1
|
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.
Collapse
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
| |
Collapse
|
2
|
JC Polyomavirus and Transplantation: Implications for Virus Reactivation after Immunosuppression in Transplant Patients and the Occurrence of PML Disease. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The JC polyomavirus (JCPyV/JCV) is a member of the Polyomaviridae family and is ubiquitious in the general population, infecting 50–80% of individuals globally. A primary infection with JCV usally results in an asymptomatic, persistent infection that establishes latency in the renourinary tract. Reactivation from latency via iatrogenic immununosuppression for allograft transplantation may result in organ pathology and a potential life-threatening neuropathological disease in the form of progressive multifocal leukoencephalopathy (PML). Currently, no treatment exists for PML, a rare complication that occurs after transplantation, with an incidence of 1.24 per 1000 persons a year among solid organ transplant patients. PML is also observed in HIV patients who are immununosuppressed and are not receiving antiretroviral therapy, as well as individuals treated with biologics to suppress chronic inflammatory responses due to multiple sclerosis, Crohn’s disease, non-Hodgkin’s lymphoma, rheumatoid arthritis, and other autoimmune-mediated hematological disorders. Here, we describe the proposed mechanisms of JCV reactivation as it relates to iatrogenic immunosuppression for graft survival and the treatment of proinflammatory disease, such as biologics, proposed trafficking of JCV from the renourinary tract, JCV central nervous system dissemination and the pathology of PML in immunosuppressed patients, and potential novel therapeutics for PML disease.
Collapse
|
3
|
Alfano G, Giaroni F, Fontana F, Neri L, Mosconi G, Mussini C, Guaraldi G, Cappelli G. Rituximab in people living with HIV affected by immune-mediated renal diseases: a case-series. Int J STD AIDS 2020; 31:1426-1431. [PMID: 33104497 DOI: 10.1177/0956462420946662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Over the last two decades, rituximab (RTX) has played an important role in the treatment of some lymphoproliferative malignancies and immune-mediated diseases. RTX administration is generally safe and well-tolerated, but side effects including late-onset neutropenia, hypogammaglobulinemia, hepatitis B reactivation and rare cases of progressive multifocal leukoencephalopathy have been observed after its administration. Although there are no absolute contraindications regarding its use in people living with HIV (PLWH), the prescription of this drug has been principally limited in patients with oncohematological diseases. In this report, we described the outcome of four PLWH who underwent RTX therapy after the diagnosis of immune-mediated renal disease. The main RTX-associated adverse effects were leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts. In addition, two of the four patients experienced pneumonia requiring hospitalization within six months from the last RTX infusion. We suggest that RTX should be used with caution in PLWH until further evidence emerges on its safety profile in this vulnerable population.
Collapse
Affiliation(s)
- G Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - F Giaroni
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - F Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - L Neri
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy
| | - G Mosconi
- Nephrology and Dialysis Unit, Hospital of Forlì-Cesena, Forlì-Cesena, Italy.,Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - C Mussini
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Guaraldi
- Clinic of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - G Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| |
Collapse
|
4
|
Infections in Heart, Lung, and Heart-Lung Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7121494 DOI: 10.1007/978-1-4939-9034-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Half a century has passed since the first orthotopic heart transplant took place. Surgical innovations allowed for heart, lung, and heart-lung transplantation to save lives of patients with incurable chronic cardiopulmonary conditions. The complexity of the surgical interventions, chronic host health conditions, and antirejection immunosuppressive medications makes infectious complications common. Infections have remained one of the main barriers for successful transplantation and a source of significant morbidity and mortality. Recognition of infections and its management in this setting require outstanding clinical skills since transplant recipients may not exhibit classic signs or symptoms of disease, and laboratory work has some pitfalls. The prevention, identification, and management of infectious diseases complications in this population are a priority to undertake to improve the medical outcomes of transplantation. Herein, we reviewed the historical aspects, epidemiology, and prophylaxis of infections in heart, lung, and heart-lung transplantation. We also discuss the most prevalent organisms affecting the host and the organ systems involved.
Collapse
|
5
|
Windpessl M, Burgstaller S, Kronbichler A, Pieringer H, Kalev O, Karrer A, Wallner M, Thaler J. Progressive Multifocal Leukoencephalopathy Following Combined Rituximab-Based Immune-Chemotherapy for Post-transplant Lymphoproliferative Disorder in a Renal Transplant Recipient: A Case Report. Transplant Proc 2018; 50:881-883. [PMID: 29661457 DOI: 10.1016/j.transproceed.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/17/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), an opportunistic infection due to reactivation of JC virus. Post-transplant lymphoproliferative disorders (PTLDs) represent a common malignancy in this population, and antiCD20-therapy has become an established component of its treatment. CASE PRESENTATION We describe the first case of a renal allograft transplant recipient with PTLD who received rituximab-based immune-chemotherapy and developed PML shortly thereafter. Despite early suspicion and diagnosis, the disease ran a relentlessly progressive course, and the patient succumbed to his illness shortly thereafter. CONCLUSION PML should be strongly suspected whenever unusual neurologic symptoms appear in the context of immunosuppression. Clinicians and patients should be aware of the potential for PML after rituximab therapy.
Collapse
Affiliation(s)
- M Windpessl
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - S Burgstaller
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - A Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, Innsbruck, Austria
| | - H Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University, Salzburg, Austria
| | - O Kalev
- Department of Neuropathology, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | - A Karrer
- Department of Radiology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - M Wallner
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - J Thaler
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| |
Collapse
|
6
|
Kronbichler A, Windpessl M, Pieringer H, Jayne DRW. Rituximab for immunologic renal disease: What the nephrologist needs to know. Autoimmun Rev 2017; 16:633-643. [PMID: 28414152 DOI: 10.1016/j.autrev.2017.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/12/2022]
Abstract
Rituximab (RTX), a chimeric, monoclonal anti-CD20 antibody, is increasingly used in immune-mediated renal diseases. While licensed in the induction treatment of ANCA-associated vasculitis, it represents one of the most commonly prescribed off-label drugs. Much of the information regarding its safety has been drawn from experience in hematology and rheumatology. Ample evidence illustrates the safety of RTX, however, rare but serious adverse events have emerged that include progressive multifocal leucoencephalopathy and hepatitis B reactivation. Moderate to severe hypogammaglobulinemia and late-onset neutropenia following RTX therapy confer an increased infectious risk and factors predicting these side effects (i.e. a genetic basis) need to be identified. Nephrologists initiating RTX need to bear in mind that long-term risks and optimal dosing for many renal indications remain unclear. Special considerations must be given when RTX is used in women of childbearing age. We summarize practical aspects concerning the use of RTX. This review will provide nephrologists with information to guide their use of RTX alerting them to safety risks and the need for patient counselling.
Collapse
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria.
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Herwig Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - David R W Jayne
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
7
|
Drug-associated progressive multifocal leukoencephalopathy: a clinical, radiological, and cerebrospinal fluid analysis of 326 cases. J Neurol 2016; 263:2004-21. [PMID: 27401179 PMCID: PMC5037162 DOI: 10.1007/s00415-016-8217-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 02/07/2023]
Abstract
The implementation of a variety of immunosuppressive therapies has made drug-associated progressive multifocal leukoencephalopathy (PML) an increasingly prevalent clinical entity. The purpose of this study was to investigate its diagnostic characteristics and to determine whether differences herein exist between the multiple sclerosis (MS), neoplasm, post-transplantation, and autoimmune disease subgroups. Reports of possible, probable, and definite PML according to the current diagnostic criteria were obtained by a systematic search of PubMed and the Dutch pharmacovigilance database. Demographic, epidemiologic, clinical, radiological, cerebrospinal fluid (CSF), and histopathological features were extracted from each report and differences were compared between the disease categories. In the 326 identified reports, PML onset occurred on average 29.5 months after drug introduction, varying from 14.2 to 37.8 months in the neoplasm and MS subgroups, respectively. The most common overall symptoms were motor weakness (48.6 %), cognitive deficits (43.2 %), dysarthria (26.3 %), and ataxia (24.1 %). The former two also constituted the most prevalent manifestations in each subgroup. Lesions were more often localized supratentorially (87.7 %) than infratentorially (27.4 %), especially in the frontal (64.1 %) and parietal lobes (46.6 %), and revealed enhancement in 27.6 % of cases, particularly in the MS (42.9 %) subgroup. Positive JC virus results in the first CSF sample were obtained in 63.5 %, while conversion after one or more negative outcomes occurred in 13.7 % of cases. 52.2 % of patients died, ranging from 12.0 to 83.3 % in the MS and neoplasm subgroups, respectively. In conclusion, despite the heterogeneous nature of the underlying diseases, motor weakness and cognitive changes were the two most common manifestations of drug-associated PML in all subgroups. The frontal and parietal lobes invariably constituted the predilection sites of drug-related PML lesions.
Collapse
|
8
|
Kurmann R, Weisstanner C, Kardas P, Hirsch HH, Wiest R, Lämmle B, Furrer H, Du Pasquier R, Bassetti CL, Sturzenegger M, Krestel H. Progressive multifocal leukoencephalopathy in common variable immunodeficiency: mitigated course under mirtazapine and mefloquine. J Neurovirol 2015; 21:694-701. [PMID: 25916731 DOI: 10.1007/s13365-015-0340-4] [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: 01/02/2015] [Revised: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 11/30/2022]
Abstract
Demonstration of survival and outcome of progressive multifocal leukoencephalopathy (PML) in a 56-year-old patient with common variable immunodeficiency, consisting of severe hypogammaglobulinemia and CD4+ T lymphocytopenia, during continuous treatment with mirtazapine (30 mg/day) and mefloquine (250 mg/week) over 23 months. Regular clinical examinations including Rankin scale and Barthel index, nine-hole peg and box and block tests, Berg balance, 10-m walking tests, and Montreal Cognitive Assessment (MoCA) were done. Laboratory diagnostics included complete blood count and JC virus (JCV) concentration in cerebrospinal fluid (CSF). The noncoding control region (NCCR) of JCV, important for neurotropism and neurovirulence, was sequenced. Repetitive MRI investigated the course of brain lesions. JCV was detected in increasing concentrations (peak 2568 copies/ml CSF), and its NCCR was genetically rearranged. Under treatment, the rearrangement changed toward the archetype sequence, and later JCV DNA became undetectable. Total brain lesion volume decreased (8.54 to 3.97 cm(3)) and atrophy increased. Barthel (60 to 100 to 80 points) and Rankin (4 to 2 to 3) scores, gait stability, and box and block (7, 35, 25 pieces) and nine-hole peg (300, 50, 300 s) test performances first improved but subsequently worsened. Cognition and walking speed remained stable. Despite initial rapid deterioration, the patient survived under continuous treatment with mirtazapine and mefloquine even though he belongs to a PML subgroup that is usually fatal within a few months. This course was paralleled by JCV clones with presumably lower replication capability before JCV became undetectable. Neurological deficits were due to PML lesions and progressive brain atrophy.
Collapse
Affiliation(s)
- Rebekka Kurmann
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Piotr Kardas
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Roland Wiest
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Bernhard Lämmle
- Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland.,Center for Thrombosis and Hemostasis, Mainz University Medical Center, Mainz, Germany.,University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Renaud Du Pasquier
- Department of Neurology, Lausanne University Hospital, Lausanne, Switzerland.,Department of Clinical Neurosciences, University of Lausanne, Lausanne, Switzerland
| | - Claudio L Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Mathias Sturzenegger
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Heinz Krestel
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland. .,University of Bern, Bern, Switzerland.
| |
Collapse
|
9
|
|
10
|
Souayah N, Noopur R, Tick-Chong PS. Beneficial effects of Rituximab in patients with anti-MAG (myelin-associated glycoprotein) neuropathy: case reports. Immunopharmacol Immunotoxicol 2013; 35:622-4. [DOI: 10.3109/08923973.2013.822507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|