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Jost S, Ahn J, Chen S, Yoder T, Gikundiro KE, Lee E, Gressens SB, Kroll K, Craemer M, Kaynor GC, Lifton M, Tan CS. Upregulation of the NKG2D Ligand ULBP2 by JC Polyomavirus Infection Promotes Immune Recognition by Natural Killer Cells. J Infect Dis 2024; 229:1836-1844. [PMID: 37774496 PMCID: PMC11175686 DOI: 10.1093/infdis/jiad424] [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: 06/15/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND JC polyomavirus (JCPyV) causes progressive multifocal leukoencephalopathy (PML), a potentially fatal complication of severe immune suppression with no effective treatment. Natural killer (NK) cells play critical roles in defense against viral infections; however, NK-cell response to JCPyV infection remains unexplored. METHODS NK- and T-cell responses against the JCPyV VP1 were compared using intracellular cytokine staining upon stimulation with peptide pools. A novel flow cytometry-based assay was developed to determine NK-cell killing efficiency of JCPyV-infected astrocyte-derived SVG-A cells. Blocking antibodies were used to evaluate the contribution of NK-cell receptors in immune recognition of JCPyV-infected cells. RESULTS In about 40% of healthy donors, we detected robust CD107a upregulation and IFN-γ production by NK cells, extending beyond T-cell responses. Next, using the NK-cell-mediated killing assay, we showed that coculture of NK cells and JCPyV-infected SVG-A cells leads to a 60% reduction in infection, on average. JCPyV-infected cells had enhanced expression of ULBP2-a ligand for the activating NK-cell receptor NKG2D, and addition of NKG2D blocking antibodies decreased NK-cell degranulation. CONCLUSIONS NKG2D-mediated activation of NK cells plays a key role in controlling JCPyV replication and may be a promising immunotherapeutic target to boost NK-cell anti-JCPyV activity.
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Affiliation(s)
- Stephanie Jost
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jenny Ahn
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Chen
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Taylor Yoder
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kayitare Eunice Gikundiro
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Esther Lee
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Simon B Gressens
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kyle Kroll
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melissa Craemer
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Michelle Lifton
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - C Sabrina Tan
- Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Cortese I, Norato G, Harrington PR, Usher T, Mainardi I, Martin-Blondel G, Cinque P, Major EO, Sheikh V. Biomarkers for progressive multifocal leukoencephalopathy: emerging data for use of JC virus DNA copy number in clinical trials. Lancet Neurol 2024; 23:534-544. [PMID: 38631769 DOI: 10.1016/s1474-4422(24)00099-1] [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: 09/28/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/19/2024]
Abstract
Progressive multifocal leukoencephalopathy is a rare but devastating demyelinating disease caused by the JC virus (JCV), for which no therapeutics are approved. To make progress towards addressing this unmet medical need, innovations in clinical trial design are needed. Quantitative JCV DNA in CSF has the potential to serve as a valuable biomarker of progressive multifocal leukoencephalopathy disease and treatment response in clinical trials to expedite therapeutic development, as do neuroimaging and other fluid biomarkers such as neurofilament light chain. Specifically, JCV DNA in CSF could be used in clinical trials as an entry criterion, stratification factor, or predictor of clinical outcomes. Insights from the investigation of candidate biomarkers for progressive multifocal leukoencephalopathy might inform approaches to biomarker development for other rare diseases.
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Affiliation(s)
- Irene Cortese
- Experimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Gina Norato
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Patrick R Harrington
- Division of Antivirals, Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Therri Usher
- Division of Biometrics IV, Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Ilaria Mainardi
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guillaume Martin-Blondel
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), INSERM UMR1291-CNRS UMR5051, Université Toulouse III, Toulouse, France
| | - Paola Cinque
- Unit of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eugene O Major
- Laboratory of Molecular Medicine and Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Virginia Sheikh
- Division of Antivirals, Office of Infectious Diseases, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
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Milburn J, Suresh R, Doyle R, Jarvis JN. The diagnosis of central nervous system infections in resource-limited settings and the use of novel and molecular diagnostic platforms to improve diagnosis. Expert Rev Mol Diagn 2024; 24:219-230. [PMID: 38369939 DOI: 10.1080/14737159.2024.2317414] [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: 10/02/2023] [Accepted: 02/07/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Central nervous system infections (CNSI) disproportionately affect individuals in low-resource settings where diagnosis is challenging; large proportions of patients never receive a confirmed microbiological diagnosis resulting in inadequate management and high mortality. The epidemiology of CNSI varies globally and conventional diagnostics deployed in resource-limited settings have significant limitations, with an urgent need for improved diagnostic strategies. AREAS COVERED This review describes molecular platforms and other novel diagnostics used in the diagnosis of CNSI that are applicable to resource-limited settings. An extensive literature search of Medline and PubMed was performed. The emphasis is on investigations targeting infections of relevance to resource-limited settings either due to variation in regional CNSI epidemiology or due to increased prevalence in patients with immunosuppression. This includes commercially available multiplex PCR platforms, mycobacterial PCR platforms, and rapid diagnostics tests. To offer a framework for the optimal implementation in clinical settings, existing evidence highlighting the advantages and limitations of available platforms is reviewed. EXPERT OPINION The implementation of molecular platforms and other novel diagnostics has the potential to transform CNSI diagnosis in resource-limited settings, with several examples of successful rollout of novel diagnostics such as Xpert MTB/RIF Ultra and cryptococcal antigen testing.
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Affiliation(s)
- James Milburn
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Rachita Suresh
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Ronan Doyle
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Moser T, Zimmermann G, Baumgartner A, Berger T, Bsteh G, Di Pauli F, Enzinger C, Fertl E, Heller T, Koppi S, Rommer PS, Safoschnik G, Seifert-Held T, Stepansky R, Sellner J. Long-term outcome of natalizumab-associated progressive multifocal leukoencephalopathy in Austria: a nationwide retrospective study. J Neurol 2024; 271:374-385. [PMID: 37728757 PMCID: PMC10770206 DOI: 10.1007/s00415-023-11924-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/28/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND/OBJECTIVE The use of natalizumab (NAT) in multiple sclerosis (MS) may be complicated by progressive multifocal leukoencephalopathy (PML), a rare and life-threatening opportunistic brain infection. We aimed to analyze the course of MS after PML recovery together with the long-term outcome of NAT-associated PML (NAT-PML) in Austria. METHODS Retrospective study based on identification of cases in the nationwide Austrian MS treatment registry (AMSTR) and MS centers with review of patient records. The expanded disability status scale (EDSS) was used to measure neurological disability and outcome. RESULTS As of December 2022, we identified 15 NAT-PML cases in Austria; only 20% occurred after 2016, when increased vigilance commenced. Two patients did not survive acute PML, and an additional patient died five years later, yielding a mortality rate of 20%. Seizures occurred exclusively in patients with pronounced EDSS increase. Gadolinium (Gd)-enhancement on brain magnetic resonance imaging (MRI) on PML suspicion was associated with minor changes of post-PML neurological disability. Long-term follow-up of up to 132 months (median 76 months) was available in 11/15. The overall median EDSS increased from 3.5 at pre-PML to 6.5 at the last assessment. Regarding inflammatory MS-related disease activity during the observation period, one single individual experienced an MS relapse and another patient had two Gd-enhancing brain lesions. Three patients converted to progressive MS within three years from PML and the EDSS further increased in 6/11. CONCLUSIONS The number of NAT-PML cases is decreasing over time. While many patients accumulated severe persistent neurological deficits compared to pre-PML, inflammatory MS-related disease activity after PML recovery was rare.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria
- Department of Research and Innovation, Paracelsus Medical University, Salzburg, Austria
| | - Anna Baumgartner
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elisabeth Fertl
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Thomas Heller
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Stefan Koppi
- Rehabilitation Clinic Montafon, Schruns, Austria
| | - Paulus S Rommer
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Johann Sellner
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria.
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstrasse 67, 2130, Mistelbach, Austria.
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Doskas T, Dardiotis E, Vavougios GD, Ntoskas KT, Sionidou P, Vadikolias K. Stroke risk in multiple sclerosis: a critical appraisal of the literature. Int J Neurosci 2023; 133:1132-1152. [PMID: 35369835 DOI: 10.1080/00207454.2022.2056459] [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: 04/21/2021] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Observational studies suggest that the occurrence of stroke on multiple sclerosis (MS) patients is higher compared to the general population. MS is a heterogeneous disease that involves an interplay of genetic, environmental and immune factors. The occurrence of stroke is subject to a wide range of both modifiable and non-modifiable, short- and long-term risk factors. Both MS and stroke share common risk factors. The immune mechanisms that underlie stroke are similar to neurodegenerative diseases and are attributed to neuroinflammation. The inflammation in autoimmune diseases may, therefore, predispose to an increased risk for stroke or potentiate the effect of conventional stroke risk factors. There are, however, additional determinants that contribute to a higher risk and incidence of stroke in MS. Due to the challenges that are associated with their differential diagnosis, the objective is to present an overview of the factors that may contribute to increased susceptibility or occurrence of stroke in MSpatients by performing a review of the available to date literature. As both MS and stroke can individually detrimentally affect the quality of life of afflicted patients, the identification of factors that contribute to an increased risk for stroke in MS is crucial for the prompt implementation of preventative therapeutic measures to limit the additive burden that stroke imposes.
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Affiliation(s)
- Triantafyllos Doskas
- Department of Neurology, Athens Naval Hospital, Athens, Greece
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University Hospital of Larissa, Larissa, Greece
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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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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Puig-Casadevall M, Álvarez-Bravo G, Varela AQ, Robles-Cedeño R, Sànchez Cirera L, Miguela A, Laguillo G, Montalban X, Hauser SL, Ramió-Torrentà L. Progressive multifocal leukoencephalopathy in a patient with relapsing multiple sclerosis treated with ocrelizumab: A case report. Eur J Neurol 2023; 30:3357-3361. [PMID: 37485841 DOI: 10.1111/ene.15988] [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: 04/25/2023] [Revised: 06/03/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Progressive multifocal leukoencephalopathy is a rare but often fatal complication of some multiple sclerosis treatments. Although it has mainly been associated with natalizumab treatment, its appearance with other immunosuppressive therapies has also been reported. AIMS The aim of this case report is to describe the development of progressive multifocal encephalopathy in a patient with relapsing-remitting multiple sclerosis treated with ocrelizumab without previous use of natalizumab. CONCLUSIONS A summary of the presentation and disease course is provided, presented in the context of the current literature and likely pathophysiology.
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Affiliation(s)
- Marc Puig-Casadevall
- Girona Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, Salt, Spain
| | - Gary Álvarez-Bravo
- Girona Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, Salt, Spain
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Salt, Spain
| | - Ana Quiroga Varela
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Salt, Spain
- Instituto de Salud Carlos III, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Enfermedades inflamatorias (RD21/0002/0063), Madrid, Spain
| | - René Robles-Cedeño
- Girona Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, Salt, Spain
- Instituto de Salud Carlos III, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Enfermedades inflamatorias (RD21/0002/0063), Madrid, Spain
- Medical Sciences Department, University of Girona, Girona, Spain
| | | | - Albert Miguela
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Salt, Spain
- Instituto de Salud Carlos III, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Enfermedades inflamatorias (RD21/0002/0063), Madrid, Spain
| | - Gemma Laguillo
- Radiology Department, Dr. Josep Trueta University Hospital, Girona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephen L Hauser
- Department of Neurology, University of California, San Francisco, California, USA
| | - Lluis Ramió-Torrentà
- Girona Neuroimmunology and Multiple Sclerosis Unit, Neurology Department, Dr. Josep Trueta University Hospital and Santa Caterina Hospital, Salt, Spain
- Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Salt, Spain
- Instituto de Salud Carlos III, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Enfermedades inflamatorias (RD21/0002/0063), Madrid, Spain
- Medical Sciences Department, University of Girona, Girona, Spain
- Neurology Department, Dr. Josep Trueta University Hospital, Girona, Spain
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8
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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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9
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Joly M, Conte C, Cazanave C, Le Moing V, Tattevin P, Delobel P, Sommet A, Martin-Blondel G. Progressive multifocal leukoencephalopathy: epidemiology and spectrum of predisposing conditions. Brain 2023; 146:349-358. [PMID: 35779271 DOI: 10.1093/brain/awac237] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/15/2022] [Accepted: 06/20/2022] [Indexed: 01/11/2023] Open
Abstract
Population-based data on the epidemiology of progressive multifocal leukoencephalopathy, its predisposing conditions and mortality rate are lacking, although such data are crucial to raise awareness among clinicians and to lay foundations for future therapeutic trials in immunomodulating therapies. In our study, patients were identified by interrogating the French national healthcare reimbursement database from 1 January 2008 to 31 December 2017, using progressive multifocal leukoencephalopathy International Classification of Diseases code and a patient's selection algorithm. Overall incidence rate, 1-year all-cause mortality rate and survival patterns were calculated, and factors associated with death were identified using a multivariate Cox proportional hazards regression model. Our cohort is the largest to date, comprising 584 patients with incident progressive multifocal leukoencephalopathy. The overall incidence in France from 2010 to 2017 was stable during the study period at 0.11 per 100 000 person-years, 95% confidence interval [0.10-0.12]. Predisposing diseases were HIV infection (43.7%), followed by haematological malignancies (21.9%), chronic inflammatory diseases (20.2%), solid organ transplantation (4.3%), solid neoplasm (4.1%) and primary immune deficiency (1.5%). The 1-year mortality rate was 38.2%, with a 95% confidence interval (34.2-42.2). In multivariate analysis, factors independently associated with death were older age [adjusted hazard ratio 0.33 (0.20-0.53) for patients aged 20 to 40 compared with patients aged over 60], male gender [adjusted hazard ratio 0.73 (0.54-0.99) for females compared with males] and predisposing immunosuppressive disease, with the highest risk for solid neoplasms [adjusted hazard ratio 4.34 (2.25-8.37)], followed by haematological malignancies [adjusted hazard ratio 3.13 (1.85-5.30)] and HIV infection [adjusted hazard ratio 1.83 (1.12-3.00)], compared with chronic inflammatory diseases. Immune reconstitution inflammatory syndrome was notified in 7.0% of patients. In conclusion, incidence of progressive multifocal leukoencephalopathy is stable in France, and HIV infection remains the main predisposing disease. This large-size cohort uncovers a higher risk of mortality for male patients compared to females, and the worst prognosis for patients with solid neoplasm, while prognosis in patients with haematological malignancies appeared less dismal than in previous studies.
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Affiliation(s)
- Marine Joly
- Department of Infectious and Tropical Diseases, Toulouse University Hospital Center, Toulouse 31300, France
| | - Cécile Conte
- Department of Medical Pharmacology, CIC 1436, Toulouse University Hospital Center, Toulouse 31300, France
| | - Charles Cazanave
- Department of Infectious and Tropical Diseases, Bordeaux University Hospital Center, Bordeaux 33300, France
| | - Vincent Le Moing
- Department of Infectious and Tropical Diseases, Montpellier University Hospital Center, Montpellier 34295, France
| | - Pierre Tattevin
- Department of Medical Intensive Care and Infectious Diseases, Rennes University Hospital Center, Rennes 35000, France
| | - Pierre Delobel
- Department of Infectious and Tropical Diseases, Toulouse University Hospital Center, Toulouse 31300, France.,Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) INSERM UMR1291, CNRS UMR5051, University of Toulouse III, Toulouse 31300, France
| | - Agnès Sommet
- Department of Medical Pharmacology, CIC 1436, Toulouse University Hospital Center, Toulouse 31300, France
| | - Guillaume Martin-Blondel
- Department of Infectious and Tropical Diseases, Toulouse University Hospital Center, Toulouse 31300, France.,Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity) INSERM UMR1291, CNRS UMR5051, University of Toulouse III, Toulouse 31300, France
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10
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Changes in Brain Volumes Are Relevant during Natalizumab-Associated Progressive Multifocal Leukoencephalopathy: Lessons from a Case Report. Int J Mol Sci 2022; 23:ijms232113642. [DOI: 10.3390/ijms232113642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/24/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
This is a case report concerning a Natalizumab-associated Progressive Multifocal Leukoencephalopathy (PML) with cerebellar localization and wakefulness disturbances. Awakening and clinical improvement dramatically occurred as soon as the immune reconstitution inflammatory syndrome (IRIS) took place, being it mild in nature and colocalizing with the PML lesion. In these ideal experimental conditions, we applied brain magnetic resonance imaging post-analysis in order to know changes in brain volumes underlying the pathological process over the infection period. White matter volume increased with a decrease in grey matter during IRIS. Conversely, we found a constant increase in cerebrospinal fluid volume throughout the duration of PML, suggesting a widespread abiotrophic effect, far from the lesion. Furthermore, brain parenchymal fraction significantly decreased as expected while the total brain volume remained stable at all times. Neurodegeneration is the main contributor to the steady disability in Natalizumab-associated PML. This process is thought to be widespread and inflammatory in nature as well as sustained by IRIS and humoral factors derived from the PML lesion.
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11
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Gomathy S, Panigrahi B, Tirlangi PK, Wig N, Brijwal M, Sharma MC, Garg A, Tripathi M, Mohta S, Doddamani R, Vibha D, Singh RK, Yadav R, Sahu S, Suri V, Kaur K, Tripathi M, Rohatgi A, Elavarasi A. Progressive multifocal leukoencephalopathy in a patient with systemic lupus erythematosus and autoimmune hepatitis. Int J Rheum Dis 2022; 25:705-713. [PMID: 35535671 DOI: 10.1111/1756-185x.14331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/15/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating central nervous system illness encountered in the setting of immunosuppressive conditions like human immunodeficiency virus / acquired immunodeficiency syndrome, autoimmune diseases and hematologic malignancies. We had a 54-year-old woman with systemic lupus erythematosus and coexisting autoimmune hepatitis who presented with progressive cognitive decline, right hemiparesis and ataxia who was found to have PML. She had severe CD4 lymphopenia. She was managed with low-dose prednisolone and plasma exchange after which she showed significant clinical improvement. This case highlights the diagnostic and therapeutic challenges encountered in managing a case of PML in the setting of autoimmune conditions with profound lymphopenia.
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Affiliation(s)
- Saranya Gomathy
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Baikuntha Panigrahi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Megha Brijwal
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar C Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajni Yadav
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Saumya Sahu
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vaishali Suri
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Kavneet Kaur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Madhavi Tripathi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anshu Rohatgi
- Department of Neurology, Sir Ganga Ram Hospital, New Delhi, India
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Krajnc N, Bsteh G, Berger T, Mares J, Hartung HP. Monoclonal Antibodies in the Treatment of Relapsing Multiple Sclerosis: an Overview with Emphasis on Pregnancy, Vaccination, and Risk Management. Neurotherapeutics 2022; 19:753-773. [PMID: 35378683 PMCID: PMC8978776 DOI: 10.1007/s13311-022-01224-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/10/2023] Open
Abstract
Monoclonal antibodies have become a mainstay in the treatment of patients with relapsing multiple sclerosis (RMS) and provide some benefit to patients with primary progressive MS. They are highly precise by specifically targeting molecules displayed on cells involved in distinct immune mechanisms of MS pathophysiology. They not only differ in the target antigen they recognize but also by the mode of action that generates their therapeutic effect. Natalizumab, an [Formula: see text]4[Formula: see text]1 integrin antagonist, works via binding to cell surface receptors, blocking the interaction with their ligands and, in that way, preventing the migration of leukocytes across the blood-brain barrier. On the other hand, the anti-CD52 monoclonal antibody alemtuzumab and the anti-CD20 monoclonal antibodies rituximab, ocrelizumab, ofatumumab, and ublituximab work via eliminating selected pathogenic cell populations. However, potential adverse effects may be serious and can necessitate treatment discontinuation. Most importantly, those are the risk for (opportunistic) infections, but also secondary autoimmune diseases or malignancies. Monoclonal antibodies also carry the risk of infusion/injection-related reactions, primarily in early phases of treatment. By careful patient selection and monitoring during therapy, the occurrence of these potentially serious adverse effects can be minimized. Monoclonal antibodies are characterized by a relatively long pharmacologic half-life and pharmacodynamic effects, which provides advantages such as permitting infrequent dosing, but also creates disadvantages regarding vaccination and family planning. This review presents an overview of currently available monoclonal antibodies for the treatment of RMS, including their mechanism of action, efficacy and safety profile. Furthermore, we provide practical recommendations for risk management, vaccination, and family planning.
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Affiliation(s)
- Nik Krajnc
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Mares
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Hans-Peter Hartung
- Department of Neurology, Medical University of Vienna, Vienna, Austria.
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic.
- Department of Neurology, Medical Faculty, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
- Brain and Mind Center, University of Sydney, Sydney, Australia.
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Engel S, Molina Galindo LS, Bittner S, Zipp F, Luessi F. A Case of Progressive Multifocal Leukoencephalopathy in a Fumaric Acid-Treated Psoriasis Patient With Severe Lymphopenia Among Other Risk Factors. J Cent Nerv Syst Dis 2022; 13:11795735211037798. [PMID: 34992484 PMCID: PMC8725211 DOI: 10.1177/11795735211037798] [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] [Indexed: 11/15/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a potentially fatal condition caused by a brain infection with JC polyomavirus (JCV), which occurs almost exclusively in immunocompromised patients. Modern immunosuppressive and immunomodulatory treatments for cancers and autoimmune diseases have been accompanied by increasing numbers of PML cases. We report a psoriasis patient treated with fumaric acid esters (FAEs) with concomitant hypopharyngeal carcinoma and chronic alcohol abuse who developed PML. Grade 4 lymphopenia at the time point of PML diagnosis suggested an immunocompromised state. This case underscores the importance of immune cell monitoring in patients treated with FAEs, even more so in the presence of additional risk factors for an immune dysfunction.
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Affiliation(s)
- Sinah Engel
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Lara S Molina Galindo
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Felix Luessi
- Department of Neurology, Focus Program Translational Neuroscience (FTN), and Immunotherapy (FZI), Rhine-Main Neuroscience Network (rmn2), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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14
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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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Bernard-Valnet R, Moisset X, Maubeuge N, Lefebvre M, Ouallet JC, Roumier M, Lebrun-Frenay C, Ciron J, Biotti D, Clavelou P, Godeau B, Du Pasquier RA, Martin-Blondel G. CCR5 Blockade in Inflammatory PML and PML-IRIS Associated With Chronic Inflammatory Diseases' Treatments. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 9:9/1/e1097. [PMID: 34728496 PMCID: PMC8564863 DOI: 10.1212/nxi.0000000000001097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/09/2021] [Indexed: 12/02/2022]
Abstract
Background and Objectives Progressive multifocal leukoencephalopathy (PML) is a disabling neurologic disorder resulting from the infection of the CNS by JC polyomavirus in immunocompromised individuals. For the last 2 decades, increasing use of immunotherapies leads to iatrogenic PML. Iatrogenic PML is often associated with signs of inflammation at onset (inflammatory PML) and/or after treatment withdrawal immune reconstitution inflammatory syndrome (PML-IRIS). Although immune reconstitution is a key element for viral clearance, it may also be harmful and induce clinical worsening. A C-C chemokine receptor type 5 (CCR5) antagonist (maraviroc) has been proposed to prevent and/or limit the deleterious immune responses underlying PML-IRIS. However, the data to support its use remain scarce and disputed. Methods We conducted a multicenter retrospective cohort study at 8 university hospitals in France and Switzerland by collecting clinical, biological, and radiologic data of patients who developed inflammatory PML (iPML) or PML-IRIS related to immunosuppressive therapies used for chronic inflammatory diseases between 2010 and 2020. We added to this cohort, a meta-analysis of individual case reports of patients with iPML/PML-IRIS treated with maraviroc published up to 2021. Results Overall, 27 cases were identified in the cohort and 9 from the literature. Among them, 27 met the inclusion criteria: 16 treated with maraviroc and 11 with standard of care (including corticosteroids use). Most cases were related to MS (92.6%) and natalizumab (88%). Inflammatory features (iPML) were present at onset in 12 patients (44.4%), and most patients (92.6%) received corticosteroids within the course of PML. Aggravation due to PML-IRIS was not prevented by maraviroc compared with patients who received only corticosteroids (adjusted odds ratio: 0.408, 95% CI: 0.06–2.63). Similarly, maraviroc did not influence time to clinical worsening due to PML-IRIS (adjusted hazard ratio = 0.529, 95% CI: 0.14–2.0) or disability at the last follow-up (adjusted odds ratio: 2, 95% CI: 0.23–17.3). Discussion The use of CCR5 blockade did not help to keep deleterious immune reconstitution in check even when associated with corticosteroids. Despite maraviroc's reassuring safety profile, this study does not support its use in iPML/PML-IRIS. Classification of Evidence This study provides Class IV evidence showing that adding maraviroc to the management of iatrogenic iPML/PML-IRIS does not improve the outcome.
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Affiliation(s)
- Raphael Bernard-Valnet
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France.
| | - Xavier Moisset
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Nicolas Maubeuge
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Mathilde Lefebvre
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Jean-Christophe Ouallet
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Mathilde Roumier
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Christine Lebrun-Frenay
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Jonathan Ciron
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Damien Biotti
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Pierre Clavelou
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Bertrand Godeau
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Renaud A Du Pasquier
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
| | - Guillaume Martin-Blondel
- From the Service of Neurology (R.B.-V., R.A.D.P.), Department of Clinical Neurosciences, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois) and Lausanne University, Switzerland; Université Clermont Auvergne (X.M., P.C.), CHU de Clermont-Ferrand, Inserm, Neuro-Dol, ; Department of Neurology (N.M.), CHU de Poitiers, Hôpital La Milétrie; Department of Infectious Diseases (M.L., G.M.-B.), Toulouse University Hospital; Service de Neurologie, Pôle des Neurosciences Cliniques (J.-C.O.), CHU de Bordeaux Pellegrin Tripode; Service de Médecine Interne (M.R., B.G.), CHU Henri Mondor, Créteil; CRCSEP Nice (C.L.-F.), CHU de Nice, Université Nice Côte D'Azur, UR2CA-URRIS, Neurologie Pasteur 2; Department of Neurosciences (J.C.,D.B.), Toulouse University Hospital, France
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Bernard-Valnet R, Koralnik IJ, Du Pasquier R. Advances in Treatment of Progressive Multifocal Leukoencephalopathy. Ann Neurol 2021; 90:865-873. [PMID: 34405435 PMCID: PMC9291129 DOI: 10.1002/ana.26198] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 12/19/2022]
Abstract
Progressive multifocal encephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by JC virus (JCV), which occurs in immunocompromised individuals. Management of PML relies on restoration of immunity within the CNS. However, when this restoration cannot be readily achieved, PML has a grim prognosis. Innovative strategies have shown promise in promoting anti‐JCV immune responses, and include T‐cell adoptive transfer or immune checkpoint inhibitor therapies. Conversely, management of immune reconstitution inflammatory syndrome, particularly in iatrogenic PML, remains a major challenge. In this paper, we review recent development in the treatment of PML. ANN NEUROL 2021;90:865–873
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Affiliation(s)
- Raphaël Bernard-Valnet
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Igor J Koralnik
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Renaud Du Pasquier
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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17
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Dohrn MF, Ellrichmann G, Pjontek R, Lukas C, Panse J, Gold R, Schulz JB, Gess B, Tauber SC. Progressive multifocal leukoencephalopathy and immune reconstitution inflammatory syndrome in seven patients with sarcoidosis: a critical discussion of treatment and prognosis. Ther Adv Neurol Disord 2021; 14:17562864211035543. [PMID: 34377151 PMCID: PMC8326823 DOI: 10.1177/17562864211035543] [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: 03/18/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a subacute brain infection by the opportunistic John Cunningham (JC) virus. Herein, we describe seven patients with PML, lymphopenia, and sarcoidosis, in three of whom PML was the first manifestation of sarcoidosis. At onset, the clinical picture comprised rapidly progressive spastic hemi- or limb pareses as well as disturbances of vision, speech, and orientation. Cerebral magnetic resonance imaging showed T2-hyperintense, confluent, mainly supratentorial lesions. Four patients developed punctate contrast enhancement as a radiological sign of an immune reconstitution inflammatory syndrome (IRIS), three of them having a fatal course. In the cerebrospinal fluid, the initial JC virus load (8–25,787 copies/ml) did not correlate with interindividual severity; however, virus load corresponded to clinical dynamics. Brain biopsies (n = 2), performed 2 months after symptom onset, showed spotted demyelination and microglial activation. All patients had lymphopenia in the range of 270–1150/µl. To control JC virus, three patients received a combination of mirtazapine and mefloquine, another two patients additionally took cidofovir. One patient was treated with cidofovir only, and one patient had a combined regimen with mirtazapine, mefloquine, cidofovir, intravenous interleukin 2, and JC capsid vaccination. To treat sarcoidosis, the four previously untreated patients received prednisolone. Three patients had taken immunosuppressants prior to PML onset, which were subsequently stopped as a potential accelerator of opportunistic infections. After 6–54 months of follow up, three patients reached an incomplete recovery, one patient progressed, but survived so far, and two patients died. One further patient was additionally diagnosed with lung cancer, which he died from after 24 months. We conclude that the combination of PML and sarcoidosis is a diagnostic and therapeutic challenge. PML can occur as the first sign of sarcoidosis without preceding immunosuppressive treatment. The development of IRIS might be an indicator of poor outcome.
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Affiliation(s)
- Maike F Dohrn
- Department of Neurology, Medical Faculty of the RWTH Aachen University, Pauwelsstr. 30, Aachen, 52074, Germany
| | - Gisa Ellrichmann
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Rastislav Pjontek
- Department of Diagnostic and Interventional Neuroradiology, Medical Faculty of the RWTH Aachen University, Aachen, Germany
| | - Carsten Lukas
- Department of Radiology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Jens Panse
- Department of Oncology, Hematology and Stem Cell Transplantation, Medical Faculty of the RWTH Aachen University, Aachen, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty of the RWTH Aachen University, Aachen, Germany
| | - Burkhard Gess
- Department of Neurology, Medical Faculty of the RWTH Aachen University, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, Medical Faculty of the RWTH Aachen University, Aachen, Germany
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18
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Borrelli S, Dachy B, Gazagnes MD, Du Pasquier R. Unexpected worsening of progressive multifocal leucoencephalopathy following COVID-19 pneumonia. J Neurovirol 2021; 27:510-513. [PMID: 33876412 PMCID: PMC8054855 DOI: 10.1007/s13365-021-00980-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/25/2021] [Accepted: 04/06/2021] [Indexed: 12/24/2022]
Abstract
Progressive multifocal leucoencephalopathy is a serious side effect of natalizumab, a humanized monoclonal antibody approved for the treatment of multiple sclerosis. Here, we report a case of unexpected worsening of natalizumab-related progressive multifocal leucoencephalopathy following COVID-19. After natalizumab discontinuation, a slight neurological improvement was observed, but, two months later the patient was admitted to the hospital because of neurological deterioration and COVID-19 mild pneumonia. Except for SARS-CoV-2 infection, no other potential factors of neurological worsening were identified. Thus, we pose the hypothesis that SARS-CoV-2 was instrumental in the progressive multifocal leucoencephalopathy deterioration.
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Affiliation(s)
- S Borrelli
- Department of Neurology, Brugmann University Hospital and Free University of Brussels (ULB), Brussels, Belgium.
| | - B Dachy
- Department of Neurology, Brugmann University Hospital and Free University of Brussels (ULB), Brussels, Belgium
| | - M-D Gazagnes
- Department of Neurology, Brugmann University Hospital and Free University of Brussels (ULB), Brussels, Belgium
| | - R Du Pasquier
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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19
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Nakamura R, Kitamura A, Tsukamoto T, Tamura R, Ogawa N, Yamakawa I, Kim H, Kawai M, Sanada M, Urushitani M. The Effect of Intravenous Methylprednisolone on Recurrent Exacerbation in Hematologic Malignancy-associated Progressive Multifocal Leukoencephalopathy. Intern Med 2021; 60:1287-1291. [PMID: 33229808 PMCID: PMC8112991 DOI: 10.2169/internalmedicine.5917-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We herein report a 65-year-old man with progressive multifocal leukoencephalopathy (PML) after 2-year remission from acute myeloid leukemia who developed recurrent episodes of left hemiparesis with gadolinium enhancement on magnetic resonance imaging. Steroid pulse therapy for each exacerbation induced clinical and radiological improvement, suggesting that exacerbations are an excessive immune response to the JC virus and distinct from immune reconstitution inflammatory syndrome (IRIS). Although glucocorticoids are recommended only for IRIS, steroid pulse therapy should be considered as a therapeutic option in cases of exacerbation of hematologic malignancy-associated PML. Importantly, neuroimaging is not sufficient to differentiate excessive inflammation from a controlled inflammatory response, for which steroids are not recommended.
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Affiliation(s)
- Ryutaro Nakamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Akihiro Kitamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | | | - Ryota Tamura
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Nobuhiro Ogawa
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Isamu Yamakawa
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Hyoh Kim
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Michihiro Kawai
- Department of Neurology, Shiga University of Medical Science, Japan
| | - Mitsuru Sanada
- Department of Neurology, Shiga University of Medical Science, Japan
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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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21
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Mansoor S, Mullane G, Adenan MH, Kelly S, Water A, McPartland G, Murphy K. Natalizumab-associated progressive multifocal leukoencephalopathy (PML) in multiple sclerosis (MS): "a case report from Ireland with review of literature, clinical pitfalls and future direction". THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021; 57:7. [PMID: 33437143 PMCID: PMC7789894 DOI: 10.1186/s41983-020-00260-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is one of the most serious treatment-related complications that is encountered in patients with multiple sclerosis (MS). PML is a serious complication of MS treatment which is most commonly related to natalizumab. Case presentation We report clinical course of progressive multifocal leukoencephalopathy (PML) in a 40-year-old man who was on treatment for highly active relapsing-remitting multiple sclerosis with natalizumab (Nz). He was treated with steroids, cidofovir, and mirtazapine and went on to develop long-term disability. The case describes the evolution of PML from diagnosis up till 5 months with changes on sequential brain scans and clinical symptoms in our patient. Conclusion Patients who are on natalizumab should be aware and consented for the risk of PML. They should be periodically re-assessed for their relative PML risk. There is a growing body of evidence that suggests switching patients from natalizumab who have a higher risk of PML to other safer treatment options.
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Affiliation(s)
- Salman Mansoor
- Department of Neurology, Sligo University Hospital, Sligo, Ireland
| | - Gerard Mullane
- Department of Neurology, Sligo University Hospital, Sligo, Ireland
| | | | - Siobhan Kelly
- Department of Neurology, Sligo University Hospital, Sligo, Ireland
| | - Aine Water
- Department of Neurology, Sligo University Hospital, Sligo, Ireland
| | | | - Kevin Murphy
- Department of Neurology, Sligo University Hospital, Sligo, Ireland
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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: 148] [Impact Index Per Article: 37.0] [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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Lauver MD, Lukacher AE. JCPyV VP1 Mutations in Progressive MultifocalLeukoencephalopathy: Altering Tropismor Mediating Immune Evasion? Viruses 2020; 12:v12101156. [PMID: 33053912 PMCID: PMC7600905 DOI: 10.3390/v12101156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022] Open
Abstract
Polyomaviruses are ubiquitous human pathogens that cause lifelong, asymptomatic infections in healthy individuals. Although these viruses are restrained by an intact immune system, immunocompromised individuals are at risk for developing severe diseases driven by resurgent viral replication. In particular, loss of immune control over JC polyomavirus can lead to the development of the demyelinating brain disease progressive multifocal leukoencephalopathy (PML). Viral isolates from PML patients frequently carry point mutations in the major capsid protein, VP1, which mediates virion binding to cellular glycan receptors. Because polyomaviruses are non-enveloped, VP1 is also the target of the host's neutralizing antibody response. Thus, VP1 mutations could affect tropism and/or recognition by polyomavirus-specific antibodies. How these mutations predispose susceptible individuals to PML and other JCPyV-associated CNS diseases remains to be fully elucidated. Here, we review the current understanding of polyomavirus capsid mutations and their effects on viral tropism, immune evasion, and virulence.
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Dunham SR, Schmidt R, Clifford DB. Treatment of Progressive Multifocal Leukoencephalopathy Using Immune Restoration. Neurotherapeutics 2020; 17:955-965. [PMID: 32166631 PMCID: PMC7641288 DOI: 10.1007/s13311-020-00848-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a viral disease of the brain associated with immunodeficiency, immune suppressing medications, and malignancy. In the absence of effective anti-viral therapy for the causative JC virus, immune restoration has emerged as the critical therapeutic alternative. The evolving treatment of PML (and other rare JC virus-associated neurologic syndromes) requires consideration of baseline immune functioning and comorbid diseases while selecting from a number of therapeutic options to restore an effective immune response. This review focuses on the current options for management of PML in typical situations where this disease presents, including several where immune restoration is a standard therapeutic approach such as in PML associated with HIV/AIDS and in multiple sclerosis associated with natalizumab. Other circumstances in which PML occurs including associated with primary immunodeficiencies, malignancies, and transplants present greater challenges to immune reconstitution, but emerging concepts may enhance therapeutic options for these situations. Particular attention is focused on recent experience with checkpoint inhibitors, guidance for MS drug discontinuation, and strategies to monitor and facilitate immune restoration.
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Affiliation(s)
- S Richard Dunham
- Department of Neurology, Washington University in St Louis, St. Louis, MO, USA
| | - Robert Schmidt
- Department of Pathology & Immunology, Washington University in St Louis, St. Louis, MO, USA
| | - David B Clifford
- Department of Neurology, Washington University in St Louis, St. Louis, MO, USA.
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25
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Bianchi A, Ragonese P, Banco MA, Realmuto S, Vazzoler G, Portera E, La Tona G, Salemi G. Four cases of progressive multifocal leukoencephalopathy in iatrogenic immunocompromised patients. eNeurologicalSci 2020; 19:100243. [PMID: 32478179 PMCID: PMC7248236 DOI: 10.1016/j.ensci.2020.100243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/03/2020] [Indexed: 11/06/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS) caused by John Cunningham Virus (JCV). We report four PML cases in immunocompromised patients, respectively treated with (1) Natalizumab, (2) Rituximab, (3) autologous stem-cell transplantation, and (4) Tacrolimus. All patients underwent neurological examination, magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), JCV-DNA research on biological samples, and lymphocytes subpopulation study. All cases presented with motor, behavioural, and cognitive disorders. Visual, sensitive, and cerebellar deficits developed in three cases. MRI revealed widespread progressive demyelinating areas with active borders; three patients presented contrast enhancement. One patient developed inflammatory reconstitution syndrome (IRIS). At MRS, all cases presented decreased N-acetyl-aspartate (NAA) and three cases showed increased choline (Cho). In one patient, plasma and urine tested positive for JCV-DNA, while cerebrospinal fluid (CSF) analysis confirmed JCV in two patients. The fourth patient had a low JCV-DNA blood titer and brain biopsy showed subacute necrosis. Two patients had abnormal lymphocyte subpopulations. Three patients underwent therapy with Mirtazapine, one of whom received Mefloquine in add-on. No clinical response was registered. Clinical onset, MRI and MRS were highly suggestive of PML in all patients, despite three cases presented contrast enhancement. In three cases JCV-DNA detection in biological samples confirmed the diagnosis. The fourth patient fulfilled diagnosis of “presumptive PML”. Our data confirm the importance to complete the diagnostic workup despite the presence of findings not completely consistent with classical PML. We hypothesize that atypical characteristics could due to the clinical conditions leading to PML. Four cases of PML in iatrogenic immunocompromised patients. Clinical presentation was typical for PML. Diagnostic findings were not completely consistent with classical PML. Atypical findings do not exclude diagnosis when clinical data are highly suggestive. It is necessary to improve the diagnostic and therapeutic management of patients.
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Affiliation(s)
- Alessia Bianchi
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Paolo Ragonese
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Maria Aurelia Banco
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Sabrina Realmuto
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy.,Clinic of Neurology and Stroke Unite, Centre of Neuroimmunology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Giulia Vazzoler
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Erika Portera
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Giuseppe La Tona
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neuroscience & Advanced Diagnostic, University of Palermo, Palermo, Italy
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26
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Schwehr NA, Kuntz KM, Enns EA, Shippee ND, Kingwell E, Tremlett H, Carpenter AF, Butler M. Informing Medication Discontinuation Decisions among Older Adults with Relapsing-Onset Multiple Sclerosis. Drugs Aging 2020; 37:225-235. [PMID: 31916231 DOI: 10.1007/s40266-019-00741-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND For older adults with relapsing-onset multiple sclerosis (MS), limited information is available to inform if, or when, disease-modifying drugs (DMDs) may be safely discontinued. OBJECTIVE The aim of this study was to project the outcomes of DMD discontinuation among older adults with relapsing-onset MS. METHODS We projected the 10-year outcomes of discontinuation of a DMD (interferon-β, fingolimod, or natalizumab) among older adults (aged 55 or 70 years) who were relapse-free for 5 or more years and had not reached an Expanded Disability Status Scale (EDSS) score of 6. Outcomes included the percentage of people who had at least one relapse or reached EDSS 6, and quality-adjusted life-years (QALYs), which incorporated both relapses and disability. We used a simulation modeling approach. With increased age, relapses decreased and the effectiveness of DMDs for disability outcomes also decreased. RESULTS We found lower projected benefits for DMD continuation at 70 years of age than at 55 years of age. Compared with discontinuation, the projected benefit of DMD continuation ranged from 0.007 to 0.017 QALYs at 55 years of age and dropped to 0.002-0.006 at 70 years of age. The annual projected benefits of DMD continuation (0.1-3.0 quality-adjusted life-days) were very low compared with typical patient preferences regarding treatment burden. CONCLUSION The benefits of DMDs may not be substantial among older adults with relapsing-onset MS. Direct clinical evidence remains limited and the decision of whether to discontinue a DMD should also take into account patient preferences. It is important to gain a better understanding of how age-related changes in the trajectory of relapsing-onset MS affect treatment effectiveness among older adults.
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Affiliation(s)
- Natalie A Schwehr
- Division of Health Policy and Management, University of Minnesota School of Public Health, MMC729, 420 Delaware St. SE, Minneapolis, MN, 55455, USA.
| | - Karen M Kuntz
- Division of Health Policy and Management, University of Minnesota School of Public Health, MMC729, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, MMC729, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Nathan D Shippee
- Division of Health Policy and Management, University of Minnesota School of Public Health, MMC729, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
| | - Elaine Kingwell
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Helen Tremlett
- Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Adam F Carpenter
- Department of Neurology, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.,Brain Sciences Center, VA Medical Center, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Mary Butler
- Division of Health Policy and Management, University of Minnesota School of Public Health, MMC729, 420 Delaware St. SE, Minneapolis, MN, 55455, USA
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Beck ES, Cortese I. Checkpoint inhibitors for the treatment of JC virus-related progressive multifocal leukoencephalopathy. Curr Opin Virol 2020; 40:19-27. [PMID: 32279025 DOI: 10.1016/j.coviro.2020.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/18/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a frequently fatal brain infection caused by the JC polyomavirus (JCV). PML occurs in people with impaired cellular immunity, and the only effective treatment is restoration of immune function. Infection in immunocompromised hosts is often associated with immune exhaustion, which is mediated by inhibitory cell surface receptors known as immune checkpoints, leading to loss of T cell effector function. Blockade of immune checkpoints can reinvigorate host responses to fight infection. Recently, there have been several reports of checkpoint blockade to treat PML in patients in whom immune reconstitution is otherwise not possible, with some evidence for positive response. Larger studies are needed to better understand efficacy of checkpoint blockade in PML and factors that determine response.
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Affiliation(s)
- Erin S Beck
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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28
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Fukase H, Kajioka T, Oikawa I, Ikeda N, Furuie H. AJM300, a novel oral antagonist of α4-integrin, sustains an increase in circulating lymphocytes: A randomised controlled trial in healthy male subjects. Br J Clin Pharmacol 2020; 86:591-600. [PMID: 31658381 PMCID: PMC7080631 DOI: 10.1111/bcp.14151] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/25/2019] [Accepted: 10/01/2019] [Indexed: 12/26/2022] Open
Abstract
Aims AJM300 is an oral antagonist of α4‐integrin that reduces inflammation by blocking leucocyte trafficking. This study aimed to investigate safety, tolerability, pharmacokinetics and pharmacodynamics of AJM300 in healthy male subjects. Methods A total of 23 subjects were randomised to receive 240 mg (n = 6), 480 mg (n = 5), 960 mg (n = 6) of AJM300 or the corresponding placebo (n = 2 per group). The study drugs were taken orally 3 times daily after each meal on the first day followed by a 4‐day washout period. Thereafter, multiple‐dose administration was conducted for 6 consecutive days. The pharmacokinetic parameters of AJM300 and its active metabolite (HCA2969) were assessed, and total white blood cells and the differential cell count were used to determine the pharmacodynamic effects. Adverse events (AEs) were also monitored. Results The plasma AJM300 and HCA2969 concentration–time curves displayed a triphasic pattern on Day 1 (single‐day administration) and Day 10 (last day of multiple dosing), whereas the concentration of HCA2969 was much higher than that of AJM300. A significant but transient increase in lymphocyte count was observed after AJM300 dosing at all dosages tested compared with the placebo. The increase was sustained over a 24‐h period only at the 960‐mg dosage. In particular, a significant increase in the lymphocyte count compared to placebo (mean, 50.58%; 95% confidence intervals, 20.40–80.76) was observed at the first 960‐mg dose on Day 10. Six (26.1%) subjects reported ≥1 AEs, all of which were mild and resolved spontaneously. Conclusion The maximal and 24‐h sustained pharmacodynamic effects were demonstrated at the 960‐mg dosage after oral administration of AJM300 3 times daily for 6 days, which was also found to be safe and well tolerated.
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Affiliation(s)
- Hiroyuki Fukase
- CPC Clinic, Medipolis Medical Research Institute, Kagoshima, Japan.,Clinical Research Hospital Tokyo, Tokyo, Japan
| | | | - Ichiro Oikawa
- Clinical Development Department, EA Pharma Co., Ltd, Tokyo, Japan
| | - Naoki Ikeda
- Clinical Development Department, EA Pharma Co., Ltd, Tokyo, Japan
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Clerico M, De Mercanti SF, Signori A, Iudicello M, Cordioli C, Signoriello E, Lus G, Bonavita S, Lavorgna L, Maniscalco GT, Curti E, Lorefice L, Cocco E, Nociti V, Mirabella M, Baroncini D, Mataluni G, Landi D, Petruzzo M, Lanzillo R, Gandoglia I, Laroni A, Frangiamore R, Sartori A, Cavalla P, Costantini G, Sormani MP, Capra R. Extending the Interval of Natalizumab Dosing: Is Efficacy Preserved? Neurotherapeutics 2020; 17:200-207. [PMID: 31452081 PMCID: PMC7007494 DOI: 10.1007/s13311-019-00776-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Extending the natalizumab interval after the 24th administration could reduce the risk of progressive multifocal leukoencephalopathy (PML). The objective is to evaluate the noninferiority of the efficacy of an extended interval dosing (EID) compared with the standard interval dosing (SID) of natalizumab. It is an observational, multicenter (14 Italian centers), retrospective cohort study, starting from the 24th natalizumab infusion to the loss of follow-up or 2 years after baseline. Patients were grouped in 2 categories according to the mean number of weeks between doses: < 5 weeks, SID; ≥ 5 weeks, EID. Three hundred and sixty patients were enrolled. Median dose interval (MDI) following 24th infusion was 4.7 weeks, with a bimodal distribution (modes at 4 and 6 weeks). Two hundred and sixteen patients were in the SID group (MDI = 4.3 weeks) and 144 in the EID group (MDI 6.2 weeks). Annualized relapse rate was 0.060 (95% CI = 0.033-0.087) in the SID group and 0.039 (95% CI = 0.017-0.063) in the EID group. The non-inferiority of EID versus SID was satisfied. In conclusion, there is no evidence of a reduced efficacy of natalizumab in an EID setting. This observation confirms previous results and together with the emerging evidence of a reduced risk of PML associated to an EID, supports the need of a randomized study to assess the need to change the standard of the natalizumab dosing schedule.
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Affiliation(s)
- Marinella Clerico
- Clinical and Biological Sciences Department, Neurology Unit, University of Torino, San Luigi Gonzaga Hospital, Regione Gonzole, 10, Orbassano, 10043, Turin, Italy
| | - Stefania Federica De Mercanti
- Clinical and Biological Sciences Department, Neurology Unit, University of Torino, San Luigi Gonzaga Hospital, Regione Gonzole, 10, Orbassano, 10043, Turin, Italy.
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Marco Iudicello
- Clinical and Biological Sciences Department, Neurology Unit, University of Torino, San Luigi Gonzaga Hospital, Regione Gonzole, 10, Orbassano, 10043, Turin, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Center, Spedali Civili of Brescia, Presidio di Montichiari, Brescia, Italy
| | - Elisabetta Signoriello
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Naples, Italy
| | - Giacomo Lus
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Naples, Italy
| | - Simona Bonavita
- Clinic of Neurology, AOU - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigi Lavorgna
- Clinic of Neurology, AOU - University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Erica Curti
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lorena Lorefice
- Multiple Sclerosis Center, Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Center, Binaghi Hospital, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Viviana Nociti
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Massimiliano Mirabella
- Multiple Sclerosis Center, Neuroscience Area, Neuroscience, Aging, Head and Neck and Orthopaedics Sciences Department, Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Damiano Baroncini
- Centro Sclerosi Multipla - Presidio ospedaliero di Gallarate - ASST Valle Olona, Gallarate, Italy
| | - Giorgia Mataluni
- UOSD Centro di Riferimento Regionale Sclerosi Multipla - Dipartimento di Neuroscienze Policlinico Tor Vergata, Rome, Italy
| | - Doriana Landi
- UOSD Centro di Riferimento Regionale Sclerosi Multipla - Dipartimento di Neuroscienze Policlinico Tor Vergata, Rome, Italy
| | - Martina Petruzzo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, Multiple Sclerosis Centre, Federico II University, Naples, Italy
| | - Roberta Lanzillo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, Multiple Sclerosis Centre, Federico II University, Naples, Italy
| | - Ilaria Gandoglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research, University of Genova, Genoa, Italy
| | - Alice Laroni
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Rita Frangiamore
- Department of Neuroimmunology and Neuromuscular Diseases, Neurological Institute C. Besta, IRCCS Foundation, Milan, Italy
| | - Arianna Sartori
- Neurology Unit, Azienda Sanitaria Univeristaria Integrata Clinica Neurologica, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Trieste, Italy
| | - Paola Cavalla
- Department of Neuroscience, Città della Salute e della Scienza di Torino University Hospital, Turin, Italy
| | - Gianfranco Costantini
- Department of Neuroscience, Città della Salute e della Scienza di Torino University Hospital, Turin, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili of Brescia, Presidio di Montichiari, Brescia, Italy
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Kartau M, Sipilä JO, Auvinen E, Palomäki M, Verkkoniemi-Ahola A. Progressive Multifocal Leukoencephalopathy: Current Insights. Degener Neurol Neuromuscul Dis 2019; 9:109-121. [PMID: 31819703 PMCID: PMC6896915 DOI: 10.2147/dnnd.s203405] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Cases of PML should be evaluated according to predisposing factors, as these subgroups differ by incidence rate, clinical course, and prognosis. The three most significant groups at risk of PML are patients with hematological malignancies mostly previously treated with immunotherapies but also untreated, patients with HIV infection, and patients using monoclonal antibody (mAb) treatments. Epidemiological data is scarce and partly conflicting, but the distribution of the subgroups appears to have changed. While there is no specific anti-JCPyV treatment, restoration of the immune function is the most effective approach to PML treatment. Research is warranted to determine whether immune checkpoint inhibitors could benefit certain PML subgroups. There are no systematic national or international records of PML diagnoses or a risk stratification algorithm, except for MS patients receiving natalizumab (NTZ). These are needed to improve PML risk assessment and to tailor better prevention strategies.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jussi Ot Sipilä
- Department of Neurology, Siun Sote, North Carelia Central Hospital, Joensuu, Finland.,Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Clinical Neurosciences, University of Turku, Turku, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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Successful treatment of non-HIV progressive multifocal leukoencephalopathy: case report and literature review. J Neurol 2019; 267:731-738. [PMID: 31728711 DOI: 10.1007/s00415-019-09629-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a subacute onset demyelinating disease caused by JC virus and characterized by multifocal involvement of the subcortical white matter and cerebellar hemispheres or peduncles on magnetic resonance imaging (MRI). However, non-HIV PML patients with brain lesions limited to the cerebellum and brainstem have not been well characterized. METHODS We report a 68-year-old man with systemic lupus erythematosus under treatment with immunosuppressants who developed non-HIV PML with brain lesions limited to the cerebellum and brainstem and successfully treated with a combination of mefloquine and mirtazapine. We performed a literature review to characterize patients with non-HIV PML with brain lesions limited to the cerebellum and brainstem. RESULTS Eight cases with non-HIV brainstem/cerebellar form PML were identified including our case. All cases had compromised status related underlying diseases. Four (50%) had a good prognosis. Five cases were treated, including 3 with favourable outcomes. Between the good prognosis group (n = 4) and the poor prognosis group (n = 4), treatment status for PML and the interval between the initial manifestation and diagnosis did not differ. Among those who performed contrast-enhanced brain imaging, lesion enhancement was related to good prognosis (good prognosis group vs. poor prognosis group; 100% vs. 0%). CONCLUSION PML should be considered in the differential diagnosis of brain lesions limited to the cerebellum and brainstem in immunocompromised patients. The presence of immune response against JC virus and inflammatory reactions may indicate good prognosis in non-HIV brainstem/cerebellar form PML.
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Padmanabhan A, Connelly-Smith L, Aqui N, Balogun RA, Klingel R, Meyer E, Pham HP, Schneiderman J, Witt V, Wu Y, Zantek ND, Dunbar NM, Schwartz GEJ. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34:171-354. [PMID: 31180581 DOI: 10.1002/jca.21705] [Citation(s) in RCA: 757] [Impact Index Per Article: 151.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute & Blood Research Institute, Versiti & Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Connelly-Smith
- Department of Medicine, Seattle Cancer Care Alliance & University of Washington, Seattle, Washington
| | - Nicole Aqui
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rasheed A Balogun
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany & First Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erin Meyer
- Department of Hematology/Oncology/BMT/Pathology, Nationwide Children's Hospital, Columbus, Ohio
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer Schneiderman
- Department of Pediatric Hematology/Oncology/Neuro-oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Volker Witt
- Department for Pediatrics, St. Anna Kinderspital, Medical University of Vienna, Vienna, Austria
| | - Yanyun Wu
- Bloodworks NW & Department of Laboratory Medicine, University of Washington, Seattle, Washington, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb) 2019; 118:101863. [PMID: 31561185 DOI: 10.1016/j.tube.2019.101863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.
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Affiliation(s)
- Paula M Cevaal
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Sabine Hermans
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands; Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
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Rommer PS, Milo R, Han MH, Satyanarayan S, Sellner J, Hauer L, Illes Z, Warnke C, Laurent S, Weber MS, Zhang Y, Stuve O. Immunological Aspects of Approved MS Therapeutics. Front Immunol 2019; 10:1564. [PMID: 31354720 PMCID: PMC6637731 DOI: 10.3389/fimmu.2019.01564] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Multiple sclerosis (MS) is the most common neurological immune-mediated disease leading to disability in young adults. The outcome of the disease is unpredictable, and over time, neurological disabilities accumulate. Interferon beta-1b was the first drug to be approved in the 1990s for relapsing-remitting MS to modulate the course of the disease. Over the past two decades, the treatment landscape has changed tremendously. Currently, more than a dozen drugs representing 1 substances with different mechanisms of action have been approved (interferon beta preparations, glatiramer acetate, fingolimod, siponimod, mitoxantrone, teriflunomide, dimethyl fumarate, cladribine, alemtuzumab, ocrelizumab, and natalizumab). Ocrelizumab was the first medication to be approved for primary progressive MS. The objective of this review is to present the modes of action of these drugs and their effects on the immunopathogenesis of MS. Each agent's clinical development and potential side effects are discussed.
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Affiliation(s)
- Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - May H. Han
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Sammita Satyanarayan
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Sarah Laurent
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Martin S. Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Yinan Zhang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Olaf Stuve
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Neurology Section, VA North Texas Health Care System, Medical Service Dallas, VA Medical Center, Dallas, TX, United States
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Prosperini L, Kinkel RP, Miravalle AA, Iaffaldano P, Fantaccini S. Post-natalizumab disease reactivation in multiple sclerosis: systematic review and meta-analysis. Ther Adv Neurol Disord 2019. [PMID: 30956686 DOI: 10.1177/1756286419837809.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Natalizumab (NTZ) is sometimes discontinued in patients with multiple sclerosis, mainly due to concerns about the risk of progressive multifocal leukoencephalopathy. However, NTZ interruption may result in recrudescence of disease activity. Objective The objective of this study was to summarize the available evidence about NTZ discontinuation and to identify which patients will experience post-NTZ disease reactivation through meta-analysis of existing literature data. Methods PubMed was searched for articles reporting the effects of NTZ withdrawal in adult patients (⩾18 years) with relapsing-remitting multiple sclerosis (RRMS). Definition of disease activity following NTZ discontinuation, proportion of patients who experienced post-NTZ disease reactivation, and timing to NTZ discontinuation to disease reactivation were systematically reviewed. A generic inverse variance with random effect was used to calculate the weighted effect of patients' clinical characteristics on the risk of post-NTZ disease reactivation, defined as the occurrence of at least one relapse. Results The original search identified 205 publications. Thirty-five articles were included in the systematic review. We found a high level of heterogeneity across studies in terms of sample size (10 to 1866 patients), baseline patient characteristics, follow up (1-24 months), outcome measures (clinical and/or radiological), and definition of post-NTZ disease reactivation or rebound. Clinical relapses were observed in 9-80% of patients and peaked at 4-7 months, whereas radiological disease activity was observed in 7-87% of patients starting at 6 weeks following NTZ discontinuation. The meta-analysis of six articles, yielding a total of 1183 patients, revealed that younger age, higher number of relapses and gadolinium-enhanced lesions before treatment start, and fewer NTZ infusions were associated with increased risk for post-NTZ disease reactivation (p ⩽ 0.05). Conclusions Results from the present review and meta-analysis can help to profile patients who are at greater risk of post-NTZ disease reactivation. However, potential reporting bias and variability in selected studies should be taken into account when interpreting our data.
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Affiliation(s)
- Luca Prosperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Revere P Kinkel
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Augusto A Miravalle
- Advanced Neurology of Colorado, MS Center of the Rockies, University of Colorado Denver, Aurora, CO, USA
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
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Prosperini L, Kinkel RP, Miravalle AA, Iaffaldano P, Fantaccini S. Post-natalizumab disease reactivation in multiple sclerosis: systematic review and meta-analysis. Ther Adv Neurol Disord 2019; 12:1756286419837809. [PMID: 30956686 PMCID: PMC6444403 DOI: 10.1177/1756286419837809] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 11/04/2018] [Indexed: 12/25/2022] Open
Abstract
Background: Natalizumab (NTZ) is sometimes discontinued in patients with multiple
sclerosis, mainly due to concerns about the risk of progressive multifocal
leukoencephalopathy. However, NTZ interruption may result in recrudescence
of disease activity. Objective: The objective of this study was to summarize the available evidence about NTZ
discontinuation and to identify which patients will experience post-NTZ
disease reactivation through meta-analysis of existing literature data. Methods: PubMed was searched for articles reporting the effects of NTZ withdrawal in
adult patients (⩾18 years) with relapsing–remitting multiple sclerosis
(RRMS). Definition of disease activity following NTZ discontinuation,
proportion of patients who experienced post-NTZ disease reactivation, and
timing to NTZ discontinuation to disease reactivation were systematically
reviewed. A generic inverse variance with random effect was used to
calculate the weighted effect of patients’ clinical characteristics on the
risk of post-NTZ disease reactivation, defined as the occurrence of at least
one relapse. Results: The original search identified 205 publications. Thirty-five articles were
included in the systematic review. We found a high level of heterogeneity
across studies in terms of sample size (10 to 1866 patients), baseline
patient characteristics, follow up (1–24 months), outcome measures (clinical
and/or radiological), and definition of post-NTZ disease reactivation or
rebound. Clinical relapses were observed in 9–80% of patients and peaked at
4–7 months, whereas radiological disease activity was observed in 7–87% of
patients starting at 6 weeks following NTZ discontinuation. The
meta-analysis of six articles, yielding a total of 1183 patients, revealed
that younger age, higher number of relapses and gadolinium-enhanced lesions
before treatment start, and fewer NTZ infusions were associated with
increased risk for post-NTZ disease reactivation (p ⩽
0.05). Conclusions: Results from the present review and meta-analysis can help to profile
patients who are at greater risk of post-NTZ disease reactivation. However,
potential reporting bias and variability in selected studies should be taken
into account when interpreting our data.
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Affiliation(s)
- Luca Prosperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Revere P Kinkel
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Augusto A Miravalle
- Advanced Neurology of Colorado, MS Center of the Rockies, University of Colorado Denver, Aurora, CO, USA
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
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Shirani A, Stüve O. Natalizumab: Perspectives from the Bench to Bedside. Cold Spring Harb Perspect Med 2018; 8:cshperspect.a029066. [PMID: 29500304 DOI: 10.1101/cshperspect.a029066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Probably no other disease-modifying drug for multiple sclerosis has a more fascinating story than natalizumab from both the bench to bedside perspective and the postmarketing experience standpoint. Natalizumab is a monoclonal antibody that inhibits the trafficking of lymphocytes from the blood into the central nervous system by blocking the adhesion molecule α4-integrin. Natalizumab was approved as a disease-modifying drug for relapsing remitting multiple sclerosis only 12 years after the discovery of its target molecule-a time line that is rather fast for drug development. However, a few months after its U.S. Food and Drug Administration approval, natalizumab was withdrawn from the market because of an unanticipated complication-progressive multifocal leukoencephalopathy. It was later reinstated with required adherence to a strict monitoring program and incorporation of mitigation strategies.
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Affiliation(s)
- Afsaneh Shirani
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas 75390
| | - Olaf Stüve
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas 75390.,Neurology Section, VA North Texas Health Care System, Medical Service Dallas, VA Medical Center, Dallas, Texas 75216
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Yamout BI, Sahraian MA, Ayoubi NE, Tamim H, Nicolas J, Khoury SJ, Zeineddine MM. Efficacy and safety of natalizumab extended interval dosing. Mult Scler Relat Disord 2018; 24:113-116. [PMID: 29982107 DOI: 10.1016/j.msard.2018.06.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/28/2018] [Accepted: 06/19/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE It is postulated that extending the dosing interval of natalizumab (NTZ) from 4 to 5-8 weeks might decrease the risk of progressive multifocal leukoencephalopathy (PML). The aim of this study was to assess the effect of extended interval dosing (EID) on the therapeutic efficacy of natalizumab. METHODS We reviewed 85 patients treated at two MS centers in the Middle East with natalizumab for at least 6 months using EID. Patients were shifted after an initial treatment period at standard interval dosing (SID) to an EID ranging from 5-8 weeks. RESULTS The mean treatment duration on SID and EID was 15.4 ± 11.9 and 11.8 ± 7.0 months, respectively. By the end of SID and EID treatment 95.3% and 93.9% of patients were free of relapses (P = 0.41) with an annualized relapse rate (ARR) of 0.0006 and 0.001 respectively (P = 0.42). The mean EDSS at the end of SID and EID periods was 2.56 ± 1.62 and 2.59 ± 1.61 respectively (P = 0.84). A total of 97.6% and 94.7% of patients had no enhancing lesions on MRI during the SID and EID periods respectively (P = 0.18). There were no cases of PML and the rate of infections was lower during the EID period. CONCLUSION In patients treated with natalizumab, shifting from SID to EID has no negative effect on efficacy as evidenced by relapse rate, disability progression and MRI activity.
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Affiliation(s)
- Bassem I Yamout
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nabil El Ayoubi
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johnny Nicolas
- Faculty of Medicine, American University of Beirut, Lebanon
| | - Samia J Khoury
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Maya M Zeineddine
- Nehme and Therese Tohme Multiple Sclerosis Center, American University of Beirut Medical Center, Beirut, Lebanon
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40
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Wattjes MP, Wijburg MT, van Eijk J, Frequin S, Uitdehaag BMJ, Barkhof F, Warnke C, Killestein J. Inflammatory natalizumab-associated PML: baseline characteristics, lesion evolution and relation with PML-IRIS. J Neurol Neurosurg Psychiatry 2018; 89:535-541. [PMID: 29142146 DOI: 10.1136/jnnp-2017-316886] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVE Natalizumab-associated progressive multifocal leukoencephalopathy (NTZ-PML) patients may show imaging signs suggestive of inflammation at diagnosis ('inflammatory PML'), reminiscent of PML-immune reconstitution inflammatory syndrome (PML-IRIS). We investigated the imaging characteristics of inflammatory NTZ-PML lesions and PML-IRIS to determine differentiating and overlapping features. METHODS We scored the presence, localisation and pattern of imaging characteristics of inflammation on brain MRI scans of inflammatory NTZ-PML patients. The imaging characteristics were followed up until the occurrence of PML-IRIS. RESULTS Ten out of the 44 NTZ-PML patients included showed signs suggestive of inflammation at the time of diagnosis. The inflammation pattern at diagnosis was similar to the pattern seen at PML-IRIS, with contrast enhancement representing the most frequent sign of inflammation (90% at diagnosis, 100% at PML-IRIS). However, the severity of inflammation differed, with absence of swelling and low frequency of perilesional oedema (10%) at diagnosis, as compared with the PML-IRIS stage (40%). CONCLUSION Patterns of inflammation at the time of PML diagnosis and at the PML-IRIS stage overlap but differ in their severity of inflammation. This supports histopathological evidence that the inflammation seen at both stages of the same disease shares a similar underlying pathophysiology, representing the immune response to the JC virus to a variable extend.
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Affiliation(s)
- Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany.,Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn T Wijburg
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Jeroen van Eijk
- Department of Neurology, Jeroen Bosch Ziekenhuis, s'Hertogenbosch, The Netherlands
| | - Stephan Frequin
- Department of Neurology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Bernard M J Uitdehaag
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.,Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Joep Killestein
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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van Langelaar J, van der Vuurst de Vries RM, Janssen M, Wierenga-Wolf AF, Spilt IM, Siepman TA, Dankers W, Verjans GMGM, de Vries HE, Lubberts E, Hintzen RQ, van Luijn MM. T helper 17.1 cells associate with multiple sclerosis disease activity: perspectives for early intervention. Brain 2018; 141:1334-1349. [DOI: 10.1093/brain/awy069] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/19/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jamie van Langelaar
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Roos M van der Vuurst de Vries
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Malou Janssen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Annet F Wierenga-Wolf
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Isis M Spilt
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Theodora A Siepman
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wendy Dankers
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Georges M G M Verjans
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Research Center for Emerging Infections and Zoonosis, University of Veterinary Medicine, Hannover, Germany
| | - Helga E de Vries
- Department of Molecular Cell Biology and Immunology; Neuroscience Campus Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Erik Lubberts
- Department of Rheumatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Rogier Q Hintzen
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marvin M van Luijn
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- MS Center ErasMS at Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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T cell deficiencies as a common risk factor for drug associated progressive multifocal leukoencephalopathy. Immunobiology 2018; 223:508-517. [PMID: 29472141 DOI: 10.1016/j.imbio.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/19/2018] [Accepted: 01/21/2018] [Indexed: 01/07/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a disease of the central nervous system caused by neuropathogenic prototypes of ubiquitous community-acquired JC virus (JCV). The disease became of particular concern following its association with certain therapies that modulate immune system function without heavy immunosuppression. Due to lack of prophylactic/treatment options and poor outcomes, which often include severe disability or death, PML is a considerable concern for development of new drugs that interfere with immune system functions. In this review of clinical and research findings, we discuss the evidence that deficiencies in CD4+ T helper cells, cytotoxic CD8+ T cells, and interferon gamma are of crucial importance for development of PML under a variety of circumstances, including those associated with use of various drugs, regardless of differences in their mechanisms of action. These deficiencies apparently enable transformation of the harmless JCV archetype into neuropathogenic prototypes, but the site(s), and the mechanisms, of this transformation are yet to be elucidated. Here we discuss the evidence for brain as one of the sites of this transformation, and propose a model of PML pathogenesis that emphasizes the central role of T cell deficiencies in the two life cycles of the JCV, one non-pathogenic and one neuropathogenic. Finally, we conclude that the development of clinical grade T cell functional tests and more consistent use of already available laboratory tests for T cell subset analysis would greatly aid the effort to more accurately predict and assess the magnitude of PML risk for concerned therapeutic interventions.
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Hodel J, Bapst B, Outteryck O, Verclytte S, Deramecourt V, Benadjaoud MA, Pruvo JP, Vermersch P, Leclerc X. Magnetic resonance imaging changes following natalizumab discontinuation in multiple sclerosis patients with progressive multifocal leukoencephalopathy. Mult Scler 2018; 24:1902-1908. [PMID: 29343163 DOI: 10.1177/1352458517750765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Detecting early progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome (PML-IRIS) is clinically relevant. OBJECTIVE Evaluating magnetic resonance imaging (MRI) changes following natalizumab (NTZ) discontinuation and preceding PML-IRIS. METHODS MRIs (including diffusion-weighted imaging (DWI), T2-weighted fluid-attenuated inversion recovery (T2-FLAIR), post-contrast T1-weighted sequences) were performed every week following PML diagnosis in 11 consecutive NTZ-PML patients. PML expansion, punctate lesions, contrast-enhancement, and mass-effect/edema were evaluated on each MRI sequence, following NTZ discontinuation. RESULTS PML-IRIS occurred from 26 to 89 days after NTZ discontinuation. MRI changes prior to early PML-IRIS appeared significantly more pronounced using DWI compared to T2-FLAIR imaging (p < 0.003). Two DWI features (marked PML expansion, punctate lesions) systematically preceded contrast-enhancement. CONCLUSION Subtle changes may occur on DWI preceding contrast-enhancement.
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Affiliation(s)
- Jérôme Hodel
- Departments of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France; Faculty of Medicine, Université Paris Est Créteil, Créteil, France
| | - Blanche Bapst
- Departments of Neuroradiology, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France/Faculty of Medicine, Université Paris Est Créteil, Créteil, France
| | - Olivier Outteryck
- Department of Neurology, CHU Lille, Lille, France/University of Lille, CHU Lille, LIRIC-INSERM U995, FHU Imminent, Lille, France
| | | | | | - Mohamed Amine Benadjaoud
- Institute of Radiological Protection and Nuclear Safety (IRSN), Human Health Radiation Protection Unit, Fontenay-aux-Roses, France
| | - Jean-Pierre Pruvo
- University of Lille, CHU Lille, INSERM U1171 - Degenerative and Vascular Cognitive Disorders, F-59045 Lille, France/Department of Neuroradiology, University of Lille, CHU Lille, F-59000, Lille, France
| | - Patrick Vermersch
- Department of Neurology, CHU Lille, Lille, France/University of Lille, CHU Lille, LIRIC-INSERM U995, FHU Imminent, Lille, France
| | - Xavier Leclerc
- University of Lille, CHU Lille, INSERM U1171 - Degenerative and Vascular Cognitive Disorders, F-59045 Lille, France/Department of Neuroradiology, University of Lille, CHU Lille, F-59000, Lille, France
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Nishiyama S, Misu T, Shishido-Hara Y, Nakamichi K, Saijo M, Takai Y, Takei K, Yamamoto N, Kuroda H, Saito R, Watanabe M, Tominaga T, Nakashima I, Fujihara K, Aoki M. Fingolimod-associated PML with mild IRIS in MS: A clinicopathologic study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 5:e415. [PMID: 29725611 PMCID: PMC5930970 DOI: 10.1212/nxi.0000000000000415] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/26/2017] [Indexed: 12/29/2022]
Abstract
Objective: To clarify the clinical, neuropathologic, and virologic characteristics of progressive multifocal leukoencephalopathy (PML) and its immune reconstitution inflammatory syndrome (IRIS) in a patient with fingolimod-treated MS. Methods: A case study. Results: A 34-year-old patient with MS using fingolimod for 4 years had a gradual progression of right hemiparesis and aphasia with a new subcortical white matter lesion in the precentral gyrus by initial MRI. Blood tests were normal, except for lymphopenia (160 cells/μL). One month after the cessation of fingolimod, brain MRI depicted a diffusely exacerbated hyperintensity on fluid-attenuated inversion recovery and diffusion-weighed imaging in the white matter with punctate gadolinium enhancement, suggesting PML-IRIS. A very low level of JC virus (JCV)-DNA (15 copies/mL) was detected in the CSF as judged by quantitative PCR. Brain tissues were biopsied from the left frontal lesion, which showed some small demyelinated foci with predominant loss of myelin-associated glycoprotein with infiltrations of lymphocytes and macrophages, but clear viral inclusion was not observed with hematoxylin-eosin staining. JCV-DNA was uniquely detectable in an active inflammatory demyelinating lesion by in situ hybridization, possibly suggesting an early phase of PML. DNA extracted from the brain sample was positive for JCV-DNA (151 copies/cell). It took 3 months to normalize the blood lymphocyte count. The patient was treated with 1 g of IV methylprednisolone for 3 days and a weekly oral dose (375 mg) of mefloquine, and her symptoms gradually improved. Conclusion: Low CSF JCV-DNA and unfound viral inclusions initially made her diagnosis difficult. The clinical course of fingolimod-associated PML may be associated with mild immune reconstitution.
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Affiliation(s)
- Shuhei Nishiyama
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Tatsuro Misu
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Yukiko Shishido-Hara
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Kazuo Nakamichi
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Masayuki Saijo
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Yoshiki Takai
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Kentarou Takei
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Naoki Yamamoto
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Hiroshi Kuroda
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Ryuta Saito
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Mika Watanabe
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Teiji Tominaga
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Ichiro Nakashima
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Kazuo Fujihara
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
| | - Masashi Aoki
- Department of Neurology (S.N., T.M., Y.T., K.T., N.Y., H.K., M.A.), Department of Multiple Sclerosis Therapeutics (T.M.), Department of Neurosurgery (R.S., T.T.), and Department of Pathology (M.W.), Tohoku University Graduate School of Medicine, Sendai; Department of Anatomic Pathology (Y.S.-H.), Tokyo Medical University; Department of Virology 1 (K.N., M.S.), Laboratory of Neurovirology, National Institute of Infectious Diseases; Department of Neurology (I.N.), Tohoku Medical and Pharmaceutical University, Sendai; and Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University School of Medicine and Multiple Sclerosis and Neuromyelitis Optica Center, Southern TOHOKU Research Institute for Neuroscience, Japan
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45
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To do or not to do? plasma exchange and timing of steroid administration in progressive multifocal leukoencephalopathy. Ann Neurol 2017; 82:697-705. [DOI: 10.1002/ana.25070] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 08/30/2017] [Accepted: 09/29/2017] [Indexed: 11/07/2022]
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Williamson EML, Berger JR. Diagnosis and Treatment of Progressive Multifocal Leukoencephalopathy Associated with Multiple Sclerosis Therapies. Neurotherapeutics 2017; 14:961-973. [PMID: 28913726 PMCID: PMC5722774 DOI: 10.1007/s13311-017-0570-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare, but serious, complication encountered in patients treated with a select number of disease-modifying therapies (DMTs) utilized in treating multiple sclerosis (MS). PML results from a viral infection in the brain for which the only demonstrated effective therapy is restoring the perturbed immune system-typically achieved in the patient with MS by removing the offending therapeutic agent or, in the case of HIV-associated PML, treatment with highly active antiretroviral therapies. Other therapies for PML remain either ineffective or experimental. Significant work to understand the virus and host interaction has been undertaken, but lack of an animal model for the disorder has significantly hindered progress, especially with respect to development of treatments. Strategies to limit risk of PML with natalizumab, a drug that carries a uniquely high risk for the development of the disorder, have been developed. Identifying factors such as positive JC virus antibody status that increase PML risk, at least in theory, should decrease the incidence rate of the disease. Whether other risk factors for PML can be identified and validated or unique strategies should be employed in association with other DMTs that predispose to PML and whether this has a salutary effect on outcome remains to be demonstrated. Identifying PML early, then promptly eliminating drug in the case of natalizumab-associated PML has demonstrated better outcomes, but the complication of PML continues to carry significant morbidity and mortality. While the scientific community has yet to identify targeted therapy with proven efficacy against JCV or PML there are several candidates being studied.
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Affiliation(s)
- Eric M L Williamson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Joseph R Berger
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Sedal L, Winkel A, Laing J, Law LY, McDonald E. Current concepts in multiple sclerosis therapy. Degener Neurol Neuromuscul Dis 2017; 7:109-125. [PMID: 30050382 PMCID: PMC6053095 DOI: 10.2147/dnnd.s109251] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Over the past 20 years, the available therapies for multiple sclerosis have expanded exponentially. With several more agents likely to be approved for public funding in Australia in the next 12 months on top of the existing multitude of Australian Pharmaceutical Benefits Scheme-subsidized therapies, the choice is becoming even more complex. This review summarizes the current state of available therapies and anticipates likely future directions, including an important focus on contemporary symptom management. For each agent, the major trials, side effects, and clinical utility are summarized, with a particular focus on the Australian experience of these therapies. It is hoped this review provides an up-to-date reference of the exciting current state of multiple sclerosis therapy.
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Affiliation(s)
- Leslie Sedal
- Department of Neurology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia,
| | - Antony Winkel
- Department of Neurology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia,
| | - Joshua Laing
- Department of Neurology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia,
| | - Lai Yin Law
- Department of Neurology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia,
| | - Elizabeth McDonald
- Department of Neurology, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia,
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Himedan M, Camelo-Piragua S, Mills EA, Gupta A, Aburashed R, Mao-Draayer Y. Pathologic Findings of Chronic PML-IRIS in a Patient with Prolonged PML Survival Following Natalizumab Treatment. J Investig Med High Impact Case Rep 2017; 5:2324709617734248. [PMID: 28989935 PMCID: PMC5624358 DOI: 10.1177/2324709617734248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/01/2017] [Accepted: 09/04/2017] [Indexed: 12/02/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a common complication during treatment for natalizumab-associated progressive multifocal leukoencephalopathy (PML). Although severe IRIS can result in acute worsening of disability and is associated with poor prognosis, effective immune reconstitution may account for the high survival rate of this cohort of PML patients. We present pathological evidence of chronic IRIS 3.5 years after diagnosis with natalizumab-associated PML. Our case showed that the IRIS initially developed after plasma exchange therapy and resolved clinically and radiologically following a combination treatment with corticosteroids, maraviroc, and cidofovir. Autopsy 3.5 years later revealed evidence of grey-white matter junction demyelinating lesions characteristic of PML and perivascular leukocyte infiltrates predominated by CD8+ T-lymphocytes, and polymerase chain reaction analysis demonstrated the presence of JC viral DNA in this tissue, indicative of persistent PML-IRIS. While clinical symptoms of PML-IRIS typically stabilize within 6 months, our case report suggests that prolonged low-grade inflammation may persist in some patients. Better assays are needed to determine the prevalence of prolonged low-grade IRIS among PML survivors.
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Davies SI, Muranski P. T cell therapies for human polyomavirus diseases. Cytotherapy 2017; 19:1302-1316. [PMID: 28927823 DOI: 10.1016/j.jcyt.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/10/2017] [Indexed: 12/24/2022]
Abstract
Rapid restoration of virus-specific T immunity via adoptive transfer of ex vivo generated T cells has been proven as a powerful therapy for patients with advanced cancers and refractory viral infections such as cytomegalovirus (CMV) and Epstein-Barr virus (EBV). BK virus (BKV), John Cunningham virus (JCV), and Merkel cell carcinoma virus (MCV) are the members of the rapidly growing human polyomavirus (hPyV) family that commonly infects most healthy humans. These viruses have a clearly established potential for causing severe end-organ damage or malignant transformation, especially in individuals with weakened immunity who are unable to mount or regain endogenous T-cell responses as a result of underlying leukemia or iatrogenic immunosuppression in autoimmunity, bone marrow and solid organ transplant settings. Here we will discuss recent advances in using T-cell-based immunotherapies to save patients suffering from PyV-associated diseases including hemorrhagic cystitis, BKV virus-associated nephropathy, and JC-associated progressive multifocal leukoencephalopathy (PML). We will also review progress in the understanding of Merkel cell carcinoma (MCC) as a virally driven tumor that is amenable to immune intervention and can be targeted with adoptively transferred T cells specific for viral oncoproteins.
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Affiliation(s)
- Sarah I Davies
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Department of Microbiology and Immunology, Georgetown University Medical Center, Washington, DC, USA
| | - Pawel Muranski
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Columbia Center for Translational Immunology, Division of Hematology and Oncology, Columbia University Medical Center, New York, NY, USA.
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Schneider R, Bellenberg B, Hoepner R, Ellrichmann G, Gold R, Lukas C. Insight into Metabolic 1H-MRS Changes in Natalizumab Induced Progressive Multifocal Leukoencephalopathy Brain Lesions. Front Neurol 2017; 8:454. [PMID: 28928709 PMCID: PMC5591840 DOI: 10.3389/fneur.2017.00454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/16/2017] [Indexed: 12/13/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is a severe complication of immunosuppressive therapies, especially of natalizumab in relapsing–remitting multiple sclerosis (MS). Metabolic changes within PML lesions have not yet been described in natalizumab-associated PML in MS patients. Objective To study metabolic profiles in natalizumab-associated PML lesions of MS patients by 1H magnetic resonance spectroscopy (1H-MRS) at different stages during the PML course. To assess changes associated with the occurrence of the immune reconstitution inflammatory syndrome (IRIS). Methods 20 patients received 1H-MRS and imaging at 3 T either in the pre-IRIS, IRIS, early-post-PML, or late post-PML setting. Five of these patients received individual follow-up examinations, including the pre-IRIS or IRIS phase. Clinical worsening was described by changes in the Karnofsky Performance Scale (KPS) and the expanded disability status scale (EDSS) 1 year before PML and scoring at the time of 1H-MRS. Results In PML lesions, increased levels of the Lip/Cr ratio, driven by rising of lipid and reduction of Creatine, were found before the occurrence of IRIS (p = 0.014) with a maximum in the PML–IRIS group (p = 0.004). By contrast, marked rises of Cho/Cr in PML lesions were detected exclusively during the IRIS phase (p = 0.003). The Lip/Cr ratio decreased to above-normal levels in early-post-PML (p = 0.007, compared to normal appearing white matter (NAWM)) and to normal levels in the late-post-PML group. NAA/Cho was reduced compared to NAWM in the pre-IRIS, IRIS, and early-post-PML group. In NAA/Cr, the same effect was seen in the pre-IRIS and early-post-PML group. These cross-sectional results were confirmed by the individual follow-up examinations of four patients. NAA/Cho, Cho/Cr, and the lipid rise relative to NAWM in PML lesions were significantly correlated with the residual clinical worsening (KPS change) in post-PML patients (Spearman correlations ρ = 0.481, p = 0.018; ρ = −0.505, p = 0.014; and ρ = −0.488, p = 0.020). Conclusion 1H-MRS detected clinically significant dynamic changes of metabolic patterns in PML lesions during the course of natalizumab-associated PML in MS patients. Lip/Cr and Cho/Cr may provide additional information for detecting the onset of the IRIS phase in the course of the PML disease.
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Affiliation(s)
- Ruth Schneider
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Barbara Bellenberg
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Robert Hoepner
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Gisa Ellrichmann
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Carsten Lukas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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