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Bernard-Valnet R, Moisset X, Maubeuge N, Lefebvre M, Ouallet JC, Roumier M, Lebrun-Frenay C, Ciron J, Biotti D, Clavelou P, Godeau B, Du Pasquier RA, Martin-Blondel G. CCR5 Blockade in Inflammatory PML and PML-IRIS Associated With Chronic Inflammatory Diseases' Treatments. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 9:9/1/e1097. [PMID: 34728496 PMCID: PMC8564863 DOI: 10.1212/nxi.0000000000001097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/09/2021] [Indexed: 12/02/2022]
Abstract
Background and Objectives Progressive multifocal leukoencephalopathy (PML) is a disabling neurologic disorder resulting from the infection of the CNS by JC polyomavirus in immunocompromised individuals. For the last 2 decades, increasing use of immunotherapies leads to iatrogenic PML. Iatrogenic PML is often associated with signs of inflammation at onset (inflammatory PML) and/or after treatment withdrawal immune reconstitution inflammatory syndrome (PML-IRIS). Although immune reconstitution is a key element for viral clearance, it may also be harmful and induce clinical worsening. A C-C chemokine receptor type 5 (CCR5) antagonist (maraviroc) has been proposed to prevent and/or limit the deleterious immune responses underlying PML-IRIS. However, the data to support its use remain scarce and disputed. Methods We conducted a multicenter retrospective cohort study at 8 university hospitals in France and Switzerland by collecting clinical, biological, and radiologic data of patients who developed inflammatory PML (iPML) or PML-IRIS related to immunosuppressive therapies used for chronic inflammatory diseases between 2010 and 2020. We added to this cohort, a meta-analysis of individual case reports of patients with iPML/PML-IRIS treated with maraviroc published up to 2021. Results Overall, 27 cases were identified in the cohort and 9 from the literature. Among them, 27 met the inclusion criteria: 16 treated with maraviroc and 11 with standard of care (including corticosteroids use). Most cases were related to MS (92.6%) and natalizumab (88%). Inflammatory features (iPML) were present at onset in 12 patients (44.4%), and most patients (92.6%) received corticosteroids within the course of PML. Aggravation due to PML-IRIS was not prevented by maraviroc compared with patients who received only corticosteroids (adjusted odds ratio: 0.408, 95% CI: 0.06–2.63). Similarly, maraviroc did not influence time to clinical worsening due to PML-IRIS (adjusted hazard ratio = 0.529, 95% CI: 0.14–2.0) or disability at the last follow-up (adjusted odds ratio: 2, 95% CI: 0.23–17.3). Discussion The use of CCR5 blockade did not help to keep deleterious immune reconstitution in check even when associated with corticosteroids. Despite maraviroc's reassuring safety profile, this study does not support its use in iPML/PML-IRIS. Classification of Evidence This study provides Class IV evidence showing that adding maraviroc to the management of iatrogenic iPML/PML-IRIS does not improve the outcome.
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Affiliation(s)
- Raphael Bernard-Valnet
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France.
| | - Xavier Moisset
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Nicolas Maubeuge
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Mathilde Lefebvre
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Jean-Christophe Ouallet
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Mathilde Roumier
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Christine Lebrun-Frenay
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Jonathan Ciron
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Damien Biotti
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Pierre Clavelou
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Bertrand Godeau
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Renaud A Du Pasquier
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Guillaume Martin-Blondel
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
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