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Dsilva L, McCarthy K, Lyons J, Cabigas B, Campbell N, Kong G, Adams B, Kuhelj R, Singhal P, Smirnakis K. Progressive multifocal leukoencephalopathy with natalizumab extended or standard interval dosing in the United States and the rest of the world. Expert Opin Drug Saf 2023; 22:995-1002. [PMID: 37272350 DOI: 10.1080/14740338.2023.2221027] [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: 12/20/2022] [Accepted: 05/05/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML), an important identified risk for natalizumab, has been described for standard interval dosing (SID; dosing interval every-4-weeks). Information on PML with natalizumab extended interval dosing (EID; dosing interval >every-4-weeks) in the US and the rest of the world (ROW) is limited. RESEARCH DESIGN AND METHODS A retrospective analysis of patient demographics, risk factors, clinical characteristics, and clinical outcomes was conducted on confirmed natalizumab EID and SID PML cases evaluated from Biogen pharmacovigilance systems. RESULTS Of 857 confirmed natalizumab PML cases, EID and SID accounted for 7.5% and 92.5%, respectively (US: 12.9% and 87.1%; ROW: 5.4% and 94.6%). PML risk factors included anti-JCV index > 1.5 (US: EID, 56.7% and SID, 12.8%; ROW: EID, 44.1% and SID, 21.0%), mean duration of natalizumab treatment (US: 90.0 and 70.2 months; ROW: 54.1 and 49.8 months), and prior immunosuppressive therapy (US: 20.0% and 21.7%; ROW:11.8% and 18.0%). In the EID and SID groups, 68.8% and 76.0% of patients, respectively, were alive at up to 2 years after diagnosis. CONCLUSIONS This analysis provides insights on PML in patients receiving natalizumab that extend current knowledge, particularly regarding PML in patients receiving natalizumab EID, which can be built upon in the future.
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Affiliation(s)
| | - Kerry McCarthy
- Drug Safety, Pharmacovigilance & Systems & Data Analytics, Biogen, Cambridge, MA, USA
| | | | | | | | | | | | | | | | - Karen Smirnakis
- Safety and Benefit Risk Management, Biogen, Cambridge, MA, USA
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Cauchi M, Willis M, Andrews A, Backx M, Brownlee W, Ford HL, Gran B, Jolles S, Price S, Rashid W, Schmierer K, Tallantyre EC. Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline. Pract Neurol 2022; 22:practneurol-2022-003370. [PMID: 35863879 DOI: 10.1136/practneurol-2022-003370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.
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Affiliation(s)
- Marija Cauchi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
| | - Angela Andrews
- Pharmacy Neurosciences Directorate, University Hospital of Wales, Cardiff, UK
| | - Matthijs Backx
- Infectious Diseases, University Hospital of Wales and Department of Microbiology, Public Health Wales, Cardiff, UK
| | - Wallace Brownlee
- Queen Square MS Centre, University College London Institute of Neurology, Queen Square Multiple Sclerosis Centre, London, UK
| | - Helen L Ford
- Centre for Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK, Leeds, UK
| | - Bruno Gran
- Department of Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Mental Health and Clinical Neuroscience Academic Unit, University of Nottingham School of Medicine, Nottingham, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Sian Price
- Department of Neuroscience, University of Sheffield, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Waqar Rashid
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Klaus Schmierer
- The Blizard Institute (Neuroscience, Surgery & Trauma), Queen Mary University of London Faculty of Medicine and Dentistry, London, UK
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Emma C Tallantyre
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, University Hospital of Wales, Cardiff, UK
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3
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Neuro-ophthalmologic manifestations of multiple sclerosis other than acute optic neuritis. Mult Scler Relat Disord 2020; 48:102730. [PMID: 33412489 DOI: 10.1016/j.msard.2020.102730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 11/21/2022]
Abstract
Acute optic neuritis is the most common neuro-opthalmologic manifestation of multiple sclerosis (MS). Treatment with high-dose intravenous corticosteroids accelerates visual recovery, although it has no long-term visual benefit. MS has several others, less common, neuro-ophthalmological manifestations, where corticotherapy may not be the best treatment option. Neuro-ophthalmologic manifestations of MS other than optic neuritis can be divided in afferent and efferent visual pathways, acute and chronic and may be associated with drugs that are employed in MS. The authors propose is to review the neuro-ophthalmologic manifestations of multiple sclerosis other than optic neuritis. Recognition of these leads to a more targeted treatment and may prevent visual deterioration.
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Pruitt AA. Central Nervous System Infections Complicating Immunosuppression and Transplantation. Continuum (Minneap Minn) 2019; 24:1370-1396. [PMID: 30273244 DOI: 10.1212/con.0000000000000653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This article reviews infections associated with cancer treatments and immunosuppressive/immunomodulatory therapies used in both neoplastic and non-neoplastic conditions, including hematopoietic cell transplantation and solid organ transplantation. It provides a clinical approach to the most commonly affected patient groups based on clinicoanatomic presentation and disease-specific risks resulting from immune deficits and drugs received. RECENT FINDINGS The clinical presentations, associated neuroimaging findings, and CSF abnormalities of patients with central nervous system infections who are immunocompromised may differ from those of patients with central nervous system infections who are immunocompetent and may be confused with noninfectious processes. Triggering of brain autoimmunity with emergence of neurotropic antibodies has emerged as a recognized parainfectious complication. New unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. SUMMARY Despite evidence-based prophylactic regimens and organism-specific antimicrobials, central nervous system infections continue to cause significant morbidity and mortality in an increasing range of patients who are immunocompromised by their conditions and therapies. Multiple new drugs put patients at risk for progressive multifocal leukoencephalopathy, which has numerous imaging and clinical manifestations; patients at risk include those with multiple sclerosis, for whom infection risk is becoming one of the most important factors in therapeutic decision making. Efficient, early diagnosis is essential to improve outcomes in these often-devastating diseases.
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Lapides DA, Batchala PP, Donahue JH, Lisak RP, Meltzer EI, Narayan RN, Nath A, Frohman TC, Costello K, Goldman MD, Zamvil SS, Frohman EM. Cerebellar syndrome in a man treated with natalizumab: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e546. [PMID: 30882020 PMCID: PMC6410929 DOI: 10.1212/nxi.0000000000000546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 11/15/2022]
Affiliation(s)
- David A Lapides
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Prem P Batchala
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Joseph H Donahue
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Robert P Lisak
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ethan I Meltzer
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ram N Narayan
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Avi Nath
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Teresa C Frohman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Kathleen Costello
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Myla D Goldman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Scott S Zamvil
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Elliot M Frohman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
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Pawlitzki M, Teuber J, Campe C, Wagner M, Schuart C, Paul F, Bittner D. VZV-associated acute retinal necrosis in a patient with MS treated with natalizumab. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 5:e475. [PMID: 29998157 PMCID: PMC6039210 DOI: 10.1212/nxi.0000000000000475] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Marc Pawlitzki
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Jan Teuber
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Christin Campe
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Markus Wagner
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Claudia Schuart
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Friedemann Paul
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - Daniel Bittner
- Department of Neurology (M.P., J.T., C.C., D.B.), Otto-von-Guericke University; Department of Ophthalmology (M.W., C.S.), Otto-von-Guericke University, Magdeburg; Charité-Universitätsmedizin Berlin (F.P.), Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure Clinical Research Center; Department of Neurology (F.P.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; and Experimental and Clinical Research Center (F.P.), Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
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Rommer PS, Zettl UK. Managing the side effects of multiple sclerosis therapy: pharmacotherapy options for patients. Expert Opin Pharmacother 2018. [PMID: 29528247 DOI: 10.1080/14656566.2018.1446944] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated and neurodegenerative disease with an unpredictable outcome. Immune-modulatory treatment aims at decreasing long-term disability. With the increasing number of treatment options, it is essential to fully digest the possible side effects of the available therapeutics and to monitor patients is essential. AREAS COVERED All approved disease-modifying drugs (DMD) for MS are discussed in this review. Mode of action, adverse effects, reported risks for infections and malignancies, and pregnancy related issues are discussed in the review. The authors also provide suggestions for monitoring therapy. For all approved DMDs the pivotal studies have been included for possible side effects, as well as reports by health authorities. For this manuscript, PubMed was checked for reports on side effects for various drugs. EXPERT OPINION Treatment options in MS are manifold, each carrying different risks. The safety-risk profile for approved agents is favorable. Knowing and monitoring these possible side effects is essential to minimize risks associated with treatment. Presently, the long-term experience for some of these therapies is missing and this must be addressed.
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Affiliation(s)
- Paulus S Rommer
- a Department of Neurology , Medical University of Vienna , Vienna , Austria
| | - Uwe K Zettl
- b Department of Neurology, Neuroimmunological Section , University of Rostock , Rostock , Germany
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Kamourieh S, Gananandan K, Raffel J, Nicholas R. Natalizumab granule cell neuronopathy: FDG-PET in diagnosis and immune reconstitution with G-CSF. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e384. [PMID: 28761903 PMCID: PMC5515596 DOI: 10.1212/nxi.0000000000000384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/30/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Salwa Kamourieh
- Department of Neurology (S.K., J.R., R.N.), Imperial College NHS Trust, London; and Department of Medicine (K.G.), Ealing Hospital, Southall, United Kingdom
| | - Kohilan Gananandan
- Department of Neurology (S.K., J.R., R.N.), Imperial College NHS Trust, London; and Department of Medicine (K.G.), Ealing Hospital, Southall, United Kingdom
| | - Joel Raffel
- Department of Neurology (S.K., J.R., R.N.), Imperial College NHS Trust, London; and Department of Medicine (K.G.), Ealing Hospital, Southall, United Kingdom
| | - Richard Nicholas
- Department of Neurology (S.K., J.R., R.N.), Imperial College NHS Trust, London; and Department of Medicine (K.G.), Ealing Hospital, Southall, United Kingdom
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9
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Holroyd KB, Sotirchos ES, DeBoer SR, Mills KA, Newsome SD. JC virus granule cell neuronopathy onset two months after chemotherapy for low-grade lymphoma. CEREBELLUM & ATAXIAS 2017; 4:8. [PMID: 28652923 PMCID: PMC5481904 DOI: 10.1186/s40673-017-0066-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/14/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Granule cell neuronopathy (GCN) is a rare disease caused by the JC virus, leading to degeneration of cerebellar granule cell neurons. Primarily described in patients with AIDS, it has also been diagnosed in patients with lymphoproliferative diseases and after long-term treatment with immune-suppressing medications such as natalizumab. CASE PRESENTATION A 69 year old woman presented with progressive ataxia which began 2 months after initiation of treatment for follicular low-grade B cell lymphoma with rituximab/bendamustine, and progressed for 2 years prior to admission. Extensive prior evaluation included MRI that showed atrophy of the cerebellum but normal CSF analysis and serum studies. Neurologic exam on admission was notable for severe appendicular ataxia and fatigable end-gaze direction-changing horizontal nystagmus. FDG-PET/CT scan was unremarkable and repeat lumbar puncture revealed 2 WBCs/mm3, 148 RBCs/mm3, glucose 70 mg/dL, protein 37.7 mg/dL and negative flow cytometry/cytopathology. Standard CSF JC virus PCR testing was negative, but ultrasensitive TaqMan real-time JC virus PCR testing was positive, consistent with JC virus-related GCN. CONCLUSIONS Because of the diagnostic challenges in identifying GCN, a high threshold of suspicion should be maintained in patients with an immune-suppressing condition such as lymphoma or on immune-suppressing agents such as rituximab, even shortly after initiation of therapy.
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Affiliation(s)
| | - Elias S Sotirchos
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Scott R DeBoer
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Kelly A Mills
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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Warnke C, Wattjes MP, Adams O, Hartung HP, Martin R, Weber T, Stangel M. [Progressive multifocal leukoencephalopathy]. DER NERVENARZT 2016; 87:1300-1304. [PMID: 27730274 DOI: 10.1007/s00115-016-0225-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a disease of immunosuppressed patients caused by the JC polyomavirus (JCPyV). Due to the elevated risk in patients treated with natalizumab for multiple sclerosis (MS) and also treatment with other biologicals for different indications, the relevance of PML has increased in recent years. This article summarizes the published knowledge on the biology and pathogenesis of PML with a focus on the role of cerebrospinal fluid diagnostics in the work-up for PML and the current PML case definition. Current recommendations regarding risk management are discussed, as are possible therapies and prevention.
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Affiliation(s)
- C Warnke
- Klinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - M P Wattjes
- Abteilung für Radiologie und Nuklearmedizin, VU University Medical Center, Amsterdam, Niederlande
| | - O Adams
- Institut für Virologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - H-P Hartung
- Klinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - R Martin
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Schweiz
| | - T Weber
- Klinik für Neurologie, Kath. Marienkrankenhaus, Hamburg, Deutschland
| | - M Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Wijburg MT, Witte BI, Vennegoor A, Roosendaal SD, Sanchez E, Liu Y, Martins Jarnalo CO, Uitdehaag BM, Barkhof F, Killestein J, Wattjes MP. MRI criteria differentiating asymptomatic PML from new MS lesions during natalizumab pharmacovigilance. J Neurol Neurosurg Psychiatry 2016; 87:1138-45. [PMID: 27530808 DOI: 10.1136/jnnp-2016-313772] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Differentiation between progressive multifocal leukoencephalopathy (PML) and new multiple sclerosis (MS) lesions on brain MRI during natalizumab pharmacovigilance in the absence of clinical signs and symptoms is challenging but is of substantial clinical relevance. We aim to define MRI characteristics that can aid in this differentiation. METHODS Reference and follow-up brain MRIs of natalizumab-treated patients with MS with asymptomatic PML (n=21), or asymptomatic new MS lesions (n=20) were evaluated with respect to characteristics of newly detected lesions by four blinded raters. We tested the association with PML for each characteristic and constructed a multivariable prediction model which we analysed using a receiver operating characteristic (ROC) curve. RESULTS Presence of punctate T2 lesions, cortical grey matter involvement, juxtacortical white matter involvement, ill-defined and mixed lesion borders towards both grey and white matter, lesion size of >3 cm, and contrast enhancement were all associated with PML. Focal lesion appearance and periventricular localisation were associated with new MS lesions. In the multivariable model, punctate T2 lesions and cortical grey matter involvement predict for PML, while focal lesion appearance and periventricular localisation predict for new MS lesions (area under the curve: 0.988, 95% CI 0.977 to 1.0, sensitivity: 100%, specificity: 80.6%). INTERPRETATION The MRI characteristics of asymptomatic natalizumab-associated PML lesions proved to differ from new MS lesions. This led to a prediction model with a high discriminating power. Careful assessment of the presence of punctate T2 lesions, cortical grey matter involvement, focal lesion appearance and periventricular localisation allows for an early diagnosis of PML.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Birgit I Witte
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Anke Vennegoor
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Esther Sanchez
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Yaou Liu
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, P. R. China
| | - Carine O Martins Jarnalo
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Bernard Mj Uitdehaag
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Wüthrich C, Batson S, Anderson MP, White LR, Koralnik IJ. JC Virus Infects Neurons and Glial Cells in the Hippocampus. J Neuropathol Exp Neurol 2016; 75:712-717. [PMID: 27297673 PMCID: PMC5909865 DOI: 10.1093/jnen/nlw050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The human polyomavirus JC (JCV) infects glial cells and is the etiologic agent of the CNS demyelinating disease progressive multifocal leukoencephalopathy. JCV can infect granule cell neurons of the cerebellum, causing JCV granule cell neuronopathy and cortical pyramidal neurons in JCV encephalopathy. Whether JCV also infects neurons in other areas of the CNS is unclear. We determined the prevalence and pattern of JCV infection of the hippocampus in archival samples from 28 patients with known JCV infection of the CNS and 66 control subjects. Among 28 patients, 11 (39.3%) had JCV infection of hippocampus structures demonstrated by immunohistochemistry. Those included gray matter (dentate gyrus and cornu ammonis, subiculum) in 11/11 and afferent or efferent white matter tracts (perforant path, alveus, fimbria) in 10/11. In the hippocampus, JCV infected granule cell and pyramidal neurons, astrocytes, and oligodendrocytes. Although glial cells expressed either JCV regulatory T Antigen or JCV VP1 capsid protein, infected neurons expressed JCV T Antigen only, suggesting an abortive/restrictive infection. None of the 66 control subjects had evidence of hippocampal JCV protein expression by immunohistochemistry or JCV DNA by in situ hybridization. These results greatly expand our understanding of JCV pathogenesis in the CNS.
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Affiliation(s)
- Christian Wüthrich
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Stephanie Batson
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Matthew P Anderson
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Lon R White
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Igor J Koralnik
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW).
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13
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Martinelli V, Dalla Costa G, Moiola L, Pavan G, Diotti RA, De Riz MA, Gerevini S, Comi G. Progressive ataxia in a natalizumab-treated multiple sclerosis patient: the dark side of JC virus infection. Eur J Neurol 2016; 23:e39-40. [DOI: 10.1111/ene.13027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- V. Martinelli
- Department of Neurology; San Raffaele Hospital; Milan Italy
| | - G. Dalla Costa
- Department of Neurology; San Raffaele Hospital; Milan Italy
| | - L. Moiola
- Department of Neurology; San Raffaele Hospital; Milan Italy
| | - G. Pavan
- Department of Neurorehabilitation; San Raffaele Hospital; Milan Italy
| | - R. A. Diotti
- Microbiology and Virology Research Unit; San Raffaele Hospital; Milan Italy
| | - M. A. De Riz
- Department of Neurology; IRCCS Ospedale Maggiore Policlinico; Milan Italy
| | - S. Gerevini
- Department of Neuroradiology; San Raffaele Hospital; Milan Italy
| | - G. Comi
- Department of Neurology; San Raffaele Hospital; Milan Italy
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15
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Jelcic I, Jelcic I, Kempf C, Largey F, Planas R, Schippling S, Budka H, Sospedra M, Martin R. Mechanisms of immune escape in central nervous system infection with neurotropic JC virus variant. Ann Neurol 2016; 79:404-18. [PMID: 26874214 DOI: 10.1002/ana.24574] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 10/20/2015] [Accepted: 11/28/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Symptomatic infections of the central nervous system (CNS) with JC polyomavirus (JCV) usually occur as a result of immunocompromise and manifest as progressive multifocal leukoencephalopathy (PML) or granule cell neuronopathy (GCN). After immune reconstitution, some of these cases may show long-term persistence of JCV and delayed clinical improvement despite inflammation. METHODS We followed 4 patients with multiple sclerosis, who developed natalizumab-associated PML or GCN with regard to JC viral load and JCV-specific T-cell responses in the CNS. All of them experienced immune reconstitution inflammatory syndrome (IRIS), but in 2 cases JCV persisted > 21 months after IRIS accompanied by delayed clinical improvement. RESULTS Persistence of JCV was associated with a lack of JCV VP1-specific T-cell responses during immune reconstitution in 1 of the patients. Detailed analysis of the brain infiltrate in another patient with neuronal persistence of JCV revealed strong infiltration of CD8(+) T cells and clonal expansion of activated CD8(+) effector T cells with a CD4(dim) CD8(+) phenotype, both exhibiting exquisite specificity for conserved epitopes of JCV large T antigen. However, clearance of JCV was not efficient, because mutations in the major capsid protein VP1 caused reduced CD4(+) T-cell responses against the identified JCV variant and subsequently resulted in a decline of CD8(+) T-cell responses after IRIS. INTERPRETATION Our findings suggest that efficient CD4(+) T-cell recognition of neurotropic JCV variants is crucial to support CD8(+) T cells in combating JCV infection of the CNS.
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Affiliation(s)
- Ivan Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Christian Kempf
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Fabienne Largey
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Raquel Planas
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Sven Schippling
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Herbert Budka
- Institute of Neuropathology, University Hospital Zurich, Zurich, Switzerland
| | - Mireia Sospedra
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
| | - Roland Martin
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology University Hospital Zurich, Zurich, Switzerland
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16
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McGuigan C, Craner M, Guadagno J, Kapoor R, Mazibrada G, Molyneux P, Nicholas R, Palace J, Pearson OR, Rog D, Young CA. Stratification and monitoring of natalizumab-associated progressive multifocal leukoencephalopathy risk: recommendations from an expert group. J Neurol Neurosurg Psychiatry 2016; 87:117-25. [PMID: 26492930 PMCID: PMC4752634 DOI: 10.1136/jnnp-2015-311100] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
The use of natalizumab for highly active relapsing-remitting multiple sclerosis (MS) is influenced by the occurrence of progressive multifocal leukoencephalopathy (PML). Through measurement of the anti-JCV antibody index, and in combination with the presence or absence of other known risk factors, it may be possible to stratify patients with MS according to their risk of developing PML during treatment with natalizumab and detect early suspected PML using MRI including a diffusion-weighted imaging sequence. This paper describes a practical consensus guideline for treating neurologists, based on current evidence, for the introduction into routine clinical practice of anti-JCV antibody index testing of immunosuppressant-naïve patients with MS, either currently being treated with, or initiating, natalizumab, based on their anti-JCV antibody status. Recommendations for the frequency and type of MRI screening in patients with varying index-associated PML risks are also discussed. This consensus paper presents a simple and pragmatic algorithm to support the introduction of anti-JCV antibody index testing and MRI monitoring into standard PML safety protocols, in order to allow some JCV positive patients who wish to begin or continue natalizumab treatment to be managed with a more individualised analysis of their PML risk.
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Affiliation(s)
- C McGuigan
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - M Craner
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - J Guadagno
- Department of Neurology, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals Trust, Newcastle, UK
| | - R Kapoor
- National Hospital for Neurology and Neurosurgery, London, UK
| | - G Mazibrada
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - P Molyneux
- Department of Neurology, West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
| | - R Nicholas
- Department of Neurology, Imperial Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - J Palace
- Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - O R Pearson
- Department of Neurology, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - D Rog
- Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - C A Young
- Walton Centre NHS Foundation Trust, Liverpool, UK
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17
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Wijburg MT, Siepman D, van Eijk JJJ, Killestein J, Wattjes MP. Concomitant granule cell neuronopathy in patients with natalizumab-associated PML. J Neurol 2016; 263:649-56. [PMID: 26810721 PMCID: PMC4826658 DOI: 10.1007/s00415-015-8001-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 12/01/2022]
Abstract
Granule cell neuronopathy (GCN) is a rare JC virus infection of the cerebellar granule cell neurons in immunocompromised patients. On brain imaging, GCN is characterized by cerebellar atrophy which can be accompanied by infratentorial white matter lesions. The objective of this study is to investigate the prevalence of MRI findings suggestive of GCN in a large natalizumab-associated progressive multifocal leukoencephalopathy (PML) cohort. MRI scans from before, at the time of, and during follow-up after diagnosis of PML in 44 natalizumab-treated MS patients, and a control group of 25 natalizumab-treated non-PML MS patients were retrospectively reviewed for imaging findings suggestive of GCN. To assess and quantify the degree of cerebellar atrophy, we used a 4 grade rating scale. Three patients in the PML group showed imaging findings suggestive of GCN and none in the control group. In two of these PML patients, cerebellar atrophy progressed from grade 0 at the time of diagnosis of isolated supratentorial PML to grade 1 and 2 after 2.5 and 3 months, respectively, in the absence of infratentorial white mater lesions. The third patient had grade 1 cerebellar atrophy before diagnosis of infra- and supratentorial PML, and showed progression of cerebellar atrophy to grade 2 in the 3 months following PML diagnosis. None of the other eight patients with infratentorial PML lesions developed cerebellar atrophy suggestive of GCN. Three cases with imaging findings suggestive of GCN were detected among 44 natalizumab-associated PML patients. GCN may, therefore, be more common than previously considered in natalizumab-associated PML patients.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.
| | - Dorine Siepman
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, MS Center, Rotterdam, The Netherlands
| | - Jeroen J J van Eijk
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Neurological immune reconstitution inflammatory response: riding the tide of immune recovery. Curr Opin Neurol 2016; 28:295-301. [PMID: 25887769 DOI: 10.1097/wco.0000000000000200] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript reviews current reports about clinical aspects of immune reconstitution inflammatory syndrome (IRIS), with a particular emphasis on IRIS in the setting of progressive multifocal leukoencephalopathy (PML) and to a lesser extent on cryptococcal meningitis and HIV. RECENT FINDINGS PML prognosis has been radically improved, as it has become possible to provide immune reconstitution, although some remaining morbidity and mortality results from excess inflammation. Similar pathologic responses are seen less often, but remain clinically important in cryptococcal meningitis, and HIV. Early diagnosis and active management of PML results in optimal outcomes with survival of 75% or higher in multiple recent series. These finding apply both to natalizumab and HIV-associated PML. Cryptococcal meningitis is frequently complicated by IRIS, and early treatment with antifungal therapy preceding HIV therapy provides optimal outcomes. HIV IRIS is reduced by early therapy, which is now recommended, but even on therapy, chronic dysregulated immune responses may play important roles in ongoing HIV-associated neurocognitive disease (HAND), which is common, as well as rare but more dramatic subacute encephalopathies. SUMMARY The clinician must actively monitor and treat both opportunistic infection and the inflammatory response that is essential to recovery but may itself augment disease and injury.
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Novel syndromes associated with JC virus infection of neurons and meningeal cells: no longer a gray area. Curr Opin Neurol 2016; 28:288-94. [PMID: 25887767 DOI: 10.1097/wco.0000000000000201] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The availability of a growing number of immunomodulatory medications over the past few years has been associated with various JC virus (JCV)-associated brain syndromes in patients with autoimmune diseases, including multiple sclerosis, Crohn's disease, and psoriasis that had not been previously recognized as predisposing factors for progressive multifocal leukoencephalopathy. This review covers the three novel syndromes discovered in the last decade that are caused by JCV infection of neurons and meningeal cells. RECENT FINDINGS For more than 30 years, JCV was thought to exclusively infect oligodendrocytes and astrocytes in the white matter of the brain of immunosuppressed individuals. We now recognize that JCV-infected glial cells are frequently located at the gray-white matter junction or exclusively within the gray matter causing demyelination in the cortex. Mutations in JCV can trigger a change in tropism leading to involvement of other cell types, such as neurons and meningeal cells, causing clinically distinct entities. These new features of JCV infection provide challenges for clinicians taking care of affected patients and investigators studying the biology of this polyomavirus, its pathogenesis, and tropism. SUMMARY We hope that increasing awareness of these syndromes will lead to early diagnosis, and pave the way for new avenues of research to better understand all aspects of JCV pathogenesis and develop efficient therapies for our patients. However, we need to remain vigilant and open to the possibility that additional JC variants or yet unknown polyomaviruses may also be associated with neurological diseases.
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Simian Virus 40 Infection in the Spinal Cord of Simian Immunodeficiency Virus-Immunosuppressed Rhesus Macaques. J Neuropathol Exp Neurol 2016; 74:1071-6. [PMID: 26469249 DOI: 10.1097/nen.0000000000000252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is an often-fatal demyelinating disease of the CNS that usually develops in immunocompromised individuals because of reactivation of quiescent JC virus (JCV). There are only a few reports of JCV infection in the human spinal cord. Progressive multifocal leukoencephalopathy-like demyelinating lesions have been documented in the brains of simian immunodeficiency virus-infected macaques. To determine whether simian virus 40 (SV40) can infect and cause PML lesions in spinal cords of immunosuppressed macaques, we examined archival spinal cord samples from 15 simian immunodeficiency virus-infected rhesus monkeys with acquired immunodeficiency syndrome and SV40 infection of the brain. Among those, 6 (40%) had SV40-infected cells in the spinal cord, including 1 with PML-like lesions, 1 with PML-like lesions and meningoencephalitis, 2 with meningoencephalitis, 1 with gray matter gliosis, and 1 with no lesions. One animal with a large PML-like lesion had extensive demyelination and SV40 infection of astrocytes, oligodendrocytes, and meningeal cells. None of the 6 animals had SV40-infected spinal cord neurons. These observations indicate that, like JCV in immunosuppressed humans, SV40 can infect glial cells and cause PML-like lesions in the spinal cord of immunosuppressed rhesus macaques. Rhesus macaques could serve as an animal model to study polyomavirus infection and pathogenesis in the spinal cord.
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Progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome (IRIS). Acta Neuropathol 2015; 130:751-64. [PMID: 26323992 DOI: 10.1007/s00401-015-1471-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 10/23/2022]
Abstract
Progressive multifocal leukoencephalopathy is a viral encephalitis induced by the John Cunningham (JC) virus, an ubiquitous neurotropic papovavirus of the genus polyomavirus that in healthy people in latency resides in kidney and bone marrow cells. Activation and entry into the CNS were first seen in patients with malignancies of the hematopoietic system and an impaired immune system. During the 1980 and the 1990s with the appearance of human immunodeficiency virus infection in humans, PML was found to be the most important opportunistic infection of the central nervous system. As a result of highly efficient immunosuppressive and immunomodulatory treatments, in recent years, the number of PML cases again increased. PML is prevented by an intact cellular immune response and accordingly immune reconstitution can terminate established disease in the CNS. However, forced immune reconstitution can lead to massive destruction of virus-infected cells. This may result in clinical exacerbation associated with high morbidity and mortality and referred to as PML with immune reconstitution inflammatory syndrome (PML-IRIS). In the present review, we discuss virological properties and routes of infection in the CNS, but mostly focus on the pathology of PML and PML-IRIS and on the role of the immune system in these disorders. We show that PML and PML-IRIS result from predominant JC virus infection of oligodendrocytes and, to a lesser extent, of infected neurons. Inflammation in these encephalitides seems to be driven by a dominant cytotoxic T cell response which is massively exaggerated during IRIS.
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Abstract
AbstractMultiple sclerosis is a chronic demyelinating disease characterized by focal and diffuse inflammation of the central nervous system resulting in significant physical and cognitive disabilities. Disease-modifying therapies targeting the dysfunctional immune response are most effective in the first few years after disease onset, indicating that there is a limited time window for therapy to influence the disease course. No evidence of disease activity is emerging as a new standard for treatment response and may be associated with improved long-term disability outcomes. An aggressive management strategy, including earlier use of more potent immunomodulatory agents and close monitoring of the clinical and radiologic response to treatment, is recommended to minimize early brain volume loss and slow the progression of physical and cognitive impairments in patients with relapsing-remitting multiple sclerosis.
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Lack of Major Histocompatibility Complex Class I Upregulation and Restrictive Infection by JC Virus Hamper Detection of Neurons by T Lymphocytes in the Central Nervous System. J Neuropathol Exp Neurol 2015; 74:791-803. [PMID: 26115192 DOI: 10.1097/nen.0000000000000218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The human polyomavirus JC (JCV) infects glial cells in immunosuppressed individuals, leading to progressive multifocal leukoencephalopathy. Polyomavirus JC can also infect neurons in patients with JCV granule cell neuronopathy and JCV encephalopathy. CD8-positive T cells play a crucial role in viral containment and outcome in progressive multifocal leukoencephalopathy, but whether CD8-positive T cells can also recognize JCV-infected neurons is unclear. We used immunohistochemistry to determine the prevalence of T cells in neuron-rich areas of archival brain samples from 77 patients with JCV CNS infections and 94 control subjects. Neurons predominantly sustained a restrictive infection with expression of JCV regulatory protein T antigen (T Ag), whereas glial cells were productively infected and expressed both T Ag and the capsid protein VP1. T cells were more prevalent near JCV-infected cells with intact nuclei expressing both T Ag and VP1 compared with those expressing either protein alone. CD8-positive T cells also colocalized more with JCV-infected glial cells than with JCV-infected neurons. Major histocompatibility complex class I expression was upregulated in JCV-infected areas but could only be detected in rare neurons interspersed with infected glial cells. These results suggest that isolated neurons harboring restrictive JCV infection do not upregulate major histocompatibility complex class I and thus may escape recognition by CD8-positive T cells.
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Jelcic I, Combaluzier B, Jelcic I, Faigle W, Senn L, Reinhart BJ, Ströh L, Nitsch RM, Stehle T, Sospedra M, Grimm J, Martin R. Broadly neutralizing human monoclonal JC polyomavirus VP1-specific antibodies as candidate therapeutics for progressive multifocal leukoencephalopathy. Sci Transl Med 2015; 7:306ra150. [PMID: 26400911 DOI: 10.1126/scitranslmed.aac8691] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/27/2015] [Indexed: 12/15/2022]
Abstract
In immunocompromised individuals, JC polyomavirus (JCPyV) may mutate and gain access to the central nervous system resulting in progressive multifocal leukoencephalopathy (PML), an often fatal opportunistic infection for which no treatments are currently available. Despite recent progress, the contribution of JCPyV-specific humoral immunity to controlling asymptomatic infection throughout life and to eliminating JCPyV from the brain is poorly understood. We examined antibody responses against JCPyV major capsid protein VP1 (viral protein 1) variants in the serum and cerebrospinal fluid (CSF) of healthy donors (HDs), JCPyV-positive multiple sclerosis patients treated with the anti-VLA-4 monoclonal antibody natalizumab (NAT), and patients with NAT-associated PML. Before and during PML, CSF antibody responses against JCPyV VP1 variants show "recognition holes"; however, upon immune reconstitution, CSF antibody titers rise, then recognize PML-associated JCPyV VP1 variants, and may be involved in elimination of the virus. We therefore reasoned that the memory B cell repertoire of individuals who recovered from PML could be a source for the molecular cloning of broadly neutralizing antibodies for passive immunization. We generated a series of memory B cell-derived JCPyV VP1-specific human monoclonal antibodies from HDs and a patient with NAT-associated PML-immune reconstitution inflammatory syndrome (IRIS). These antibodies exhibited diverse binding affinity, cross-reactivity with the closely related BK polyomavirus, recognition of PML-causing VP1 variants, and JCPyV neutralization. Almost all antibodies with exquisite specificity for JCPyV, neutralizing activity, recognition of all tested JCPyV PML variants, and high affinity were derived from one patient who had recovered from PML. These antibodies are promising drug candidates for the development of a treatment of PML.
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Affiliation(s)
- Ivan Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Ilijas Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Wolfgang Faigle
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Luzia Senn
- Neurimmune Holding AG, 8952 Schlieren, Switzerland
| | - Brenda J Reinhart
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Luisa Ströh
- Interfaculty Institute of Biochemistry, University of Tübingen, 72076 Tübingen, Germany
| | - Roger M Nitsch
- Neurimmune Holding AG, 8952 Schlieren, Switzerland. Division of Psychiatry Research, University of Zurich, 8952 Schlieren, Switzerland
| | - Thilo Stehle
- Interfaculty Institute of Biochemistry, University of Tübingen, 72076 Tübingen, Germany. Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Mireia Sospedra
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Jan Grimm
- Neurimmune Holding AG, 8952 Schlieren, Switzerland.
| | - Roland Martin
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University of Zurich, University Hospital Zurich, 8091 Zurich, Switzerland.
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25
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Subei AM, Ontaneda D. Risk Mitigation Strategies for Adverse Reactions Associated with the Disease-Modifying Drugs in Multiple Sclerosis. CNS Drugs 2015; 29:759-71. [PMID: 26407624 PMCID: PMC4621807 DOI: 10.1007/s40263-015-0277-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past several years, the number of disease-modifying therapies (DMTs) for the treatment of multiple sclerosis (MS) has doubled in number. The 13 approved agents have shown a wide range of efficacy and safety in their clinical trials and post-marketing experience. While the availability of the newer agents allows for a wider selection of therapy for clinicians and patients, there is a need for careful understanding of the benefits and risks of each agent. Several factors such as the medication efficacy, side-effect profile, patient's preference, and co-morbidities need to be considered. An individualized treatment approach is thus imperative. In this review, risk stratification and mitigation strategies of the various disease-modifying agents are discussed.
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Affiliation(s)
- Adnan M Subei
- Mellen Center for MS Treatment and Research, Cleveland Clinic Foundation, 9500 Euclid Avenue/U10, Cleveland, OH, 44195, USA.
| | - Daniel Ontaneda
- Mellen Center for MS Treatment and Research, Cleveland Clinic Foundation, 9500 Euclid Avenue/U10, Cleveland, OH, 44195, USA.
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26
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Dammeier N, Schubert V, Hauser TK, Bornemann A, Bischof F. Case report of a patient with progressive multifocal leukoencephalopathy under treatment with dimethyl fumarate. BMC Neurol 2015; 15:108. [PMID: 26152311 PMCID: PMC4495627 DOI: 10.1186/s12883-015-0363-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 06/24/2015] [Indexed: 01/17/2023] Open
Abstract
Background Progressive multifocal leukoencephalopathy is a severe demyelinating disease caused by the polyoma JC virus in patients with reduced immunocompetence. A few cases of progressive multifocal leukoencephalopathy have been reported in patients treated with fumaric acid esters. Case presentation A 53-year-old Caucasian woman reported to our clinic with a first focal epileptic seizure and mild cognitive impairment. Since 1.5 years, she was treated with fumaderm for her psoriasis. During that time, her lymphocyte counts ranged between 450 and 700/μl. Cerebral magnet resonance imaging showed multifocal subcortical T2 hyperintense lesions with partial gadolinium enhancement. She did not have antibodies against human immunodeficiency virus 1 and 2 and cerebrospinal fluid-polymerase chain reaction for viral infections including a sensitive JC-virus polymerase chain reaction were negative. The diagnosis of progressive multifocal leukoencephalopathy was established by histological analysis and detection of JC-virus desoxyribonucleic acid in brain biopsy specimens. Dimethyl fumarate was stopped and Mirtazapin and Mefloquin were initiated. Neurological examination and imaging remained stable. Conclusions Progressive multifocal leukoencephalopathy can occur in patients with lymphocyte counts between 450 and 700/μl, produce only faint symptoms and is not excluded by negative JC-virus-polymerase chain reaction in cerebrospinal fluid. The incidence of progressive multifocal leukoencephalopathy may thus be underestimated and a more careful surveillance of patients would be necessary.
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Affiliation(s)
- Nele Dammeier
- University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.
| | - Victoria Schubert
- University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.
| | - Till-Karsten Hauser
- University Tübingen, Diagnostic and interventional Neuroradiology, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.
| | - Antje Bornemann
- Institute for pathology und neuropathology, section neuropathology, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.
| | - Felix Bischof
- University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany.
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27
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Wattjes MP, Vennegoor A, Steenwijk MD, de Vos M, Killestein J, van Oosten BW, Mostert J, Siepman DA, Moll W, van Golde AEL, Frequin STFM, Richert ND, Barkhof F. MRI pattern in asymptomatic natalizumab-associated PML. J Neurol Neurosurg Psychiatry 2015; 86:793-8. [PMID: 25205744 DOI: 10.1136/jnnp-2014-308630] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 08/08/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the MRI manifestation pattern of asymptomatic natalizumab-associated progressive multifocal leukoencephalopathy (PML) in patients with multiple sclerosis (MS). METHODS 18 patients with MS with natalizumab-associated PML lesions on MRI were included. In 6 patients, the PML lesions were identified on MRI prospectively and in 12 patients PML lesions were identified retrospectively. MRI sequences were analysed for PML lesion distribution, appearance, grey matter/white matter involvement and possible signs of inflammation. Lesion probability maps were created to demonstrate lesion distribution pattern. RESULTS The frontal lobe was involved in 14 patients (77.8%) and the parietal lobe in 4 patients (22.2%). Most patients presented with focal lesions (13 patients, 72.2%) involving one single lobe (12 patients, 66.7%). The cortical grey matter was affected in 15 patients (83.3%) and 13 patients (72.2%) presented with a combination of cortical grey and white matter involvement. Signs of inflammation were detected in 7 patients (38.8%). Among patients with available diffusion-weighted imaging, 6 patients (40%) did not show high-signal-intensity lesions. A classical imaging pattern including unilateral and unilobar focal lesions in the frontal lobe affecting the cortical grey matter or the cortical grey and adjacent white matter was observed in 8 patients (44.4%). CONCLUSIONS Asymptomatic natalizumab-associated PML manifestations on MRI show a rather localised disease, frequently located in the frontal lobes, affecting the cortical grey matter and adjacent juxtacortical white matter. Awareness of this lesion pattern facilitates an earlier diagnosis of natalizumab-associated PML in an asymptomatic stage associated with a more favourable prognosis.
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Affiliation(s)
- Mike P Wattjes
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Anke Vennegoor
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn D Steenwijk
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Marlieke de Vos
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Bob W van Oosten
- Department of Neurology, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Dorine A Siepman
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, MS Center, Rotterdam, The Netherlands
| | - Wiebe Moll
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | | | - Nancy D Richert
- Multiple Sclerosis Clinical Development Group, Biogen Idec, Cambridge, Massachusetts, USA
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Henry C, Jouan F, De Broucker T. JC virus granule cell neuronopathy: A cause of infectious cerebellar degeneration. J Neurol Sci 2015; 354:86-90. [PMID: 26003226 DOI: 10.1016/j.jns.2015.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 05/01/2015] [Accepted: 05/03/2015] [Indexed: 11/16/2022]
Abstract
JC virus (JCV) infection of glial cells can lead to progressive multifocal leukoencephalopathy (PML) in immunocompromised patients. A newly described phenotype of the infection is infection of neurons. This distinct clinical and radiological syndrome is named JCV granule cell neuronopathy, characterized by exclusive or predominant cerebellar atrophy. We report the clinical and radiological longitudinal findings of 5 HIV-infected patients referred to us between September 2004 and November 2011 who exhibited JCV granule cell neuronopathy (4 probable cases and 1 possible). The association of immunocompromised status, progressive cerebellar syndrome, MRI abnormalities with cortical cerebellar atrophy and cerebrospinal fluid positive for JCV on PCR allowed for a highly probable diagnosis. The reversal of the immunocompromised status is the only way to stop the disease evolution. Motor functioning can remain impaired, but the illness itself, unlike progressive multifocal leukoencephalopathy, does not seem to threaten life.
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Affiliation(s)
- Carole Henry
- Department of Neurology, Saint-Denis Hospital (93), France.
| | - Fanny Jouan
- Department of Neurology, Saint-Denis Hospital (93), France
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29
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Jelcic I, Jelcic I, Faigle W, Sospedra M, Martin R. Immunology of progressive multifocal leukoencephalopathy. J Neurovirol 2015; 21:614-22. [PMID: 25740538 DOI: 10.1007/s13365-014-0294-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/10/2014] [Accepted: 09/18/2014] [Indexed: 11/30/2022]
Abstract
The high prevalence of asymptomatic JC polyomavirus (JCV) infection in the general population indicates coexistence with the human host and efficient immune control in healthy individuals. For unknown reasons, kidney-resident archetypic JCV strains can turn into neurotropic JCV strains which in hereditary or acquired states of immunodeficiency cause opportunistic infection and cytolytic destruction of glial cells or granule cell neurons resulting in progressive multifocal demyelination in the central nervous system (CNS) or cerebellar atrophy, respectively. Immunomodulatory or immunosuppressive therapies with specific monoclonal antibodies including natalizumab, efalizumab, and rituximab have increased the risk of progressive multifocal leukoencephalopathy (PML) among treated patients, highlighting that symptomatic JCV infection of the CNS is associated with disturbances of adaptive immunity affecting B cells, antibodies, and CD4(+) and/or CD8(+) T cells. To date, no specific therapy to overcome PML is available and the only way to eliminate the virus from the CNS is to reconstitute global immune function. However, since the identification of JCV as the causative agent of PML 40 years ago, it is still not fully understood which components of the immune system prevent the development of PML and which immune mechanisms are involved in eliminating the virus from the CNS. This review gives an update about adaptive JCV-specific immune responses.
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Affiliation(s)
- Ivan Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Ilijas Jelcic
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Wolfgang Faigle
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Mireia Sospedra
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Roland Martin
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich, 8091, Zurich, Switzerland.
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30
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Heterogeneous imaging characteristics of JC virus granule cell neuronopathy (GCN): a case series and review of the literature. J Neurol 2014; 262:65-73. [PMID: 25297924 DOI: 10.1007/s00415-014-7530-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/02/2014] [Accepted: 10/03/2014] [Indexed: 10/24/2022]
Abstract
Granule cell neuronopathy (GCN) is a rare JC virus (JCV)-related disease in immunocompromised patients, characterized by lytic infection of the cerebellar granule cell layer. To enable early diagnosis and intervention, we identify features of GCN and describe possible aspects of disease heterogeneity. We report on two new cases of GCN in HIV-infected patients of whom we retrospectively assessed clinical and radiologic data. In addition, we carried out a literature search and review of clinical, radiologic and histopathologic findings of all published GCN cases. Including the two new cases reported here, a total of 18 GCN cases were included in this study. HIV infection, present in 12 of the cases, was the most common underlying condition, followed by monoclonal antibody treatment which was present in three cases. Cerebellar atrophy was detected in all except two cases. In 12 patients a heterogeneous distribution pattern of white matter changes in the cerebellum and brainstem was observed. Imaging findings in GCN are remarkably heterogeneous; exhibiting cerebellar atrophy, as well as white matter pathology, particularly in the adjacent infratentorial white matter. This suggests an overlap of GCN with other JCV-related diseases, such as progressive multifocal leukoencephalopathy.
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31
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Agnihotri SP, Dang X, Carter JL, Fife TD, Bord E, Batson S, Koralnik IJ. JCV GCN in a natalizumab-treated MS patient is associated with mutations of the VP1 capsid gene. Neurology 2014; 83:727-32. [PMID: 25037207 DOI: 10.1212/wnl.0000000000000713] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To describe the clinical, neuroimaging, immunologic, and virologic characteristics of JC virus-associated granule cell neuronopathy (JCV GCN) in a natalizumab-treated patient with multiple sclerosis (MS) who developed immune reconstitution inflammatory syndrome (IRIS) after natalizumab withdrawal. METHODS We obtained longitudinal clinical data as well as MRI and proton magnetic resonance spectroscopy from this patient with MS. We measured JCV-specific cellular immune response in his peripheral blood by intracellular cytokine staining and sequenced a fragment of JCV VP1 capsid gene detected in his CSF. We contrast our findings with the first recently reported case. RESULTS This patient presented with worsening cerebellar symptoms and progressive cerebellar atrophy without new MS lesions on MRI after 63 months of natalizumab monotherapy. JCV DNA was detected in his CSF by PCR and harbored novel GCN-type mutations in the VP1 gene. He developed IRIS upon discontinuation of natalizumab and plasma exchange, which manifested itself by a worsening of clinical symptoms and contrast enhancement in the cerebellum on MRI. Treatment with corticosteroids resulted in resolution of IRIS, as demonstrated by proton magnetic resonance spectroscopy. The patient had a strong JCV-specific T-cell response in his peripheral blood and remains alive after 15 months from onset of symptoms, although with significant disability. He did not have MS relapse on glatiramer acetate. CONCLUSIONS JCV GCN should be considered in patients on natalizumab presenting with progressive cerebellar symptoms and cerebellar atrophy, and is associated with mutations in the JCV VP1 gene. Natalizumab withdrawal may be complicated by JCV GCN IRIS, and require treatment with corticosteroids.
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Affiliation(s)
- Shruti P Agnihotri
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Xin Dang
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Jonathan L Carter
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Terry D Fife
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Evelyn Bord
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Stephanie Batson
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Igor J Koralnik
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ.
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Carruthers RL, Berger J. Progressive multifocal leukoencephalopathy and JC Virus-related disease in modern neurology practice. Mult Scler Relat Disord 2014; 3:419-30. [DOI: 10.1016/j.msard.2014.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/30/2014] [Accepted: 01/31/2014] [Indexed: 11/25/2022]
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Agnihotri SP, Wuthrich C, Dang X, Nauen D, Karimi R, Viscidi R, Bord E, Batson S, Troncoso J, Koralnik IJ. A fatal case of JC virus meningitis presenting with hydrocephalus in a human immunodeficiency virus-seronegative patient. Ann Neurol 2014; 76:140-7. [PMID: 24895208 DOI: 10.1002/ana.24192] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/02/2014] [Accepted: 06/02/2014] [Indexed: 01/26/2023]
Abstract
JC virus (JCV) is the etiologic agent of progressive multifocal leukoencephalopathy, JCV granule cell neuronopathy, and JCV encephalopathy. Whether JCV can also cause meningitis has not yet been demonstrated. We report a case of aseptic meningitis resulting in symptomatic hydrocephalus in a human immunodeficiency virus-seronegative patient. Brain imaging showed enlargement of ventricles but no parenchymal lesion. She had a very high JC viral load in the cerebrospinal fluid (CSF) and developed progressive cognitive dysfunction despite ventricular drainage. She was diagnosed with pancytopenia and passed away after 5.5 months. Postmortem examination revealed productive JCV infection of leptomeningeal and choroid plexus cells, and limited parenchymal involvement. Sequencing of JCV CSF strain showed an archetype-like regulatory region. Further studies of the role of JCV in aseptic meningitis and in idiopathic hydrocephalus are warranted.
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Affiliation(s)
- Shruti P Agnihotri
- Division of Neuro-Virology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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34
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Diagnosis of natalizumab-associated progressive multifocal leukoencephalopathy using MRI. Curr Opin Neurol 2014; 27:260-70. [DOI: 10.1097/wco.0000000000000099] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Dang X, Koralnik IJ. Gone over to the dark side: Natalizumab-associated JC virus infection of neurons in cerebellar gray matter. Ann Neurol 2014; 74:503-5. [PMID: 23913509 DOI: 10.1002/ana.23985] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 07/26/2013] [Accepted: 07/27/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Xin Dang
- Division of Neurovirology, Department of Neurology and Center for Virology and Vaccine Research Department of Medicine Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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