433 - Rapid Improvement in Parvovirus Associated Acute Cerebellitis with PLEX Therapy

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

IS

Ibrahim J. Samarra'e, MD

Resident Physician
University of Arkansas for Medical Sciences
Little Rock, Arkansas, United States

Co-Author(s)

SA

Suzanne Abou- Diab, MD

Co author
University of Arkansas Medical Sciences
Little Rock, Arkansas, United States
OT

Olivia Tzeng, BA

MS4
University of Arkansas for Medical Science
Little Rock, Arkansas, United States
VS

VIKKI A. STEFANS, MD, MS

Professor
UAMS
LITTLE ROCK, Arkansas, United States

Case Diagnosis: Acute cerebellitis as sequelae of parvovirus infection

Case Description: A teenager presented with dizziness, slurring and poor balance. On exam, they exhibited ataxic speech, mild ataxia on tandem toe and heel walk, nystagmus, upper motor neuron signs, and dysphagia. ID workup was significant for mildly elevated WBC, positive Monospot test, parvovirus IgG+ and IgM+, EBV VCA IgM+, EBV EA-D IgG+ and EBNA IgG- suggesting past infection. Remainder of extensive infectious workup negative. MRI showed cerebellar hyperintensity consistent with autoimmune cerebellitis vs post infectious acute cerebellar ataxia. They received methylprednisolone followed by IVIG. After a week without improvement, we started plasmapheresis (PLEX) with significant recovery. Their course was complicated by one seizure-like episode treated with Keppra. On discharge they needed standby assist for ambulation with mildly wide based gait but resolved dysmetria. CASPR2 and LGI1 IGg later returned negative. On 2-month follow up they had returned to baseline with normal neuromotor exam.

Discussions: Post-infectious cerebellar ataxia has been well documented in association with varicella, mumps, and mycoplasma but rarely mentioned in association with parvovirus in immunocompetent patients. Our patient did not present with classic symptoms such as fever, rash or headache. They did have ataxia, emesis and nystagmus which has been associated with presentation of parvovirus cerebellitis. In documented cases, patients improved with steroids or IVIG. Conversely, after both interventions our patient’s cerebellar symptoms worsened but quickly improved with initiation of PLEX which is not extensively described in the literature to our knowledge.

Conclusions: For patients with ataxia who concurrently present with headache, emesis and/or nystagmus parvovirus cerebellitis can be considered. The use of PLEX can be considered earlier in their treatment, particularly when IVIG has failed.