Progressive multifocal leukoencephalopathy in an HTLV-I carrier

Inflammatory progressive multifocal leukoencephalopathy with human T-cell lymphotropic virus-1 coinfection

A middle-aged man with progressive multifocal leukoencephalopathy (PML) in a human T-cell lymphotropic virus type-1 (HTLV-1) carrier on haemodialysis presented with mild dysarthria and ataxia. Brain MRI revealed asymmetric T2-hyperintense lesions in the cerebral white matter, cerebellum and brainstem. A small amount of JC virus (JCV) genome in cerebrospinal fluid was detected by PCR and cerebellar biopsy demonstrated JCV-DNA presence. Pathological findings showed demyelinating lesions and glial cells with mildly enlarged nuclei, accompanied by T-lymphocytes, neutrophils and plasma cell infiltration. The CD4+/CD8+ratio was 0.83. High-dose corticosteroid therapy was effective for inflammatory PML lesions, and the administration of mefloquine combined with mirtazapine led to favourable outcome. The encephalitis in this case is considered to have occurred secondarily to JCV infection in the presence of HTLV-1 infection. Therefore, it is crucial to investigate the presence of HTLV-1 in order to understand the aetiology of this brain inflammation.

A human T-lymphotropic virus-1 carrier who developed progressive multifocal leukoencephalopathy following immunotherapy for sarcoidosis: a case report

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a devastating demyelinating disorder of the central nervous system caused by opportunistic infection of the JC virus (JCV).

CASE PRESENTATION

A 58-year-old Japanese woman was admitted to our hospital for aphasia. She had a 5-year history of untreated sarcoidosis and was a human T cell lymphotropic virus-1 (HTLV-1) carrier. Serum angiotensin-converting enzyme, soluble interleukin-2 receptor, lysozyme, and calcium levels were elevated. JCV-DNA was not detected in cerebrospinal fluid by PCR testing. Skin biopsy revealed noncaseating granuloma formation. Bilateral multiple nodular lesions were present on chest X-ray. Brain magnetic resonance imaging showed left frontal and temporal lesions without gadolinium enhancement. As we suspected that systemic sarcoidosis had developed into neurosarcoidosis, we started steroid and infliximab administration. After treatment, the chest X-ray and serum abnormalities ameliorated, but the neurological deficits remained. At 1 month after immunotherapy, she developed right hemiparesis. Cerebrospinal fluid was positive for prototype (PML-type) JCV on repeated PCR testing. Brain biopsy revealed demyelinating lesions with macrophage infiltration, atypical astrocytes, and JCV antigen-positive cells. We diagnosed her with PML and started mefloquine, leading to partial remission.

CONCLUSIONS

Sarcoidosis and HTLV-1 infection both affect T cell function, especially CD4⁺ T cells, and may developped the patient's PML. The comorbidity of sarcoidosis, PML, and HTLV-1 infection has not been reported, and this is the world's first report of PML associated with HTLV-1 infection and sarcoidosis.

[A case of progressive multifocal leukoencephalopathy with Takayasu arteritis and indolent adult T-cell lymphoma/leukemia]

A 65-year-old man with Takayasu arteritis in a stable condition was admitted to our hospital because of rapid progressive dementia. Brain FLAIR/T2-weighted magnetic resonance images revealed high signal intensity in the diffuse subcortical white matter. John Cunningham virus (JCV) genome in cerebrospinal fluid was detected by polymerase chain reaction. Finally, progressive multifocal leukoencephalopathy was diagnosed definitely by brain biopsy. In addition, the patient was found to be complicated by chronic/smoldering adult T-cell leukemia/lymphoma. The administration of mefloquine with mirtazapine was early started within two months after the onset. However, the combination treatment led to no improvement in symptoms and lesion size. The patient died six months after the onset. Therefore, this case suggested that both of HTLV-I infection and B cell abnormalities due to Takasasu arteritis impaired the therapeutic effect.

Adult T-cell lymphoma/leukemia presenting as isolated central nervous system T-cell lymphoma

Adult T-cell leukemia/lymphoma (ATLL) is a T-cell neoplasm, associated with infection by the retrovirus human T-lymphotropic virus type 1 (HTLV-1). Central nervous system (CNS) involved by ATLL is often occurred in advanced disease, such as acute and lymphomatous variants. On the other hand, isolated CNS lymphoma is rare. We repot a 50-year-old woman who presented with multiple infiltrative brain lesions on the magnetic resonance (MR) imaging. Results of initial biopsy of brain tumor indicated CNS vasculitis. The patient received one course of high-dose methotrexate and MR imaging of brain revealed remission of infiltrative lesions. Two years later, new brain lesions were detected. Histopathologic examination of specimens via craniotomy revealed T-cell lymphoma. The patient responded poorly to subsequent chemotherapy, and salvage whole-brain irradiation was performed. Six months later, the patient had hepatosplenomegaly, hypercalcemia, and multiple lymphocytes with a cloverleaf appearance in circulation. Results of flow cytometry analysis of peripheral blood indicated ATLL and antibodies to human T-lymphotropic virus type 1 (HTLV-1) were detected. Clinicians should screen HTLV-1 infection when patients are diagnosed with peripheral T-cell lymphoma. Combined antiviral therapy and intensive chemotherapy may improve the outcomes of ATLL.

Role of stereotactic biopsy in histological diagnosis of multiple brain lesions

Background and Aim:

The current advances in diagnostic and therapeutic modalities and increasing in survival of patients with systemic diseases and immunosuppressive cases have caused to increasing frequency and variety of Central Nervous System neuropathologic processes indicating the necessary need for accurate localization of space-occupying lesions by cytology and histology. This study was aimed to evaluate the usefulness and safety of stereotactic biopsy in histological diagnosis of such lesions.

Materials and Methods:

Of 2081 patients underwent stereotactic biopsy of brain lesions using Riechert-Mundinger system, 158 had multifocal brain lesions, and were enrolled.

Results:

The ages of studied cases were ranged from 2 years to 75 years (Mean age: 41.3 year), 114 were male and 44 were females. Incidence of histopathologic diagnosis of multifocal brain lesions included Astrocytoma grade II (41.3%), Astrocytoma grade I (12.9%), glioblastoma multiform (11.1%), Astrocytoma grade III (10.2%), malignant lymphoma (10.2%), metastasis (4.6%), pilocytic Astrocytoma (2.7%), abscess (2.7%), craniopharyngioma (1.8%) vascular malformations (0.9%), and tuberculosis (0.9%). Mortality due to operation is none.

Conclusions:

Histopathologic diagnosis of multiple brain lesions is necessary for decision of appropriate management and stereotactic biopsy of brain lesion is a useful and safe method for histological diagnosis.

Newer developments in adult T-cell leukemia/lymphoma therapeutics

INTRODUCTION

Adult T-cell leukemia/lymphoma (ATL) is a rare disease with a unique geographic distribution. Conducting controlled randomized trials to assess the effective therapeutic strategies has therefore been a significant challenge to date.

AREAS COVERED

This review explores the natural history and diagnostic evaluation of ATL, followed by a focused review of existing studies on the most potent individual pharmaceutical agents and combinations used in the therapy of this malignancy. Readers will acquire considerable insights about the clinical subsets, diagnosis and the most effective therapies used in various ATL types.

EXPERT OPINION

International, multicenter, randomized clinical trials are essential to design optimal therapeutic strategies for various ATL subsets. It appears that patients with acute ATL type benefit considerably from the first-line combined antiviral therapy with zidovudine and interferon alpha, whereas patients with ATL of the lymphoma type may experience a better outcome with intensive chemotherapy. The role of therapy in smoldering and chronic disease types remains to be clarified. In addition, the results of allogeneic stem-cell transplantation in ATL appear promising, as up to 40% of patients who achieve remission and have suitable donors can now become long-term survivors. Prospective evaluation of novel effective agents and their incorporation into various therapeutic algorithms is stringently needed.

Interferon- alpha and - beta restrict polyomavirus JC replication in primary human fetal glial cells: implications for progressive multifocal leukoencephalopathy therapy

One of the major limitations of highly active antiretroviral therapy is its inability to inhibit the replication of polyomavirus JC (JCV), the etiologic agent of progressive multifocal leukoencephalopathy (PML), an acquired immunodeficiency syndrome-defining illness. We previously demonstrated the induction of interferon (IFN)-stimulated genes (ISGs) by JCV. In the present study, we characterize the specific viral events required to induce ISGs and the potential antiviral effects of type I IFN on JCV replication in human fetal glial cells in the presence and absence of type I IFNs. Productive JCV replication was essential for the induction of the antiviral host response. JCV replication at all steps was significantly inhibited in the presence of IFN, and neutralizing anti-IFN antibody rescued the inhibitory effect of IFN. These results support the use of IFN as an adjunct therapy for patients with PML. Because IFN cannot cross the blood-brain barrier to achieve its direct antiviral effect, intrathecal administration of IFN is warranted.