
2
cence and persistent neurological sequelae. situation permits. Still, the resulting protec-
tion rate remains unknown.
Expectedly, the inability to generate an
antibody response renders rituximab-treated In a recent report an immunosuppressed
patients susceptible to TBE and it also patient in Italy had persistent viremia associ-
impedes laboratory diagnosis. It is reported ated to the erythrocyte fraction and shedding
that in patients under rituximab therapy the of the virus in the urine for more than six
antibody response is deficient for up to 6 weeks, while receiving chemotherapy for
months, making vaccination of these patients relapsing blastic plasmacytoid dendritic cell
3
a challenge. The above case of a young patient neoplasm. Another dramatic case of TBE in a
who developed life-threatening TBE one year 12-year-old patient was published by Chmelik
after rituximab medication was stopped shows et al., where the immunosuppressive treat-
that rituximab-induced B-cell response/ ment regimen including dexamethasone and
antibody-deficiency may even last up to one etoposide resulted in viral replication and fatal
4
year. Therefore, with patients receiving outcome. It has also been reported that
rituximab, information should be stressed on thymectomized patients showed a delayed
5
the importance of protecting themselves from humoral immune response to TBE virus.
tick bites and unpasteurized milk. There are
no general recommendations to vaccinate Lipowski et al. recently described three
patients against TBE before rituximab therapy. patients who had received solid organ trans-
To obtain a good level of protection, repeated plants from a single (undiagnosed viremic)
vaccine doses over time are needed, and this donor (2 received a kidney, and 1 received a
may not be possible in patients with an acute liver) and all organ recipients developed TBE-
diagnosis of cancer . An accelerated schedule, encephalitis 17–49 days after transplantation
6
with three doses on days 0, 7 and 21, has been with fatal outcomes. The incubation period
used in some centers for patients with ranged from 17 to 51 days and thus was

Table 1: Compilation of three patients with TBE after solid organ transplantation

Immuno-
Patient Organ suppressive Incubation Symptoms Duration Outcome
No.
treatment

Fever,
Steroids, meningitis,
1 Liver 17 days 69 days fatal
tacrolimus encephalitis,
tetraplegia
Steroids,
Fever, meningi-
tacrolimus,
2 Kidney 22 days tis, encephalitis, 36 days fatal
mycophenolate
brain bleeding
mofetil
Steroids,
Fever,
tacrolimus,
3 Kidney 49 days meningitis, 83 days fatal
mycophenolate
encephalitis
mofetil

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