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A difficult case
Rituximab leading to an atypical presentation of neuroborreliosis and false negative serology
  1. Åslaug Rudjord Lorentzen1,2,
  2. Kristine Karlsrud Berg3,
  3. Unn Ljøstad1,4
  1. 1 Department of Neurology, Sørlandet Sykehus HF, Kristiansand, Norway
  2. 2 Norwegian National Advisory Unit on Tick-Borne Diseases, Sørlandet Sykehus HF, Kristiansand, Norway
  3. 3 Department of Medical Microbiology, Sørlandet Sykehus HF, Kristiansand, Norway
  4. 4 Institute of Clinical Medicine, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Åslaug Rudjord Lorentzen, Department of Neurology, Sørlandet Sykehus HF, Kristiansand 4604, Norway; aslaug.rudjord.lorentzen{at}sshf.no

Abstract

Two patients, recently treated with the B-cell-depleting monoclonal antibody, rituximab, had 2–3 months of progressive systemic symptoms; comprehensive investigations did not clarify the diagnosis. Transient radicular pain at disease onset had suggested neuroborreliosis, but seronegativity and an atypical clinical course made this unlikely. However, PCR identified Borrelia burgdorferi DNA in cerebrospinal fluid, establishing the diagnosis of neuroborreliosis. Both the clinical picture and the laboratory findings can be atypical in people with neuroborreliosis who have recently been treated with rituximab. In B-cell depleted patients living in endemic areas, one should suspect neuroborreliosis even when the typical symptoms are drowned out by more atypical symptoms; PCR should be used as a diagnostic supplement when the serological response is uncertain or absent.

  • INFECTIOUS DISEASES
  • BORRELIA
  • IMMUNOLOGY
  • CLINICAL NEUROLOGY
  • NEUROIMMUNOLOGY

Data availability statement

Data are available on reasonable request.

https://doi.org/10.1136/pn-2023-003976

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    Data availability statement

    Data are available on reasonable request.

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    Footnotes

    • Contributors ARL and UL have been involved in the investigation and treatment of both patients. KKB has been consulting regard to microbiological analyses. All have contributed to the writing process and have read the final version of the draft.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally reviewed by Amy Ross-Russell, Southampton, UK.