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Anada M, Tohyama M, Oda Y, Kamoshima Y, Amino I, Nakano F, Miyazaki Y, Akimoto S, Minami N, Kikuchi S, Terae S, Niino M. Progressive Multifocal Leukoencephalopathy during Tocilizumab Treatment for Rheumatoid Arthritis. Intern Med 2020; 59:2053-2059. [PMID: 32448834 PMCID: PMC7492111 DOI: 10.2169/internalmedicine.4431-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 61-year-old woman was diagnosed with rheumatoid arthritis 12 years ago and received multiple treatment regimens before achieving symptomatic stability with methotrexate plus tocilizumab, a humanized monoclonal antibody against the IL-6 receptor, about 2 years prior to the current presentation. Sixteen months after tocilizumab initiation, she exhibited dysarthria and disorientation; five months later, she was hospitalized with movement difficulties. Her neurological symptoms deteriorated thereafter, accompanied by enlarged cerebral white matter lesions on magnetic resonance imaging. A biopsy of the right frontal lesion confirmed progressive multifocal leukoencephalopathy (PML). While several therapeutic monoclonal antibodies have been linked to PML, this is the first case associated with tocilizumab.
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Affiliation(s)
- Mamiko Anada
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | | | - Yoshitaka Oda
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Japan
| | - Yuuta Kamoshima
- Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital, Japan
| | - Itaru Amino
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Fumihito Nakano
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Yusei Miyazaki
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Sachiko Akimoto
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Seiji Kikuchi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Satoshi Terae
- Department of Diagnostic Radiology, Sapporo City General Hospital, Japan
| | - Masaaki Niino
- Department of Clinical Research, National Hospital Organization Hokkaido Medical Center, Japan
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T cell deficiencies as a common risk factor for drug associated progressive multifocal leukoencephalopathy. Immunobiology 2018; 223:508-517. [PMID: 29472141 DOI: 10.1016/j.imbio.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/19/2018] [Accepted: 01/21/2018] [Indexed: 01/07/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a disease of the central nervous system caused by neuropathogenic prototypes of ubiquitous community-acquired JC virus (JCV). The disease became of particular concern following its association with certain therapies that modulate immune system function without heavy immunosuppression. Due to lack of prophylactic/treatment options and poor outcomes, which often include severe disability or death, PML is a considerable concern for development of new drugs that interfere with immune system functions. In this review of clinical and research findings, we discuss the evidence that deficiencies in CD4+ T helper cells, cytotoxic CD8+ T cells, and interferon gamma are of crucial importance for development of PML under a variety of circumstances, including those associated with use of various drugs, regardless of differences in their mechanisms of action. These deficiencies apparently enable transformation of the harmless JCV archetype into neuropathogenic prototypes, but the site(s), and the mechanisms, of this transformation are yet to be elucidated. Here we discuss the evidence for brain as one of the sites of this transformation, and propose a model of PML pathogenesis that emphasizes the central role of T cell deficiencies in the two life cycles of the JCV, one non-pathogenic and one neuropathogenic. Finally, we conclude that the development of clinical grade T cell functional tests and more consistent use of already available laboratory tests for T cell subset analysis would greatly aid the effort to more accurately predict and assess the magnitude of PML risk for concerned therapeutic interventions.
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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.
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Henegar CE, Eudy AM, Kharat V, Hill DD, Bennett D, Haight B. Progressive multifocal leukoencephalopathy in patients with systemic lupus erythematosus: a systematic literature review. Lupus 2016; 25:617-26. [PMID: 26743322 DOI: 10.1177/0961203315622819] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/24/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine risk factors for progressive multifocal leukoencephalopathy (PML) in systemic lupus erythematosus (SLE) patients, and understand how underlying disease or treatment for SLE may be associated with PML in this population. METHODS Studies published in English between January 1, 1984 and October 31, 2014 that reported PML in adult SLE patients were included. Immunosuppression was defined as exposure to ≥1 immunosuppressant drug of interest at PML diagnosis: belimumab, rituximab, mycophenolate mofetil, azathioprine, cyclophosphamide, methotrexate and high-dose corticosteroids (>15 mg/day). Minimal immunosuppression was defined as low-dose corticosteroids (≤15 mg/day) and/or anti-malarials. RESULTS Thirty-five publications met our inclusion criteria: four observational studies, two large case series, and 29 case reports that described 35 cases. Reported PML incidence rates among SLE patients based on observational studies ranged from 1.0 to 2.4 cases/100,000 person-years. Of the 35 case reports, three cases were exposed to no immunosuppressant drugs at PML diagnosis, five cases had minimal immunosuppression, 23 cases had immunosuppression, and four cases were indeterminate. CONCLUSIONS The evidence from this literature review suggests that, while PML is a very rare disease in SLE patients, there does appear to be an increased risk of PML associated with SLE compared to the general population, potentially due to immunosuppression, other contributing factors in their underlying disease, treatments prescribed to manage disease, or some combination of these factors. Additional large observational studies, designed to assess exposure to drugs of interest and complicated treatment histories, are needed to provide further evidence about potential mechanisms contributing to the onset of PML in SLE patients.
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Affiliation(s)
- C E Henegar
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - A M Eudy
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - V Kharat
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D D Hill
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D Bennett
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - B Haight
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Research Triangle Park, USA
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Caza T, Oaks Z, Perl A. Interplay of Infections, Autoimmunity, and Immunosuppression in Systemic Lupus Erythematosus. Int Rev Immunol 2014; 33:330-63. [DOI: 10.3109/08830185.2013.863305] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nardis C, Anzivino E, Bellizzi A, Rodio DM, De Pità O, Chiarini F, Pietropaolo V. Reactivation of human polyomavirus JC in patients affected by psoriasis vulgaris and psoriatic arthritis and treated with biological drugs: Preliminary results. J Cell Physiol 2012; 227:3796-802. [DOI: 10.1002/jcp.24089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Palazzo E, Yahia SA. Progressive multifocal leukoencephalopathy in autoimmune diseases. Joint Bone Spine 2012; 79:351-5. [DOI: 10.1016/j.jbspin.2011.11.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2011] [Indexed: 02/08/2023]
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Pavlovic AM, Bonaci-Nikolic B, Kozic D, Ostojic J, Abinun M, Svabic-Medjedovic T, Nikolic M, Sternic N. Progressive multifocal leukoencephalopathy associated with mycophenolate mofetil treatment in a woman with lupus and CD4+ T-lymphocyte deficiency. Lupus 2011; 21:100-2. [DOI: 10.1177/0961203311416693] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is an increase in the number of patients with systemic lupus erythematosus (SLE) reported as developing progressive multifocal leukoencephalopathy (PML) while on intensive immunosuppressive therapy. A 39-year-old HIV-negative woman with a 10-year history of SLE presented with progressive left-side weakness while on maintenance therapy with oral prednisone and mycophenolate mofetil (MMF). On several occasions low CD4+ T-lymphocyte counts were found (68/µL). Brain magnetic resonance imaging (MRI) revealed a large lesion in the right subcortical fronto-parietal region and a smaller one in the left frontal subcortex, corresponding to the PML. In cerebrospinal fluid, polymerase chain reaction (PCR) for JC virus (JCV) was negative, but anti-JCV antibodies were highly positive. Diagnosis of probable PML was made and MMF was withdrawn. The patient's condition improved with marked reduction of left-side weakness and an increase in CD4+ T-lymphocyte count (141/µL). Follow-up MRI showed regression of lesions and over the next 6 months the patient remained stable. In spite of the grave prognosis associated with PML, SLE patients can have an excellent outcome if immunosuppressants are discontinued as soon as the correct diagnosis is made. SLE patients with associated low CD4+ T-lymphocyte counts should be monitored for the development of PML during immunosuppressive therapy in particular.
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Affiliation(s)
- AM Pavlovic
- Clinic for Neurology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - B Bonaci-Nikolic
- Clinic for Allergy and Clinical Immunology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - D Kozic
- Oncology Institute of Vojvodina Sremska Kamenica, Diagnostic Imaging Centre, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - J Ostojic
- Oncology Institute of Vojvodina Sremska Kamenica, Diagnostic Imaging Centre, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - M Abinun
- Department of Paediatric Immunology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - T Svabic-Medjedovic
- Clinic for Neurology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - M Nikolic
- Clinic for Dermatovenereology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - N Sternic
- Clinic for Neurology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Kumar D, Bouldin TW, Berger RG. A case of progressive multifocal leukoencephalopathy in a patient treated with infliximab. ARTHRITIS AND RHEUMATISM 2010; 62:3191-3195. [PMID: 20722036 DOI: 10.1002/art.27687] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We describe a 72-year-old white man with erosive rheumatoid arthritis in whom subacute neurologic and psychiatric symptoms developed after 3 years of treatment with infliximab, prednisone, and methotrexate. White matter demyelination was seen on magnetic resonance imaging of the brain, and progressive multifocal leukoencephalopathy (PML) was ultimately confirmed by brain biopsy. The patient was treated with supportive therapy and discontinuation of disease-modifying antirheumatic drugs, resulting in stabilization of the disease process. The patient survived, but neurologic and cognitive deficits persisted. The distribution and pathology of this patient's disease are unique from almost all reported incidents of oral methotrexate-associated leukoencephalopathy. The pathogenesis of disease may be linked to a T cell-mediated process that is potentially impacted by infliximab. This case provides the first reported evidence that PML can be seen in association with infliximab therapy.
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Affiliation(s)
- Deepak Kumar
- University of North Carolina at Chapel Hill, Chapel Hill, NC 27517, USA
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[Progressive multifocal leukoencephalopathy. Undesirable side effect of immunotherapy]. DER NERVENARZT 2010; 80:1143-4, 1146-8, 1150-3. [PMID: 19357826 DOI: 10.1007/s00115-009-2701-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
As new cases arise of progressive multifocal leukoencephalopathy (PML) in patients with multiple sclerosis (MS) treated with the monoclonal antibody natalizumab, a critical discussion about risks and advantages of this specific kind of immunotherapy appears necessary. Practical consequences and treatment options are addressed based on current concepts of PML's pathogenesis in patients treated with natalizumab. Critical patient selection based on risk:benefit considerations, limited therapy regimens, early diagnosis of PML by clinical and paraclinical criteria, and therapeutic perspectives for treating PML are discussed. The risk of PML in patients with MS needs to be continually monitored and should be reduced with all means available to ensure optimal outcome.
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Lefèvre G, Queyrel V, Maurage CA, Laurent C, Launay D, Lacour A, Charlanne H, Morell-Dubois S, Lambert M, Maillard H, Vermersch P, Hachulla E, Hatron PY. Effective immune restoration after immunosuppressant discontinuation in a lupus patient presenting progressive multifocal leukoencephalopathy. J Neurol Sci 2009; 287:246-9. [DOI: 10.1016/j.jns.2009.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 09/09/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
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