Increased risk of disseminated cryptococcal infection in a patient with multiple sclerosis on fingolimod

Cryptococcosis Associated With Biologic Therapy: A Narrative Review

Cryptococcus is an opportunistic fungal pathogen that can cause disseminated infection with predominant central nervous system involvement in patients with compromised immunity. Biologics are increasingly used in the treatment of neoplasms and autoimmune/inflammatory conditions and the prevention of transplant rejection, which may affect human defense mechanisms against cryptococcosis. In this review, we comprehensively investigate the association between cryptococcosis and various biologics, highlighting their risks of infection, clinical manifestations, and clinical outcomes. Clinicians should remain vigilant for the risk of cryptococcosis in patients receiving biologics that affect the Th1/macrophage activation pathways, such as tumor necrosis factor α antagonists, Bruton tyrosine kinase inhibitors, fingolimod, JAK/STAT inhibitors (Janus kinase/signal transducer and activator of transcription), and monoclonal antibody against CD52. Other risk factors-such as age, underlying condition, and concurrent immunosuppressants, especially corticosteroids-should also be taken into account during risk stratification.

Cryptococcal meningoencephalitis in multiple sclerosis treated with fingolimod

A 21-year-old woman with multiple sclerosis (taking regular fingolimod) developed sudden-onset severe headache with nausea and malaise. Neurological examination was normal and she was afebrile. Blood results showed lymphocytes 0.53 x 109/L and C reactive protein 19 mg/L. CT scan of head and venogram were normal. CSF showed an opening pressure of 33 cm H2O and an incidental light growth of Cryptococcus neoformans, confirmed with positive India Ink stain and a positive cryptococcal antigen (1:100). She was treated for cryptococcal meningoencephalitis with amphotericin and flucytosine. Her presenting symptoms had closely mimicked subarachnoid haemorrhage. This atypical presentation of cryptococcal CNS infection highlights the need for vigilance in immunosuppressed patients.

Cutaneous presentation of cryptococcal infection with subclinical central nervous system involvement secondary to fingolimod therapy

Fingolimod is a multiple sclerosis disease-modifying therapy which sequestrates lymphocytes in the lymph nodes, thereby reducing peripheral blood lymphocytes. Cryptococcal infection is an important adverse effect which should be recognised. We report a case of cutaneous and central nervous system infection who presented with isolated cutaneous symptoms in the absence of neurological or systemic manifestations.

Cryptococcal chest wall mass and rib osteomyelitis associated with the use of fingolimod: A case report and literature review

Being introduced in 2010, fingolimod was among the first oral therapies for relapsing multiple sclerosis (MS). Since that time, postmarketing surveillance has noted several case reports of various cryptococcal infections associated with fingolimod use. To date, approximately 15 such case reports have been published. We present the first and unique case of cryptococcal chest wall mass and rib osteomyelitis associated with fingolimod use. The patient presented with left-side chest pain and was found to have a lower left chest wall mass. Computerized tomography (CT) showed chest wall mass with the destruction of left 7th rib. Aspirate from the mass grew Cryptococcus neoformans. The isolate was serotype A. Fingolimod was stopped. The patient received liposomal amphotericin B for 2 weeks and started on fluconazole with a plan to continue for 6–12 months. The follow-up CT in 6 weeks showed a marked decrease in the size of the chest wall mass. In conclusion, our case highlights the atypical and aggressive form of cryptococcal infection possibly related to immunosuppression from fingolimod use.

Assessing and mitigating risk of infection in patients with multiple sclerosis on disease modifying treatment

Introduction: The important development that the multiple sclerosis (MS) treatment field has experienced in the last years comes along with the need of dealing with new adverse events such as the increase risk of infections. In the shared therapeutic decision-making process, the MS expert neurologist should also balance the risks of specific infections under each particular treatment and be familiar with new mitigation strategies.Areas covered: In this review, the authors provide an up-to-date review of the infection risk associated with MS treatments with a specific focus on risk mitigating strategies. The search was conducted using Pubmed® database (2000 - present) to identify publications that reported infection rates and infection complications for each treatment (interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate, fingolimod, cladribine, natalizumab, alemtuzumab, rituximab, and ocrelizumab).Expert opinion: Since the emergence of the first natalizumab-related PML case, the arrival of new MS therapies has come hand in hand with new infectious complications. MS-specialist neurologist has to face new challenges regarding the management of immunosuppression-related infectious complications. The implementation of patient-centered management focus on preventive and mitigating strategies with a multidisciplinary approach should be seen in the future as a marker of excellence of MS management.