Brain abscess following rituximab infusion in a patient with pemphigus vulgaris

Abstract

Background: Immunocompromised patients are at increased risk for developing meningitis or, rarely, brain abscess with opportunistic organisms like Listeria monocytogenes.

Case report: A 52 year-old Saudi Arabian woman who was diagnosed with pemphigus vulgaris and diabetes and had been on prednisolone and azathioprine for about 4 years. She presented with headache, low-grade fever, and left-sided weakness 2 weeks after receiving the second dose of rituximab infusion. Magnetic resonance imaging revealed an enhanced space-occupying lesion with multiple small cyst-like structures and vasogenic edema in the right temporoparietal area. Her blood culture was positive for Listeria monocytogenes, and a brain biopsy showed necrotic tissues with pus and inflammatory cells. She recovered after a 6-week course of antibiotics with ampicillin and gentamycin.

Conclusions: Brain abscess due to Listeria monocytogenes is a risk that should be considered when adding rituximab to the regimen of a patient who is already Immunocompromised.

Figure 1.

Brain MRI, next day of presentation to the emergency room. (A) Preoperative MRI scan, T2 coronal window, showing a large abscess in the right temporal lobe surrounded by extensive vasogenic edema. (B) MRI of the brain, T1 weighted images with gadolinium, coronal window showing multiple abscesses in the right temporal.

Figure 2.

Brain MRI 4 months, post treatment. (A) MRI, T2 weighted image, coronal window, showing residual low signal intensity, gliosis and atrophy on the right temporal lobe. (B) MRI, T1 coronal window post contrast, showing right temporal low signal intensity, gliosis and atrophy with no contrast enhancement.