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Amirifard H, Shahbazi M, Farahmand G, Ranjbar Z, Kaeedi M, Heydari Havadaragh S. Progressive multifocal leukoencephalopathy in a patient with B-cell chronic lymphocytic leukemia after COVID-19 vaccination, complicated with COVID-19 and mucormycosis: a case report. BMC Neurol 2024; 24:151. [PMID: 38704555 PMCID: PMC11069241 DOI: 10.1186/s12883-024-03650-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rare and fatal opportunistic viral demyelinating infectious disease of the central nervous system (CNS). There are various clinical presenting symptoms for the disease. CASE PRESENTATION This paper presents a clinical case of PML in a patient with B-Chronic lymphocytic leukemia (B-CLL), previously treated with Chlorambucil, later complicated later with COVID-19 and mucormycosis. CONCLUSION PML can develop in the setting of cellular immune dysfunction. Late diagnosis of this disease based on nonspecific symptoms is common, therefore when we face a neurological complication in a CLL or immunocompromised patient, we should consider PML infection. A remarkable feature of this case is the possible triggering effect of COVID-19 vaccination for emergence of PML as the disease can be asymptomatic or sub-clinical before diagnosis.
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Affiliation(s)
- Hamed Amirifard
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Mojtaba Shahbazi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Ghasem Farahmand
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Ranjbar
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Maryam Kaeedi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Sanaz Heydari Havadaragh
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran.
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Milburn J, Suresh R, Doyle R, Jarvis JN. The diagnosis of central nervous system infections in resource-limited settings and the use of novel and molecular diagnostic platforms to improve diagnosis. Expert Rev Mol Diagn 2024; 24:219-230. [PMID: 38369939 DOI: 10.1080/14737159.2024.2317414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 02/07/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Central nervous system infections (CNSI) disproportionately affect individuals in low-resource settings where diagnosis is challenging; large proportions of patients never receive a confirmed microbiological diagnosis resulting in inadequate management and high mortality. The epidemiology of CNSI varies globally and conventional diagnostics deployed in resource-limited settings have significant limitations, with an urgent need for improved diagnostic strategies. AREAS COVERED This review describes molecular platforms and other novel diagnostics used in the diagnosis of CNSI that are applicable to resource-limited settings. An extensive literature search of Medline and PubMed was performed. The emphasis is on investigations targeting infections of relevance to resource-limited settings either due to variation in regional CNSI epidemiology or due to increased prevalence in patients with immunosuppression. This includes commercially available multiplex PCR platforms, mycobacterial PCR platforms, and rapid diagnostics tests. To offer a framework for the optimal implementation in clinical settings, existing evidence highlighting the advantages and limitations of available platforms is reviewed. EXPERT OPINION The implementation of molecular platforms and other novel diagnostics has the potential to transform CNSI diagnosis in resource-limited settings, with several examples of successful rollout of novel diagnostics such as Xpert MTB/RIF Ultra and cryptococcal antigen testing.
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Affiliation(s)
- James Milburn
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Rachita Suresh
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Ronan Doyle
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Algahtani H, Shirah B, Othman L, Almarri AK, Alwafi E, Alassiri AH. Progressive Multifocal Leukoencephalopathy Misdiagnosed as Neuropsychiatric Systemic Lupus Erythematosus With a Catastrophic Outcome. Neurologist 2022; 27:271-275. [PMID: 34855662 DOI: 10.1097/nrl.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Progressive multifocal leukoencephalopathy (PML) is a rare infection of the central nervous system due to the reactivation of the John Cunningham polyomavirus. It is commonly a progressive fatal disease with worldwide distribution. CASE REPORT We describe a rare case of PML, which was misdiagnosed as neuropsychiatric systemic lupus erythematosus (SLE) with a catastrophic outcome due to delay in diagnosis with superadded cyclophosphamide therapy. CONCLUSION There are several lessons taught from our case. Firstly, in patients with autoimmune disorders who are strongly immunosuppressed, the new onset of cognitive impairment and seizures should alert the treating physician to look carefully for PML. Secondly, in cases of SLE where the diagnosis of the cause of cognitive impairment and seizures is not clear, we suggest that immunosuppression should not be intensified until PML has clearly been ruled out. Lastly, multidisciplinary care in patients with suspected neuropsychiatric SLE including a neurologist, an infectious diseases consultant, a neuroradiologist, and a rheumatologist is needed.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre
| | - Leen Othman
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
| | | | - Emad Alwafi
- King Abdulaziz Medical City
- Department of Neuroscience, King Faisal Specialist Hospital & Research Centre
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
| | - Ali H Alassiri
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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4
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Wijburg MT, Warnke C, McGuigan C, Koralnik IJ, Barkhof F, Killestein J, Wattjes MP. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92:177-188. [PMID: 33229453 DOI: 10.1136/jnnp-2020-324534] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
An increasing number of highly effective disease-modifying therapies for people with multiple sclerosis (MS) have recently gained marketing approval. While the beneficial effects of these drugs in terms of clinical and imaging outcome measures is welcomed, these therapeutics are associated with substance-specific or group-specific adverse events that include severe and fatal complications. These adverse events comprise both infectious and non-infectious complications that can occur within, or outside of the central nervous system (CNS). Awareness and risk assessment strategies thus require interdisciplinary management, and robust clinical and paraclinical surveillance strategies. In this review, we discuss the current role of MRI in safety monitoring during pharmacovigilance of patients treated with (selective) immune suppressive therapies for MS. MRI, particularly brain MRI, has a pivotal role in the early diagnosis of CNS complications that potentially are severely debilitating and may even be lethal. Early recognition of such CNS complications may improve functional outcome and survival, and thus knowledge on MRI features of treatment-associated complications is of paramount importance to MS clinicians, but also of relevance to general neurologists and radiologists.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands .,Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Clemens Warnke
- Department of Neurology, University Hospital Köln, University of Cologne, Köln, Germany.,Department of Neurology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Christopher McGuigan
- Department of Neurology, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Igor J Koralnik
- Department of Neurological Sciences, Division of Neuroinfectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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Progressive multifocal leukoencephalopathy in a patient with relapsed chronic lymphocytic leukemia treated with Ibrutinib. Hematol Transfus Cell Ther 2020; 44:437-439. [PMID: 33454288 PMCID: PMC9477769 DOI: 10.1016/j.htct.2020.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 01/04/2023] Open
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Lippa AM, Ocwieja KE, Iglesias J, Fawaz R, Elisofon S, Lee C, Sharma TS. Progressive multifocal leukoencephalopathy presenting with acute sensorineural hearing loss in an intestinal transplant recipient. Transpl Infect Dis 2020; 22:e13304. [PMID: 32367644 DOI: 10.1111/tid.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/12/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
A 20-year-old male presented 3.5 years after intestinal transplantation with rapidly progressive sensorineural hearing loss. Initial brain imaging was consistent with inflammation and/or demyelination. Lumbar puncture was initially non-diagnostic and a broad infectious workup was unrevealing. Three months after presentation, a repeat LP detected JC virus for which tests had not earlier been conducted. He continued to deteriorate despite withdrawal of prior immunosuppression and addition of mirtazapine, maraviroc, and steroids. He died of progressive neurologic decompensation 5 months after his initial presentation. This case highlights progressive multifocal leukoencephalopathy (PML) as a rare complication after solid organ transplantation and acute sensorineural hearing loss as an unusual first presenting symptom of PML. JC virus should be considered in the differential diagnosis of acute sensorineural hearing loss in any immunocompromised patient.
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Affiliation(s)
- Andrew M Lippa
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Karen E Ocwieja
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Julie Iglesias
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Rima Fawaz
- Division of Gastroenterology and Hepatology, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Scott Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Christine Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
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Anand P, Hotan GC, Vogel A, Venna N, Mateen FJ. Progressive multifocal leukoencephalopathy: A 25-year retrospective cohort study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/6/e618. [PMID: 31554669 PMCID: PMC6814409 DOI: 10.1212/nxi.0000000000000618] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/13/2019] [Indexed: 11/30/2022]
Abstract
Objective To characterize the risk factors, clinical course, and treatment of patients with progressive multifocal leukoencephalopathy (PML) diagnosed and followed over a 25-year epoch at 2 academic hospitals. Methods Patients with a definite diagnosis of PML were identified by positive CSF PCR for JC virus or histopathology between January 1, 1994, and January 1, 2019. Demographic and PML-specific variables were recorded on symptomatic presentation and at follow-up, including risk factors, clinical outcome, neuroimaging findings, and modified Rankin Scale (mRS) score at last follow-up. Results There were 91 patients with confirmed PML. HIV infection was the most common risk factor, identified in 49% (n = 45). Other frequent risk factors included lymphoma, leukemia, or myelodysplasia, identified in 31% of patients (n = 28); exposure to chemotherapeutic medications (30%, n = 27); and exposure to monoclonal antibody therapies (19%, n = 17). Thirty percent of the cohort was alive at the time of censoring, with a median mRS of 2 points, indicating slight disability at last follow-up. Median survival following PML diagnosis in HIV-infected patients was longer than in HIV-uninfected patients (1,992 vs 101 days, p = 0.024). Forty patients survived more than 1 year after PML symptom onset, of whom 24 were HIV infected (60%). Thirteen patients survived more than 10 years after PML symptom onset, all HIV infected, of the 59 patients diagnosed before June 1, 2009, and eligible for 10-year survivor status (22%). Conclusions We add to the limited literature on PML by reporting its epidemiology in a large observational cohort. These parameters may be useful for future clinical trials that measure survival and clinical outcomes.
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Affiliation(s)
- Pria Anand
- From the Department of Neurology (P.A., A.V., N.V., F.J.M.), Massachusetts General Hospital, Boston; and Department of Brain and Cognitive Sciences (G.C.H.), Massachusetts Institute of Technology, Cambridge.
| | - Gladia C Hotan
- From the Department of Neurology (P.A., A.V., N.V., F.J.M.), Massachusetts General Hospital, Boston; and Department of Brain and Cognitive Sciences (G.C.H.), Massachusetts Institute of Technology, Cambridge
| | - Andre Vogel
- From the Department of Neurology (P.A., A.V., N.V., F.J.M.), Massachusetts General Hospital, Boston; and Department of Brain and Cognitive Sciences (G.C.H.), Massachusetts Institute of Technology, Cambridge
| | - Nagagopal Venna
- From the Department of Neurology (P.A., A.V., N.V., F.J.M.), Massachusetts General Hospital, Boston; and Department of Brain and Cognitive Sciences (G.C.H.), Massachusetts Institute of Technology, Cambridge
| | - Farrah J Mateen
- From the Department of Neurology (P.A., A.V., N.V., F.J.M.), Massachusetts General Hospital, Boston; and Department of Brain and Cognitive Sciences (G.C.H.), Massachusetts Institute of Technology, Cambridge
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Abstract
PURPOSE OF REVIEW Widespread use of antiretroviral therapy (ART) has led to near-normal life expectancy in people with human immunodeficiency virus (HIV) infection. However, neurologic complications of HIV remain common; can affect any part of the neuraxis; and are due to direct effects of the virus, immunosuppression because of untreated HIV infection, aberrant immune responses in the setting of ART initiation, and ART toxicities. RECENT FINDINGS HIV-associated neurocognitive disorder (HAND) remains one of the most common neurologic complications of HIV encountered today, but milder forms predominate in people on ART. No specific treatments for HAND exist, but small trials and epidemiologic evidence suggest paroxetine, intranasal insulin, and maraviroc may have utility in its treatment; further trials of these agents are ongoing. Widespread ART use has decreased the incidence of central nervous system opportunistic infections, but prognosis often remains poor in those who develop opportunistic infections. High-titer positive serum cryptococcal antigen is strongly predictive of cryptococcal meningitis and provides a tool to enhance diagnosis in areas with limited resources. HIV is an independent risk factor for stroke, and accelerated aging associated with HIV infection results in neurologic diseases of older age occurring at much younger ages in individuals infected with HIV. Ongoing HIV replication in the CSF despite peripheral virologic suppression may contribute to the development of HAND and may not improve despite adjusting the ART regimen to increase central nervous system penetrance. SUMMARY Neurologists are likely to encounter patients infected with HIV in clinical practice. This article reviews the presentation, diagnosis, and management of the most common neurologic conditions associated with HIV infection and ART.
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Lopes CCB, Crivillari M, Prado JCM, Ferreira CR, Dos Santos PJ, Takayasu V, Laborda LS. Progressive multifocal leukoencephalopathy: a challenging diagnosis established at autopsy. AUTOPSY AND CASE REPORTS 2019; 9:e2018063. [PMID: 30863734 PMCID: PMC6394363 DOI: 10.4322/acr.2018.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/13/2018] [Indexed: 01/19/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a feared entity that occurs most frequently in conditions of extreme immunodeficiency. The diagnosis is often made long after the onset of symptoms due to the physicians’ unfamiliarity, and the unavailability of diagnostic tests in some medical centers. Although the incidence of PML is decreasing among HIV patients with the advent of highly active antiretroviral therapy (HAART), in Brazil this entity is the fourth highest neurological complication among these patients. The authors present the case of a middle-aged man who tested positive for HIV concomitantly with the presentation of hyposensitivity in the face and the right side of the body, accompanied by mild weakness in the left upper limb. The clinical features worsened rapidly within a couple of weeks. The diagnostic work-up pointed to the working diagnosis of PML after brain magnetic resonance imaging; however, the detection of the John Cunningham virus (JCV) in the cerebral spinal fluid was negative. HAART was started but the patient died after 7 weeks of hospitalization. The autopsy revealed extensive multifocal patchy areas of demyelination in the white matter where the microscopy depicted demyelination, oligodendrocytes alterations, bizarre atypical astrocytes, and perivascular lymphocytic infiltration. The immunohistochemistry was positive for anti-SV40, and the polymerase chain reaction of the brain paraffin-embedded tissue was positive for JCV. The authors highlight the challenges for diagnosing PML, as well as the devastating outcome of PML among HIV patients.
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Affiliation(s)
| | | | - José Carlos Mann Prado
- Universidade de São Paulo (USP), Biomedical Sciences Institute, Department of Microbiology, Laboratory of Oncovirology. São Paulo, SP, Brazil
| | - Cristiane Rubia Ferreira
- Universidade de São Paulo (USP), Hospital Universitário, Anatomic Pathology Service. São Paulo, SP, Brazil
| | - Pedro José Dos Santos
- Universidade de São Paulo (USP), Hospital Universitário, Department of Radiology. São Paulo, SP, Brazil
| | - Vilma Takayasu
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division. São Paulo, SP, Brazil
| | - Lorena Silva Laborda
- Universidade de São Paulo (USP), Hospital Universitário, Internal Medicine Division. São Paulo, SP, Brazil
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Kartau M, Verkkoniemi-Ahola A, Paetau A, Palomäki M, Janes R, Ristola M, Lappalainen M, Anttila VJ. The Incidence and Predisposing Factors of John Cunningham Virus-Induced Progressive Multifocal Leukoencephalopathy in Southern Finland: A Population-Based Study. Open Forum Infect Dis 2019; 6:ofz024. [PMID: 30815501 PMCID: PMC6386113 DOI: 10.1093/ofid/ofz024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/22/2018] [Accepted: 01/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to assess the prevalence, incidence rate (IR), predisposing factors, survival rate, and diagnostic delay of progressive multifocal leukoencephalopathy (PML) across medical specialties. Another objective was to survey how PML diagnosis was made in the studied cases. Methods This is a cross-sectional retrospective observational study of PML cases across different medical specialties during 2004–2016 in the Finnish Capital Region and Southern Finland. Data were obtained from clinical records, clinical microbiology, pathology and radiology department records, and human immunodeficiency virus (HIV) quality register medical records. Results A total of 31 patients were diagnosed with PML. The prevalence of PML was 1.56 per 100 000 people and the IR was 0.12 per 100 000 individuals per year during 2004–2016. Hematologic malignancies (n = 19) and HIV/acquired immune deficiency syndrome (n = 5) were the most common underlying diseases, and all patients who had malignant diseases had received cancer treatment. Before PML diagnosis, 21 (67.7%) patients were treated with chemotherapy, 14 (45.2%) patients with rituximab, and 1 patient (3.2%) with natalizumab. Two patients (6.5%) had no obvious immunocompromising disease or treatment. Neither gender, age, first symptoms, previous medication, nor underlying disease influenced the survival of PML patients significantly. The 5-year survival rate was poor, at less than 10%. Conclusions The majority of PML patients in our study had a predisposing disease or had immunosuppressive or monoclonal antibody therapy. In the future, broader use of immunosuppressive and immunomodulatory medications may increase incidence of PML among patients with diseases unassociated with PML. Safety screening protocols for John Cunningham virus and PML are important to prevent new PML cases.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Finland
| | - Anders Paetau
- Department of Pathology (Neuropathology), Helsinki University Hospital Laboratory (HUSLAB), Helsinki University Hospital and Helsinki University, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki University Hospital and Helsinki University, Finland
| | - Rita Janes
- Department of Oncology, Helsinki University Hospital and Helsinki University, Finland
| | - Matti Ristola
- Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital and Helsinki University, Finland
| | - Maija Lappalainen
- Laboratory Services (HUSLAB), Department of Virology and Immunology, Helsinki University Hospital and Helsinki University, Finland
| | - Veli-Jukka Anttila
- Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital and Helsinki University, Finland
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Smith B. Toward Understanding the When and Why of Human Immunodeficiency Virus-Associated Stroke. J Infect Dis 2018; 216:509-510. [PMID: 28931223 DOI: 10.1093/infdis/jix343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bryan Smith
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Pathogenesis of progressive multifocal leukoencephalopathy and risks associated with treatments for multiple sclerosis: a decade of lessons learned. Lancet Neurol 2018; 17:467-480. [DOI: 10.1016/s1474-4422(18)30040-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 11/30/2017] [Accepted: 01/25/2018] [Indexed: 12/12/2022]
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Sierra Morales F, Illingworth C, Lin K, Rivera Agosto I, Powell C, Sloane JA, Koralnik IJ. PML-IRIS in an HIV-2-infected patient presenting as Bell's palsy. J Neurovirol 2017; 23:789-792. [PMID: 28831749 PMCID: PMC5718171 DOI: 10.1007/s13365-017-0565-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 07/24/2017] [Accepted: 07/30/2017] [Indexed: 10/19/2022]
Abstract
We present the case of an HIV-2-infected patient who developed progressive multifocal leukoencephalopathy (PML) in the setting of immune reconstitution inflammatory syndrome (IRIS) presenting as Bell's palsy. The brain MRI showed a single lesion in the facial colliculus considered initially to be ischemic in nature. This case report should alert clinicians that PML can occur in the setting of HIV-2 infection. It also illustrates the difficulty of establishing the diagnosis of PML.
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Affiliation(s)
- Fabian Sierra Morales
- Section of Neuro-Infectious Diseases, Rush University Medical Center, 1725 W. Harrison Street, Suite 1106, Chicago, IL, 60612, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Carlos Illingworth
- Department of Neurology, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Kathie Lin
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ivia Rivera Agosto
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chloé Powell
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jacob A Sloane
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Igor J Koralnik
- Section of Neuro-Infectious Diseases, Rush University Medical Center, 1725 W. Harrison Street, Suite 1106, Chicago, IL, 60612, USA.
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA.
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Sundbom P, Hubbert L, Serrander L. Progressive multifocal leukoencephalopathy after heart transplantation: 4 years of clinically stable infection on low-dose immunosuppressive therapy. Oxf Med Case Reports 2017; 2017:omx003. [PMID: 28473916 PMCID: PMC5410880 DOI: 10.1093/omcr/omx003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/01/2017] [Accepted: 01/19/2017] [Indexed: 12/22/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML), caused by reactivation of JC-virus is a relatively rare complication seen in patients with compromised immune system. There are no evidence-based treatment available and prognosis is poor. Withdrawal of immunosuppressant can result in further neurological deterioration and for patients with solid organ transplantations, fatal graft rejection. We report a 52-year-old women that presented with seizures within 1 month after heart transplantation. Initial diagnosis was vascular disease. After clinical deterioration 10 months after transplantation, further examinations led to the diagnosis. Minimizing tacrolimus, to a concentration of 2 ng/ml, and extensive physical therapy has improved the physical capacity of the patient. The patient has now been clinically stable for 4 years and extended survival for 5 years. This case adds to the limited adult cases of PML within the population of heart transplant recipients and the need for increased awareness to minimize diagnosis delay.
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Affiliation(s)
- Per Sundbom
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Laila Hubbert
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lena Serrander
- Department of Infectious Diseases and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Scarpazza C, De Rossi N, Moiola L, Gerevini S, Cosottini M, Capra R, Mattioli F. The still under-investigated role of cognitive deficits in PML diagnosis. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40893-016-0018-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Prosperini L, de Rossi N, Scarpazza C, Moiola L, Cosottini M, Gerevini S, Capra R. Natalizumab-Related Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis: Findings from an Italian Independent Registry. PLoS One 2016; 11:e0168376. [PMID: 27997580 PMCID: PMC5172579 DOI: 10.1371/journal.pone.0168376] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/29/2016] [Indexed: 12/31/2022] Open
Abstract
Background The monoclonal antibody natalizumab (NTZ) is a highly effective treatment for patients with multiple sclerosis (MS). However, this drug is associated with increased risk of developing Progressive Multifocal Leukoencephalopathy (PML), an opportunistic infection of central nervous system (CNS) caused by the John Cunningham polyomavirus (JCV). Objective To describe the 12-month clinical course of 39 patients with MS (28 women, 11 men) who developed NTZ-related PML after a mean exposure of 39 infusions. Methods An Italian independent collaborative repository initiative collected and analyzed socio-demographic, clinical, magnetic resonance imaging (MRI) data and number of JCV-DNA copies detected on cerebrospinal fluid (CSF) samples of patients diagnosed as affected by NTZ-related PML. The evolution of disability, measured by the Expanded Disability Status Scale, was assessed at NTZ start, at PML diagnosis and after 2, 6 and 12 months from PML diagnosis. The effect of clinical and paraclinical characteristics at PML diagnosis on the final outcome was also investigated. Results Ten patients (25.6%) were diagnosed before 24 NTZ infusions. In six cases (15.4%) the PML suspect was made on the basis of highly suggestive MRI findings in absence of any detectable change of clinical conditions (asymptomatic PML). In patients with symptomatic PML, the diagnosis was quicker for those who presented with cognitive symptoms (n = 12) rather than for those with other neurological pictures (n = 21) (p = 0.003). Three patients (7.7%) died during the 12-month observation period, resulting in a survival rate of 92.3%. Asymptomatic PML, more localized brain involvement and gadolinium-enhancement detected at MRI, as well as lower viral load were associated with a better disability outcome (p-values<0.01). Conclusion Our findings support that early PML diagnosis, limited CNS involvement and initial signs of immune restoration are associated with a better outcome and higher survival rate, and confirm the utility of MRI as a surveillance tool for NTZ-treated patients.
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Affiliation(s)
- Luca Prosperini
- Dept. of Neurology and Psychiatry, Sapienza University, Viale Dell’Università, Rome, Italy
- * E-mail:
| | - Nicola de Rossi
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Via Ciotti, Montichiari, Brescia, Italy
| | - Cristina Scarpazza
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Via Ciotti, Montichiari, Brescia, Italy
| | - Lucia Moiola
- Dept. of Neurology, San Raffaele Scientific Institute, Via Olgettina, Milan, Italy
| | - Mirco Cosottini
- Dept. of Translational Research and New Surgical and Medical Technologies, University of Pisa, Via Paradisa, Pisa, Italy
| | - Simonetta Gerevini
- Dept. of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, Milan, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili di Brescia, Via Ciotti, Montichiari, Brescia, Italy
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