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Rischall A, Olson A. SOHO State of the Art Updates and Next Questions | CTLs for Infections Following Stem Cell Transplantation. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:340-347. [PMID: 38267354 DOI: 10.1016/j.clml.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/26/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (AHSCT) is an important modality in the treatment of acute leukemia and other hematologic disorders. The post-transplant period is associated with prolonged periods of impaired immune function. Delayed T-cell immune reconstitution is correlated with increased risk of viral, bacterial, and fungal infections. This risk increases with high intensity inductions regimens often required for alternative donor sources. Current therapies for prophylaxis and treatment of these infections are limited by poor efficacy and significant toxicity. Adoptive cell therapy with cytotoxic T lymphocytes (CTL) has proven to be both efficacious and safe in the management of post-transplant viral infections. Recent advances have led to faster production of CTLs and broadened applications for their use. In particular, the generation of third party CTLs has helped ameliorate the problems related to donor availability and product generation time. In this review we aim to describe both the history of CTL use and current advances in the field.
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Affiliation(s)
- Ariel Rischall
- Department of Medical Oncology, The University of Texas Medical Branch, Galveston, TX
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX.
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2
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Brown JD, Muston BT, Massey J. Switching from natalizumab to an anti-CD20 monoclonal antibody in relapsing remitting multiple sclerosis: A systematic review. Mult Scler Relat Disord 2024; 86:105605. [PMID: 38640586 DOI: 10.1016/j.msard.2024.105605] [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] [Received: 11/22/2023] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Use of natalizumab (NTZ) is precluded in many Multiple Sclerosis (MS) patients by the risk of progressive multifocal leukoencephalopathy (PML). Regardless, some patients may commence natalizumab for short term disease control in spite of being seropositive, and others may seroconvert whilst on treatment. In these circumstances, discontinuation of NTZ should not occur until a clear exit strategy is established to prevent post-NTZ disease reactivation, which often exceeds the severity of disease activity prior to NTZ treatment. The objective of this systematic review was to summarise the available evidence for CD20-monoclonal antibodies (CD20mAb) as a suitable NTZ exit strategy, and to identify whether a superior switch protocol can be established. METHODS In accordance with PRISMA guidelines, a total of 2393 references were extracted from a search of three online databases (PubMed, Scopus, MEDLINE). Following the application of inclusion/exclusion criteria, a total of 5 studies representing 331 patients were included. RESULTS The overall incidence of clinical relapse during washout periods ranging from 4.4-10.7 weeks was 0 %. The incidence of clinical relapse during two-year follow-up ranged from 1.8 % to 10 % for switches to all types of CD20 monoclonal antibody. The weighted mean for clinical relapse at 12 months was 8.8 %. Three studies reported an annualised relapse rate (ARR) ranging from 0.02-0.12 with a weighted mean ARR of 0.07. The overall incidence of PML during washout was 0 % and the overall incidence of PML within 6 months follow-up was 0.6 %. CONCLUSIONS This systematic review provides the first attempt at identifying a superior switch protocol in patients at risk of PML transitioning from NTZ to a CD20mAb. Our results indicate that CD20mAb's are a suitable transitional option for patients who discontinue NTZ, with our cohort demonstrating very low rates of carryover PML and low rates of clinical relapse. The most appropriate washout period is unclear due to confounding factors but is likely between 4 and 12 weeks.
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Affiliation(s)
| | - Benjamin T Muston
- Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; The Collaborative Research Group (CORE), Sydney, Australia
| | - Jennifer Massey
- Faculty of Medicine and Health, University of New South Wales, Sydney, Australia; Neurology Department, St Vincent's Hospital Sydney, Australia
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Arvanitis P, Farmakiotis D, Pelcovits A. Progressive Multifocal Leukoencephalopathy Unmasked by Teclistamab in a Refractory Multiple Myeloma Patient. Curr Oncol 2024; 31:2670-2678. [PMID: 38785483 PMCID: PMC11119787 DOI: 10.3390/curroncol31050202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/04/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
This case report describes the development of Progressive Multifocal Leukoencephalopathy (PML) in a 72-year-old male with relapsed/refractory multiple myeloma (RRMM), following a single dose of teclistamab amidst a COVID-19 infection. Shortly after starting teclistamab treatment, the patient developed symptoms, including fever, altered mental status, and right-sided paresis. A diagnosis of PML was confirmed through the detection of JC virus PCR in the cerebrospinal fluid. Our report emphasizes the occurrence of PML after only one dose of teclistamab and highlights teclistamab's potential for severe infectious complications, despite its promise in treating RRMM.
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Affiliation(s)
- Panos Arvanitis
- Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Gerry House 111, Providence, RI 02903, USA
| | - Dimitrios Farmakiotis
- Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Gerry House 111, Providence, RI 02903, USA
| | - Ari Pelcovits
- Division of Hematology-Oncology, Rhode Island Hospital, 593 Eddy Street, Gerry House 111, Providence, RI 02903, USA
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Amirifard H, Shahbazi M, Farahmand G, Ranjbar Z, Kaeedi M, Heydari Havadaragh S. Progressive multifocal leukoencephalopathy in a patient with B-cell chronic lymphocytic leukemia after COVID-19 vaccination, complicated with COVID-19 and mucormycosis: a case report. BMC Neurol 2024; 24:151. [PMID: 38704555 PMCID: PMC11069241 DOI: 10.1186/s12883-024-03650-y] [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] [Received: 02/12/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rare and fatal opportunistic viral demyelinating infectious disease of the central nervous system (CNS). There are various clinical presenting symptoms for the disease. CASE PRESENTATION This paper presents a clinical case of PML in a patient with B-Chronic lymphocytic leukemia (B-CLL), previously treated with Chlorambucil, later complicated later with COVID-19 and mucormycosis. CONCLUSION PML can develop in the setting of cellular immune dysfunction. Late diagnosis of this disease based on nonspecific symptoms is common, therefore when we face a neurological complication in a CLL or immunocompromised patient, we should consider PML infection. A remarkable feature of this case is the possible triggering effect of COVID-19 vaccination for emergence of PML as the disease can be asymptomatic or sub-clinical before diagnosis.
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Affiliation(s)
- Hamed Amirifard
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Mojtaba Shahbazi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Ghasem Farahmand
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Ranjbar
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Maryam Kaeedi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Sanaz Heydari Havadaragh
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Neurology, Iranian Center of Neurological Research, Tehran University of medical sciences, Imam Khomeini Hospital Complex, Tehran, Iran.
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5
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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.
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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;
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Alsufayan R, Hess C, Krings T. Monoclonal Antibodies: What the Diagnostic Neuroradiologist Needs to Know. AJNR Am J Neuroradiol 2023; 44:1358-1366. [PMID: 37591772 PMCID: PMC10714862 DOI: 10.3174/ajnr.a7974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023]
Abstract
Monoclonal antibodies have become increasingly popular as novel therapeutics against a variety of diseases due to their specificity, affinity, and serum stability. Due to the nearly infinite repertoire of monoclonal antibodies, their therapeutic use is rapidly expanding, revolutionizing disease course and management, and what is now considered experimental therapy may soon become approved practice. Therefore, it is important for radiologists, neuroradiologists, and neurologists to be aware of these drugs and their possible different imaging-related manifestations, including expected and adverse effects of these novel drugs. Herein, we review the most commonly used monoclonal antibody-targeted therapeutic agents, their mechanism of action, clinical applications, and major adverse events with a focus on neurologic and neurographic effects and discuss differential considerations, to assist in the diagnosis of these conditions.
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Affiliation(s)
- R Alsufayan
- From the Division of Neuroradiology, Department of Medical Imaging (R.A., T.K.), University of Toronto, Toronto Western Hospital, University Health Network and University Medical Imaging, Toronto, Ontario, Canada
- Department of Diagnostic Imaging (R.A.), Peterborough Regional Health Centre, Peterborough, Ontario, Canada
| | - C Hess
- Deartment of Radiology and Biomedical Imaging (C.H.), University of California, San Francisco, San Francisco, California
| | - T Krings
- From the Division of Neuroradiology, Department of Medical Imaging (R.A., T.K.), University of Toronto, Toronto Western Hospital, University Health Network and University Medical Imaging, Toronto, Ontario, Canada
- Division of Neurosurgery (T.K.), Sprott Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Schweitzer F, Laurent S, Cortese I, Fink GR, Silling S, Skripuletz T, Metz I, Wattjes MP, Warnke C. Progressive Multifocal Leukoencephalopathy: Pathogenesis, Diagnostic Tools, and Potential Biomarkers of Response to Therapy. Neurology 2023; 101:700-713. [PMID: 37487750 PMCID: PMC10585672 DOI: 10.1212/wnl.0000000000207622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/19/2023] [Indexed: 07/26/2023] Open
Abstract
JC polyomavirus (JCV) establishes an asymptomatic latent and/or persistent infection in most of the adult population. However, in immunocompromised individuals, JCV can cause a symptomatic infection of the brain, foremost progressive multifocal leukoencephalopathy (PML). In the past 2 decades, there has been increasing concern among patients and the medical community because PML was observed as an adverse event in individuals treated with modern (selective) immune suppressive treatments for various immune-mediated diseases, especially multiple sclerosis. It became evident that this devastating complication also needs to be considered beyond the patient populations historically at risk, including those with hematologic malignancies or HIV-infected individuals. We review the clinical presentation of PML, its variants, pathogenesis, and current diagnostic approaches. We further discuss the need to validate JCV-directed interventions and highlight current management strategies based on early diagnosis and restoring JCV-specific cellular immunity, which is crucial for viral clearance and survival. Finally, we discuss the importance of biomarkers for diagnosis and response to therapy, instrumental in defining sensitive study end points for successful clinical trials of curative or preventive therapeutics. Advances in understanding PML pathophysiology, host and viral genetics, and diagnostics in conjunction with novel immunotherapeutic approaches indicate that the time is right to design and perform definitive trials to develop preventive options and curative therapy for JCV-associated diseases.
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Affiliation(s)
- Finja Schweitzer
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Sarah Laurent
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Irene Cortese
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Gereon R Fink
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Steffi Silling
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Thomas Skripuletz
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Imke Metz
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Mike P Wattjes
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany
| | - Clemens Warnke
- From the Department of Neurology (F.S., S.L., G.R.F., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany; Experimental Immunotherapeutics Unit (I.C.), NIH, Bethesda, MD; Cognitive Neuroscience (G.R.F.), Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich; Institute of Virology (S.S.), National Reference Center for Papilloma- and Polyomaviruses, Faculty of Medicine, University Hospital Cologne; Department of Neurology (T.S.), Hannover Medical School; Institute of Neuropathology (I.M.), University Medical Center Göttingen; and Department of Neuroradiology (M.P.W.), Hannover Medical School, Germany.
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Aye SL, Trivedi Y, Bolgarina Z, Desai HN, Senaratne M, Swami SS, Mohammed L. The Prognosis of Progressive Multifocal Leukoencephalopathy in HIV/AIDS Patients Undergoing Highly Active Antiretroviral Treatment: A Systematic Review. Cureus 2023; 15:e45155. [PMID: 37842471 PMCID: PMC10575567 DOI: 10.7759/cureus.45155] [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: 07/26/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML), a viral infection of the central nervous system (CNS), is most commonly associated with advanced HIV infection. Although the severe neurological conditions - PML and progressive multifocal leukoencephalopathy immune reconstitution inflammatory syndrome (PML-IRIS) - are linked to HIV, little is known about their characteristics in the era of established antiretroviral therapy (ART). The aim of this systematic review, which was performed by adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, was to determine the prognosis of PML in patients with HIV. We gathered and examined articles, including case-control and cohort studies, systematic reviews, and meta-analyses that were published between January 1, 2013, and May 2023. These articles were compiled from the following databases: Pubmed, Pubmed Central, Google Scholar, Wiley Library, and ScienceDirect. A total of 519 records were found from these databases for our systematic review after applying the proper filters. They were then further screened and put through quality appraisal tools, which ultimately led to the selection of 10 articles for the final analysis. This research offers crucial insights into the clinical consequences of PML in HIV patients receiving highly active antiretroviral therapy (HAART).
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Affiliation(s)
- Soe Lwin Aye
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Yash Trivedi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zoryana Bolgarina
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Heet N Desai
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mithum Senaratne
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Shivling S Swami
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Paolucci M, Gentile L, Gentile M, Borghi A, Merli E, Marchionni E, Guerra L, Galluzzo S, Cilloni N, Simonetti L, Zini A. Progressive multifocal leukoencephalopathy in multiple myeloma: a case report of a patient with SARS-CoV-2 infection and an updated systematic literature review. Neurol Sci 2023; 44:2995-2998. [PMID: 37421487 DOI: 10.1007/s10072-023-06944-0] [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] [Received: 03/23/2023] [Accepted: 07/04/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a reactivation of the human polyomavirus 2 (HPyV-2, previously known as JCV) in immunosuppressed individuals. Few cases of PML have been described in multiple myeloma (MM) patients. METHODS We described a case of PML in a patient with MM with fatal worsening that occurred during SARS-CoV-2 infection. We also performed a literature review to update the 16 cases series of MM patients with PML already collected until April 2020. RESULTS A 79-year-old female patient with refractory IgA lambda MM in Pomalidomide- Cyclophosphamide-Dexamethasone regimen developed gradual lower limbs and left arm paresis along with a decreased consciousness 3.5 years after the MM diagnosis. Symptoms developed shortly after the recognition of hypogammaglobulinemia. After SARS-CoV-2 infection, her neurological status quickly worsened until she deceased. MRI features and JCV-positive PCR on CSF confirmed the PML diagnosis. Our literature review adds sixteen clinical cases of PML in MM published between May 2020 and March 2023 to the 16 cases already collected in the previously published review by Koutsavlis. DISCUSSION PML has been increasingly described in MM patients. It remains questionable if the HPyV-2 reactivation is determined by the severity of MM itself, by the effect of drugs or by a combination of both. SARS-CoV-2 infection may have a role in worsening PML in affected patients.
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Affiliation(s)
- Matteo Paolucci
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy.
| | - Luana Gentile
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Mauro Gentile
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Annamaria Borghi
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Elena Merli
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Elisa Marchionni
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna Bologna, Bologna, Italy
| | - Luca Guerra
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna Bologna, Bologna, Italy
| | - Simone Galluzzo
- UOSI Neuroradiologia Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Nicola Cilloni
- Intensive Care Unit, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Luigi Simonetti
- UOSI Neuroradiologia Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
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10
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Ostolaza A, Gastón I, Marta J, Ormazabal I, Erro ME. Progressive multifocal leukoencephalopathy: Report of a case preceding the diagnosis of systemic lymphoma. Neurologia 2023; 38:511-513. [PMID: 36162701 DOI: 10.1016/j.nrleng.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/15/2022] [Indexed: 10/14/2022] Open
Affiliation(s)
- A Ostolaza
- Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Spain.
| | - I Gastón
- Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J Marta
- Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - I Ormazabal
- Servicio de Hematología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - M E Erro
- Servicio de Neurología, Complejo Hospitalario de Navarra, Pamplona, Spain; Laboratorio de Neuroepigenética-Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA (Navarra Institute for Health Research), Pamplona, Spain
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11
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Bakirtzis C, Lima M, De Lorenzo SS, Artemiadis A, Theotokis P, Kesidou E, Konstantinidou N, Sintila SA, Boziki MK, Parissis D, Ioannidis P, Karapanayiotides T, Hadjigeorgiou G, Grigoriadis N. Secondary Central Nervous System Demyelinating Disorders in the Elderly: A Narrative Review. Healthcare (Basel) 2023; 11:2126. [PMID: 37570367 PMCID: PMC10418902 DOI: 10.3390/healthcare11152126] [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: 06/07/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Secondary demyelinating diseases comprise a wide spectrum group of pathological conditions and may either be attributed to a disorder primarily affecting the neurons or axons, followed by demyelination, or to an underlying condition leading to secondary damage of the myelin sheath. In the elderly, primary demyelinating diseases of the central nervous system (CNS), such as multiple sclerosis, are relatively uncommon. However, secondary causes of CNS demyelination may often occur and in this case, extensive diagnostic workup is usually needed. Infectious, postinfectious, or postvaccinal demyelination may be observed, attributed to age-related alterations of the immune system in this population. Osmotic disturbances and nutritional deficiencies, more commonly observed in the elderly, may lead to conditions such as pontine/extrapontine myelinolysis, Wernicke encephalopathy, and demyelination of the posterior columns of the spinal cord. The prevalence of malignancies is higher in the elderly, sometimes leading to radiation-induced, immunotherapy-related, or paraneoplastic CNS demyelination. This review intends to aid clinical neurologists in broadening their diagnostic approach to secondary CNS demyelinating diseases in the elderly. Common clinical conditions leading to secondary demyelination and their clinical manifestations are summarized here, while the current knowledge of the underlying pathophysiological mechanisms is additionally presented.
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Affiliation(s)
- Christos Bakirtzis
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Maria Lima
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Sotiria Stavropoulou De Lorenzo
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Artemios Artemiadis
- Faculty of Medicine, University of Cyprus, Nicosia CY-2029, Cyprus; (A.A.); (G.H.)
| | - Paschalis Theotokis
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Evangelia Kesidou
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Natalia Konstantinidou
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Styliani-Aggeliki Sintila
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Marina-Kleopatra Boziki
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Dimitrios Parissis
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Panagiotis Ioannidis
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | - Theodoros Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
| | | | - Nikolaos Grigoriadis
- Second Department of Neurology, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (M.L.); (S.S.D.L.); (P.T.); (E.K.); (N.K.); (S.-A.S.); (M.-K.B.); (D.P.); (P.I.); (T.K.); (N.G.)
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12
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Pathogen-specific T Cells: Targeting Old Enemies and New Invaders in Transplantation and Beyond. Hemasphere 2023; 7:e809. [PMID: 36698615 PMCID: PMC9831191 DOI: 10.1097/hs9.0000000000000809] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/07/2022] [Indexed: 01/27/2023] Open
Abstract
Adoptive immunotherapy with virus-specific cytotoxic T cells (VSTs) has evolved over the last three decades as a strategy to rapidly restore virus-specific immunity to prevent or treat viral diseases after solid organ or allogeneic hematopoietic cell-transplantation (allo-HCT). Since the early proof-of-principle studies demonstrating that seropositive donor-derived T cells, specific for the commonest pathogens post transplantation, namely cytomegalovirus or Epstein-Barr virus (EBV) and generated by time- and labor-intensive protocols, could effectively control viral infections, major breakthroughs have then streamlined the manufacturing process of pathogen-specific T cells (pSTs), broadened the breadth of target recognition to even include novel emerging pathogens and enabled off-the-shelf administration or pathogen-naive donor pST production. We herein review the journey of evolution of adoptive immunotherapy with nonengineered, natural pSTs against infections and virus-associated malignancies in the transplant setting and briefly touch upon recent achievements using pSTs outside this context.
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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.
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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
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14
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Muacevic A, Adler JR, Dória MDC, Rêgo A, Rocha M, Madeira D, Valido T. Progressive Multifocal Leukoencephalopathy Associated With Idiopathic CD8+ Lymphocytopenia. Cureus 2022; 14:e32870. [PMID: 36694528 PMCID: PMC9867889 DOI: 10.7759/cureus.32870] [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] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by the polyoma John Cunningham (JC) virus. This virus is rarely pathogenic in immunocompetent individuals, being associated with profound cellular immunosuppression. We present a case of a 72-year-old woman with schizoaffective disorder who presented to the emergency department with dysarthria and right hemiataxia. The initial computer tomography was normal and the diagnosis of ischemic stroke was first assumed. However, during hospitalization there was a progressive worsening of symptoms with cerebellar ataxia, and the magnetic resonance revealed a lesion in the right middle cerebellar peduncle hypointense in T1 and hyperintense on T2/fluid attenuated inversion recovery (FLAIR) sequence, suggestive of PML. Although the first cerebrospinal fluid analysis was negative, the second one was positive for the JC virus. Furthermore, due to radiological and clinical progression, mirtazapine was started and the patient underwent a course of intravenous immunoglobulin, with no response. In parallel, causes of immunosuppression were investigated, which led to the diagnosis of idiopathic CD8+ lymphocytopenia. Due to rapid progression of symptoms and radiological worsening of lesions, pembrolizumab was administered. After the first administration of pembrolizumab there was a transitory clinical stabilization. However, shortly after the second administration of pembrolizumab, the patient developed stridor with bilateral vocal cord paralysis and subsequent symptom progression, which led to the death of the patient three months after the appearance of initial symptoms. In conclusion, we report a case of a PML in a patient with idiopathic CD8+ lymphocytopenia, enhancing the need for a high suspicion index for this entity as well as for occult and less frequent forms of immunosuppression. Although there have been various case reports of favourable outcomes with pembrolizumab for PML, more research is needed, particularly to identify patient factors that might be associated with better responses to this therapy.
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15
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Muacevic A, Adler JR, Duro J, Lessa Simões M, Aguiar P. Progressive Multifocal Leukoencephalopathy in a Chemotherapy-Naive Patient With Chronic Lymphocytic Leukemia: A Case Report. Cureus 2022; 14:e32912. [PMID: 36699752 PMCID: PMC9871684 DOI: 10.7759/cureus.32912] [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] [Accepted: 12/24/2022] [Indexed: 12/26/2022] Open
Abstract
Progressive multifocal leukoencephalopathy is a rare, progressive demyelinating disease of the central nervous system caused by reactivation and replication of the John Cunningham (JC) virus in cerebral oligodendrocytes. The JC virus is a small ubiquitous polyomavirus that can be detected in up to 50% of the adult population. It affects almost exclusively immunocompromised patients and is generally observed in patients with acquired immunodeficiency syndrome and patients with hematologic malignancies and autoimmune or chronic inflammatory diseases medicated with immunosuppressive and immunomodulatory drugs. However, it is rarely described in patients with hematologic malignancies, not undergoing chemotherapy or immunosuppressive therapy. It has a poor prognosis, and the treatment is based on restoring the immune system, given that no specific antiviral treatment is available. We present a case of a chemotherapy-naive patient with chronic lymphocytic leukemia associated with progressive multifocal leukoencephalopathy.
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16
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Mehmood K, Wilczek MP, DuShane JK, Parent MT, Mayberry CL, Wallace JN, Levasseur FL, Fong TM, Hess ST, Maginnis MS. Dynamics and Patterning of 5-Hydroxytryptamine 2 Subtype Receptors in JC Polyomavirus Entry. Viruses 2022; 14:v14122597. [PMID: 36560603 PMCID: PMC9782046 DOI: 10.3390/v14122597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
The organization and dynamics of plasma membrane receptors are a critical link in virus-receptor interactions, which finetune signaling efficiency and determine cellular responses during infection. Characterizing the mechanisms responsible for the active rearrangement and clustering of receptors may aid in developing novel strategies for the therapeutic treatment of viruses. Virus-receptor interactions are poorly understood at the nanoscale, yet they present an attractive target for the design of drugs and for the illumination of viral infection and pathogenesis. This study utilizes super-resolution microscopy and related techniques, which surpass traditional microscopy resolution limitations, to provide both a spatial and temporal assessment of the interactions of human JC polyomavirus (JCPyV) with 5-hydroxytrypamine 2 receptors (5-HT2Rs) subtypes during viral entry. JCPyV causes asymptomatic kidney infection in the majority of the population and can cause fatal brain disease, and progressive multifocal leukoencephalopathy (PML), in immunocompromised individuals. Using Fluorescence Photoactivation Localization Microscopy (FPALM), the colocalization of JCPyV with 5-HT2 receptor subtypes (5-HT2A, 5-HT2B, and 5-HT2C) during viral attachment and viral entry was analyzed. JCPyV was found to significantly enhance the clustering of 5-HT2 receptors during entry. Cluster analysis of infected cells reveals changes in 5-HT2 receptor cluster attributes, and radial distribution function (RDF) analyses suggest a significant increase in the aggregation of JCPyV particles colocalized with 5-HT2 receptor clusters in JCPyV-infected samples. These findings provide novel insights into receptor patterning during viral entry and highlight improved technologies for the future development of therapies for JCPyV infection as well as therapies for diseases involving 5-HT2 receptors.
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Affiliation(s)
- Kashif Mehmood
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Michael P. Wilczek
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Jeanne K. DuShane
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Matthew T. Parent
- Department of Physics & Astronomy, The University of Maine, Orono, ME 04469, USA
| | - Colleen L. Mayberry
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Jaqulin N. Wallace
- Department of Physics & Astronomy, The University of Maine, Orono, ME 04469, USA
| | - Francois L. Levasseur
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Tristan M. Fong
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
| | - Samuel T. Hess
- Department of Physics & Astronomy, The University of Maine, Orono, ME 04469, USA
- Graduate School of Biomedical Science and Engineering, The University of Maine, Orono, ME 04469, USA
- Correspondence: (S.T.H.); (M.S.M.)
| | - Melissa S. Maginnis
- Department of Molecular and Biomedical Sciences, The University of Maine, Orono, ME 04469, USA
- Graduate School of Biomedical Science and Engineering, The University of Maine, Orono, ME 04469, USA
- Correspondence: (S.T.H.); (M.S.M.)
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17
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Garg D, Goyal V. Progressive Multifocal Leukoencephalopathy-Immune Reconstitution Inflammatory Syndrome (PML-IRIS) Presenting with Refractory Status Epilepticus in a Patient with HIV-1. Ann Indian Acad Neurol 2022; 25:1221-1222. [PMID: 36911483 PMCID: PMC9996511 DOI: 10.4103/aian.aian_419_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Vinay Goyal
- Department of Neurology, Neurosciences Institute, Medanta the Medicity, Gurugram, Haryana, India
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18
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Ostolaza A, Gastón I, Marta J, Ormazabal I, Erro M. Leucoencefalopatía multifocal progresiva: a propósito de un caso que precede al diagnóstico de un linfoma sistémico. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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19
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Mayr P, Lutz M, Schmutz M, Hoeppner J, Liesche-Starnecker F, Schlegel J, Gaedcke J, Claus R. Progressive multifocal leukoencephalopathy associated with chemotherapy induced lymphocytopenia in solid tumors – case report of an underestimated complication. Front Oncol 2022; 12:905103. [PMID: 36003787 PMCID: PMC9394442 DOI: 10.3389/fonc.2022.905103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/24/2022] [Indexed: 11/19/2022] Open
Abstract
Background JC virus reactivation causing progressive multifocal leukoencephalopathy (PML) occurs preferentially in human immunodeficiency virus (HIV) positive individuals or patients suffering from hematologic neoplasms due to impaired viral control. Reactivation in patients suffering from solid malignancies is rarely described in published literature. Case Presentation Here we describe a case of PML in a male patient suffering from esophageal cancer who underwent neoadjuvant radiochemotherapy and surgical resection in curative intent resulting in complete tumor remission. The radiochemotherapy regimen contained carboplatin and paclitaxel (CROSS protocol). Since therapy onset, the patient presented with persistent and progredient leukopenia and lymphopenia in absence of otherwise known risk factors for PML. Symptom onset, which comprised aphasia, word finding disorder, and paresis, was apparent 7 months after therapy initiation. There was no relief in symptoms despite standard of care PML directed supportive therapy. The patient died two months after therapy onset. Conclusion PML is a very rare event in solid tumors without obvious states of immununosuppression and thus harbors the risk of unawareness. The reported patient suffered from lymphopenia, associated with systemic therapy, but was an otherwise immunocompetent individual. In case of neurologic impairment in patients suffering from leukopenia, PML must be considered – even in the absence of hematologic neoplasia or HIV infection.
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Blauciak M, Bladowska J, Zagrajek M, Guranski K, Paradowski B. Progressive Multifocal Leukoencephalopathy in Patient with Primary Immunodeficiency Syndrome. Neurol India 2022; 70:1762-1763. [PMID: 36076726 DOI: 10.4103/0028-3886.355187] [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]
Affiliation(s)
- Malorzata Blauciak
- Department of Neurology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
| | - Joanna Bladowska
- Department of General Radiology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
| | - Mieszko Zagrajek
- Department of Neurology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
| | - Konstanty Guranski
- Department of Neurology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
| | - Boguslaw Paradowski
- Department of Neurology, Interventional Radiology and Neuroradiology, Wroclaw Medical University, Wroclaw, Poland
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The Inhibition of DNA Viruses by the Amphibian Antimicrobial Peptide Temporin G: A Virological Study Addressing HSV-1 and JPCyV. Int J Mol Sci 2022; 23:ijms23137194. [PMID: 35806198 PMCID: PMC9266403 DOI: 10.3390/ijms23137194] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/17/2022] Open
Abstract
Herpes simplex virus type-1 (HSV-1) and John Cunningham polyomavirus (JCPyV) are widely distributed DNA viruses causing mainly asymptomatic infection, but also mild to very severe diseases, especially when these viruses reach the brain. Some drugs have been developed to inhibit HSV-1 replication in host cells, but their prolonged use may induce resistance phenomena. In contrast, to date, there is no cure for JCPyV. The search for alternative drugs that can reduce viral infections without undermining the host cell is moving toward antimicrobial peptides (AMPs) of natural occurrence. These include amphibian AMPs belonging to the temporin family. Herein, we focus on temporin G (TG), showing that it strongly affects HSV-1 replication by acting either during the earliest stages of its life cycle or directly on the virion. Computational studies have revealed the ability of TG to interact with HSV-1 glycoprotein B. We also found that TG reduced JCPyV infection, probably affecting both the earliest phases of its life cycle and the viral particle, likely through an interaction with the viral capsid protein VP1. Overall, our results are promising for the development of short naturally occurring peptides as antiviral agents used to counteract diseases related to HSV-1 and JCPyV.
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Progressive Multifocal Leukoencephalopathy in B-CLL Successfully Treated With Venetoclax and Pembrolizumab. Hemasphere 2022; 6:e723. [PMID: 35747841 PMCID: PMC9208891 DOI: 10.1097/hs9.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022] Open
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Rearrangement in the Hypervariable Region of JC Polyomavirus Genomes Isolated from Patient Samples and Impact on Transcription Factor-Binding Sites and Disease Outcomes. Int J Mol Sci 2022; 23:ijms23105699. [PMID: 35628509 PMCID: PMC9144386 DOI: 10.3390/ijms23105699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 12/20/2022] Open
Abstract
JC polyomavirus (JCPyV) is the causative agent of the fatal, incurable, neurological disease, progressive multifocal leukoencephalopathy (PML). The virus is present in most of the adult population as a persistent, asymptotic infection in the kidneys. During immunosuppression, JCPyV reactivates and invades the central nervous system. A main predictor of disease outcome is determined by mutations within the hypervariable region of the viral genome. In patients with PML, JCPyV undergoes genetic rearrangements in the noncoding control region (NCCR). The outcome of these rearrangements influences transcription factor binding to the NCCR, orchestrating viral gene transcription. This study examines 989 NCCR sequences from patient isolates deposited in GenBank to determine the frequency of mutations based on patient isolation site and disease status. The transcription factor binding sites (TFBS) were also analyzed to understand how these rearrangements could influence viral transcription. It was determined that the number of TFBS was significantly higher in PML samples compared to non-PML samples. Additionally, TFBS that could promote JCPyV infection were more prevalent in samples isolated from the cerebrospinal fluid compared to other locations. Collectively, this research describes the extent of mutations in the NCCR that alter TFBS and how they correlate with disease outcome.
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Lo Buono V, D’Aleo G, Cammaroto S, De Cola MC, Palmese F, Smorto C, Marino S, Venuti G, Sessa E, Rifici C, Corallo F. Neuropsychological Disability in the Case of Natalizumab-Related Progressive Multifocal Leukoencephalopathy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58040551. [PMID: 35454389 PMCID: PMC9025511 DOI: 10.3390/medicina58040551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a viral disease characterized by progressive damage or inflammation of the cerebral white matter that can be encountered in patients with multiple sclerosis (MS). There are cases of PML caused by pharmacological agents including natalizumab. Therefore, in patients treated with this drug, early identification of PML allows changes in the treatment plan, reducing the risks of morbidity and mortality. CASE PRESENTATION We reported the case of a 57-year-old female diagnosed with relapsing-remitting MS, who presented with PML related to natalizumab. The patient presented with change in behavioral, radiological abnormalities in the left parieto-temporal lobes. We described the longitudinal course of PML, from the diagnosis until the patient's death, documenting the progressive deterioration of her cognitive functioning, supported by changes on sequential brain scans and neurophysiological data. CONCLUSION The neuropsychological impairment documented in this case study expands the range of treatment-related complications associated with natalizumab, and provides evidence that occurrence of "atypical" cognitive deficits in MS may support the early diagnosis of PML.
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Affiliation(s)
- Viviana Lo Buono
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Giangaetano D’Aleo
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Simona Cammaroto
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Maria Cristina De Cola
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
- Correspondence:
| | - Francesca Palmese
- Azienda ULSS Marca Trevigiana, Ospedale Cà Foncello, 31100 Treviso, Italy;
| | - Chiara Smorto
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Silvia Marino
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Giuseppe Venuti
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Edoardo Sessa
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Carmela Rifici
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
| | - Francesco Corallo
- IRCCS Centro Neurolesi Bonino Pulejo, 98100 Messina, Italy; (V.L.B.); (G.D.); (S.C.); (C.S.); (S.M.); (G.V.); (E.S.); (C.R.); (F.C.)
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Dalla-Pozza P, Hentzien M, Allavena C, Doe de Maindreville A, Bouiller K, Valantin MA, Lafont E, Zaegel-Faucher O, Cheret A, Martin-Blondel G, Cotte L, Bani-Sadr F. Progressive multifocal leukoencephalopathy in patients with immunovirological control and at least 6 months of combination antiretroviral therapy. AIDS 2022; 36:539-549. [PMID: 34873087 DOI: 10.1097/qad.0000000000003145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES AND METHODS : Progressive multifocal leukoencephalopathy (PML) has rarely been reported in people with HIV (PWH) with long-term HIV immune-virological control. We describe the clinical and biological characteristics of patients with confirmed PML among PWH with a CD4+ cell count more than 200 cells/μl and an undetectable HIV RNA viral load after at least 6 months of combined antiretroviral therapy (cART) at the time of PML diagnosis, in the large French multicenter Dat'AIDS cohort. RESULTS : Among 571 diagnoses of PML reported in the Dat'AIDS cohort between 2000 and 2019, 10 cases (1.75%) occurred in PWH with a CD4+ cell count greater than 200 cells/μl and an undetectable HIV RNA viral load after at least 6 months of cART. Median CD4+ cell count at PML diagnosis was 395 cells/μl (IQR 310-477). The median duration between the last detectable HIV viral load and the PML diagnosis was 41.1 months (IQR 8.2-67.4). Only one patient treated with rituximab-based chemotherapy for a large B-cell lymphoma had an established risk factor for PML. Among the nine other patients with no apparent severe immunodeficiency, multiple factors of impaired immunity could have led to the development of PML: hepatitis C virus (HCV) co-infection (n = 6), cirrhosis (n = 4), HHV-8 co-infection (n = 3) with Kaposi's sarcoma (n = 2) in association with Castleman's disease (n = 1) and indolent IgA multiple myeloma (n = 1). CONCLUSION : This study highlights that factors other than low CD4+ cell count and high HIV viral load may be associated with the occurrence of PML. Further studies are warranted to investigate in greater detail the immunologic characteristics of PWH with immune-virological control who develop PML.
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Affiliation(s)
- Paul Dalla-Pozza
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
| | - Maxime Hentzien
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
| | - Clotilde Allavena
- Department of Infectious Diseases, University Hospital of Nantes, Nantes
| | | | - Kévin Bouiller
- Department of Infectious Diseases, University Hospital of Besancon
| | - Marc-Antoine Valantin
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, Assistance Publique des Hôpitaux de Paris
| | - Emmanuel Lafont
- Department of Infectious Diseases, Necker Hospital, Assistance Publique des Hôpitaux de Paris, Paris
| | - Olivia Zaegel-Faucher
- Department of Immunology and Hematology, Sainte-Marguerite Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille
| | - Antoine Cheret
- Department of Internal Medicine, Kremlin Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, Bicêtre
| | - Guillaume Martin-Blondel
- Department of Infectious Diseases, University Hospital of Toulouse, Toulouse, France and Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291 - CNRS UMR5051 - Université Toulouse III, Toulouse
| | - Laurent Cotte
- Department of Infectious Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, and INSERM U1052, Lyon
| | - Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital of Reims
- University of Reims Champagne-Ardenne, EA-4684/SFR CAP-SANTE, Reims, F-51095, France
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Innovative therapeutic concepts of progressive multifocal leukoencephalopathy. J Neurol 2022; 269:2403-2413. [PMID: 34994851 PMCID: PMC8739669 DOI: 10.1007/s00415-021-10952-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 02/04/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral disease of the brain-caused by human polyomavirus 2. It affects patients whose immune system is compromised by a corresponding underlying disease or by drugs. Patients with an underlying lymphoproliferative disease have the worst prognosis with a mortality rate of up to 90%. Several therapeutic strategies have been proposed but failed to show any benefit so far. Therefore, the primary therapeutic strategy aims to reconstitute the impaired immune system to generate an effective endogenous antiviral response. Recently, anti-PD-1 antibodies and application of allogeneic virus-specific T cells demonstrated promising effects on the outcome in individual PML patients. This article aims to provide a detailed overview of the literature with a focus on these two treatment approaches.
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27
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Naro A, Billeri L, Lauria P, Manuli A, Calabrò RS. Toward Improving Functional Recovery in AIDS-associated Progressive Multifocal Leukoencephalopathy: A Single Case Pilot Study on a Novel Neuromodulation Approach. INNOVATIONS IN CLINICAL NEUROSCIENCE 2022; 19:15-18. [PMID: 35382071 PMCID: PMC8970235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Patients with progressive multifocal leukoencephalopathy (PML) in the context of human immunodeficiency virus-acquired immunodeficiency syndrome (HIV-AIDS) show a partial improvement following rehabilitation; however, this improvement is rapidly lost if the patient is not provided with intensive rehabilitation. A 42-year-old patient affected by HIV-AIDS had a clinical worsening within a few months following PML onset, despite being treated with antiretroviral drugs and conventional rehabilitation. He developed severe paraparesis and significant dependency in the activities of daily life. A first cycle of intensive rehabilitation provided the patient with some significant functional outcomes, although he experienced a worsening of the clinical condition after two months of rest, before admission to our rehabilitation unit. We thus sought to evaluate the effects of intensive robot-aided gait training (RAGT) coupled with transcranial direct current stimulation (tDCS). The patient significantly improved when provided with intensive RAGT coupled with tDCS (as per 10-meter Walk Test [10MWT] and 6-minute Walk Test [6MWT]), and the improvement was maintained at three-month follow-up. As this advanced approach was feasible, safe, and potentially effective, this case suggests that patients with PML-HIV require prolonged multidisciplinary rehabilitation treatment. We can speculate that individuals with PML should also be treated with innovative technology to improve their functional outcomes and therefore quality of life.
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Affiliation(s)
- Antonino Naro
- Drs. Naro and Calabrò, Ms. Billeri, Ms. Lauria, and Mr. Manuli are with IRCCS Centro Neurolesi Bonino Pulejo-Piemonte in Messina, Italy
| | - Luana Billeri
- Drs. Naro and Calabrò, Ms. Billeri, Ms. Lauria, and Mr. Manuli are with IRCCS Centro Neurolesi Bonino Pulejo-Piemonte in Messina, Italy
| | - Paola Lauria
- Drs. Naro and Calabrò, Ms. Billeri, Ms. Lauria, and Mr. Manuli are with IRCCS Centro Neurolesi Bonino Pulejo-Piemonte in Messina, Italy
| | - Alfredo Manuli
- Drs. Naro and Calabrò, Ms. Billeri, Ms. Lauria, and Mr. Manuli are with IRCCS Centro Neurolesi Bonino Pulejo-Piemonte in Messina, Italy
| | - Rocco Salvatore Calabrò
- Drs. Naro and Calabrò, Ms. Billeri, Ms. Lauria, and Mr. Manuli are with IRCCS Centro Neurolesi Bonino Pulejo-Piemonte in Messina, Italy
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28
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Maher KR, Bouligny IM, Yeager AM. Prevention and management of infections after exposure to ionising radiation. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R176-R188. [PMID: 34265748 DOI: 10.1088/1361-6498/ac14d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
Ionising radiation impacts many organ systems, each of which comprises a level of immunity to infectious disease. Bone marrow toxicity after radiation results in a predisposition to leukopenia and subsequent susceptibility to bacterial, viral, and fungal infections. Radiation-induced damage to mucosal, integumentary, and solid organ structures disrupts additional lines of innate defense. Over the past three decades, much progress has been made in effective antimicrobial prophylaxis, resulting in decreased infectious complications and improved survival. Vaccination schedules following myeloablative radiation have become highly regimented and treatment of overt infectious complications is largely standardised. In this article, we discuss consequences, prevention, and management of infections following exposure to ionising radiation.
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Affiliation(s)
- Keri R Maher
- Department of Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, United States of America
- Virginia Commonwealth University Massey Cancer Center, Richmond, VA 23298, United States of America
| | - Ian M Bouligny
- Department of Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, United States of America
| | - Andrew M Yeager
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, United States of America
- Blood and Marrow Transplantation Program, University of Arizona Cancer Center, Tucson, AZ 85724, United States of America
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PI3K/AKT/mTOR Signaling Pathway Is Required for JCPyV Infection in Primary Astrocytes. Cells 2021; 10:cells10113218. [PMID: 34831441 PMCID: PMC8624856 DOI: 10.3390/cells10113218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/05/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022] Open
Abstract
Astrocytes are a main target of JC polyomavirus (JCPyV) in the central nervous system (CNS), where the destruction of these cells, along with oligodendrocytes, leads to the fatal disease progressive multifocal leukoencephalopathy (PML). There is no cure currently available for PML, so it is essential to discover antivirals for this aggressive disease. Additionally, the lack of a tractable in vivo models for studying JCPyV infection makes primary cells an accurate alternative for elucidating mechanisms of viral infection in the CNS. This research to better understand the signaling pathways activated in response to JCPyV infection reveals and establishes the importance of the PI3K/AKT/mTOR signaling pathway in JCPyV infection in primary human astrocytes compared to transformed cell lines. Using RNA sequencing and chemical inhibitors to target PI3K, AKT, and mTOR, we have demonstrated the importance of this signaling pathway in JCPyV infection of primary astrocytes not observed in transformed cells. Collectively, these findings illuminate the potential for repurposing drugs that are involved with inhibition of the PI3K/AKT/mTOR signaling pathway and cancer treatment as potential therapeutics for PML, caused by this neuroinvasive virus.
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30
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Burn SC, Kalro A. Progressive multifocal leukoencephalopathy: a complication of prolonged immunosuppression for plasma cell myeloma. Med J Aust 2021; 215:454-455. [PMID: 34687047 DOI: 10.5694/mja2.51315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | - Akash Kalro
- Central Adelaide Local Health Network, Adelaide, SA
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31
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Disease-modifying therapies and progressive multifocal leukoencephalopathy in multiple sclerosis: A systematic review and meta-analysis. J Neuroimmunol 2021; 360:577721. [PMID: 34547511 PMCID: PMC9810068 DOI: 10.1016/j.jneuroim.2021.577721] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/20/2021] [Accepted: 09/12/2021] [Indexed: 01/05/2023]
Abstract
Background High efficacy disease modifying therapies (DMT) in the management of Multiple Sclerosis (MS) have a favorable effect on relapse rate and disability progression; however, they can expose patients to significant risks, such as progressive multifocal leukoencephalopathy (PML). Objective The study aims to investigate prognostic factors that can determine outcome in MS-related PML patients. Methods We conducted a literature review and meta-analysis of 194 patients from 62 articles in PubMed, SCOPUS and EMBASE. Results Out of 194 patients (66.5% women, 33.5% men), 81% had progression in their EDSS score by at least 1 point from the time of PML diagnosis (EDSS-P group). The remaining patients had either stable or improved EDSS (EDSS-S group). In univariate analysis, older age at the time of PML diagnosis was associated with higher probability of disability accumulation and worsening of EDSS by at least 1 point (mean age = 44.8, p = 0.046). After adjusting for other variables, age at time of PML diagnosis remained a significant predictive variable in the multivariable logistic model (OR = 0.93, 95% CI: 0.88-0.99, p = 0.037). Natalizumab is the most commonly associated DMT linked to PML, followed by fingolimod and others including dimethyl fumarate, ocrelizumab, alemtuzumab. Among the different treatments used, no therapeutic agent was found to be superior in improving post-PML EDSS. Conclusions Younger age and lower JCV viral load at the time of PML diagnosis were associated with better outcome in MS-associate PML, while none of the PML therapies was superior over the others or associated with favorable outcome.
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32
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Wilczek MP, Armstrong FJ, Geohegan RP, Mayberry CL, DuShane JK, King BL, Maginnis MS. The MAPK/ERK Pathway and the Role of DUSP1 in JCPyV Infection of Primary Astrocytes. Viruses 2021; 13:v13091834. [PMID: 34578413 PMCID: PMC8473072 DOI: 10.3390/v13091834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/02/2021] [Accepted: 09/09/2021] [Indexed: 12/13/2022] Open
Abstract
JC polyomavirus (JCPyV) is a neuroinvasive pathogen causing a fatal, demyelinating disease of the central nervous system (CNS) known as progressive multifocal leukoencephalopathy (PML). Within the CNS, JCPyV predominately targets two cell types: oligodendrocytes and astrocytes. The underlying mechanisms of astrocytic infection are poorly understood, yet recent findings suggest critical differences in JCPyV infection of primary astrocytes compared to a widely studied immortalized cell model. RNA sequencing was performed in primary normal human astrocytes (NHAs) to analyze the transcriptomic profile that emerges during JCPyV infection. Through a comparative analysis, it was validated that JCPyV requires the mitogen-activated protein kinase, extracellular signal-regulated kinase (MAPK/ERK) pathway, and additionally requires the expression of dual-specificity phosphatases (DUSPs). Specifically, the expression of DUSP1 is needed to establish a successful infection in NHAs, yet this was not observed in an immortalized cell model of JCPyV infection. Additional analyses demonstrated immune activation uniquely observed in NHAs. These results support the hypothesis that DUSPs within the MAPK/ERK pathway impact viral infection and influence potential downstream targets and cellular pathways. Collectively, this research implicates DUSP1 in JCPyV infection of primary human astrocytes, and most importantly, further resolves the signaling events that lead to successful JCPyV infection in the CNS.
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Affiliation(s)
- Michael P. Wilczek
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
| | - Francesca J. Armstrong
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
| | - Remi P. Geohegan
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
| | - Colleen L. Mayberry
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
| | - Jeanne K. DuShane
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
| | - Benjamin L. King
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
- Graduate School in Biomedical Sciences and Engineering, University of Maine, Orono, ME 04469, USA
| | - Melissa S. Maginnis
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, ME 04469, USA; (M.P.W.); (F.J.A.); (R.P.G.); (C.L.M.); (J.K.D.); (B.L.K.)
- Graduate School in Biomedical Sciences and Engineering, University of Maine, Orono, ME 04469, USA
- Correspondence:
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33
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Lan TY, Chen YS, Cheng CF, Huang ST, Shen CY, Hsu PN. Progressive multifocal leukoencephalopathy in systemic lupus erythematosus managed with pembrolizumab: A case report with literature review. Lupus 2021; 30:1849-1855. [PMID: 34325541 DOI: 10.1177/09612033211035443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is one of the rare but lethal infectious complication in patients with SLE, manifesting progressive central nervous demyelination caused by JC virus (JCV). There have been no effective antiviral agents so far; however, immune checkpoint inhibitors (ICI) have been demonstrated as potential treatments by reinvigorating antiviral T-cell activity against JC virus. To date, sixteen PML cases treated with anti-PD-1 have been reported; however, there was no report addressing the use of ICI in patients with concomitant PML and rheumatic disease, possibly due to the concern for possible autoimmune disease flare-up. In addition, treatment outcomes of these ICI-treated cases were heterogeneous. Experiences from these cases suggested that high disease burden, JC viral load in CSF, and severe immunosuppression status at baseline may predict poor response to treatment. Our case, a 62-year-old woman with long-standing SLE, turned out to have a delayed but effective response to prolonged ICI treatment despite of her high JC viral load and immunosuppressed status caused by high-dose steroid and rituximab. To our knowledge, this is the first case report with SLE complicated with PML clinically improved by pembrolizumab treatment without consequent immune related adverse events (irAE). Considering the lethal nature of PML and absence of effective medication, ICI is a reasonable consideration in patients with SLE and progressive PML.
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Affiliation(s)
- Ting-Yuan Lan
- Department of Internal Medicine, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan
| | - Yan-Siou Chen
- Department of Internal Medicine, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiao-Feng Cheng
- Department of Internal Medicine, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan
| | - Sin-Tuan Huang
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Chieh-Yu Shen
- Department of Internal Medicine, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Ning Hsu
- Department of Internal Medicine, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan.,Department of Oncology, 38006National Taiwan University Hospital, National Taiwan University Hospital, Taipei, Taiwan
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34
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Demirbuğa A, Kaba O, Törün SH, Yıldız EP, Yücel E, Somer A. Progressive Multifocal Leukoencephalopathy in Children with Primary and Secondary Immune Deficiency. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2021; 34:109-111. [PMID: 34142853 DOI: 10.1089/ped.2020.1330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating disease of the central nervous system that is caused by John Cunningham virus (JCV). It occurs almost exclusively in immunosuppressed individuals, for example, patients with AIDS and hematological and lymphoreticular malignancies. In this article, we present a review of the literature and 2 case reports with PML. The first report examines a 15-year-old male (who presented with dedicator of cytokinesis 8 deficiency) who was diagnosed as having PML based on characteristic magnetic resonance imaging (MRI) lesions and a positive PCR for JCV in cerebrospinal fluid. He was transferred for bone marrow transplantation after stabilization with therapy of maraviroc and cidofovir. The second report examines a 6-year-old male who presented with encephalitis and was also diagnosed with AIDS. He was diagnosed with PML and started treatment with cidofovir. His clinical status and MRI findings deteriorated rapidly. In immunosuppressive patients who developed encephalopathy, JCV ought to be considered.
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Affiliation(s)
- Asuman Demirbuğa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozge Kaba
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selda Hançerli Törün
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Edibe Pembegül Yıldız
- Division of Pediatric Neurology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esra Yücel
- Department of Pediatric Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayper Somer
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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35
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Cheema I, Ng N, Chen T. Clinical Reasoning: A 71-Year-Old Man With Horizontal Gaze Palsy, Anarthria, and Quadriparesis. Neurology 2021; 96:1146-1150. [PMID: 33853895 DOI: 10.1212/wnl.0000000000012048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ikreet Cheema
- From the Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
| | - Nicole Ng
- From the Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Tychicus Chen
- From the Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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36
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Orphal J, Terai N. [Initial ophthalmic manifestation of a fatal underlying disease : Importance of perimetry in unspecific visual deterioration]. Ophthalmologe 2021; 118:590-592. [PMID: 32642881 DOI: 10.1007/s00347-020-01164-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 55-year-old male patient presented with bilateral blurred vision. Chronic lymphocytic leukemia was generally known in the medical history, which was treated by immunochemotherapy with fludarabine, cyclophosphamide and rituximab. Static perimetry revealed a homonymous hemianopia to the left. The neurological examination was otherwise unremarkable. Progressive multifocal leukoencephalopathy (PML) was diagnosed by cranial magnetic resonance imaging and detection of JC virus DNA in the cerebrospinal fluid. The PML is a rare demyelinating disease of the central nervous system caused by reactivation of the JC virus. It affects patients with HIV, malignant hematological diseases and immunomodulatory therapy. A specific, antiviral treatment does not yet exist. The prognosis of PML is therefore poor. After a progressive course of the disease the patient died 4 months after the diagnosis.
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Affiliation(s)
- J Orphal
- Augenklinik, Univ. Klinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - N Terai
- Augenklinik, Univ. Klinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
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37
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Patel A, Sul J, Gordon ML, Steinklein J, Sanguinetti S, Pramanik B, Purohit D, Haroutunian V, Williamson A, Koralnik I, Harel A. Progressive Multifocal Leukoencephalopathy in a Patient With Progressive Multiple Sclerosis Treated With Ocrelizumab Monotherapy. JAMA Neurol 2021; 78:736-740. [PMID: 33724354 DOI: 10.1001/jamaneurol.2021.0627] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection caused by the JC virus that has no proven effective treatment. Although rare cases of PML have occurred with other anti-CD20 therapies, there had been no prior cases associated with ocrelizumab. Objective To report the first ever case of PML occurring with ocrelizumab monotherapy in a patient with progressive multiple sclerosis without prior immunomodulation. Design, Setting, and Participant This case was reported from an academic medical center. The patient had multiple sclerosis while receiving ocrelizumab monotherapy. Exposures Ocrelizumab monotherapy. Results A 78-year-old man with progressive multiple sclerosis treated with ocrelizumab monotherapy for 2 years presented with 2 weeks of progressive visual disturbance and confusion. Examination demonstrated a right homonymous hemianopia, and magnetic resonance imaging revealed an enlarging nonenhancing left parietal lesion without mass effect. Cerebrospinal fluid revealed 1000 copies/mL of JC virus, confirming the diagnosis of PML. Blood work on diagnosis revealed grade 2 lymphopenia, with absolute lymphocyte count of 710/μL, CD4 of 294/μL (reference range, 325-1251/μL), CD8 of 85/μL (reference range, 90-775/μL), CD19 of 1/μL, preserved CD4/CD8 ratio (3.45), and negative HIV serology. Retrospective absolute lymphocyte count revealed intermittent grade 1 lymphopenia that preceded ocrelizumab (absolute lymphocyte count range, 800-1200/μL). The patient's symptoms progressed over weeks to involve bilateral visual loss, right-sided facial droop, and dysphasia. Ocrelizumab was discontinued and off-label pembrolizumab treatment was initiated. The patient nevertheless declined rapidly and ultimately died. PML was confirmed at autopsy. Conclusions and Relevance In this case report, PML occurrence was likely a result of the immunomodulatory function of ocrelizumab as well as age-related immunosenescence. This case report emphasizes the importance of a thorough discussion of the risks and benefits of ocrelizumab, especially in patients at higher risk for infections such as elderly patients.
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Affiliation(s)
- Arpan Patel
- Department of Neurology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - James Sul
- Department of Neurology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Marc L Gordon
- Department of Neurology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Manhasset, New York.,Department of Psychiatry, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jared Steinklein
- Division of Neuroradiology, Department of Radiology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Shayna Sanguinetti
- Department of Neurology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Bidyut Pramanik
- Division of Neuroradiology, Department of Radiology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Dushyant Purohit
- Department of Pathology, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York.,Department of Psychiatry, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York
| | - Vahram Haroutunian
- Department of Psychiatry, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York.,MIRECC, JJ Peters VA Medical Center, Bronx, New York.,Department of Neuroscience, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York
| | - Alex Williamson
- Department of Pathology & Laboratory Medicine, LIJ Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Igor Koralnik
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Asaff Harel
- Division of Neuro-Immunology, Department of Neurology, Lenox Hill Hospital, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, New York
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38
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De Mercanti SF, Gned D, Matta M, Iudicello M, Franchin E, Clerico M. Atypical Multiple Sclerosis Lesions or Progressive Multifocal Leukoencephalopathy Lesions: That Is the Question. J Investig Med High Impact Case Rep 2021; 8:2324709620939802. [PMID: 32646245 PMCID: PMC7357099 DOI: 10.1177/2324709620939802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a serious infective disease of the central nervous system that may occur in case of severe immunosuppression or after some treatment for multiple sclerosis (MS) with natalizumab, dimethyl fumarate, and fingolimod. In these case reports, we highlight the importance of differential diagnosis between PML and MS lesions in order to provide rapidly the best treatment option, by discussing the finding of brain (magnetic resonance imaging) MRI suggestive for PML in 2 MS patients, one treated with dimethyl fumarate and the other during natalizumab withdrawal. In both cases, although brain MRI was highly suggestive for PML, the detection of John Cunningham virus-DNA copies in cerebrospinal fluid resulted in negative result. These case reports illustrate the diagnostic process in case of suspected PML, as both patients were diagnosed with suspected PML during a routine brain MRI control, and highlights the importance of providing a strict brain MRI follow-up during dimethyl fumarate treatment, although only a few cases of PML during this therapy have been detected, and during natalizumab suspension phase. In clinical practice, in case of a radiologically suspected case of PML, although not confirmed by the cerebrospinal fluid analysis, the best approach could be to perform a close radiological and clinical monitoring before starting a new MS therapy.
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Affiliation(s)
- Stefania Federica De Mercanti
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
- Stefania Federica De Mercanti, Clinical and Biological Sciences Department, San Luigi Gonzaga Hospital, Regione Gonzole, 10, Orbassano 10043, Italy.
| | - Dario Gned
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Manuela Matta
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Marco Iudicello
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Emanuele Franchin
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Marinella Clerico
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
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Mahajan KR, Amin M, Poturalski M, Lee J, Herman D, Zheng Y, Androjna C, Howell M, Fox RJ, Trapp BD, Jones SE, Nakamura K, Ontaneda D. Juxtacortical susceptibility changes in progressive multifocal leukoencephalopathy at the gray-white matter junction correlates with iron-enriched macrophages. Mult Scler 2021; 27:2159-2169. [PMID: 33749379 DOI: 10.1177/1352458521999651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Describe magnetic resonance imaging (MRI) susceptibility changes in progressive multifocal leukoencephalopathy (PML) and identify neuropathological correlates. METHODS PML cases and matched controls with primary central nervous system lymphoma (PCNSL) were retrospectively identified. MRI brain at 3 T and 7 T were reviewed. MRI-pathology correlations in fixed brain autopsy tissue were conducted in three subjects with confirmed PML. RESULTS With PML (n = 26 total, n = 5 multiple sclerosis natalizumab-associated), juxtacortical changes on susceptibility-weighted imaging (SWI) or gradient echo (GRE) sequences were noted in 3/3 cases on 7 T MRI and 14/22 cases (63.6%) on 1.5 T or 8/22 (36.4%) 3 T MRI. Similar findings were only noted in 3/25 (12.0%) of PCNSL patients (odds ratio (OR) 12.83, 95% confidence interval (CI), 2.9-56.7, p < 0.001) on 1.5 or 3 T MRI. On susceptibility sequences available prior to diagnosis of PML, 7 (87.5%) had changes present on average 2.7 ± 1.8 months (mean ± SD) prior to diagnosis. Postmortem 7 T MRI showed SWI changes corresponded to areas of increased iron density along the gray-white matter (GM-WM) junction predominantly in macrophages. CONCLUSION Susceptibility changes in PML along the GM-WM junction can precede noticeable fluid-attenuated inversion recovery (FLAIR) changes and correlates with iron accumulation in macrophages.
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Affiliation(s)
- Kedar R Mahajan
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA/Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Poturalski
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan Lee
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Danielle Herman
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yufan Zheng
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caroline Androjna
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Howell
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce D Trapp
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen E Jones
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kunio Nakamura
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
The risk of JC polyomavirus encephalopathy varies among biologic classes and among agents within the same class. Of currently used biologics, the highest risk is seen with natalizumab followed by rituximab. Multiple other agents have also been implicated. Drug-specific causality is difficult to establish because many patients receive multiple immunomodulatory medications concomitantly or sequentially, and have other immunocompromising factors related to their underlying disease. As use of biologic therapies continues to expand, further research is needed into pathogenesis, treatment, and prevention of JC polyomavirus encephalopathy such that risk for its development is better understood and mitigated, if not eliminated altogether.
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41
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GRK2 mediates β-arrestin interactions with 5-HT 2 receptors for JC polyomavirus endocytosis. J Virol 2021; 95:JVI.02139-20. [PMID: 33441347 PMCID: PMC8092707 DOI: 10.1128/jvi.02139-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
JC polyomavirus (JCPyV) infects the majority of the population, establishing a lifelong, asymptomatic infection in the kidney of healthy individuals. People that become severely immunocompromised may experience JCPyV reactivation, which can cause progressive multifocal leukoencephalopathy (PML), a neurodegenerative disease. Due to a lack of therapeutic options, PML results in fatality or significant debilitation among affected individuals. Cellular internalization of JCPyV is mediated by serotonin 5-hydroxytryptamine subfamily 2 receptors (5-HT2Rs) via clathrin-mediated endocytosis. The JCPyV entry process requires the clathrin-scaffolding proteins β-arrestin, adaptor protein 2 (AP2), and dynamin. Further, a β-arrestin interacting domain, the Ala-Ser-Lys (ASK) motif, within the C-terminus of 5-HT2AR is important for JCPyV internalization and infection. Interestingly, 5-HT2R subtypes A, B, and C equally support JCPyV entry and infection, and all subtypes contain an ASK motif, suggesting a conserved mechanism for viral entry. However, the role of the 5-HT2R ASK motifs and the activation of β-arrestin-associated proteins during internalization has not been fully elucidated. Through mutagenesis, the ASK motifs within 5-HT2BR and 5-HT2CR were identified as critical for JCPyV internalization and infectivity. Further, utilizing biochemical pulldown techniques, mutagenesis of the ASK motifs in 5-HT2BR and 5-HT2CR resulted in reduced β-arrestin binding. Utilizing small-molecule chemical inhibitors and RNA interference, G-protein receptor kinase 2 (GRK2) was determined to be required for JCPyV internalization and infection by mediating interactions between β-arrestin and the ASK motif of 5-HT2Rs. These findings demonstrate that GRK2 and β-arrestin interactions with 5-HT2Rs are critical for JCPyV entry by clathrin-mediated endocytosis and resultant infection.IMPORTANCE As intracellular parasites, viruses require a host cell to replicate and cause disease. Therefore, virus-host interactions contribute to viral pathogenesis. JC polyomavirus (JCPyV) infects most of the population, establishing a lifelong asymptomatic infection within the kidney. Under conditions of severe immunosuppression JCPyV may spread to the central nervous system, causing the fatal demyelinating disease progressive multifocal leukoencephalopathy (PML). Individuals living with HIV or undergoing immunomodulatory therapies are at risk for developing PML. The mechanisms of how JCPyV uses specific receptors on the surface of host cells to initiate internalization and infection is a poorly understood process. We have further identified cellular proteins involved in JCPyV internalization and infection and elucidated their specific interactions that are responsible for activation of receptors. Collectively, these findings illuminate how viruses usurp cellular receptors during infection, contributing to current development efforts for therapeutic options for the treatment or prevention of PML.
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42
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Möhn N, Wattjes MP, Adams O, Nay S, Tkachenko D, Salge F, Heine J, Pars K, Höglinger G, Respondek G, Stangel M, Skripuletz T, Jacobs R, Sühs KW. PD-1-inhibitor pembrolizumab for treatment of progressive multifocal leukoencephalopathy. Ther Adv Neurol Disord 2021; 14:1756286421993684. [PMID: 34035834 PMCID: PMC8129640 DOI: 10.1177/1756286421993684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
The reactivation of human JC polyoma virus (JCPyV) results in lytic infection of oligodendrocytes and neuronal cells. The corresponding clinical picture is called progressive multifocal leukoencephalopathy (PML) and results mostly from a disease-related or drug-induced immunosuppression. The opportunistic brain infection leads to a progressive demyelination of multiple areas of the central nervous system. Patients can present with various neurological deficits ranging from slight motoric symptoms to marked aphasia or reduced vigilance. Currently, there is no effective causal therapy for PML. Survival depends on the ability to achieve timely immune reconstitution. If the immune system cannot be restored, PML progresses rapidly and often ends fatally within months. Recently, some evidence for positive response has been reported in patients treated with immune checkpoint inhibitor therapy. Here, we provide a case series of three PML patients with underlying hematological malignancies who were treated with anti-PD-1-antibody pembrolizumab at Hannover Medical School. All patients received an extensive diagnostic follow-up including cerebrospinal fluid analysis, brain imaging, and lymphocyte-phenotyping via flow cytometry. Our patients had very different outcomes, with the only patient showing a specific anti-JCPyV immune response in the sense of an increased JCPyV antibody index clearly benefiting most from the treatment. Our results partly support the hypothesis that anti-PD-1 therapy may represent a promising treatment option for patients with PML. However, there is a current lack of pre-therapeutic stratification regarding the therapeutic response rates. Before larger studies can be initiated to further evaluate the efficacy of anti-PD-1 antibodies in PML, it is imperative to develop a reliable strategy for selecting suitable patients.
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Affiliation(s)
- Nora Möhn
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Mike P Wattjes
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Ortwin Adams
- Department of Virology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Sandra Nay
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Daria Tkachenko
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Friederike Salge
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanne Heine
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Kaweh Pars
- Department of Neurology, European Medical School, University Oldenburg, Oldenburg, Germany
| | - Günter Höglinger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gesine Respondek
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Roland Jacobs
- Department of Rheumatology & Clinical Immunology, Hannover Medical School, Hannover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, 30625, Germany
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43
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Berzero G, Basso S, Stoppini L, Palermo A, Pichiecchio A, Paoletti M, Lucev F, Gerevini S, Rossi A, Vegezzi E, Diamanti L, Bini P, Gastaldi M, Delbue S, Perotti C, Seminari E, Faraci M, Luppi M, Baldanti F, Zecca M, Marchioni E, Comoli P. Adoptive Transfer of JC Virus-Specific T Lymphocytes for the Treatment of Progressive Multifocal Leukoencephalopathy. Ann Neurol 2021; 89:769-779. [PMID: 33459417 PMCID: PMC8248385 DOI: 10.1002/ana.26020] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Progressive multifocal leukoencephalopathy (PML) is still burdened by high mortality in a subset of patients, such as those affected by hematological malignancies. The aim of this study was to analyze the safety and carry out preliminary evaluation of the efficacy of polyomavirus JC (JCPyV)-specific T cell therapy in a cohort of hematological patients with PML. METHODS Between 2014 and 2019, 9 patients with a diagnosis of "definite PML" according to the 2013 consensus who were showing progressive clinical deterioration received JCPyV-specific T cells. Cell lines were expanded from autologous or allogenic peripheral blood mononuclear cells by stimulation with JCPyV antigen-derived peptides. RESULTS None of the patients experienced treatment-related adverse events. In the evaluable patients, an increase in the frequency of circulating JCPyV-specific lymphocytes was observed, with a decrease or clearance of JCPyV viral load in cerebrospinal fluid. In responsive patients, transient appearance of punctate areas of contrast enhancement within, or close to, PML lesions was observed, which was interpreted as a sign of immune control and which regressed spontaneously without the need for steroid treatment. Six of 9 patients achieved PML control, with 5 alive and in good clinical condition at their last follow-up. INTERPRETATION Among other novel treatments, T cell therapy is emerging as a viable treatment option in patients with PML, particularly for those not amenable to restoration of specific immunity. Neurologists should be encouraged to refer PML patients to specialized centers to allow access to this treatment strategy. ANN NEUROL 2021;89:769-779.
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Affiliation(s)
- Giulia Berzero
- Neuroncology Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Sabrina Basso
- Cell Factory, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.,Pediatric Hematology-Oncology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Luca Stoppini
- Cell Factory, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.,Pediatric Hematology-Oncology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Andrea Palermo
- Neuroncology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Neuroradiology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Federica Lucev
- Neuroradiology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Simonetta Gerevini
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elisa Vegezzi
- Neuroncology Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Luca Diamanti
- Neuroncology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Paola Bini
- Neuroncology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Cesare Perotti
- Transfusion Service, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Elena Seminari
- Infectious Disease Department, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Maura Faraci
- HSCT Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Fausto Baldanti
- Molecular Virology, IRCCS Fondazione Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Marco Zecca
- Pediatric Hematology-Oncology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | | | - Patrizia Comoli
- Cell Factory, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.,Pediatric Hematology-Oncology Unit, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
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Graf LM, Rosenkranz SC, Hölzemer A, Hagel C, Goebell E, Jordan S, Friese MA, Addo MM, Schulze Zur Wiesch J, Beisel C. Clinical Presentation and Disease Course of 37 Consecutive Cases of Progressive Multifocal Leukoencephalopathy (PML) at a German Tertiary-Care Hospital: A Retrospective Observational Study. Front Neurol 2021; 12:632535. [PMID: 33613439 PMCID: PMC7890249 DOI: 10.3389/fneur.2021.632535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/04/2021] [Indexed: 01/27/2023] Open
Abstract
Background: Progressive multifocal leukoencephalopathy (PML) caused by JCV is a rare but frequently fatal disease of the central nervous system, usually affecting immunocompromised individuals. Our study aims to expand the data on patient characteristics, diagnosis, clinical course, possible PML-directed treatment, and outcome of patients with PML at a German tertiary-care hospital. Methods:In this single-center observational cohort study, 37 consecutive patients with a confirmed diagnosis of PML seen at the University Medical Center Hamburg-Eppendorf from 2013 until 2019 were retrospectively analyzed by chart review with a special focus on demographics, risk factors, and clinical aspects as well as PML-directed treatment and survival. Results:We identified 37 patients with definite, probable, and possible PML diagnosis. 36 patients (97%) had underlying immunosuppressive disorders such as HIV/AIDS (n = 17; 46%), previous treatment with monoclonal antibodies (n = 6; 16%), hematological or oncological malignancies (n = 6; 16%), sarcoidosis (n = 5; 14%), solid organ transplantation (n = 1; 3%), and diagnosis of mixed connective tissue disease (n = 1; 3%). In only one patient no evident immunocompromised condition was detected (n = 1; 3%). Treatment attempts to improve the outcome of PML were reported in 13 patients (n = 13; 35%). Twenty seven percent of patients were lost to follow-up (n = 10). Twenty four-month survival rate after diagnosis of PML was 56% (n = 15). Conclusion: This interdisciplinary retrospective study describes epidemiology, risk factors, clinical course, and treatment trials in patients with PML at a German tertiary-care hospital. Acquired immunosuppression due to HIV-1 constituted the leading cause of PML in this monocenter cohort.
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Affiliation(s)
- Lisa M Graf
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sina C Rosenkranz
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angelique Hölzemer
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.,Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
| | - Christian Hagel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Einar Goebell
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Jordan
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marylyn M Addo
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Claudia Beisel
- Division of Infectious Disease, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany.,Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Hamburg, Germany
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45
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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.
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46
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Progressive multifocal leukoencephalopathy in a patient with relapsed chronic lymphocytic leukemia treated with Ibrutinib. Hematol Transfus Cell Ther 2020; 44:437-439. [PMID: 33454288 PMCID: PMC9477769 DOI: 10.1016/j.htct.2020.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 01/04/2023] Open
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Solis M, Guffroy A, Lersy F, Soulier E, Gallais F, Renaud M, Douiri N, Argemi X, Hansmann Y, De Sèze J, Kremer S, Fafi-Kremer S. Inadequate Immune Humoral Response against JC Virus in Progressive Multifocal Leukoencephalopathy Non-Survivors. Viruses 2020; 12:v12121380. [PMID: 33276614 PMCID: PMC7761562 DOI: 10.3390/v12121380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/17/2020] [Accepted: 11/29/2020] [Indexed: 11/16/2022] Open
Abstract
JC virus (JCV) causes progressive multifocal leukoencephalopathy (PML) in immunosuppressed patients. There is currently no effective specific antiviral treatment and PML management relies on immune restoration. Prognosis markers are crucially needed in this disease because of its high mortality rate. In this work, we investigated the compartmentalization of JCV strains as well as the humoral neutralizing response in various matrices to further understand the pathophysiology of PML and define markers of survival. Four patients were included, of which three died in the few months following PML onset. Cerebrospinal fluid (CSF) viral loads were the highest, with plasma samples having lower viral loads and urine samples being mostly negative. Whether at PML onset or during follow-up, neutralizing antibody (NAb) titers directed against the same autologous strain (genotype or mutant) were the highest in plasma, with CSF titers being on average 430-fold lower and urine titers 500-fold lower at the same timepoint. Plasma NAb titers against autologous genotype or mutant were lower in non-survivor patients, though no neutralization “blind spot” was observed. The surviving patient was followed up until nine months after PML onset and presented, at that time, an increase in neutralizing titers, from 38-fold against the autologous genotype to around 200-fold against PML mutants. Our results suggest that patients’ humoral neutralizing response against their autologous strain may play a role in PML outcome, with survivors developing high NAb titers in both plasma and CSF.
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Affiliation(s)
- Morgane Solis
- Virology Laboratory, Strasbourg University Hospitals, 67000 Strasbourg, France; (M.S.); (F.G.)
- INSERM UMR-S 1109 LabEx TRANSPLANTEX, Strasbourg University, 67000 Strasbourg, France;
| | - Aurélien Guffroy
- Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases, Strasbourg University Hospitals, 67000 Strasbourg, France;
| | - François Lersy
- Service d’Imagerie 2, Strasbourg University Hospitals, 67000 Strasbourg, France; (F.L.); (S.K.)
| | - Eric Soulier
- INSERM UMR-S 1109 LabEx TRANSPLANTEX, Strasbourg University, 67000 Strasbourg, France;
| | - Floriane Gallais
- Virology Laboratory, Strasbourg University Hospitals, 67000 Strasbourg, France; (M.S.); (F.G.)
- INSERM UMR-S 1109 LabEx TRANSPLANTEX, Strasbourg University, 67000 Strasbourg, France;
| | - Mathilde Renaud
- Neurology Department, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg University Hospitals, 67000 Strasbourg, France; (M.R.); (J.D.S.)
| | - Nawal Douiri
- Department of Infectious Diseases, Strasbourg University Hospitals, 67000 Strasbourg, France; (N.D.); (X.A.); (Y.H.)
| | - Xavier Argemi
- Department of Infectious Diseases, Strasbourg University Hospitals, 67000 Strasbourg, France; (N.D.); (X.A.); (Y.H.)
| | - Yves Hansmann
- Department of Infectious Diseases, Strasbourg University Hospitals, 67000 Strasbourg, France; (N.D.); (X.A.); (Y.H.)
| | - Jérôme De Sèze
- Neurology Department, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg University Hospitals, 67000 Strasbourg, France; (M.R.); (J.D.S.)
- Clinical Investigation Center, INSERM 1434, Strasbourg University Hospitals, 67000 Strasbourg, France
| | - Stéphane Kremer
- Service d’Imagerie 2, Strasbourg University Hospitals, 67000 Strasbourg, France; (F.L.); (S.K.)
- Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, 67000 Strasbourg, France
| | - Samira Fafi-Kremer
- Virology Laboratory, Strasbourg University Hospitals, 67000 Strasbourg, France; (M.S.); (F.G.)
- INSERM UMR-S 1109 LabEx TRANSPLANTEX, Strasbourg University, 67000 Strasbourg, France;
- Correspondence: ; Tel.: +33-3-69-55-14-38; Fax: +33-3-68-85-37-50
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Targeted metabolomic profiling of cerebrospinal fluid from patients with progressive multifocal leukoencephalopathy. PLoS One 2020; 15:e0242321. [PMID: 33232337 PMCID: PMC7685473 DOI: 10.1371/journal.pone.0242321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/01/2020] [Indexed: 11/19/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML), caused by JC polyomavirus, is a demyelinating disease of the central nervous system that primarily affects oligodendrocytes. It can cause significant morbidity and mortality. An early diagnosis is of high relevance as timely immune reconstitution is essential. However, diagnosis can be challenging if virus detection via cerebrospinal fluid (CSF) PCR remains negative. Hence, identifying CSF biomarkers for this disease is of crucial importance. We applied a targeted metabolomic screen to CSF from 23 PML patients and eight normal pressure hydrocephalus (NPH) patients as controls. Out of 188 potentially detectable metabolites, 48 (13 amino acids, 4 biogenic amines, 1 acylcarnitine, 21 phosphatidylcholines, 8 sphingolipids, and the sum of hexoses) passed the quality screen and were included in the analyses. Even though there was a tendency towards lower concentrations in PML (mostly of phosphatidylcholines and sphingomyelins), none of the differences between PML and controls in individual metabolite concentrations reached statistical significance (lowest p = 0.104) and there were no potential diagnostic biomarkers (highest area under the ROC curve 0.68). Thus, CSF metabolite changes in PML are likely subtle and possibly larger group sizes and broader metabolite screens are needed to identify potential CSF metabolite biomarkers for PML.
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Cortese I, Reich DS, Nath A. Progressive multifocal leukoencephalopathy and the spectrum of JC virus-related disease. Nat Rev Neurol 2020; 17:37-51. [PMID: 33219338 PMCID: PMC7678594 DOI: 10.1038/s41582-020-00427-y] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a devastating CNS infection caused by JC virus (JCV), a polyomavirus that commonly establishes persistent, asymptomatic infection in the general population. Emerging evidence that PML can be ameliorated with novel immunotherapeutic approaches calls for reassessment of PML pathophysiology and clinical course. PML results from JCV reactivation in the setting of impaired cellular immunity, and no antiviral therapies are available, so survival depends on reversal of the underlying immunosuppression. Antiretroviral therapies greatly reduce the risk of HIV-related PML, but many modern treatments for cancers, organ transplantation and chronic inflammatory disease cause immunosuppression that can be difficult to reverse. These treatments — most notably natalizumab for multiple sclerosis — have led to a surge of iatrogenic PML. The spectrum of presentations of JCV-related disease has evolved over time and may challenge current diagnostic criteria. Immunotherapeutic interventions, such as use of checkpoint inhibitors and adoptive T cell transfer, have shown promise but caution is needed in the management of immune reconstitution inflammatory syndrome, an exuberant immune response that can contribute to morbidity and death. Many people who survive PML are left with neurological sequelae and some with persistent, low-level viral replication in the CNS. As the number of people who survive PML increases, this lack of viral clearance could create challenges in the subsequent management of some underlying diseases. In this Review, Cortese et al. provide an overview of the pathobiology and evolving presentations of progressive multifocal leukoencephalopathy and other diseases caused by JC virus, and discuss emerging immunotherapeutic approaches that could increase survival. Progressive multifocal leukoencephalopathy (PML) is a rare, debilitating and often fatal disease of the CNS caused by JC virus (JCV). JCV establishes asymptomatic, lifelong persistent or latent infection in immune competent hosts, but impairment of cellular immunity can lead to reactivation of JCV and PML. PML most commonly occurs in patients with HIV infection or lymphoproliferative disease and in patients who are receiving natalizumab for treatment of multiple sclerosis. The clinical phenotype of PML varies and is shaped primarily by the host immune response; changes in the treatment of underlying diseases associated with PML have changed phenotypes over time. Other clinical manifestations of JCV infection have been described, including granule cell neuronopathy. Survival of PML depends on reversal of the underlying immunosuppression; emerging immunotherapeutic strategies include use of checkpoint inhibitors and adoptive T cell transfer.
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Affiliation(s)
- Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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Guduru M, Bendi VS, Bebawy MS, Bande D, Matta A. Posterior Fossa Progressive Multifocal Leukoencephalopathy Secondary to Rituximab. Cureus 2020; 12:e10888. [PMID: 33178540 PMCID: PMC7652356 DOI: 10.7759/cureus.10888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare fatal central nervous system disorder characterized by infection-induced demyelination of white matter due to the opportunistic reactivation of John Cunningham virus in an immunocompromised patient. PML is associated with many immune-mediated diseases, lymphoproliferative conditions, and immunosuppressive agents. In this case report, we present a 79-year-old female patient diagnosed with rheumatoid arthritis who developed posterior fossa PML while on rituximab. She presented with subacute cerebellar ataxia, dysarthria, and nystagmus, and her brain MRI showed right pontine and pontocerebellar lesion with diffusion restriction and heterogenous enhancement highly characteristic of PML. Though many cases of PML with rituximab were reported in the literature, our case describes a rare type of PML affecting the posterior fossa in an HIV-negative patient on rituximab.
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