Evidence of disease activity during pregnancy and post-partum in MS patients treated with high-efficacy therapies

BACKGROUND

Multiple sclerosis (MS) predominantly affects women of childbearing age. Due to the risk of teratogenicity, women with active multiple sclerosis (MS) who require high-efficacy therapies (HET) may need to discontinue treatment during pregnancy. Fingolimod and Natalizumab withdrawal increases the risk of disease reactivation, a risk not commonly associated with anti-CD20 therapies. However, comparative data are limited during pregnancy and post-partum. Our aim was to compare evidence of disease activity during pregnancy and post-partum in women treated with HET (anti-CD20 therapies, Natalizumab or Fingolimod) before conception, whether or not exposed during pregnancy.

METHODS

In this single-center retrospective study, we included consecutive pregnancies of relapsing-remitting MS patients and classified them in three groups according to the last HET used before conception: « anti-CD20 » « Natalizumab (NTZ) » and « Fingolimod (FGD) ». The main outcome was annualized relapse rate (ARR) during pregnancy and post-partum.

RESULTS

We included 66 pregnancies: 21, 24 and 21 in anti-CD20, NTZ and FGD groups respectively. Overall, mean ARR (SD) increased from 0.36 (0.6) during the preconception year to 0.60 (1.3) during pregnancy and to 1.03 (2.0) in the first 3 months post-partum. Mean ARR in anti-CD20 group (0.09 (0.3)) during pregnancy and the first 3 months post-partum was lower compared with NTZ (0.48 (0.6); p = 0,09) and FGD (1.50 (1.8); p = 0.001) groups. Proportion of pregnancies with radiological activity during pregnancy and post-partum in anti-CD20 group (5.2 %) was lower compared with NTZ (63.1 %; p < 0.001) and FGD (72.2 %; p < 0.001) groups. There was no significant difference in the evolution of EDSS score from conception to post-partum between each group (p = 0.75).

CONCLUSION

Evidence of disease activity was significantly lower in patients exposed to anti-CD20 therapies before conception. This study suggests that use of anti-CD20 therapies is an efficient option to prevent disease reactivation during pregnancy and post-partum.

Impact of Immune Checkpoint Inhibitors on the Course of Multiple Sclerosis

OBJECTIVES

Immune checkpoint inhibitors (ICIs) are increasingly used in cancer treatment. Their mechanism of action raises the question of possible exacerbation of preexisting multiple sclerosis (MS). The aim of our study was to assess the risk of increased MS activity, defined by the occurrence of a relapse and/or a new MRI lesion, after ICI initiation.

METHODS

This French multicentric study collected retrospective and prospective data on patients with MS treated with ICIs after a cancer diagnosis.

RESULTS

We identified 18 patients with a median age of 48 years. Three of them (17%), all aged 50 years or younger, with a relapsing-remitting course, showed clinical and/or radiologic signs of MS activity 3 to 6 months after ICI initiation. They had stopped disease-modifying treatment (DMT) several months earlier, at the time of cancer diagnosis. Only one had both clinical and MRI activity, with mild severity and complete recovery.

DISCUSSION

Our study suggests that the overall risk of MS activity under ICI is low and could be mainly driven by DMT discontinuation, as in MS in general. Although larger studies are needed for better risk assessment in younger patients with more active disease, ICI should be considered when needed in patients with MS.

Recurrence of severe symptomatic late-onset neutropenia on ocrelizumab

BACKGROUND

Late-onset neutropenia (LON), defined as an absolute neutrophil count (ANC) < 1500/mm3 that develops between 4 weeks and 6 months after the last drug administration, is a rare side effect of anti-CD20 drugs including ocrelizumab. Although continuation of ocrelizumab after LON is not contraindicated, the risk of LON recurrence is not well known.

CASES

We report three cases of recurrent symptomatic agranulocytosis (ANC < 500/mm3) occurring under ocrelizumab.

CONCLUSION

Given the risk of recurrence of symptomatic agranulocytosis and the availability of other treatments, a therapeutic switch may be discussed after the first episode of LON.

Is vaccine response to SARS-CoV-2 preserved after switching to anti-CD20 therapies in patients with multiple sclerosis or related disorders?

BACKGROUND

Although vaccination against SARS-CoV-2 is recommended prior to introducing anti-CD20 therapies, limited data are available regarding the evolution of post-vaccinal immunity.

METHODS

This retrospective study compared anti-Spike antibody titres at 6 and 12 months from SARS-CoV-2 vaccination between patients vaccinated before switching to anti-CD20 ('Switch') and two control groups: (1) patients vaccinated under disease-modifying therapies (DMTs) other than fingolimod and anti-CD20 ('Other DMTs'); (2) patients vaccinated on anti-CD20 ('Anti-CD20'). Anti-Spike-specific T-cell responses were compared between 'Switch' and 'Anti-CD20' groups.

RESULTS

Fifty-three patients were included in the 'Switch' group, 54 in the 'Other DMTs' group and 141 in the 'Anti-CD20' group. At 6 months, in the subset of patients who received a booster dose, the 'Switch' group had lower anti-Spike titres compared with the 'Other DMTs' group (median 241.0 IQR (88.0; 504.0) BAU/mL vs 2034 (1155; 4634) BAU/mL, p<0.001), and less patients in the 'Switch' group reached the protective threshold of 264 BAU/mL. The 'Switch' group had higher anti-Spike titres than the 'Anti-CD20' group (7.5 (0.0; 62.1) BAU/mL, p=0.001). Anti-Spike titres were not different between the 'Switch' and 'Other DMTs' groups before booster administration. These results were similar at 12 months. Spike-specific T-cell positivity was similar between the 'Switch' and 'Anti-CD20' groups at 6 and 12 months (60.4% vs 61.0%, p=0.53, and 79.4% vs 87.5%, p=0.31, respectively).

CONCLUSIONS

Despite a primary vaccination performed before the first anti-CD20 cycle, our results suggest weaker immune responses at 6 and 12 months and decreased booster efficacy after introducing anti-CD20. Patients vaccinated prior to anti-CD20 introduction might falsely be considered as fully protected by vaccination.

Phase contrast imaging to detect transparent cells in the retinal ganglion cells layer

The eye is an optical window giving access to neural networks in a non-invasive way. It is possible to find in the retina biomarkers informing about the pathological state of other parts of the human body, and in particular of the brain. Neurodegenerative diseases could thus be diagnosed early and monitored by high-resolution imaging of the retina. However, a large part of the neurons in the retina are too transparent to be detected by existing techniques. At the Quinze-Vingts hospital, we have a unique retinal imaging platform in which ophthalmologists, neurologists and engineers participate. We implemented a technique based on scanning laser ophthalmoscopy (SLO) to capture the fine variations in refractive index between retinal cells. In this project we aimed at imaging and monitor cellular changes on transparent cells in the retinal ganglion cells layer in vivo on healthy participants and patients with neurodegenerative diseases.

A comparative evaluation of different neuromyelitis optica spectrum disorder sets of criteria

BACKGROUND AND PURPOSE

Three different sets of criteria have been proposed for the diagnosis of neuromyelitis optica spectrum disorder (NMOSD). The objective was to compare the specificity, sensitivity and diagnostic accuracy of the three different sets of NMOSD criteria in patients presenting with inflammatory disorders of the central nervous system suggestive of NMOSD.

METHODS

For 236 suspected NMOSD patients referred for serum aquaporin-4 immunoglobulin G antibody (AQP4-IgG) testing between 2012 and 2014, the three sets of NMOSD criteria [1999, 2006 NMO criteria and 2015 International Panel for NMO Diagnosis (IPND) criteria] were applied and compared to the final diagnosis.

RESULTS

Seventy-six patients fulfilled at least one set of criteria and 28 patients fulfilled all NMOSD sets of criteria. The final diagnosis was NMOSD in 66 cases, multiple sclerosis according to the MacDonald 2010 criteria in 85 cases and another diagnosis in 85 cases. The 2006 NMO criteria have the highest specificity (99%) and the 2015 IPND NMOSD criteria the highest sensitivity (97%). For the 1999, 2006 and 2015 IPND NMOSD criteria, the accuracy was respectively 82%, 87% and 97%.

CONCLUSIONS

Our study highlights the limitations of the first set of criteria that include the optico-spinal form of multiple sclerosis. The accuracy of NMOSD diagnostic criteria improved from 1999 to 2015. It confirms the increased performance of the last set of criteria which covers a larger spectrum of clinical presentation. This study raises some concerns for classifying patients with seronegative transverse myelitis or optic neuritis, and myelin oligodendrocyte glycoprotein (MOG) antibody- associated disease.

Secondary hypersomnia as an initial manifestation of neuromyelitis optica spectrum disorders

The identification of AQP4-IgG, a specific and pathogenic antibody of NMO/SD has led to a broadening of the clinical spectrum of manifestations of NMO/SD including the presence of encephalic symptoms. Lesions are often distributed on peri‑ependymal area and sometimes affected the diencephalon leading to sleep disorders. We report a case of hypersomnia with polysomnographic documentation during the first attack of NMO/SD. Brain MRI revealed bilateral hypothalamic lesions around the third ventricle, whereas optic nerves and spinal cord were intact. The record of the nocturnal video-polysomnography followed by multiple sleep latency tests (MSLT) revealed an abnormal shortened sleep period with a single sleep onset in REM allowing secondary central hypersomnia diagnosis. The recovery of hypersomnia was complete within few months without psychostimulant treatment and the diencephalic lesion disappeared. Thus, diencephalic form of NMO/SD seems to cause narcolepsy or non-narcoleptic central hypersomnia and have a good recovery.

Coronary Artery Calcium Score Improves the Prediction of Occult Coronary Artery Stenosis in Ischemic Stroke Patients

BACKGROUND

Coronary heart disease is a significant cause of morbidity and mortality in stroke patients. The coronary artery calcium score (CACS) has emerged as a robust and noninvasive predictor of coronary events. We assessed the predictive ability of CACS to identify stroke patients with severe (≥50%) occult coronary artery stenosis in a stroke/transient ischemic attack population, in addition to the PRECORIS score, based on Framingham Risk Score and presence of cervicocephalic artery stenosis, which was derived and validated for that purpose.

METHODS AND RESULTS

We enrolled consecutive patients aged 45 to 75 years referred to our stroke unit with noncardioembolic ischemic stroke or transient ischemic attack, and no prior history of coronary disease. The presence of coronary stenosis was assessed with 64-section computed tomography coronary angiography, and all patients had a detailed etiological work-up. CACS was determined from computed tomography measurement using the Agatson score. The predictive value of CACS was assessed by logistic regression and reclassification method. Among 300 patients included in the study, 274 had computed tomography coronary angiography. Fifty patients (18%) had at least 1 coronary artery stenosis ≥50%. In multivariable analysis, after adjustment for the PRECORIS score, CACS was strongly associated with the presence of occult coronary artery stenosis (odds ratio=14.8 [1.8-120.3] for CACS [1-100] and 70.9 [8.9-562.0] for CACS >100). When CACS was added to the standard model, model fit was improved (P<0.001), Net Reclassification Improvement was 28.2% (P<0.001), and Integrated Discrimination Index was 18.2% (P<0.001).

CONCLUSIONS

In stroke/transient ischemic attack patients, CACS improves the prediction of occult coronary stenosis beyond classical risk factors.