1
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Nay S, Möhn N, Grote-Levi L, Bonifacius A, Saßmann ML, Karacondi K, Tischer-Zimmermann S, Pöter H, Mahmoudi N, Wattjes MP, Maecker-Kolhoff B, Höglinger G, Eiz-Vesper B, Skripuletz T. Combined treatment with allogeneic Epstein-Barr- and human polyomavirus 1 specific T-cells in progressive multifocal leukoencephalopathy and EBV infection: a case report. Ther Adv Neurol Disord 2024; 17:17562864241253917. [PMID: 38813521 PMCID: PMC11135084 DOI: 10.1177/17562864241253917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/23/2024] [Indexed: 05/31/2024] Open
Abstract
Opportunistic viral infections in individuals with severe immunodeficiency can lead to fatal conditions such as progressive multifocal leukoencephalopathy (PML), for which treatment options are limited. These infections pose significant risks, especially when co-infections with other viruses occur. We describe a combined therapy approach using directly isolated allogeneic Human Polyomavirus 1 (also known as BKV) and Epstein-Barr virus (EBV) specific cytotoxic T-cells for the treatment of PML in conjunction with identified EBV in the cerebrospinal fluid (CSF) of a male patient infected with human immunodeficiency virus (HIV). A 53-year-old HIV-positive male, recently diagnosed with PML, presented with rapidly worsening symptoms, including ataxia, tetraparesis, dysarthria, and dysphagia, leading to respiratory failure. The patient developed PML even after commencing highly active antiretroviral therapy (HAART) 3 months prior. Brain magnetic resonance imaging (MRI) revealed multifocal demyelination lesions involving the posterior fossa and right thalamus suggestive of PML. In addition to the detection of human polyomavirus 2 (also known as JCV), analysis of CSF showed positive results for EBV deoxyribonucleic acid (DNA). His neurological condition markedly deteriorated over the following 2 months. Based on MRI, there was no evidence of Immune Reconstitution Inflammatory Syndrome contributing to this decline. The patient did not have endogenous virus-specific T-cells. We initiated an allogeneic, partially human leukocyte antigen-matched transfer of EBV and utilizing the cross-reactivity between BKV and JCV-BKV specific T-cells. This intervention led to notable neurological improvement and partial resolution of the MRI lesions within 6 weeks. Our case of a patient with acquired immune deficiency syndrome demonstrates that PML and concurrent EBV co-infection can still occur despite undergoing HAART treatment. This innovative experimental therapy, involving a combination of virus-specific T-cells, was demonstrated to be an effective treatment option in this patient.
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Affiliation(s)
- Sandra Nay
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Nora Möhn
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Lea Grote-Levi
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Agnes Bonifacius
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Mieke L. Saßmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Kevin Karacondi
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Henning Pöter
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Nima Mahmoudi
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
- Department of Neuroradiology, Charité Berlin, Corporate Member of Freie Universität zu Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mike P. Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
- Department of Neuroradiology, Charité Berlin, Corporate Member of Freie Universität zu Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research, Hannover, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- German Center for Neurodegenerative Diseases, Munich, Germany
- Munich Cluster for Systems Neurology, Munich, Germany
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- German Center for Infection Research, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany
- Centre for Individualised Infection Medicine, Hannover, Germany
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2
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Moussaoui NE, Lambert N, Moussaoui ME, Bianchi E, Léonard P, Moïse M, Maquet P. Spinal cord involvement in progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome. J Neurovirol 2024:10.1007/s13365-024-01213-y. [PMID: 38778006 DOI: 10.1007/s13365-024-01213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic infectious demyelinating disease of the central nervous system caused by JC polyomavirus predominantly affecting immunocompromised individuals. Nowadays, HIV, hematological malignancies and iatrogenic immune suppression account for most PML cases. For unknown reasons, spinal cord is classically protected from PML lesions. Here, we report the course of a patient harboring spinal cord lesions in the context of PML with immune reconstitution inflammatory syndrome and review the eight other cases reported in the literature so far. Then, we discuss the evolving spectrum of PML over recent years, potentially making its diagnosis more challenging.
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Affiliation(s)
| | - Nicolas Lambert
- Department of Neurology, University Hospital of Liège, Liège, Belgium.
- Service de Neurologie, CHU de Liège, Avenue de l'Hopital, 1, 4000, Liège, Belgium.
| | - Majdouline El Moussaoui
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liège, Belgium
| | - Elettra Bianchi
- Department of Anatomopathology, University Hospital of Liège, Liège, Belgium
| | - Philippe Léonard
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liège, Belgium
| | - Martin Moïse
- Department of Radiology, University Hospital of Liège, Liège, Belgium
| | - Pierre Maquet
- Department of Neurology, University Hospital of Liège, Liège, Belgium
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3
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Cortese I, Norato G, Harrington PR, Usher T, Mainardi I, Martin-Blondel G, Cinque P, Major EO, Sheikh V. Biomarkers for progressive multifocal leukoencephalopathy: emerging data for use of JC virus DNA copy number in clinical trials. Lancet Neurol 2024; 23:534-544. [PMID: 38631769 DOI: 10.1016/s1474-4422(24)00099-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/19/2024]
Abstract
Progressive multifocal leukoencephalopathy is a rare but devastating demyelinating disease caused by the JC virus (JCV), for which no therapeutics are approved. To make progress towards addressing this unmet medical need, innovations in clinical trial design are needed. Quantitative JCV DNA in CSF has the potential to serve as a valuable biomarker of progressive multifocal leukoencephalopathy disease and treatment response in clinical trials to expedite therapeutic development, as do neuroimaging and other fluid biomarkers such as neurofilament light chain. Specifically, JCV DNA in CSF could be used in clinical trials as an entry criterion, stratification factor, or predictor of clinical outcomes. Insights from the investigation of candidate biomarkers for progressive multifocal leukoencephalopathy might inform approaches to biomarker development for other rare diseases.
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Affiliation(s)
- Irene Cortese
- Experimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Gina Norato
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Patrick R Harrington
- Division of Antivirals, Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Therri Usher
- Division of Biometrics IV, Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Ilaria Mainardi
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guillaume Martin-Blondel
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291-CNRS UMR5051, Université Toulouse III, Toulouse, France
| | - Paola Cinque
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eugene O Major
- Laboratory of Molecular Medicine and Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Virginia Sheikh
- Division of Antivirals, Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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4
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Schweitzer L, Barkati S, Laneuville P, Fox S, Vinh DC. Treatment of Progressive Multifocal Leukoencephalopathy with IL-2 and Mirtazapine. J Clin Immunol 2024; 44:97. [PMID: 38587706 DOI: 10.1007/s10875-024-01698-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 03/29/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Lorne Schweitzer
- Department of Medicine, Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sapha Barkati
- Department of Medicine, Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pierre Laneuville
- Department of Medicine, Division of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Susan Fox
- Department of Medicine, Division of Hematology and Oncology, Hôpital Charles-Lemoyne, Longueuil, Quebec, Canada
| | - Donald C Vinh
- Department of Medicine, Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada.
- IiMMUNO-GRAM (Infection and IMMunity Genetic Research to Advance Molecular medicine) Center of Reference, Research Institute - McGill University Health Centre, 1001 Decarie Blvd; Block E (EM3-3211), Montreal, Quebec, H4A 3J1, Canada.
- Department of OptiLab (Division of Medical Microbiology, Division of Molecular Genetics-Immunology), McGill University Health Centre - Research Institute, 1001 Decarie Blvd; Block E; Rm EM3-3230 (Mail Drop: EM3-3211), Montreal, Quebec, H4A 3J1, Canada.
- Department of Human Genetics, McGill University Health Centre - Research Institute, 1001 Decarie Blvd; Block E; Rm EM3-3230 (Mail Drop: EM3-3211), Montreal, Quebec, H4A 3J1, Canada.
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5
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Jeantin L, Shor N, Coustans M, Roos-Weil D, Quintin-Roué I, Bellanger A, Le Garff-Tavernier M, Ben Jemaa R, Thabut D, Pourcher V, Weiss N. Progressive multifocal leukoencephalopathy in patients with chronic liver disease successfully treated with pembrolizumab. J Neurol 2024; 271:2119-2124. [PMID: 38143261 DOI: 10.1007/s00415-023-12163-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Lina Jeantin
- Département de Neurologie, Sorbonne Université, Médecine Intensive Réanimation à Orientation Neurologique, AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de L'hôpital, 75013, Paris, France
| | - Natalia Shor
- Department of Neuroradiology, Pitié-Salpétrière University Hospital, AP-HP, 47-83 bd de L'hôpital, 75013, Paris, France
| | - Marc Coustans
- Department of Neurology, CHIC Quimper-Concarneau, 14 Avenue Yves Thépot - BP 1757, 29107, Quimper, Cedex, France
| | - Damien Roos-Weil
- Sorbonne Université, Department of Clinical Hematology, Pitié-Salpétrière University Hospital, AP-HP, 47-83 bd de L'hôpital, 75013, Paris, France
| | | | - Agnès Bellanger
- Pharmacie hospitalière, Sorbonne Université, AP-HP, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | - Magali Le Garff-Tavernier
- Department of Biological Hematology, Pitié-Salpétrière University Hospital, AP-HP, 47-83 bd de L'hôpital, 75013, Paris, France
| | - Rahma Ben Jemaa
- Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Sorbonne Université, 75005, Paris, France
| | - Dominique Thabut
- Brain Liver Salpêtrière Study Group, Sorbonne Université, INSERM UMR_S 938, Centre de Recherche Saint-Antoine & Institute of Cardiometabolism and Nutrition (ICAN), 75013, Paris, France
- Liver Intensive Care Unit, Hepatogastroenterology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Sorbonne Université, 75005, Paris, France
| | - Valérie Pourcher
- Sorbonne Université, 75005, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), AP-HP, Hôpital Pitié Salpêtrière, Service Des Maladies Infectieuses et Tropicales, Paris, France
| | - Nicolas Weiss
- Département de Neurologie, Sorbonne Université, Médecine Intensive Réanimation à Orientation Neurologique, AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de L'hôpital, 75013, Paris, France.
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
- Groupe de Recherche Clinique en REanimation et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Paris, France.
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6
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Cimmino AT, Carlomagno V, Sciarrone MA, Di Lazzaro G, Silvestri G. Isolated pontocerebellar leukoencephalopathy in HIV-related PML: focus on the "shrimp sign". Neurol Sci 2024; 45:1295-1298. [PMID: 37870644 DOI: 10.1007/s10072-023-07133-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Affiliation(s)
| | - Vincenzo Carlomagno
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giulia Di Lazzaro
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gabriella Silvestri
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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7
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Shishido-Hara Y, Akimoto J, Fukami S, Kohno M, Matsubayashi J, Nagao T. Pathology for severe inflammatory PML with PD1/PD-L1 expression of favorable prognosis: What's a prognostic factor for PML-IRIS? Neuropathology 2024; 44:47-58. [PMID: 37424276 DOI: 10.1111/neup.12929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023]
Abstract
A 72-year-old woman with dermatomyositis (DM) developed neurological manifestation, and magnetic resonance imaging (MRI) revealed multiple T2/fluid-attenuated inversion recovery (FLAIR)-hyperintense lesions predominantly in the deep white matter of the cerebral hemisphere. Punctate or linear contrast enhancement was observed surrounding the T1-hypointense area. Multiple T2/FLAIR-hyperintense lesions were aligned along with the corona radiata. Malignant lymphoma was first suspected, and a brain biopsy was performed. Pathological investigation suggested the provisional diagnosis of "suspicious of malignant lymphoma." Owing to emergent clinical conditions, high-dose methotrexate (MTX) therapy was conducted, and then T2/FLAIR-hyperintense lesions were dramatically reduced. However, the diagnosis of malignant lymphoma was concerning since multiplex PCR demonstrated clonal restriction of the Ig H gene for B cells and TCR beta genes for T cells. Histopathology revealed the infiltration of both CD4+ and CD8+ T cells, and the CD4+ /CD8+ ratio was 4.0. Moreover, prominent plasma cells were observed, in addition to CD20+ B cells. Atypical cells with enlarged nuclei were present, and they were not hematopoietic but found as glial cells. JC virus (JCV) infection was verified with both immunohistochemistry and in situ hybridization; the final diagnosis was progressive multifocal leukoencephalopathy (PML). The patient was treated with mefloquine and discharged. This case is informative in understanding the host anti-viral response. Variable inflammatory cells were observed, including CD4+ and CD8+ T cells, plasma cells, and a small amount of perivascular CD20+ B cells. PD-1 and PD-L1 expression was observed in lymphoid cells and macrophages, respectively. PML with inflammatory reactions was thought fatal, and autopsy cases of PML with immune reconstitution inflammatory syndrome (IRIS) demonstrated excessive infiltration of only CD8+ T cells. However, this case revealed infiltration of variable inflammatory cells, and a favorable prognosis would be expected under PD-1/PD-L1 immune-checkpoint regulation.
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Affiliation(s)
- Yukiko Shishido-Hara
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
- Department of Pathology and Applied Neurobiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jiro Akimoto
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Shinjiro Fukami
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Matsubayashi
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Toshitaka Nagao
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
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8
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Jeantin L, Shor N, Pallix-Guyot M, Roos-Weil D, Bellanger A, Le Garff-Tavernier M, Papeix C, Weiss N, Pourcher V. Halting progressive multifocal leukoencephalopathy with pembrolizumab: the case of a patient with multiple sclerosis under fingolimod. J Neurol 2024; 271:729-732. [PMID: 37910249 DOI: 10.1007/s00415-023-12055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Lina Jeantin
- Département de neurologie, unité de Médecine Intensive Réanimation à orientation neurologique, Sorbonne Université, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Natalia Shor
- Department of Neuroradiology, Sorbonne Université, AP-HP, Hôpital de la Pitié-Salpêtrière, 47-83 Bd de l'Hôpital, Paris, France
| | - Maud Pallix-Guyot
- Department of Neurology, Orléans Hospital, 14 avenue de l'Hôpital, Orléans, France
| | - Damien Roos-Weil
- Department of Clinical Hematology, Pitié-Salpétrière University Hospital, 47-83 Bd de l'Hôpital, Paris, France
| | - Agnès Bellanger
- Département de Santé Publique, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, IPLESP, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Magali Le Garff-Tavernier
- Department of Biological Hematology, Sorbonne Université, AP-HP, Hôpital de la Pitié-Salpêtrière, 47-83 Bd de l'Hôpital, 75013, Paris, France
| | - Caroline Papeix
- Department of Neurology, Hospital Foundation Adolphe de Rothschild, 25-29 rue Manin, Paris, France
| | - Nicolas Weiss
- Département de neurologie, unité de Médecine Intensive Réanimation à orientation neurologique, Sorbonne Université, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France & Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Paris, France
| | - Valérie Pourcher
- Service des Maladies infectieuses et tropicales, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), AP-HP, Hôpital Pitié Salpêtrière, Paris, France.
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9
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Varmpompiti K, Westwood AJ, Ben-Joseph A, Sibtain N, Ibrahim MAA, Stanton B, Zuckerman M, Hadden R, Ritter LM. Progressive multifocal leukoencephalopathy secondary to idiopathic CD4 lymphocytopenia treated with pembrolizumab. J Neuroimmunol 2023; 385:578248. [PMID: 37995595 DOI: 10.1016/j.jneuroim.2023.578248] [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: 09/26/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease due to a lytic infection of oligodendrocytes caused by John Cunningham polyoma virus (JCV) infection. Idiopathic CD4+ T-cell lymphocytopenia (ICL) is a very rare cause of PML. METHODS We present an individual with PML secondary to ICL treated with 3 doses of pembrolizumab, a Programmed-Death-1 Immune Checkpoint Inhibitor following with complete resolution of symptoms and conduct a review of the literature. CONCLUSION This report illustrates the objective clinical and radiological improvement in a patient with PML due to ICL and suggests further study of immune checkpoint inhibitors as potential treatment for patients with PML.
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Affiliation(s)
| | - Andrew J Westwood
- Maidstone and Tunbridge Wells NHS Tust, Hermitage Lane Maidstone, Kent, United Kingdom
| | - Aaron Ben-Joseph
- Maidstone and Tunbridge Wells NHS Tust, Hermitage Lane Maidstone, Kent, United Kingdom
| | - Naomi Sibtain
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Biba Stanton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark Zuckerman
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Robert Hadden
- King's College Hospital NHS Foundation Trust, London, United Kingdom; Maidstone and Tunbridge Wells NHS Tust, Hermitage Lane Maidstone, Kent, United Kingdom
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10
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Fan S, Liu M, Bai L, Chen S, Hou B, Lin N, Yuan J, Mao C, Niu J, Ren H, Zhao Y, Zhang Z, Zhu Y, Peng B, Guan H. Pembrolizumab for the treatment of progressive multifocal leukoencephalopathy in China. J Neurovirol 2023; 29:692-698. [PMID: 37898569 DOI: 10.1007/s13365-023-01180-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/06/2023] [Accepted: 10/12/2023] [Indexed: 10/30/2023]
Abstract
The aim of this study is to analyze the clinical characteristics and outcomes of Chinese patients with progressive multifocal leukoencephalopathy (PML) who were treated with programmed cell death protein 1 (PD1) blockade therapies. We retrospectively analyzed patients who were admitted to our hospital between October 1, 2020, and October 1, 2022, diagnosed with PML and treated with PD1 blockade therapies. Four patients with PML who were treated with PD1 blockade therapies were identified. All patients were male, and their ages ranged from 19 to 54 years old. One patient (Case 2) exhibited mild pleocytosis, while three patients (Cases 2-4) had markedly reduced T lymphocyte cell counts prior to treatment. The time interval between symptom onset and treatment initiation ranged from six to 54 weeks. All patients received pembrolizumab treatment, with a total of two to four doses administered. Three patients who responded to pembrolizumab treatment showed clinical improvement starting around 8 weeks after the initiation of therapy. Although one patient did not show clinical improvement, they ultimately survived until the last follow-up. None of the patients in this study exhibited immune-related adverse events or immune reconstitution inflammatory syndrome. PD1 blockade appears to be a promising novel therapeutic option for PML; additional prospective studies are necessary to confirm its efficacy.
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Affiliation(s)
- Siyuan Fan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Mange Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Lin Bai
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Sixian Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Nan Lin
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Jing Yuan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Chenhui Mao
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Yanhuan Zhao
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Zaiqiang Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 100050, Beijing, China
| | - Yicheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, China.
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11
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Del Bello A, Treiner E. Immune Checkpoints in Solid Organ Transplantation. BIOLOGY 2023; 12:1358. [PMID: 37887068 PMCID: PMC10604300 DOI: 10.3390/biology12101358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023]
Abstract
Allogenic graft acceptance is only achieved by life-long immunosuppression, which comes at the cost of significant toxicity. Clinicians face the challenge of adapting the patients' treatments over long periods to lower the risks associated with these toxicities, permanently leveraging the risk of excessive versus insufficient immunosuppression. A major goal and challenge in the field of solid organ transplantation (SOT) is to attain a state of stable immune tolerance specifically towards the grafted organ. The immune system is equipped with a set of inhibitory co-receptors known as immune checkpoints (ICs), which physiologically regulate numerous effector functions. Insufficient regulation through these ICs can lead to autoimmunity and/or immune-mediated toxicity, while excessive expression of ICs induces stable hypo-responsiveness, especially in T cells, a state sometimes referred to as exhaustion. IC blockade has emerged in the last decade as a powerful therapeutic tool against cancer. The opposite action, i.e., subverting IC for the benefit of establishing a state of specific hypo-responsiveness against auto- or allo-antigens, is still in its infancy. In this review, we will summarize the available literature on the role of ICs in SOT and the relevance of ICs with graft acceptance. We will also discuss the possible influence of current immunosuppressive medications on IC functions.
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Affiliation(s)
- Arnaud Del Bello
- Department of Nephrology, University Hospital of Toulouse, 31400 Toulouse, France
- Metabolic and Cardiovascular Research Institute (I2MC), Inserm UMR1297, CEDEX 4, 31432 Toulouse, France
- Faculty of Medicine, University Toulouse III Paul Sabatier, 31062 Toulouse, France
| | - Emmanuel Treiner
- Faculty of Medicine, University Toulouse III Paul Sabatier, 31062 Toulouse, France
- Laboratory of Immunology, University Hospital of Toulouse, 31300 Toulouse, France
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Inserm UMR1291, 31024 Toulouse, France
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12
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Hoff FW, Rolwes J, Hardeman PA, Perkins M, Major EO, Douek D, Collins RH, Greenberg BM. Long-term outcome of progressive multifocal leukoencephalopathy with recombinant interleukin-2 treatment and an associated increase in the number of HPyV-2-specific T-cells: a case report. Ther Adv Hematol 2023; 14:20406207231201721. [PMID: 37822572 PMCID: PMC10563476 DOI: 10.1177/20406207231201721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease caused by reactivation of the human polyomavirus 2 (HPyV-2). PML is associated with a high morbidity and mortality rate and there is currently no standard curative therapy. We report short-term immunologic response and long-term clinical outcomes in a patient diagnosed with follicular lymphoma (FL) who developed PML. Diagnosis of PML was established conclusively based on findings from a brain biopsy. The patient was treated with recombinant interleukin 2 (IL-2) and showed rapid clinical improvement. HPyV-2-specific T-cells were tracked longitudinally and correlation with clinical status, viral load, and radiographic imaging was documented. After the progression of the patient's FL, which required an allogeneic bone marrow transplant, the patient prophylactically received human leukocyte antigen-matched donor-derived HPyV-2 T-cells to prevent the recurrence of the PML as part of a clinical trial. Twelve years after the initial diagnosis of PML, he did not develop a relapse of his PML, supporting data that therapies that increase HPyV-2-specific T-cells, including IL-2, may be effective in the management of PML.
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Affiliation(s)
- Fieke W Hoff
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - John Rolwes
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Paula A Hardeman
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Molly Perkins
- Human Immunology Section, Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Eugene O Major
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Daniel Douek
- Human Immunology Section, Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert H Collins
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8806, USA
| | - Benjamin M Greenberg
- Department of Neurology, O'Donnell Brain Institute, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8806, USA
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13
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Gkrania-Klotsas E. Infections in patients with primary immunodeficiencies: Insight into infections in secondary immunodeficiency and transplantation. Transpl Infect Dis 2023; 25:e14124. [PMID: 37573149 DOI: 10.1111/tid.14124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Effrossyni Gkrania-Klotsas
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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14
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Jain V, Branstetter H, Savaram S, Vasquez M, Swords G, Aghili-Mehrizi S, Rees J, Rivera-Zengotita M, Montalvo M, Chuquilin M, Patterson A, Rempe T. Progressive multifocal leukoencephalopathy without overt immunosuppression. Medicine (Baltimore) 2023; 102:e35265. [PMID: 37773871 PMCID: PMC10545270 DOI: 10.1097/md.0000000000035265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a central nervous system disease caused by the human polyomavirus 2 that usually occurs in a setting of immunodeficiency. PML without overt immunosuppression is considered a rare occurrence but has been described in multiple previous case reports and series. Its prevalence, overall frequency, and prognosis are largely unknown. This is a single-center retrospective review of all University of Florida cases with the ICD10 PML diagnosis code (A81.2). PML without overt immunosuppression was defined as absence of human immunodeficiency virus (HIV) infection, hematological malignancy, immunomodulatory/-suppressive medications, autoimmune conditions with a propensity for PML (sarcoidosis, systemic lupus erythematosus). Cases that did not fulfill criteria for clinically or histologically definite PML were excluded. Of 52 patients with the ICD10 code A 81.2, 17 fulfilled definite diagnostic criteria for PML. Overt immunosuppression was identified in 15/17 (88.2%) cases (10/17 (58.8%): human immunodeficiency virus; 5/17 (29.4%): immunomodulatory/-suppressive medication). Two/seventeen (11.8%) cases were consistent with PML without overt immunosuppression. Possible contributing factors were a preceding dog bite and mild hypogammaglobulinemia M (39 mg/dL) in case 1 and significant alcohol use without evidence for liver disease in case 2. Both cases were fatal within 6 (case 1) and 2 (case 2) months. The results suggest that PML without overt immunosuppression may be more common than previously described. Therefore, PML should be considered even in the absence of overt immunosuppression if clinical and radiographic findings are suggestive of the diagnosis.
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Affiliation(s)
- Varun Jain
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Hannah Branstetter
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Srikar Savaram
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Matthew Vasquez
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Gabriel Swords
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Sina Aghili-Mehrizi
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - John Rees
- Department of Radiology, College of Medicine, University of Florida, Gainesville, FL
| | | | - Mayra Montalvo
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Miguel Chuquilin
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Addie Patterson
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
| | - Torge Rempe
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL
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15
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Born T, Vassallo P, Golshayan D, Di Liberto G, Brouland JP, Egervari K, Merkler D, Du Pasquier RA, Bernard-Valnet R. Bridging the Gap: Immunotherapy in Progressive Multifocal Leukoencephalopathy: A New Hope? Neurology 2023; 101:e1382-e1386. [PMID: 37407265 PMCID: PMC10558171 DOI: 10.1212/wnl.0000000000207533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/04/2023] [Indexed: 07/07/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe infection of the CNS occurring in immunocompromised individuals in which large demyelinating lesions are induced by polyomavirus JC (JCV). In the absence of effective antiviral treatment, control of the infection relies on restoring anti-JCV immunity. Thus, particularly in long-standing immunocompromising conditions such as organ transplantation, lymphoproliferative disorders, or idiopathic lymphopenia, new strategies to boost anti-JCV immune responses are needed. Here, we report the case of a patient developing PML in the context of kidney transplantation who received recombinant human interleukin 7 to foster immune responses against JCV. We give an overview of the immunologic mechanisms underlying the development of PML and immune restoration within the CNS after JCV infection. Immunotherapeutic strategies developed based on current understanding of the disease hold promise in managing patients with PML.
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Affiliation(s)
- Tristan Born
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Paola Vassallo
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Dela Golshayan
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Giovanni Di Liberto
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Jean-Philippe Brouland
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Kristof Egervari
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Doron Merkler
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Renaud A Du Pasquier
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland
| | - Raphael Bernard-Valnet
- From the Neurology Service (T.B., P.V., G.D.L., R.A.D.P., R.B.-V.), Department of Clinical Neurosciences, Transplantation Center (D.G.), Department of Medicine, and Pathology Department (J.-P.B.), Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and the University of Lausanne; and Service of Clinical Pathology (K.E., D.M.), Department of Pathology and Immunology and Diagnostic Department, University Hospitals of Geneva, Switzerland.
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16
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Lambert N, El Moussaoui M, Baron F, Maquet P, Darcis G. Virus-Specific T-Cell Therapy for Viral Infections of the Central Nervous System: A Review. Viruses 2023; 15:1510. [PMID: 37515196 PMCID: PMC10383098 DOI: 10.3390/v15071510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Opportunistic viral infections of the central nervous system represent a significant cause of morbidity and mortality among an increasing number of immunocompromised patients. Since antiviral treatments are usually poorly effective, the prognosis generally relies on the ability to achieve timely immune reconstitution. Hence, strategies aimed at reinvigorating antiviral immune activity have recently emerged. Among these, virus-specific T-cells are increasingly perceived as a principled and valuable tool to treat opportunistic viral infections. Here we briefly discuss how to develop and select virus-specific T-cells, then review their main indications in central nervous system infections, including progressive multifocal leukoencephalopathy, CMV infection, and adenovirus infection. We also discuss their potential interest in the treatment of progressive multiple sclerosis, or EBV-associated central nervous system inflammatory disease. We finish with the key future milestones of this promising treatment strategy.
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Affiliation(s)
- Nicolas Lambert
- Department of Neurology, University Hospital of Liège, 4000 Liège, Belgium
| | - Majdouline El Moussaoui
- Department of General Internal Medicine and Infectious Diseases, University Hospital of Liège, 4000 Liège, Belgium
| | - Frédéric Baron
- Department of Hematology, University Hospital of Liège, 4000 Liège, Belgium
| | - Pierre Maquet
- Department of Neurology, University Hospital of Liège, 4000 Liège, Belgium
| | - Gilles Darcis
- Department of General Internal Medicine and Infectious Diseases, University Hospital of Liège, 4000 Liège, Belgium
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17
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Mousa A, Rashid MH, Arslan K, Lofrese CN, Najeeb N. Misdiagnosed Progressive Multifocal Leukoencephalopathy (PML) in an HIV-Negative Patient With Discoid Lupus: A Case Report. Cureus 2023; 15:e42030. [PMID: 37593275 PMCID: PMC10431692 DOI: 10.7759/cureus.42030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare fetal disease that has been uprising since the 1980s. Accurate diagnosis can be challenging and requires a thorough clinical suspicion, particularly among individuals who do not have HIV infection. Further diagnostics studies including cerebrospinal fluid analysis are required for DNA polymerase chain reaction (PCR) and if negative, more invasive tests like Brain biopsy are required. Herein, we describe a rare case of a 64-year-old female with a history of discoid lupus for 30 years who was not on any medications and presented to the hospital multiple times with different neurological deficits. The initial diagnosis consistently pointed toward a stroke until a critical turning point when a cerebrospinal fluid sample tested positive for John Cunningham (JC) virus DNA. Unfortunately, by the time the disease was identified, it had already progressed significantly, resulting in the unfortunate demise of the patient. To our knowledge, this represents the second reported case of PML in a patient with discoid lupus who lacks other commonly observed risk factors for the disease. This finding underscores the significance of maintaining clinical attentiveness within this specific patient population.
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Affiliation(s)
- Aliaa Mousa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Muhammad Humayoun Rashid
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
- Internal Medicine, Nishtar Medical University, Multan, PAK
| | - Kudret Arslan
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | | | - Nazish Najeeb
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
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18
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Motte J, Gold R. Immune checkpoint inhibitors: A potential bright spot in the treatment of progressive multifocal leukoencephalopathy in multiple sclerosis. Mult Scler 2023; 29:306-307. [PMID: 36451582 DOI: 10.1177/13524585221137275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
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19
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Chandler S, Isbel N. Progressive multifocal leukoencephalopathy 10 years following transplant: 5HT receptor antagonism as an adjunct to immune reconstitution. BMJ Case Rep 2022; 15:e252284. [PMID: 36524258 PMCID: PMC9748958 DOI: 10.1136/bcr-2022-252284] [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] [Indexed: 12/15/2022] Open
Abstract
We report a case of a patient presenting with subacute neurological symptoms 10 years postkidney transplant. Cognitive deficits included acalculia and left upper limb dysesthesia, progressing to hemiplegic upper motor neuron weakness. Investigations included an MRI with multiple FLAIR hyperintensities, while a lumbar puncture was sterile with negative flow cytometry. Ultimately, PCR testing for John Cunningham virus was positive on cerebrospinal fluid. The diagnosis of progressive multifocal leukoencephalopathy (PML) was confirmed on the basis of the above.Initially, the patient was managed with withdrawal of immunosuppressants and close observation. Mirtazapine was commenced based on case reports of successful use in non-transplant patients; the patient's recovery was temporally related to withdrawal of immunosuppression and increasing mirtazapine dosage. The patient is currently maintained on prednisolone and mirtazapine with stable graft function and improved mobility and cognitive function.
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Affiliation(s)
- Shaun Chandler
- Metro North Kidney Health Service, Queensland Health, Brisbane, Queensland, Australia
| | - Nicole Isbel
- Metro South Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- The University of Queensland Faculty of Medicine, Herston, Queensland, Australia
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20
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Muacevic A, Adler JR, Duro J, Lessa Simões M, Aguiar P. Progressive Multifocal Leukoencephalopathy in a Chemotherapy-Naive Patient With Chronic Lymphocytic Leukemia: A Case Report. Cureus 2022; 14:e32912. [PMID: 36699752 PMCID: PMC9871684 DOI: 10.7759/cureus.32912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2022] [Indexed: 12/26/2022] Open
Abstract
Progressive multifocal leukoencephalopathy is a rare, progressive demyelinating disease of the central nervous system caused by reactivation and replication of the John Cunningham (JC) virus in cerebral oligodendrocytes. The JC virus is a small ubiquitous polyomavirus that can be detected in up to 50% of the adult population. It affects almost exclusively immunocompromised patients and is generally observed in patients with acquired immunodeficiency syndrome and patients with hematologic malignancies and autoimmune or chronic inflammatory diseases medicated with immunosuppressive and immunomodulatory drugs. However, it is rarely described in patients with hematologic malignancies, not undergoing chemotherapy or immunosuppressive therapy. It has a poor prognosis, and the treatment is based on restoring the immune system, given that no specific antiviral treatment is available. We present a case of a chemotherapy-naive patient with chronic lymphocytic leukemia associated with progressive multifocal leukoencephalopathy.
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