1
|
Pjanic M, Aleckovic-Halilovic M, Basic-Jukic N. JC Virus in Kidney Transplant Population: Are We Cautious Enough? J Clin Med 2024; 13:2217. [PMID: 38673491 PMCID: PMC11050714 DOI: 10.3390/jcm13082217] [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: 02/06/2024] [Revised: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The John Cunningham virus (JCV) is a polyomavirus that usually infects people at a young age and does not cause any symptoms in immunocompetent individuals. However, in immunocompromised individuals, such as kidney transplant recipients, JCV can cause severe and potentially fatal disease. Unfortunately, JCV has not been researched as extensively as the BK virus and is not mentioned in relevant kidney transplant guidelines. This lack of attention to JCV can lead to less consideration in kidney transplant patients' care. Surveillance using locally available diagnostic methods is of the utmost importance. The presence of JCV can be diagnosed with urine decoy cells, viruria, or viremia verified by the PCR method. A low threshold for considering JCV as a possible cause of any neurological or renal dysfunction in kidney transplant recipients must be maintained. In such cases, kidney and brain biopsy are indicated. Maintaining the appropriate immunosuppression while avoiding over-immunosuppression to prevent JCV disease is crucial, and the approach should be individual, according to overall immunological risk. We hypothesize that the presence of the JCV can indicate overt immunosuppression and identify kidney transplant recipients more prone to opportunistic infections and diseases, including some malignancies. To explore that, future observational studies are needed.
Collapse
Affiliation(s)
- Mirha Pjanic
- Clinic for Internal Diseases, Department of Nephrology, Dialysis and Kidney Transplantation, University Clinical Center Tuzla, 75000 Tuzla, Bosnia and Herzegovina;
| | - Mirna Aleckovic-Halilovic
- Clinic for Internal Diseases, Department of Nephrology, Dialysis and Kidney Transplantation, University Clinical Center Tuzla, 75000 Tuzla, Bosnia and Herzegovina;
| | - Nikolina Basic-Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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
|
4
|
Keykhosravi S, Khosravi M, Shenagari M, Hasan-Alizadeh E, Mosadegh M, Noori Goodarzi N, Monfared A, Ashrafkhani B, Hasandokht T. Determining host factors contributing to the reactivation of JC virus in kidney transplant recipients. Virol J 2022; 19:131. [PMID: 35941650 PMCID: PMC9358911 DOI: 10.1186/s12985-022-01843-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 05/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS The John Cunningham virus (JCV) is the established etiological agent of the polyomavirus-associated nephropathy among renal transplant recipients. In the present study, we aimed to determine the probable predictive factors leading to JCV replication in renal transplant patients. MATERIAL AND METHODS Urine and plasma samples were collected from a total of 120 consecutive renal-transplanted patients without preliminary screening from Jan 2018 to Mar 2019. After DNA extraction, the simultaneous detection and quantification of JCV and BK polyomavirus (BKV) were conducted using a Real-time quantitative PCR method. Moreover, statistical analyses were performed using the statistical software packages, SPSS version 21. RESULTS The prevalence of JCV viruria and viremia among renal transplant recipients were 26 (21.67%) and 20 (16.67%), respectively. A significant association was observed between the JCV and two risk factors, diabetes mellitus (P = 0.002) and renal stones (P = 0.015). The prevalence of JCV viremia among recipients who were grafted near time to sampling was significantly higher (P = 0.02). There was a statistically significant coexistence between BK and JC viruses among our patients (P = 0.029). The frequency of JCV viruria in males was reported almost three times more than in females (P = 0.005). The JCV shedding in urine was significantly associated with the tropical steroids like prednisolone acetate, which have been the standard regimen (P = 0.039). Multivariable analysis revealed duration of post-transplantation (OR, 0.89; P = 0.038), diabetes mellitus (OR, 1.85; P = 0.034), and renal stone (OR 1.10; P = 0.04) as independent risk factors associated with JCV viremia post-renal transplantation. CONCLUSION It seems that the discovery of potential risk factors, including immunological and non-immunological elements, may offer a possible preventive or therapeutic approach in the JCV disease episodes. The results of this study may also help clarify the probable clinical risk factors involving in progressive multifocal leukoencephalopathy development.
Collapse
Affiliation(s)
- Sajedeh Keykhosravi
- Department of Microbiology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Masoud Khosravi
- Urology Research Center, Guilan University of Medical Sciences, Rasht, Iran.,Organ Transplant Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad Shenagari
- Department of Microbiology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran. .,Organ Transplant Research Center, Guilan University of Medical Sciences, Rasht, Iran.
| | | | - Mehrdad Mosadegh
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Narjes Noori Goodarzi
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Monfared
- Urology Research Center, Guilan University of Medical Sciences, Rasht, Iran.,Organ Transplant Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Babak Ashrafkhani
- Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Tolou Hasandokht
- Department of Community Medicine, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| |
Collapse
|
5
|
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
|
6
|
Lippa AM, Ocwieja KE, Iglesias J, Fawaz R, Elisofon S, Lee C, Sharma TS. Progressive multifocal leukoencephalopathy presenting with acute sensorineural hearing loss in an intestinal transplant recipient. Transpl Infect Dis 2020; 22:e13304. [PMID: 32367644 DOI: 10.1111/tid.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/12/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
A 20-year-old male presented 3.5 years after intestinal transplantation with rapidly progressive sensorineural hearing loss. Initial brain imaging was consistent with inflammation and/or demyelination. Lumbar puncture was initially non-diagnostic and a broad infectious workup was unrevealing. Three months after presentation, a repeat LP detected JC virus for which tests had not earlier been conducted. He continued to deteriorate despite withdrawal of prior immunosuppression and addition of mirtazapine, maraviroc, and steroids. He died of progressive neurologic decompensation 5 months after his initial presentation. This case highlights progressive multifocal leukoencephalopathy (PML) as a rare complication after solid organ transplantation and acute sensorineural hearing loss as an unusual first presenting symptom of PML. JC virus should be considered in the differential diagnosis of acute sensorineural hearing loss in any immunocompromised patient.
Collapse
Affiliation(s)
- Andrew M Lippa
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Karen E Ocwieja
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Julie Iglesias
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Rima Fawaz
- Division of Gastroenterology and Hepatology, Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Scott Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Christine Lee
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
7
|
Tawara T, Kai H, Kageyama M, Akiyama T, Matsunaga T, Sakuma A, Ishii R, Tsunoda R, Kawamura T, Fujita A, Kaneko S, Morito N, Saito C, Usui J, Yamagata K. A case report of progressive multifocal leukoencephalopathy during steroid treatment for ANCA-associated renal vasculitis. CEN Case Rep 2020; 9:354-358. [PMID: 32388828 DOI: 10.1007/s13730-020-00482-w] [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] [Received: 02/10/2020] [Accepted: 04/15/2020] [Indexed: 11/29/2022] Open
Abstract
CASE REPORT an 80-year-old woman presented with rapidly progressive glomerulonephritis and was admitted to our hospital. Myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA) was positive. We diagnosed ANCA-associated renal vasculitis (ANCA-RV). Treatment was initiated with intravenous methylprednisolone pulse therapy, followed by prednisolone (PSL) at 30 mg/day. We gradually reduced the PSL dose to 7.5 mg/day over 6 months. At that time, the patient developed disturbances of consciousness which progressed subacutely. MRI revealed regions of patchy white matter with an increased signal on T2-weighted, fluid attenuated inversion recovery (FLAIR) sequences and diffusion-weighted sequences. JC virus DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR), leading to a diagnosis of progressive multifocal leukoencephalopathy (PML). PML is a rare infectious demyelinating disease of the central nervous system caused by JC virus infection, occurring in highly immunosuppressed individuals such as HIV-infected patients and patients using some biological agents, and having a very poor prognosis. In the present case, PML may have been associated with steroid use, although there are very few case reports of PML in patients taking only steroids. We report progressive multifocal leukoencephalopathy during steroid treatment of ANCA-RV. When patients show progressive disturbance of consciousness during treatment for ANCA-RV, we need to take PML into consideration for differential diagnosis.
Collapse
Affiliation(s)
- Takashi Tawara
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hirayasu Kai
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Mikiko Kageyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tomoki Akiyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takahiro Matsunaga
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Aki Sakuma
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryota Ishii
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryouya Tsunoda
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tetusya Kawamura
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akiko Fujita
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shuzo Kaneko
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Morito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Chie Saito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Joichi Usui
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kunihiro Yamagata
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
| |
Collapse
|
8
|
Boziki MK, Karapanayotides T, Papadopoulos G, Lagoudaki R, Melo P, Bakirtzis C, Nikolaidis I, Gounari E, Tsavdaridou V, Skoura L, Afrantou T, Tatsi T, Grigoriadou E, Polyzoidou E, Mandoras N, Giantzi V, Kalogera-Fountzila A, Ioannidis P, Parissis D, Pelidou SH, Zoidou S, Grigoriadis N. Reduced expression of L-selectin in T-cells correlates with relative lymphocyte increase in patients with RRMS treated with natalizumab - functional implication towards PML risk. Neurol Res 2020; 42:209-221. [PMID: 32048570 DOI: 10.1080/01616412.2020.1722913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives: Natalizumab (NTZ), a treatment indicated for patients with highly active Relapsing - Remitting Multiple Sclerosis (RRMS), is known to induce increased relative frequency of lymphocytes. Progressive Multifocal Leukoencephalitis (PML) is a rare but serious adverse event related to NTZ. Moreover, reduced L-selectin (CD62L) expression in T-cells in cryopreserved samples of patients with RRMS under NTZ has been proposed as a biomarker of pre-PML state. We explore the association between L-selectin expression in T-cells and hematological parameters in freshly processed samples of patients with RRMS under NTZ.Methods: We studied L-selectin expression in patients with: RRMS under NTZ (n=34), fingolimod (FTY, n=14), interferon-beta (IFNβ, n=22), glatiramer acetate (GA, N=17); in 9 patients with secondary progressive (SP) MS and in 6 healthy controls. Twenty-two patients under NTZ and 6 patients under FTY were followed for 18 months. One NTZ-treated patient developed PML during the study.Results: Patients under NTZ exhibited increased relative frequency of lymphocytes (40.02±1.45) compared to patients under first-line treatment (30.57±1.68, p<0.001) and to patients with SPMS (29±1.56, p=0.02), and a lower mean L-selectin expression in (69.39±1.73) compared to patients under first-line treatment (79.1±1.17, p=0.003). A negative correlation between the relative frequency of CD4+CD62L+ T-cells and the absolute lymphocyte counts (Pearson's r=0.367, p=0.033) was observed.Discussion: We hereby provide mechanistic insight in a possible pathway implicated in NTZ-related PML risk. These results further underline the need for thorough validation of L-selectin expression in T-cells as a potential pre-PML biomarker.
Collapse
Affiliation(s)
- Marina Kleopatra Boziki
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodoros Karapanayotides
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios Papadopoulos
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Roza Lagoudaki
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Pamela Melo
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Bakirtzis
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Ioannis Nikolaidis
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Evdoxia Gounari
- Laboratory of Immunology, Department of Microbiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Vasiliki Tsavdaridou
- Laboratory of Immunology, Department of Microbiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Lemonia Skoura
- Laboratory of Immunology, Department of Microbiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodora Afrantou
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theano Tatsi
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Eleni Grigoriadou
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Eleni Polyzoidou
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Nikolaos Mandoras
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Virginia Giantzi
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Anna Kalogera-Fountzila
- Department of Radiology, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Panagiotis Ioannidis
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitrios Parissis
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Sygkliti-Henrietta Pelidou
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Sofia Zoidou
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Nikolaos Grigoriadis
- 2nd Neurological University Clinic, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| |
Collapse
|
9
|
Ishii K, Yamamoto F, Homma S, Okada Y, Nakamichi K, Saijo M, Tamaoka A. Probable progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with immunosuppressant dose reduction following lung transplantation: a case report and literature review. BMC Neurol 2019; 19:263. [PMID: 31672142 PMCID: PMC6822459 DOI: 10.1186/s12883-019-1493-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 10/09/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rapidly developing demyelinating disease in the cerebral white matter and is often caused by JC polyomavirus (JCV). PML after lung transplantation is rare and has a poor prognosis, with no established therapies. Reducing the patient's immunosuppressant doses, thereby restoring immunity, could be used to treat PML. However, some patients develop immune reconstitution inflammatory syndrome (IRIS) with this treatment, an immune-induced inflammatory response to JCV that results in serious neuronal damage. We herein report a case of a 60-year-old female who suffered from PML 5 years after lung transplantation, had worsened brain lesions thought to be related to PML-IRIS at the time of immunosuppressant reduction, and missed treatment opportunities. CASE PRESENTATION A 60-year-old female developed PML 5 years after lung transplantation. Fluid-attenuated inversion recovery and diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple high-signal lesions, mainly in the cerebral white matter. Polymerase chain reaction found 0.32 million copies/mL of JCV in the cerebrospinal fluid. Thus, she was given a diagnosis of PML. Mycophenolate mofetil and tacrolimus dosages were reduced, and CD4-positive cell counts and the blood concentration of each immunosuppressant were monitored. Mefloquine was also orally administered at a daily dose of 275 mg for 3 days and was then administered at a dose of 275 mg per week. Although the patient's CD4-positive cell counts increased and her immune system recovered, her symptoms and brain MRI findings worsened. We suspected PML progression or a transition to PML-IRIS. Steroid pulse therapy to suppress the inflammatory lesions was not possible but was retrospectively indicated. The patient rapidly began to exhibit akinetic mutism and died 4 months after the onset of neurologic symptoms. CONCLUSIONS When neurologic symptoms and abnormal brain MRI findings are noted during immune recovery, it is often difficult to distinguish between progressed PML and PML-IRIS. However, the pathogenesis of brain lesions usually involves inflammation and immune-reactive mechanisms for JCV. Steroid pulse therapy, which can reduce inflammation, should thus be administered in organ transplantation cases with differential diagnoses including PML-IRIS.
Collapse
Affiliation(s)
- Kazuhiro Ishii
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Fumiko Yamamoto
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinsuke Homma
- Department of Pulmonology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi, Aoba-ku Sendai, 980-8575, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Toyama 1-23-1, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Masayuki Saijo
- Department of Virology 1, National Institute of Infectious Diseases, Toyama 1-23-1, Shinjuku-ku, Tokyo, 162-8640, Japan
| | - Akira Tamaoka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Ten'noudai, Tsukuba, Ibaraki, 305-8575, Japan
| |
Collapse
|
10
|
Kirincich J, Basic-Jukic N, Radic J, Lovric-Kujundzic S, Kastelan Z. A Kidney Transplant Recipient With Fulminant Progressive Multifocal Leukoencephalopathy-Immune Reconstitution Inflammatory Syndrome: A Rare Clinical Outcome and Review of the Literature. EXP CLIN TRANSPLANT 2019; 18:242-246. [PMID: 31580233 DOI: 10.6002/ect.2018.0227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy is a devastating disease affecting the central nervous system that may be seen in immunocompromised patients. We present a case of a kidney transplant recipient who received tacrolimus, mycophenolic acid, and prednisone and who developed motor deficits, altered cognition, and speech abnormalities, which culminated in a coma. The diagnosis was made by detecting John Cunningham polyomavirus DNA with polymerase chain reaction and observing characteristic findings on magnetic resonance imaging. Soon after immunosuppressive therapy was withdrawn, the patient's clinical status deteriorated due to immune reconstitution inflammatory syndrome, and prednisone was administered. Unfortunately, the patient died about 9 months after onset of symptoms. This case serves to illustrate the fulminant progression of progressive multifocal leukoencephalopathy and the possible complications that may arise when treating it.
Collapse
Affiliation(s)
- Jason Kirincich
- >From the Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | | | | | | |
Collapse
|
11
|
Ahmadinejad Z, Talebi F, Yazdi NA, Ghiasvand F. A 41-year-old female with progressive multifocal leukoencephalopathy after liver transplant. J Neurovirol 2019; 25:605-607. [PMID: 31140129 DOI: 10.1007/s13365-019-00742-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 03/21/2019] [Indexed: 11/26/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease caused by JC virus reactivation. Its occurrence is very rare after solid organ transplantation, especially liver transplantation. We report a patient who received liver transplantation due to liver failure resulting from autoimmune hepatitis and advanced PML presenting with aphasia. A 41-year-old female with a history of liver transplantation who received a usual immunosuppression regimen was admitted with a stroke attack resulting in right hemiplegia 2 months after liver transplantation. Surprisingly, she gradually developed dysarthria and left central facial paresis. A brain MRI showed an abnormal multifocal area with a high T2/flair signal in the deep subcortical white matter of the left hemisphere as well as the splenium of the corpus callosum. PCR evaluation of CSF for JCV was positive while other PCR results were negative. A liver transplant recipient receiving immunosuppressive treatment for a long time could develop PML due to JCV reactivation. Only eight cases of JCV infection were reported after liver transplantation by the time of reporting this case. Unfortunately, there is no definite treatment for PML.
Collapse
Affiliation(s)
- Zahra Ahmadinejad
- Liver transplantation Research Center, Department of Infectious Diseases, Imam Khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Talebi
- Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
| | - Niloofar Ayoobi Yazdi
- Department of Radiology, Advanced Diagnostic and Interventional Radiology (ADIR) Research Center, Tehran University of Medical Science, Tehran, Iran
| | - Fereshteh Ghiasvand
- Liver transplantation Research Center, Department of Infectious Diseases, Imam Khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
12
|
Rastogi A, Gulati N, Bihari C, Chaudhary A, Bansal K, Sasturkar S, Thapar S, Pamecha V. JC Virus-Related Progressive Multifocal Leukoencephalopathy After Living-Donor Liver Transplant: A Rare Case. EXP CLIN TRANSPLANT 2017; 17:414-417. [PMID: 28800720 DOI: 10.6002/ect.2016.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy caused by polyoma JC virus is a rare and severe demyelinating disease of the central nervous system. It occurs in immunocompromised patients and is scarcely reported in liver transplant recipients. Brain biopsy demonstrating demyelination with presence of foamy macrophages, relative preservation of axons, astrogliosis, and typical polyomavirus inclusions in the enlarged oligodendroglial nuclei is essential for diagnosis. Here, we report a case of JC virus-associated progressive multifocal leukoencephalopathy in a living-donor liver transplant recipient who was transplanted for hepatitis C virus-related decompensated cirrhosis. Brain biopsy with immunohistochemistry confirmed the diagnosis of progressive multifocal leukoencephalopathy secondary to JC virus. JC virus related-progressive multifocal leukoencephalopathy is associated with extremely poor prognosis. Awareness and consideration of this entity in liver transplant recipients who present with sudden progressive neurologic manifestations can help in prompt diagnosis and timely treatment.
Collapse
Affiliation(s)
- Archana Rastogi
- From the Department of Pathology, Institute of Liver and Biliary Sciences, Delhi, India
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Sauer R, Gölitz P, Jacobi J, Schwab S, Linker RA, Lee DH. Good outcome of brain stem progressive multifocal leukoencephalopathy in an immunosuppressed renal transplant patient: Importance of early detection and rapid immune reconstitution. J Neurol Sci 2017; 375:76-79. [DOI: 10.1016/j.jns.2017.01.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 12/23/2022]
|
14
|
Davydovskaya MV, Khachanova NV, Evdoshenko EP, Pronin IN, Boiko AN, Zakharova MN, Alifirova VM, Turova EA, Malkova NA, Sivertseva SA, Tsukurova LA, Skoromets AA, Solodun IY. [Recommendations on the algorithms for drug choice and risk management plan in the treatment of patients with remitting multiple sclerosis with natalizumab]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 116:79-97. [PMID: 28139616 DOI: 10.17116/jnevro201611610279-97] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- M V Davydovskaya
- Pirogov Russian National Research Medical University, Moscow, Russia; Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
| | - N V Khachanova
- Pirogov Russian National Research Medical University, Moscow, Russia; Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
| | - E P Evdoshenko
- Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia; City Center of Multiple Sclerosis And Autoimmune Diseases at Hospital #31, Moscow, Russia
| | - I N Pronin
- Burdenko Research Institute of Neurosurgery, Moscow, Russia
| | - A N Boiko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | | | - E A Turova
- Siberian Regional Hospital #1, Yekaterinburg, Russia
| | - N A Malkova
- Novosibirsk State Medical University, Novosibirsk, Russia
| | | | - L A Tsukurova
- Research Institute - Ochapovsky Regional Hospital #1, Krasnodar, Russia
| | - A A Skoromets
- Pavlov St. Petersburg State Medical University, St. Petersburg, Russia
| | - I Yu Solodun
- Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
| |
Collapse
|
15
|
Dumortier J, Guillaud O, Bosch A, Coppéré B, Petiot P, Roggerone S, Vukusic S, Boillot O. Progressive multifocal leukoencephalopathy after liver transplantation can have favorable or unfavorable outcome. Transpl Infect Dis 2016; 18:606-10. [DOI: 10.1111/tid.12554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/14/2016] [Accepted: 03/17/2016] [Indexed: 12/31/2022]
Affiliation(s)
- J. Dumortier
- Fédération des Spécialités Digestives; Hospices civils de Lyon; Hôpital Edouard Herriot; Lyon France
- Université Claude Bernard Lyon 1; Lyon France
| | - O. Guillaud
- Fédération des Spécialités Digestives; Hospices civils de Lyon; Hôpital Edouard Herriot; Lyon France
| | - A. Bosch
- Fédération des Spécialités Digestives; Hospices civils de Lyon; Hôpital Edouard Herriot; Lyon France
- Université Claude Bernard Lyon 1; Lyon France
| | - B. Coppéré
- Service de Médecine Interne; Hospices civils de Lyon; Hôpital Edouard Herriot; Lyon France
| | - P. Petiot
- Service d'Explorations Fonctionnelles Neurologiques; Hospices civils de Lyon; Hôpital de la Croix-Rousse; Lyon France
| | - S. Roggerone
- Université Claude Bernard Lyon 1; Lyon France
- Service de Neurologie Unité 102; Hospices civils de Lyon; Hôpital Neurologique Pierre Wertheimer; Lyon France
| | - S. Vukusic
- Université Claude Bernard Lyon 1; Lyon France
- Service de Neurologie Unité 102; Hospices civils de Lyon; Hôpital Neurologique Pierre Wertheimer; Lyon France
| | - O. Boillot
- Fédération des Spécialités Digestives; Hospices civils de Lyon; Hôpital Edouard Herriot; Lyon France
- Université Claude Bernard Lyon 1; Lyon France
| |
Collapse
|
16
|
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
|
17
|
Abstract
Progressive multifocal leukoencephalopathy is a rare, highly fatal demyelinating brain infection caused by the JC virus. This infection is associated with immunosuppressive agents and is emerging in the transplant population. There has never been a documented case of progressive multifocal leukoencephalopathy in a transplant recipient receiving sirolimus. We present a study, in which the JC virus was found in a 68-year-old man who had received a postorthotopic heart transplant 3 years earlier and who was receiving sirolimus and prednisone for immunosuppression. We review the clinical presentation, diagnosis, current treatment options, and the outcomes of progressive multifocal leukoencephalopathy in transplant recipients.
Collapse
|
18
|
SantaCruz KS, Roy G, Spigel J, Bearer EL. Neuropathology of JC virus infection in progressive multifocal leukoencephalopathy in remission. World J Virol 2016; 5:31-37. [PMID: 26870672 PMCID: PMC4735552 DOI: 10.5501/wjv.v5.i1.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/10/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate the neuropathology of the brain in a rare case of remission following diagnosis of progressive multifocal leukoencephalopathy (PML).
METHODS: Consent from the family for an autopsy was obtained, clinical records and radiograms were retrieved. A complete autopsy was performed, with brain examination after fixation and coronal sectioning at 1 cm intervals. Fourteen regions were collected for paraffin embedding and staining for microscopic analysis. Histologic sections were stained with Luxol blue, hematoxylin/eosin, and immunostained for myelin basic protein, neurofilament, SV40 T antigen and p53. The biopsy material was also retrieved and sections were stained with hematoxylin/eosin and immunostained for SV40 and p53. Sections were examined by American Board of Pathology certified pathologists and images captured digitally.
RESULTS: Review of the clinical records was notable for a history of ulcerative colitis resulting in total colectomy in 1977 and a liver transplant in 1998 followed by immune-suppressive therapy. Neurological symptoms presented immediately, therefore a biopsy was obtained which was diagnosed as PML. Immunotherapy was adjusted and clinical improvement was noted. No subsequent progression was reported. Review of the biopsy demonstrated atypical astrocytes and enlarged hyperchromatic oligodendroglial cells consistent with JC virus infection. Strong SV40 and p53 staining was found in glial cells and regions of dense macrophage infiltration were present. On gross examination of the post-mortem brain, a lesion in the same site as the original biopsy in the cerebellum was identified but no other lesions in the brain were found. Microscopic analysis of this cerebellar lesion revealed a loss of myelin and axons, and evidence of axonal damage. This single burned-out lesion was equivocally positive for SV40 antigen with little p53 staining. Examination of thirteen other brain regions found no other occult sites.
CONCLUSION: Our study reveals residual damage, rare macrophages or other inflammation and minimal evidence of persistent virus. This case demonstrates the possibility of complete remission of PML.
Collapse
|
19
|
Hirsch HH, Babel N, Comoli P, Friman V, Ginevri F, Jardine A, Lautenschlager I, Legendre C, Midtvedt K, Muñoz P, Randhawa P, Rinaldo CH, Wieszek A. European perspective on human polyomavirus infection, replication and disease in solid organ transplantation. Clin Microbiol Infect 2015; 20 Suppl 7:74-88. [PMID: 24476010 DOI: 10.1111/1469-0691.12538] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/27/2013] [Indexed: 01/15/2023]
Abstract
Human polyomaviruses (HPyVs) are a growing challenge in immunocompromised patients in view of the increasing number of now 12 HPyV species and their diverse disease potential. Currently, histological evidence of disease is available for BKPyV causing nephropathy and haemorrhagic cystitis, JCPyV causing progressive multifocal leukoencephalopathy and occasionally nephropathy, MCPyV causing Merkel cell carcinoma and TSPyV causing trichodysplasia spinulosa, the last two being proliferative skin diseases. Here, the current role of HPyV in solid organ transplantation (SOT) was reviewed and recommendations regarding screening, monitoring and intervention were made. Pre-transplant screening of SOT donor or recipient for serostatus or active replication is currently not recommended for any HPyV. Post-transplant, however, regular clinical search for skin lesions, including those associated with MCPyV or TSPyV, is recommended in all SOT recipients. Also, regular screening for BKPyV replication (e.g. by plasma viral load) is recommended in kidney transplant recipients. For SOT patients with probable or proven HPyV disease, reducing immunosuppression should be considered to permit regaining of immune control. Antivirals would be desirable for treating proven HPyV disease, but are solely considered as adjunct local treatment of trichodysplasia spinulosa, whereas surgical resection and chemotherapy are key in Merkel cell carcinoma. Overall, the quality of the clinical evidence and the strength of most recommendations are presently limited, but are expected to improve in the coming years.
Collapse
Affiliation(s)
- H H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland; Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
JC polyomavirus reactivation is common following allogeneic stem cell transplantation and its preemptive detection may prevent lethal complications. Bone Marrow Transplant 2015; 50:984-91. [PMID: 25867649 DOI: 10.1038/bmt.2015.68] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/08/2015] [Accepted: 01/09/2015] [Indexed: 01/06/2023]
Abstract
Extended application of allogeneic stem cell transplantation (alloSCT) is expected to increase the frequency of JC polyomavirus (JCPyV)-related progressive multifocal leukoencephalopathy (PML). The aim of this study was to assess frequency, risk factors and course of JCPyV reactivation in allografted hematology patients. This retrospective study included consecutive adult patients, treated with alloSCT between January 2008 and December 2011. Quantitative JCPyV-PCR analysis was performed on whole blood DNA samples, originally drawn for cytomegalovirus detection since transplant date. The study included 164 patients diagnosed with hematological malignancies. Patients received reduced-intensity conditioning (n=74) or myeloablative conditioning (n=90), followed by alloSCT. Twenty patients developed transient and 20 had persistent JCPyV reactivation. Two of the patients with persistent reactivation showed a gradual increase in JCPyV levels, preceding PML development by 96 and 127 days. Cessation of immunosuppression resulted in complete resolution of neurological symptoms in one patient, while the other died of PML. Seventy percent of the 'persistently reactivating' patients died. Multivariate analysis confirmed age to be the only significant predictive factor for JCPyV reactivation. In conclusion, JCPyV reactivation occurs in a quarter of allografted patients. Preemptive detection of JCPyV reactivation in high-risk subjects and early discontinuation of immunosuppressive therapy may prevent development of lethal PML.
Collapse
|
21
|
Carlson N, Hansen J. Fatal Progressive Multifocal Leukoencephalopathy in a Kidney Transplant Recipient 19 Years After Successful Renal Allograft Transplantation. Transplant Proc 2014; 46:2403-5. [DOI: 10.1016/j.transproceed.2013.12.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 12/16/2013] [Indexed: 01/04/2023]
|
22
|
Ohara H, Kataoka H, Nakamichi K, Saijo M, Ueno S. Favorable outcome after withdrawal of immunosuppressant therapy in progressive multifocal leukoencephalopathy after renal transplantation: Case report and literature review. J Neurol Sci 2014; 341:144-6. [DOI: 10.1016/j.jns.2014.03.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/20/2014] [Accepted: 03/25/2014] [Indexed: 02/03/2023]
|
23
|
Hoffman MJ, Stosor V. Central nervous system infections in cancer patients and hematopoietic stem cell transplant recipients. Cancer Treat Res 2014; 161:253-298. [PMID: 24706228 DOI: 10.1007/978-3-319-04220-6_9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Central nervous system (CNS) infections in cancer patients present a diagnostic and therapeutic challenge for clinicians. While CNS infections are not frequent complications of cancer, its therapies, or hematopoietic stem cell transplantation, the importance of CNS infections lies in their propensity to result in profound morbidity and substantial mortality in this vulnerable patient population. With an expanding population of patients with malignant disease undergoing more potent and aggressive therapies and with the advent of newer immunomodulatory agents, the incidence of CNS infectious complications is likely to rise. This chapter will summarize the clinical and diagnostic evaluation of potential infections of the CNS in these patients and will discuss particular pathogens of interest with regard to this at-risk patient population.
Collapse
Affiliation(s)
- Michael J Hoffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron St. Feinberg 16-738, Chicago, IL, 60605, USA,
| | | |
Collapse
|
24
|
Cohen BA, Stosor V. Opportunistic Infections of the Central Nervous System in the Transplant Patient. Curr Neurol Neurosci Rep 2013; 13:376. [DOI: 10.1007/s11910-013-0376-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
25
|
JC polyomavirus (JCV) and monoclonal antibodies: friends or potential foes? Clin Dev Immunol 2013; 2013:967581. [PMID: 23878587 PMCID: PMC3708391 DOI: 10.1155/2013/967581] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 06/13/2013] [Indexed: 12/13/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS), observed in immunodeficient patients and caused by JC virus ((JCV), also called JC polyomavirus (JCPyV)). After the HIV pandemic and the introduction of immunomodulatory therapy, the PML incidence significantly increased. The correlation between the use of natalizumab, a drug used in multiple sclerosis (MS), and the PML development of particular relevance. The high incidence of PML in natalizumab-treated patients has highlighted the importance of two factors: the need of PML risk stratification among natalizumab-treated patients and the need of effective therapeutic options. In this review, we discuss these two needs under the light of the major viral models of PML etiopathogenesis.
Collapse
|
26
|
Hirsch HH, Kardas P, Kranz D, Leboeuf C. The human JC polyomavirus (JCPyV): virological background and clinical implications. APMIS 2013; 121:685-727. [PMID: 23781977 DOI: 10.1111/apm.12128] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/29/2013] [Indexed: 02/06/2023]
Abstract
JC polyomavirus (JCPyV) was the first of now 12 PyVs detected in humans, when in 1964, PyV particles were revealed by electron microscopy in progressive multifocal leukoencephalopathy (PML) tissues. JCPyV infection is common in 35-70% of the general population, and the virus thereafter persists in the renourinary tract. One third of healthy adults asymptomatically shed JCPyV at approximately 50,000 copies/mL urine. PML is rare having an incidence of <0.3 per 100,000 person years in the general population. This increased to 2.4 per 1000 person years in HIV-AIDS patients without combination antiretroviral therapy (cART). Recently, PML emerged in multiple sclerosis patients treated with natalizumab to 2.13 cases per 1000 patients. Natalizumab blocks α4-integrin-dependent lymphocyte homing to the brain suggesting that not the overall cellular immunodeficiency but local failure of brain immune surveillance is a pivotal factor for PML. Recovering JCPyV-specific immune control, e.g., by starting cART or discontinuing natalizumab, significantly improves PML survival, but is challenged by the immune reconstitution inflammatory syndrome. Important steps of PML pathogenesis are undefined, and antiviral therapies are lacking. New clues might come from molecular and functional profiling of JCPyV and PML pathology and comparison with other replicative pathologies such as granule cell neuronopathy and (meningo-)encephalitis, and non-replicative JCPyV pathology possibly contributing to some malignancies. Given the increasing number of immunologically vulnerable patients, a critical reappraisal of JCPyV infection, replication and disease seems warranted.
Collapse
Affiliation(s)
- Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.
| | | | | | | |
Collapse
|
27
|
Nwankwo N, Yeddula K, Vogel J. Progressive neurological deficit in an HIV patient. BMJ Case Rep 2013; 2013:bcr-2013-009985. [PMID: 23771974 DOI: 10.1136/bcr-2013-009985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nwabundo Nwankwo
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA.
| | | | | |
Collapse
|
28
|
A review on JC virus infection in kidney transplant recipients. Clin Dev Immunol 2013; 2013:926391. [PMID: 23424601 PMCID: PMC3569895 DOI: 10.1155/2013/926391] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 01/03/2013] [Accepted: 01/03/2013] [Indexed: 01/28/2023]
Abstract
The polyomavirus (PyV), JC virus (JCV), is a small nonenveloped DNA virus that asymptomatically infects about 80% of healthy adults and establishes latency in the kidney tissue. In case of immunodeficient hosts, JCV can lytically infect the oligodendrocytes, causing a fatal demyelinating disease, known as progressive multifocal leukoencephalopathy (PML). Although the reactivation of another human PyV, BK virus (BKV), is relatively common and its association with the polyomavirus associated nephropathy (PyVAN) following renal transplantation is proven, JCV replication and its impact on graft function and survival are less well studied. Here we describe the biology of JCV and its pathological features and we review the literature regarding the JCV infection analyzed in the setting of transplantations.
Collapse
|
29
|
Greenwald JL, McDermott S, Dighe AS. Case records of the Massachusetts General Hospital. Case 35-2012. A 69-year-old chronically ill man with weakness, anorexia, and diffuse pain. N Engl J Med 2012; 367:1940-8. [PMID: 23150962 DOI: 10.1056/nejmcpc1209437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
30
|
Moal V, Zandotti C, Colson P. Emerging viral diseases in kidney transplant recipients. Rev Med Virol 2012; 23:50-69. [PMID: 23132728 PMCID: PMC7169126 DOI: 10.1002/rmv.1732] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 09/13/2012] [Accepted: 09/20/2012] [Indexed: 12/22/2022]
Abstract
Viruses are the most important cause of infections and a major source of mortality in Kidney Transplant Recipients (KTRs). These patients may acquire viral infections through exogenous routes including community exposure, donor organs, and blood products or by endogenous reactivation of latent viruses. Beside major opportunistic infections due to CMV and EBV and viral hepatitis B and C, several viral diseases have recently emerged in KTRs. New medical practices or technologies, implementation of new diagnostic tools, and improved medical information have contributed to the emergence of these viral diseases in this special population. The purpose of this review is to summarize the current knowledge on emerging viral diseases and newly discovered viruses in KTRs over the last two decades. We identified viruses in the field of KT that had shown the greatest increase in numbers of citations in the NCBI PubMed database. BKV was the most cited in the literature and linked to an emerging disease that represents a great clinical concern in KTRs. HHV-8, PVB19, WNV, JCV, H1N1 influenza virus A, HEV, and GB virus were the main other emerging viruses. Excluding HHV8, newly discovered viruses have been infrequently linked to clinical diseases in KTRs. Nonetheless, pathogenicity can emerge long after the discovery of the causative agent, as has been the case for BKV. Overall, antiviral treatments are very limited, and reducing immunosuppressive therapy remains the cornerstone of management.
Collapse
Affiliation(s)
- Valérie Moal
- Centre de Néphrologie et Transplantation Rénale, APHM, CHU Conception, Marseille, France.
| | | | | |
Collapse
|
31
|
Mateen FJ, Muralidharan R, Carone M, van de Beek D, Harrison DM, Aksamit AJ, Gould MS, Clifford DB, Nath A. Progressive multifocal leukoencephalopathy in transplant recipients. Ann Neurol 2011; 70:305-22. [PMID: 21823157 DOI: 10.1002/ana.22408] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), a rare demyelinating disorder caused by oligodendrocyte destruction by JC virus. METHODS Reports of PML following transplantation were found using PubMed Entrez (1958-July 2010). A multicenter, retrospective cohort study also identified all cases of PML among transplant recipients diagnosed at Mayo Clinic, Johns Hopkins University, Washington University, and Amsterdam Academic Medical Center. At 1 institution, the incidence of posttransplantation PML was calculated. RESULTS A total of 69 cases (44 solid organ, 25 bone marrow) of posttransplantation PML were found including 15 from the 4 medical centers and another 54 from the literature. The median time to development of first symptoms of PML following transplantation was longer in solid organ vs bone marrow recipients (27 vs 11 months, p = 0.0005, range of <1 to >240). Median survival following symptom onset was 6.4 months in solid organ vs 19.5 months in bone marrow recipients (p = 0.068). Case fatality was 84% (95% confidence interval [CI], 70.3-92.4%) and survival beyond 1 year was 55.7% (95% CI, 41.2-67.2%). The incidence of PML among heart and/or lung transplant recipients at 1 institution was 1.24 per 1,000 posttransplantation person-years (95% CI, 0.25-3.61). No clear association was found with any 1 immunosuppressant agent. No treatment provided demonstrable therapeutic benefit. INTERPRETATION The risk of PML exists throughout the posttransplantation period. Bone marrow recipients survive longer than solid organ recipients but may have a lower median time to first symptoms of PML. Posttransplantation PML has a higher case fatality and may have a higher incidence than reported in human immunodeficiency virus (HIV) patients on highly-active antiretroviral therapy (HAART) or multiple sclerosis patients treated with natalizumab.
Collapse
Affiliation(s)
- Farrah J Mateen
- Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Natalizumab is an α4-integrin antagonist approved as monotherapy for patients with relapsing multiple sclerosis (MS), based on demonstrated efficacy in the pivotal AFFIRM study (N = 942). Natalizumab monotherapy reduced risk of disability progression by 42%–54% and annualized relapse rate by 68% during a period of 2 years. Natalizumab was also associated with significant reductions in number of T2-hyperintense, gadolinium-enhancing, and T1-hypointense lesions and in volume of T2-hyperintense lesions (all p < 0.001) on magnetic resonance imaging. Furthermore, natalizumab-treated patients in AFFIRM experienced significant improvements from baseline in the physical and mental components of the Short Form-36 (p ≤ 0.01) and a 35% reduction in risk of clinically significant vision loss (p = 0.008 vs placebo). Natalizumab was well tolerated in phase 3 studies. Common adverse events were generally mild and included headache, fatigue, urinary tract infections, and arthralgia. Serious adverse events were similar between treatment groups. The incidence of serious hypersensitivity reactions associated with natalizumab was <1%. Progressive multifocal leukoencephalopathy was a rare complication of treatment, observed in 2 patients with MS who received natalizumab plus interferon β-1a. The robust clinical benefits of natalizumab, including benefits on patient-reported quality of life, make it an important addition to disease-modifying therapies available to patients with relapsing MS.
Collapse
|
33
|
Weber SC, Uhlenberg B, Raile K, Querfeld U, Müller D. Polyoma virus-associated progressive multifocal leukoencephalopathy after renal transplantation: regression following withdrawal of mycophenolate mofetil. Pediatr Transplant 2011; 15:E19-24. [PMID: 20880091 DOI: 10.1111/j.1399-3046.2010.01368.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The 2008-released FDA safety report described a potential association between use of MMF and progressive multifocal leukoencephalopathy. We here report the case of an 11-yr-old kidney transplanted boy suffering from PML who showed rapid improvement parallel to withdrawal of MMF. This case contributes to the increasing knowledge on side effects of MMF treatment in children.
Collapse
Affiliation(s)
- Sven C Weber
- Department of Pediatric Nephrology, Charité, Universitätsmedizin, Berlin, Germany.
| | | | | | | | | |
Collapse
|
34
|
|
35
|
Warnke C, Menge T, Hartung HP, Racke MK, Cravens PD, Bennett JL, Frohman EM, Greenberg BM, Zamvil SS, Gold R, Hemmer B, Kieseier BC, Stüve O. Natalizumab and progressive multifocal leukoencephalopathy: what are the causal factors and can it be avoided? ACTA ACUST UNITED AC 2010; 67:923-30. [PMID: 20697042 DOI: 10.1001/archneurol.2010.161] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Natalizumab (Tysabri) was the first monoclonal antibody approved for the treatment of relapsing forms of multiple sclerosis (MS). After its initial approval, 3 patients undergoing natalizumab therapy in combination with other immunoregulatory and immunosuppressive agents were diagnosed with progressive multifocal leukoencephalopathy (PML). The agent was later reapproved and its use restricted to monotherapy in patients with relapsing forms of MS. Since reapproval in 2006, additional cases of PML were reported in patients with MS receiving natalizumab monotherapy. Thus, there is currently no convincing evidence that natalizumab-associated PML is restricted to combination therapy with other disease-modifying or immunosuppressive agents. In addition, recent data indicate that risk of PML might increase beyond 24 months of treatment.
Collapse
Affiliation(s)
- Clemens Warnke
- Neurology Section, VA North Texas Health Care System, Medical Service, 4500 S Lancaster Rd, Dallas, TX 75216, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Brinkert F, Briem-Richter A, Ilchmann C, Kemper MJ, Ganschow R. Prevalence of polyomavirus viruria (JC virus/BK virus) in children following liver transplantation. Pediatr Transplant 2010; 14:105-8. [PMID: 19254269 DOI: 10.1111/j.1399-3046.2009.01139.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BKV infection is a potential cause of renal dysfunction in non-renal organ transplant recipients. JCV is the causative agent of PML. Furthermore, polyomaviruses are tumor inducing viruses and molecular data suggest an association with malignancies among solid organ transplant patients. So far, there are no studies analyzing polyomavirus viruria following Ltx in children. We performed a prospective prevalence study at a mean of 2187 (range 20-5671) days after transplantation in 100 consecutive children admitted for the routine follow-up examination post-Ltx. The urine was screened for BKV and JCV DNA by using PCR in each case. A plasma analysis by PCR was also done if more than 100,000 DNA copies/mL urine were detected. BKV or JCV viruria was found in 19% (n = 19) of our patients. All patients were free of clinical signs of viral infection, PML, or nephropathy. GFR was normal in 97% of patients and we found no statistical difference of kidney function between patients with and without BKV/JCV viruria. The extent of immunosuppressive therapy had no influence on the polyomavirus viruria. Overall, we found a higher prevalence of polyomavirus viruria in our pediatric liver transplant recipients than reported in adult patients.
Collapse
Affiliation(s)
- Florian Brinkert
- Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | | | | | | |
Collapse
|
37
|
|
38
|
Boothpur R, Brennan DC. Human polyoma viruses and disease with emphasis on clinical BK and JC. J Clin Virol 2010; 47:306-12. [PMID: 20060360 DOI: 10.1016/j.jcv.2009.12.006] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 12/04/2009] [Accepted: 12/08/2009] [Indexed: 12/16/2022]
Abstract
Polyoma viruses are ubiquitous infecting many different mammalian species including humans. There are five known human polyoma viruses. JC virus and BK virus are two polyoma viruses identified nearly three decades ago. Recently WU, KI and Merkel cell polyoma viruses have been isolated from humans. The exact role of these three newly discovered viruses in human disease is not known. Most human polyoma disease is caused by BK and JC viruses which are usually acquired in childhood. Approximately 50-80% of humans have seropositivity to these viruses. Clinically apparent diseases in immunocompetent hosts are extremely rare. These viruses remain latent possibly in the lymphoid organs, neuronal tissue, and kidney and under the circumstances of severe immunosuppression both these viruses reactivate. Neurotropic JC virus reaches the brain and causes progressive multifocal leukoencephalopathy, a demyelinating disease of the central nervous system with a high mortality rate. BK virus is urotheliotropic and its reactivation causes a form of interstitial nephritis, known as BK or polyoma virus associated nephropathy which is associated with high graft loss if not recognized early. There are no known effective antiviral agents for any of the polyoma viruses.
Collapse
|
39
|
Chihara D, Takeoka T, Shirase T, Kishimoto W, Arimoto-Miyamoto K, Tsuji M, Ohno T. Progressive multifocal leukoencephalopathy in myelodysplastic syndrome involving pure red cell aplasia. Intern Med 2010; 49:2347-52. [PMID: 21048373 DOI: 10.2169/internalmedicine.49.4081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare and fatal demyelinating disease of the central nervous system caused by JC polyomavirus (JCV) reactivation in an immunocompromised host. We describe a case of PML in a 76-year-old woman with myelodysplastic syndrome, who had been treated with azathioprine for a pure red cell aplasia-like condition. PML was diagnosed based on the neurologic symptoms, the magnetic resonance imaging patterns and the detection of JCV DNA in the cerebrospinal fluid. She died ten months after the diagnosis. An autopsy confirmed the diagnosis, and JCV DNA was detected in the cerebrum. Azathioprine might have triggered PML.
Collapse
Affiliation(s)
- Dai Chihara
- Division of Hematology and Immunology, Department of Internal Medicine, Ohtsu Red Cross Hospital, Ohtsu
| | | | | | | | | | | | | |
Collapse
|
40
|
Affiliation(s)
- H H Hirsch
- Transplantation Virology, Department of Biomedicine, Institute for Medical Microbiology, University of Basel, Basel, Switzerland.
| | | | | |
Collapse
|
41
|
Coyle PK, Foley JF, Fox EJ, Jeffery DR, Munschauer FE, Tornatore C. Best practice recommendations for the selection and management of patients with multiple sclerosis receiving natalizumab therapy. Mult Scler 2009. [DOI: 10.1177/1352458509347131] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Natalizumab, a humanized monoclonal antibody directed against α4-integrin is a first-in-class disease-modifying therapy for the treatment of relapsing multiple sclerosis. Natalizumab is highly effective but has been associated with a risk of progressive multifocal leukoencephalopathy. Since the efficacy of natalizumab in relapsing forms of multiple sclerosis is viewed as superior to first-line agents, a growing number of neurologists are using natalizumab as the treatment of choice for patients with worsening MS. Owing to the recently reported cases of progressive multifocal leukoencephalopathy, a panel of neurologists met in February 2009 to discuss best practices for the use of natalizumab, with the goal of developing consensus-based recommendations on patient management to minimize the risk of progressive multifocal leukoencephalopathy. The panel consisted of a cross section of academic and community neurologists from the United States who treat multiple sclerosis in large centers and have extensive experience with natalizumab (approximating 2000 patient-years combined experience). This paper summarizes the panel's recommendations on the following: (1) appropriate patient selection for natalizumab; (2) routine monitoring and management of adverse events during natalizumab therapy; and (3) clinical vigilance monitoring and risk reduction for progressive multifocal leukoencephalopathy.
Collapse
Affiliation(s)
- Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center and Stony Brook MS Comprehensive Care Center, Stony Brook, NY, USA
| | - John F Foley
- Rocky Mountain MS Clinic, Rocky Mountain Neurological Associates, Salt Lake City, UT, USA
| | - Edward J Fox
- MS Clinic of Central Texas and University of Texas Medical Branch, Central Texas Neurology Consultants, Round Rock, TX, USA
| | - Douglas R Jeffery
- Department of Neurology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA
| | - Frederick E Munschauer
- Department of Neurology, The Jacobs Neurological Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Carlo Tornatore
- Department of Neurology, Multiple Sclerosis Center, Georgetown University Medical Center, Washington, DC, USA
| |
Collapse
|
42
|
Epker JL, van Biezen P, van Daele PLA, van Gelder T, Vossen A, van Saase JLCM. Progressive multifocal leukoencephalopathy, a review and an extended report of five patients with different immune compromised states. Eur J Intern Med 2009; 20:261-7. [PMID: 19393493 DOI: 10.1016/j.ejim.2008.07.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 05/19/2008] [Accepted: 07/07/2008] [Indexed: 10/21/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the brain caused by the JC-virus. Both a decreased cellular or humoral immune response can increase the susceptibility for JC-virus induced PML. Not only HIV infected people are at risk, a wide range of otherwise immune compromised patients are a potential target for this virus. This report of five PML patients shows the importance of a clinician's familiarity with this disease and it's presenting symptoms. The presenting symptoms of PML can sometimes mimic worsening of the underlying disease. Although different therapeutic strategies have been tried, the outcomes remain very poor. In this series, treatment with cidofovir appears not to be effective in treating PML, neither in HIV positive nor HIV negative patients. Experimental therapy with leflunomide, after tapering of the immunosuppressive medication, did change the natural course of PML in one patient.
Collapse
Affiliation(s)
- Jelle L Epker
- Erasmus Medical Centre, Department of Intensive Care Medicine, The Netherlands.
| | | | | | | | | | | |
Collapse
|
43
|
Manfro R, Vedolin L, Cantarelli M, Oppitz P, Antunes A, Rieder C. Progressive multifocal leukoencephalopathy in a kidney transplant recipient after conversion to mycophenolic acid therapy. Transpl Infect Dis 2009; 11:189-90. [DOI: 10.1111/j.1399-3062.2009.00368.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
44
|
Khatri BO, Man S, Giovannoni G, Koo AP, Lee JC, Tucky B, Lynn F, Jurgensen S, Woodworth J, Goelz S, Duda PW, Panzara MA, Ransohoff RM, Fox RJ. Effect of plasma exchange in accelerating natalizumab clearance and restoring leukocyte function. Neurology 2009; 72:402-9. [PMID: 19188571 DOI: 10.1212/01.wnl.0000341766.59028.9d] [Citation(s) in RCA: 224] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Accelerating the clearance of therapeutic monoclonal antibodies (mAbs) from the body may be useful to address uncommon but serious complications from treatment, such as progressive multifocal leukoencephalopathy (PML). Treatment of PML requires immune reconstitution. Plasma exchange (PLEX) may accelerate mAb clearance, restoring the function of inhibited proteins and increasing the number or function of leukocytes entering the CNS. We evaluated the efficacy of PLEX in accelerating natalizumab (a therapy for multiple sclerosis [MS] and Crohn disease) clearance and alpha4-integrin desaturation. Restoration of leukocyte transmigratory capacity was evaluated using an in vitro blood-brain barrier (ivBBB). METHODS Twelve patients with MS receiving natalizumab underwent three 1.5-volume PLEX sessions over 5 or 8 days. Natalizumab concentrations and alpha4-integrin saturation were assessed daily throughout PLEX and three times over the subsequent 2 weeks, comparing results with the same patients the previous month. Peripheral blood mononuclear cell (PBMC) migration (induced by the chemokine CCL2) across an ivBBB was assessed in a subset of six patients with and without PLEX. RESULTS Serum natalizumab concentrations were reduced by a mean of 92% from baseline to 1 week after three PLEX sessions (p < 0.001). Although average alpha4-integrin saturation was not reduced after PLEX, it was reduced to less than 50% when natalizumab concentrations were below 1 mug/mL. PBMC transmigratory capacity increased 2.2-fold after PLEX (p < 0.006). CONCLUSIONS Plasma exchange (PLEX) accelerated clearance of natalizumab, and at natalizumab concentrations below 1 mug/mL, desaturation of alpha4-integrin was observed. Also, CCL2-induced leukocyte transmigration across an in vitro blood-brain barrier was increased after PLEX. Therefore, PLEX may be effective in restoring immune effector function in natalizumab-treated patients.
Collapse
Affiliation(s)
- B O Khatri
- Regional Multiple Sclerosis Center and Center for Neurological Disorders, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Identification and characterization of mefloquine efficacy against JC virus in vitro. Antimicrob Agents Chemother 2009; 53:1840-9. [PMID: 19258267 DOI: 10.1128/aac.01614-08] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare but frequently fatal disease caused by the uncontrolled replication of JC virus (JCV), a polyomavirus, in the brains of some immunocompromised individuals. Currently, no effective antiviral treatment for this disease has been identified. As a first step in the identification of such therapy, we screened the Spectrum collection of 2,000 approved drugs and biologically active molecules for their anti-JCV activities in an in vitro infection assay. We identified a number of different drugs and compounds that had significant anti-JCV activities at micromolar concentrations and lacked cellular toxicity. Of the compounds with anti-JCV activities, only mefloquine, an antimalarial agent, has been reported to show sufficiently high penetration into the central nervous system such that it would be predicted to achieve efficacious concentrations in the brain. Additional in vitro experiments demonstrated that mefloquine inhibits the viral infection rates of three different JCV isolates, JCV(Mad1), JCV(Mad4), and JCV(M1/SVEDelta), and does so in three different cell types, transformed human glial (SVG-A) cells, primary human fetal glial cells, and primary human astrocytes. Using quantitative PCR to quantify the number of viral copies in cultured cells, we have also shown that mefloquine inhibits viral DNA replication. Finally, we demonstrated that mefloquine does not block viral cell entry; rather, it inhibits viral replication in cells after viral entry. Although no suitable animal model of PML or JCV infection is available for the testing of mefloquine in vivo, our in vitro results, combined with biodistribution data published in the literature, suggest that mefloquine could be an effective therapy for PML.
Collapse
|
46
|
Abstract
Natalizumab reduced the rate of clinical relapse at one year by 68% and the risk of sustained progression of disability by 42-54% over 2 years in its pivotal phase III trial (AFFIRM) in relapsing-remitting multiple sclerosis (RRMS). Natalizumab is generally well tolerated, but due to rare and potentially fatal side-effects, it was approved with a restricted-distribution format in 2006. Expert statements and the European Medical Agency recommend the use of natalizumab after failure of first-line disease-modifying therapies in patients with relapsing forms of MS. As part of the risk management plan, worldwide extensive safety programmes aim to provide more data on natalizumab safety in clinical practice. At the end of September 2008, 48 000 patients have received natalizumab and 18000 patients are on treatment for at least 1 year. The assessment of risk and benefit is still ongoing.
Collapse
Affiliation(s)
| | - Norman Putzki
- Cantonal Hospital, St. Gallen, Switzerland and Department of Neurology,
University Clinic Duisburg-Essen, Germany
| |
Collapse
|
47
|
JC virus-specific immune responses in human immunodeficiency virus type 1 patients with progressive multifocal leukoencephalopathy. J Virol 2009; 83:4404-11. [PMID: 19211737 DOI: 10.1128/jvi.02657-08] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a frequently fatal disease caused by uncontrolled polyomavirus JC (JCV) in severely immunodeficient patients. We investigated the JCV-specific cellular and humoral immunity in the Swiss HIV Cohort Study. We identified PML cases (n = 29), as well as three matched controls per case (n = 87), with prospectively cryopreserved peripheral blood mononuclear cells and plasma at diagnosis. Nested controls were matched according to age, gender, CD4(+) T-cell count, and decline. Survivors (n = 18) were defined as being alive for >1 year after diagnosis. Using gamma interferon enzyme-linked immunospot assays, we found that JCV-specific T-cell responses were lower in nonsurvivors than in their matched controls (P = 0.08), which was highly significant for laboratory- and histologically confirmed PML cases (P = 0.004). No difference was found between PML survivors and controls or for cytomegalovirus-specific T-cell responses. PML survivors showed significant increases in JCV-specific T cells (P = 0.04) and immunoglobulin G (IgG) responses (P = 0.005). IgG responses in survivors were positively correlated with CD4(+) T-cell counts (P = 0.049) and negatively with human immunodeficiency virus RNA loads (P = 0.03). We conclude that PML nonsurvivors had selectively impaired JCV-specific T-cell responses compared to CD4(+) T-cell-matched controls and failed to mount JCV-specific antibody responses. JCV-specific T-cell and IgG responses may serve as prognostic markers for patients at risk.
Collapse
|
48
|
Neff RT, Hurst FP, Falta EM, Bohen EM, Lentine KL, Dharnidharka VR, Agodoa LY, Jindal RM, Yuan CM, Abbott KC. Progressive Multifocal Leukoencephalopathy and Use of Mycophenolate Mofetil After Kidney Transplantation. Transplantation 2008; 86:1474-8. [DOI: 10.1097/tp.0b013e31818b62c8] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
49
|
Chakravarty EF. Viral infection and reactivation in autoimmune disease. ACTA ACUST UNITED AC 2008; 58:2949-57. [DOI: 10.1002/art.23883] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
50
|
|