Eosinophilic Meningoencephalitis Occurred during Oral Corticosteroid Tapering and after Switching from Anti-IL-5 to Anti-IgE Treatment

Abstract

A 49-year-old man with severe eosinophilic asthma, sinusitis, and esophagitis was admitted with a sudden severe headache. The patient was diagnosed with eosinophilic meningoencephalitis based on frontotemporal abnormalities on brain magnetic resonance imaging and high eosinophil counts in the cerebrospinal fluid. His allergic-disease control levels were poor, requiring regular oral corticosteroid (OCS) use. He was switched from anti-interleukin (IL)-5 to anti-IgE therapy because of worsening urticaria and asthma symptoms during OCS tapering. We suspect this was a case of complex eosinophilic meningoencephalitis caused by the combination of OCS tapering and anti-IL-5 therapy cessation that acquired anti-IgE antibody sensitization based on positive drug-induced lymphocyte stimulation test results.

Keywords: biologic therapy; eosinophilic meningoencephalitis; omalizumab; oral corticosteroid reduction; severe bronchial asthma.

Figure 1.

Brain MRI findings. Brain MR images at the onset (A)-(I) and three months after initiating treatment (J)-(O) are shown. On FLAIR images (A)-(C) and T2-weighted images (D)-(F), asymmetrical, faint, high-signal lesions were observed in the subcortical white matter of the bilateral frontal and temporal lobes. No obvious restricted diffusion was observed in (G)-(I). FLAIR (J-L) and T2-weighted (M-O) images obtained 3 months after treatment initiation revealed the disappearance of multiple high-signal areas in the subcortical white matter of the bilateral frontal and temporal lobes. FLAIR: fluid-attenuated inversion recovery, MRI: magnetic resonance imaging

Figure 2.

Eosinophils in the CSF. The arrows indicate the presence of eosinophils or plasma cells in the CSF. CSF: cerebrospinal fluid