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Ssemmanda S. Hot cross bun sign in JC-Virus Granule cell neuronopathy in HIV infected patient - a case report. BMC Neurol 2024; 24:263. [PMID: 39075442 PMCID: PMC11285301 DOI: 10.1186/s12883-024-03776-z] [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: 04/27/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND John Cunningham virus related granule cell neuronopathy (JCV-GCN) is a rare manifestation of the reactivation of infection of the cerebellar granule cells by the JCV, mostly in immunocompromised individuals. The "hot cross bun" (HCB) sign is a cruciform hyperintensity seen in the midpons on T2-weighted and fluid attenuated inversion recovery (FLAIR) sequences on magnetic resonance imaging (MRI) of the brain. An index sub-Saharan Africa report of a case of JCV-GCN with HCB sign follows. CASE PRESENTATION A 27-year-old HIV positive female with JCV-GCN was re-evaluated for chronic ataxia complicated by subacute progressive horizontal diplopia. Cerebrospinal fluid (CSF) had trace Mycobacterium tuberculosis (MTB) detected by GeneXpert Mycobacterium Tuberculosis/Rifampicin resistance (MTB/RIF) assay test. Brain MRI revealed diffuse severe cerebellar atrophy with a hot cross bun sign and patchy enhancement contiguous to the cerebellar dentate nuclei bilaterally. She continued Highly Active Antiretroviral Therapy (HAART) pending CSF HIV viral load counts and started standard brain TB local treatment regimen protocols with progressive improvement in limb ataxia. CONCLUSIONS In conclusion, finding of the HCB sign may be indicative of and aid diagnosis of JCV-GCN in the right clinical context. This could be an important neuroimaging marker in this context, that may radiologically be more evident in later stages of the condition.
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Affiliation(s)
- Salvatore Ssemmanda
- C-Care International Hospital Kampala, Plot 4686 Barnabas Road, Kampala, Uganda.
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2
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Lv Y, Liu X. Hemorrhagic cystitis induced by JC polyomavirus infection following COVID-19: a case report. BMC Urol 2024; 24:87. [PMID: 38627797 PMCID: PMC11020351 DOI: 10.1186/s12894-024-01464-1] [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: 10/20/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
JC polyomavirus (JCPyV) is a human polyomavirus that can establish lifelong persistent infection in the majority of adults. It is typically asymptomatic in immunocompetent individuals. However, there is a risk of developing progressive multifocal leukoencephalopathy (PML) in immunocompromised or immunosuppressed patients. Though JCPyV commonly resides in the kidney-urinary tract, its involvement in urinary system diseases is extremely rare. Here, we reported a case of a 60-year-old male patient with coronavirus disease 2019 (COVID-19) infection who developed hemorrhagic cystitis after receiving treatment with nirmatrelvir 300 mg/ritonavir 100 mg quaque die (QD). Subsequent metagenomic next-generation sequencing (mNGS) confirmed the infection to be caused by JCPyV type 2. Then, human immunoglobulin (PH4) for intravenous injection at a dose of 25 g QD was administered to the patient. Three days later, the hematuria resolved. This case illustrates that in the setting of compromised host immune function, JCPyV is not limited to causing central nervous system diseases but can also exhibit pathogenicity in the urinary system. Moreover, mNGS technology facilitates rapid diagnosis of infectious etiology by clinical practitioners, contributing to precise treatment for patients.
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Affiliation(s)
- Yuanjie Lv
- Department of Infection, Hospital of Traditional Chinese Medicine, Xinchang County, No.188 Shijiu Feng Road, Qixing Street, Shaoxing, 312500, China.
| | - Xiaoping Liu
- Department of Infection, Hospital of Traditional Chinese Medicine, Xinchang County, No.188 Shijiu Feng Road, Qixing Street, Shaoxing, 312500, China
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3
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Stephen CD, Vangel M, Gupta AS, MacMore JP, Schmahmann JD. Rates of change of pons and middle cerebellar peduncle diameters are diagnostic of multiple system atrophy of the cerebellar type. Brain Commun 2024; 6:fcae019. [PMID: 38410617 PMCID: PMC10896291 DOI: 10.1093/braincomms/fcae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/01/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024] Open
Abstract
Definitive diagnosis of multiple system atrophy of the cerebellar type (MSA-C) is challenging. We hypothesized that rates of change of pons and middle cerebellar peduncle diameters on MRI would be unique to MSA-C and serve as diagnostic biomarkers. We defined the normative data for anterior-posterior pons and transverse middle cerebellar peduncle diameters on brain MRI in healthy controls, performed diameter-volume correlations and measured intra- and inter-rater reliability. We studied an Exploratory cohort (2002-2014) of 88 MSA-C and 78 other cerebellar ataxia patients, and a Validation cohort (2015-2021) of 49 MSA-C, 13 multiple system atrophy of the parkinsonian type (MSA-P), 99 other cerebellar ataxia patients and 314 non-ataxia patients. We measured anterior-posterior pons and middle cerebellar peduncle diameters on baseline and subsequent MRIs, and correlated results with Brief Ataxia Rating Scale scores. We assessed midbrain:pons and middle cerebellar peduncle:pons ratios over time. The normative anterior-posterior pons diameter was 23.6 ± 1.6 mm, and middle cerebellar peduncle diameter 16.4 ± 1.4 mm. Pons diameter correlated with volume, r = 0.94, P < 0.0001. The anterior-posterior pons and middle cerebellar peduncle measures were smaller at first scan in MSA-C compared to all other ataxias; anterior-posterior pons diameter: Exploratory, 19.3 ± 2.6 mm versus 20.7 ± 2.6 mm, Validation, 19.9 ± 2.1 mm versus 21.1 ± 2.1 mm; middle cerebellar peduncle transverse diameter, Exploratory, 12.0 ± 2.6 mm versus 14.3 ±2.1 mm, Validation, 13.6 ± 2.1 mm versus 15.1 ± 1.8 mm, all P < 0.001. The anterior-posterior pons and middle cerebellar peduncle rates of change were faster in MSA-C than in all other ataxias; anterior-posterior pons diameter rates of change: Exploratory, -0.87 ± 0.04 mm/year versus -0.09 ± 0.02 mm/year, Validation, -0.89 ± 0.48 mm/year versus -0.10 ± 0.21 mm/year; middle cerebellar peduncle transverse diameter rates of change: Exploratory, -0.84 ± 0.05 mm/year versus -0.08 ± 0.02 mm/year, Validation, -0.94 ± 0.64 mm/year versus -0.11 ± 0.27 mm/year, all values P < 0.0001. Anterior-posterior pons and middle cerebellar peduncle diameters were indistinguishable between Possible, Probable and Definite MSA-C. The rate of anterior-posterior pons atrophy was linear, correlating with ataxia severity. Using a lower threshold anterior-posterior pons diameter decrease of -0.4 mm/year to balance sensitivity and specificity, area under the curve analysis discriminating MSA-C from other ataxias was 0.94, yielding sensitivity 0.92 and specificity 0.87. For the middle cerebellar peduncle, with threshold decline -0.5 mm/year, area under the curve was 0.90 yielding sensitivity 0.85 and specificity 0.79. The midbrain:pons ratio increased progressively in MSA-C, whereas the middle cerebellar peduncle:pons ratio was almost unchanged. Anterior-posterior pons and middle cerebellar peduncle diameters were smaller in MSA-C than in MSA-P, P < 0.001. We conclude from this 20-year longitudinal clinical and imaging study that anterior-posterior pons and middle cerebellar peduncle diameters are phenotypic imaging biomarkers of MSA-C. In the correct clinical context, an anterior-posterior pons and transverse middle cerebellar peduncle diameter decline of ∼0.8 mm/year is sufficient for and diagnostic of MSA-C.
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Affiliation(s)
- Christopher D Stephen
- Ataxia Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Cognitive Behavioral Neurology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Mark Vangel
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02129, USA
| | - Anoopum S Gupta
- Ataxia Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Cognitive Behavioral Neurology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Jason P MacMore
- Ataxia Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Cognitive Behavioral Neurology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Jeremy D Schmahmann
- Ataxia Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Cognitive Behavioral Neurology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
- Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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4
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Tarasov DO, Lebedev IA, Seliverstov EA. [Progressive multifocal leukoencephalopathy in HIV-positive individuals]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:39-46. [PMID: 39269295 DOI: 10.17116/jnevro202412408139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
The article discusses the historical aspect and modern ideas about the etiology and pathogenesis of progressive multifocal leukoencephalopathy in patients with HIV infection. An analysis and synthesis of literature data on the clinical presentation of this pathology was carried out. The possibilities and limitations of laboratory and instrumental diagnostic methods, including neuroimaging methods, are discussed in detail. The pathomorphological signs of the disease in HIV-positive individuals are covered.
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Affiliation(s)
| | - I A Lebedev
- Tyumen State Medical University, Tyumen, Russia
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Butic AB, Spencer SA, Shaheen SK, Lukacher AE. Polyomavirus Wakes Up and Chooses Neurovirulence. Viruses 2023; 15:2112. [PMID: 37896889 PMCID: PMC10612099 DOI: 10.3390/v15102112] [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: 09/29/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
JC polyomavirus (JCPyV) is a human-specific polyomavirus that establishes a silent lifelong infection in multiple peripheral organs, predominantly those of the urinary tract, of immunocompetent individuals. In immunocompromised settings, however, JCPyV can infiltrate the central nervous system (CNS), where it causes several encephalopathies of high morbidity and mortality. JCPyV-induced progressive multifocal leukoencephalopathy (PML), a devastating demyelinating brain disease, was an AIDS-defining illness before antiretroviral therapy that has "reemerged" as a complication of immunomodulating and chemotherapeutic agents. No effective anti-polyomavirus therapeutics are currently available. How depressed immune status sets the stage for JCPyV resurgence in the urinary tract, how the virus evades pre-existing antiviral antibodies to become viremic, and where/how it enters the CNS are incompletely understood. Addressing these questions requires a tractable animal model of JCPyV CNS infection. Although no animal model can replicate all aspects of any human disease, mouse polyomavirus (MuPyV) in mice and JCPyV in humans share key features of peripheral and CNS infection and antiviral immunity. In this review, we discuss the evidence suggesting how JCPyV migrates from the periphery to the CNS, innate and adaptive immune responses to polyomavirus infection, and how the MuPyV-mouse model provides insights into the pathogenesis of JCPyV CNS disease.
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Affiliation(s)
| | | | | | - Aron E. Lukacher
- Department of Microbiology and Immunology, Penn State College of Medicine, Hershey, PA 17033, USA; (A.B.B.); (S.A.S.); (S.K.S.)
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6
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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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7
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Grote-Levi L, Möhn N, Bonifacius A, Tischer-Zimmermann S, Schweitzer F, Mahmoudi N, Silling S, Warnke C, Maecker-Kolhoff B, Wattjes MP, Eiz-Vesper B, Höglinger GU, Skripuletz T. Adoptive Allogeneic T-Cell Therapy Improves the Clinical Outcome of JC Virus Granule Cell Neuronopathy: A Case Report. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:e200138. [PMID: 37385737 PMCID: PMC10474852 DOI: 10.1212/nxi.0000000000200138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/08/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES JC virus granule cell neuronopathy is a potentially fatal otherwise highly disabling disease without an approved therapeutic option. This case report presents the positive record to T-cell therapy in JC virus granule cell neuronopathy. METHODS The patient represented with subacute cerebellar symptoms. Diagnosis of JC virus granule cell neuronopathy was made because of infratentorially accentuated brain volume atrophy shown by brain MRI and the detection of JC virus DNA in the CSF. RESULTS Six doses of virus-specific T cells were administered. Within 12 months after therapy initiation, the patient showed clear clinical benefit with improvement of symptoms, and JC viral DNA load significantly declined. DISCUSSION We present the case report of a positive response to T-cell therapy in JC virus granule cell neuronopathy, leading to an improvement of symptoms.
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Affiliation(s)
- Lea Grote-Levi
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Nora Möhn
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Agnes Bonifacius
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Sabine Tischer-Zimmermann
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Finja Schweitzer
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Nima Mahmoudi
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Steffi Silling
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Clemens Warnke
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Britta Maecker-Kolhoff
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Mike P Wattjes
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Britta Eiz-Vesper
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Günter U Höglinger
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.)
| | - Thomas Skripuletz
- From the Department of Neurology (L.G.-L., N. Möhn, G.U.H., T.S.); Institute of Transfusion Medicine and Transplant Engineering (A.B., S.T.-Z., B.E.-V.), Hannover Medical School; Department of Neurology (F.S., C.W.), Faculty of Medicine and University Hospital Cologne, University of Cologne; Department of Diagnostic and Interventional Neuroradiology (N. Mahmoudi, M.P.W.), Hannover Medical School; National Reference Center for Papilloma- and Polyomaviruses (S.S.), Institute of Virology, University of Cologne; Department of Pediatric Hematology and Oncology (B.M.-K.), Hannover Medical School, Germany; and German Center for Infection Research (DZIF) (B.M.-K., B.E.-V.).
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Silva-Rosas C, Abudinén G, Quijada-Riquelme A, Angus-Leppan H. Teaching NeuroImage: Cerebellar Atrophy Due to JC Virus Granule Cell Neuronopathy: A Clinical Syndrome Distinct From Classic PML. Neurology 2023; 101:e343-e344. [PMID: 36805431 PMCID: PMC10382267 DOI: 10.1212/wnl.0000000000207155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/20/2023] [Indexed: 02/22/2023] Open
Affiliation(s)
- Carlos Silva-Rosas
- From the Department of Neurology & Neurosurgery (C.S.-R., G.A., A.Q.-R.), Clinical Hospital of University of Chile, Santiago de Chile; Royal Free London NHS Foundation Trust (H.A.-L.); and Department of Clinical and Movement Neurosciences (H.A.-L.), UCL Queen Square Institute of Neurology, United Kingdom.
| | - Gabriel Abudinén
- From the Department of Neurology & Neurosurgery (C.S.-R., G.A., A.Q.-R.), Clinical Hospital of University of Chile, Santiago de Chile; Royal Free London NHS Foundation Trust (H.A.-L.); and Department of Clinical and Movement Neurosciences (H.A.-L.), UCL Queen Square Institute of Neurology, United Kingdom
| | - Alonso Quijada-Riquelme
- From the Department of Neurology & Neurosurgery (C.S.-R., G.A., A.Q.-R.), Clinical Hospital of University of Chile, Santiago de Chile; Royal Free London NHS Foundation Trust (H.A.-L.); and Department of Clinical and Movement Neurosciences (H.A.-L.), UCL Queen Square Institute of Neurology, United Kingdom
| | - Heather Angus-Leppan
- From the Department of Neurology & Neurosurgery (C.S.-R., G.A., A.Q.-R.), Clinical Hospital of University of Chile, Santiago de Chile; Royal Free London NHS Foundation Trust (H.A.-L.); and Department of Clinical and Movement Neurosciences (H.A.-L.), UCL Queen Square Institute of Neurology, United Kingdom
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9
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Alvarez-Mulett S, Sepkowitz E, Sepkowitz D. Newly diagnosed AIDS patient with cerebellar JC virus. IDCases 2023; 33:e01842. [PMID: 37645527 PMCID: PMC10461121 DOI: 10.1016/j.idcr.2023.e01842] [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: 05/10/2023] [Accepted: 07/04/2023] [Indexed: 08/31/2023] Open
Abstract
We present a case of a 57-year-old man with newly diagnosed acquired immunodeficiency syndrome (AIDS) infection who initially sought care for progressive dysarthria and gait instability. Neuroimaging and CSF studies revealed a diagnosis of progressive multifocal leukoencephalopathy (PML). Although the patient's human immunodeficiency virus (HIV) decreased considerably in response to anti-retroviral therapy, he continued to deteriorate clinically. Ultimately, the central nervous system (CNS) lesions, which were once centered in the cerebellum, became expansile throughout his posterior fossa. There are few reported cases of cerebellar PML in patients with AIDS.
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Affiliation(s)
| | - Eli Sepkowitz
- Department of Physical Medicine & Rehabilitation, Northwell Hospital, Manhasset, NY, USA
| | - Douglas Sepkowitz
- Department of Infectious Disease, NYP-Brooklyn Methodist Hospital, Brooklyn, NY, USA
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10
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Naidoo AK, Wells CD, Rugbeer Y, Naidoo N. The "Hot Cross Bun Sign" in Spinocerebellar Ataxia Types 2 and 7-Case Reports and Review of Literature. Mov Disord Clin Pract 2022; 9:1105-1113. [PMID: 36339304 PMCID: PMC9631856 DOI: 10.1002/mdc3.13550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 09/19/2023] Open
Abstract
Background The "hot cross bun" sign is a cruciform hyperintensity is seen on T2 weighted imaging within the pons. The sign is considered to be pathognomic for Multiple system atrophy type C. The clinical and radiological features of Multiple system atrophy type C overlap with the autosomal dominant inherited ataxias. We present a case series of 3 African patients with genetically proven Spinocerebellar Ataxia presenting with the Hot cross bun sign and a scoping review of similar studies. Cases We described the phenotypic and radiological presentation of genetically confirmed SCA-2 in two, and SCA-7 in one patient, with the "hot cross bun" sign. Literature Review We performed a scoping review on the Hot Cross Bun Sign.A total of 66 articles were retrieved. We describe the diverse aetiologies of the sign and associated phenotypic and radiological features. We review the Spinocerebellar Ataxias described with a Hot cross bun sign and make comparisons to Multiple System Atrophy Type C [Ref. 1,2]. Conclusions To our knowledge this is the first description of an African cohort presenting with the Hot Cross Bun Sign. We expand the differential diagnosis of the Hot Cross Bun Sign.
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Affiliation(s)
- Ansuya Kasavelu Naidoo
- Greys Academic HospitalPietermaritzburgSouth Africa
- School of Clinical Medicine, Division NeurologyUniversity of KwaZulu NatalDurbanSouth Africa
| | - Cait‐Lynn Deanne Wells
- Greys Academic HospitalPietermaritzburgSouth Africa
- School of Clinical Medicine, Division NeurologyUniversity of KwaZulu NatalDurbanSouth Africa
| | | | - Neil Naidoo
- Greys Academic HospitalPietermaritzburgSouth Africa
- School of Clinical Medicine, Division NeurologyUniversity of KwaZulu NatalDurbanSouth Africa
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11
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Ngouth N, Monaco MC, Walker L, Corey S, Ikpeama I, Fahle G, Cortese I, Das S, Jacobson S. Comparison of qPCR with ddPCR for the Quantification of JC Polyomavirus in CSF from Patients with Progressive Multifocal Leukoencephalopathy. Viruses 2022; 14:v14061246. [PMID: 35746716 PMCID: PMC9229850 DOI: 10.3390/v14061246] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Lytic infection of oligodendrocytes by the human JC polyomavirus (JCPyV) results in the demyelinating disease called progressive multifocal leukoencephalopathy (PML). The detection of viral DNA in the cerebrospinal fluid (CSF) by PCR is an important diagnostic tool and, in conjunction with defined radiological and clinical features, can provide diagnosis of definite PML, avoiding the need for brain biopsy. The main aim of this study is to compare the droplet digital PCR (ddPCR) assay with the gold standard quantitative PCR (qPCR) for the quantification of JC viral loads in clinical samples. Methods: A total of 62 CSF samples from 31 patients with PML were analyzed to compare the qPCR gold standard technique with ddPCR to detect conserved viral DNA sequences in the JCPyV genome. As part of the validation process, ddPCR results were compared to qPCR data obtained in 42 different laboratories around the world. In addition, the characterization of a novel triplex ddPCR to detect viral DNA sequence from both prototype and archetype variants and a cellular housekeeping reference gene is described. Triplex ddPCR was used to analyze the serum from six PML patients and from three additional cohorts, including 20 healthy controls (HC), 20 patients with multiple sclerosis (MS) who had never been treated with natalizumab (no-NTZ-treated), and 14 patients with MS who were being treated with natalizumab (NTZ-treated); three from this last group seroconverted during the course of treatment with natalizumab. Results: JCPyV DNA was detected only by ddPCR for 5 of the 62 CSF samples (8%), while remaining undetected by qPCR. For nine CSF samples (15%), JCPyV DNA was at the lower limit of quantification for qPCR, set at <250 copies/mL, and therefore no relative quantitation could be determined. By contrast, exact copies of JCPyV for each of these samples were quantified by ddPCR. No differences were observed between qPCR and ddPCR when five standardized plasma samples were analyzed for JCPyV in 42 laboratories in the United States and Europe. JCPyV-DNA was undetected in all the sera from HC and MS cohorts tested by triplex ddPCR, while serum samples from six patients with PML tested positive for JCPyV. Conclusion: This study shows strong correlation between ddPCR and qPCR with increased sensitivity of the ddPCR assay. Further work will be needed to determine whether multiplex ddPCR can be useful to determine PML risk in natalizumab-treated MS patients.
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Affiliation(s)
- Nyater Ngouth
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (N.N.); (M.C.M.)
| | - Maria Chiara Monaco
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (N.N.); (M.C.M.)
| | - Lorenzo Walker
- Department of Laboratory Medicine, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (L.W.); (I.I.); (G.F.); (S.D.)
| | - Sydney Corey
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (S.C.); (I.C.)
| | - Ijeoma Ikpeama
- Department of Laboratory Medicine, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (L.W.); (I.I.); (G.F.); (S.D.)
| | - Gary Fahle
- Department of Laboratory Medicine, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (L.W.); (I.I.); (G.F.); (S.D.)
| | - Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (S.C.); (I.C.)
| | - Sanchita Das
- Department of Laboratory Medicine, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (L.W.); (I.I.); (G.F.); (S.D.)
| | - Steven Jacobson
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH), Bethesda, MD 20892, USA; (N.N.); (M.C.M.)
- Correspondence:
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12
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Outcome of progressive multifocal leukoencephalopathy treated by Interleukin‐ 7. Ann Neurol 2022; 91:496-505. [DOI: 10.1002/ana.26307] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 11/07/2022]
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13
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Baldassari LE, Wattjes MP, Cortese ICM, Gass A, Metz I, Yousry T, Reich DS, Richert N. The neuroradiology of progressive multifocal leukoencephalopathy: a clinical trial perspective. Brain 2021; 145:426-440. [PMID: 34791056 DOI: 10.1093/brain/awab419] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/29/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the central nervous system caused by the JC virus, which infects white and grey matter cells and leads to irreversible demyelination and neuroaxonal damage. Brain magnetic resonance imaging (MRI), in addition to the clinical presentation and demonstration of JC virus DNA either in the CSF or by histopathology, is an important tool in the detection of PML. In clinical practice, standard MRI pulse sequences are utilized for screening, diagnosis, and monitoring of PML, but validated imaging-based outcome measures for use in prospective, interventional clinical trials for PML have yet to be established. We review the existing literature regarding the use of MRI and positron emission tomography imaging in PML and discuss the implications of PML histopathology for neuroradiology. MRI not only demonstrates the localization and extent of PML lesions, but also mirrors the tissue destruction, ongoing viral spread, and resulting inflammation. Finally, we explore the potential for imaging measures to serve as an outcome in PML clinical trials and provide recommendations for current and future imaging outcome measure development in this area.
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Affiliation(s)
- Laura E Baldassari
- Division of Neurology 2, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, 20993, USA
| | - Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, 30625 Hannover, Germany
| | - Irene C M Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, 20892, USA
| | - Achim Gass
- Department of Neurology/Neuroimaging, Mannheim Center of Translational Neuroscience, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Imke Metz
- Institute of Neuropathology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Tarek Yousry
- Neuroradiological Academic Unit, UCL IoN; Lysholm Department of Neuroradiology, UCLH National Hospital for Neurology and Neurosurgery, London, UK
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, 20892, USA
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Abstract
PURPOSE OF REVIEW This article reviews the neurologic complications associated with human immunodeficiency virus (HIV) infection. RECENT FINDINGS Neurologic complications of HIV may be caused by direct virally mediated pathology, immune-mediated phenomena in response to viral infection, or opportunistic infections secondary to depletion of lymphocytes. These neurologic disorders may be influenced by the degree of immunosuppression (ie, CD4+ T-cell lymphocyte count) and stage of infection (early versus late), as well as use of antiretroviral therapy, and may manifest as a variety of central and peripheral neurologic syndromes, including the more commonly encountered HIV-associated cognitive disorders and length-dependent sensorimotor polyneuropathy, respectively. Immune dysregulation underlies the majority of these neurologic phenomena, as well as other HIV-associated conditions including immune reconstitution inflammatory syndrome (IRIS), CD8 lymphocytosis, and potentially the development of compartmentalized infection within the CSF, also referred to as CSF escape. SUMMARY This article reviews a spectrum of clinical syndromes and related neuropathologic states associated with HIV infection.
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15
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Anand P. Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies. ACTA ACUST UNITED AC 2021; 27:1066-1104. [PMID: 34623105 DOI: 10.1212/con.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised. RECENT FINDINGS Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population. SUMMARY A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.
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16
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A Case of John Cunningham Virus Induced Rhombencephalitis after Rituximab Therapy for Idiopathic Thrombocytopenic Purpura. Case Rep Infect Dis 2021; 2021:5525053. [PMID: 34221521 PMCID: PMC8219458 DOI: 10.1155/2021/5525053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background John Cunningham virus (JCV) is known to cause progressive multifocal leukoencephalopathy (PML) in immuno-compromised patients due to lytic infection of oligodendrocytes and astrocytes. Rarely, it may also present as granule cell neuronopathy (GCN), leading to degeneration of cerebellar granule cell neurons. It is described in patients with underlying conditions or medication contributing to immune compromise. Case Presentation. A 73-year-old man presented with ataxia and difficulty in speech which began 3 months after initiation of treatment for idiopathic thrombocytopenic purpura with rituximab. Neurological examination was significant for torsional nystagmus, motor aphasia, right-sided dysmetria, and dysdiadochokinesia with gait ataxia. Magnetic resonance imaging (MRI) showed right cerebellar lesion and cerebrospinal fluid (CSF) polymerase chain reaction (PCR) was positive for JC virus. Conclusion The diagnosis of JC virus-related cerebellar disease can be missed, due to the subacute to chronic onset and challenges in detection. Clinicians should have a high degree of suspicion for development of these symptoms, even a few months after initiation of immune-modulatory therapy because the progression and outcomes can be disastrous.
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17
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Adra N, Goodheart AE, Rapalino O, Caruso P, Mukerji SS, González RG, Venna N, Schmahmann JD. MRI Shrimp Sign in Cerebellar Progressive Multifocal Leukoencephalopathy: Description and Validation of a Novel Observation. AJNR Am J Neuroradiol 2021; 42:1073-1079. [PMID: 33985948 DOI: 10.3174/ajnr.a7145] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/07/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE There are no validated imaging criteria for the diagnosis of progressive multifocal leukoencephalopathy in the cerebellum. Here we introduce the MR imaging shrimp sign, a cerebellar white matter lesion identifiable in patients with cerebellar progressive multifocal leukoencephalopathy, and we evaluate its sensitivity and specificity. MATERIALS AND METHODS We first identified patients with progressive multifocal leukoencephalopathy seen at Massachusetts General Hospital between 1998 and 2019 whose radiology reports included the term "cerebellum." Drawing on a priori knowledge, 2 investigators developed preliminary diagnostic criteria for the shrimp sign. These criteria were revised and validated in 2 successive stages by 4 additional blinded investigators. After defining the MR imaging shrimp sign, we assessed its sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS We identified 20 patients with cerebellar progressive multifocal leukoencephalopathy: 16 with definite progressive multifocal leukoencephalopathy (mean, 46.4 [SD, 9.2] years of age; 5 women), and 4 with possible progressive multifocal leukoencephalopathy (mean, 45.8 [SD, 8.5] years of age; 1 woman). We studied 40 disease controls (mean, 43.6 [SD, 21.0] years of age; 16 women) with conditions known to affect the cerebellar white matter. We defined the MR imaging shrimp sign as a T2- and FLAIR-hyperintense, T1-hypointense, discrete cerebellar white matter lesion abutting-but-sparing the dentate nucleus. MR imaging shrimp sign sensitivity was 0.85; specificity, 1; positive predictive value, 1; and negative predictive value, 0.93. The shrimp sign was also seen in fragile X-associated tremor ataxia syndrome, but radiographic and clinical features distinguished it from progressive multifocal leukoencephalopathy. CONCLUSIONS In the right clinical context, the MR imaging shrimp sign has excellent sensitivity and specificity for cerebellar progressive multifocal leukoencephalopathy, providing a new radiologic marker of the disease.
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Affiliation(s)
- N Adra
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.).,Wellesley College (N.A.), Wellesley, Massachusetts
| | - A E Goodheart
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.)
| | - O Rapalino
- Neuroradiology Division (O.R., P.C., R.G.G.)
| | - P Caruso
- Neuroradiology Division (O.R., P.C., R.G.G.)
| | - S S Mukerji
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Department of Neurology, (S.S.M., N.V.), Neuroinfectious Diseases Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - N Venna
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.).,Department of Neurology, (S.S.M., N.V.), Neuroinfectious Diseases Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - J D Schmahmann
- From the Department of Neurology (N.A., A.E.G., S.S.M., N.V., J.D.S.) .,Ataxia Center, Cognitive Behavioral Neurology Unit, Laboratory for Neuroanatomy and Cerebellar Neurobiology (N.A., A.E.G., J.D.S.)
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18
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Review of the neurological aspects of HIV infection. J Neurol Sci 2021; 425:117453. [PMID: 33895464 DOI: 10.1016/j.jns.2021.117453] [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: 08/12/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/20/2022]
Abstract
There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.
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Sakuraba M, Watanabe S, Nishiyama Y, Takahashi K, Nakamichi K, Suzuki M, Nawata T, Komai K, Gono T, Takeno M, Suzuki T, Kimura K, Kuwana M. Infratentorial onset of progressive multifocal leukoencephalopathy in a patient with systematic lupus erythematosus complicated with lymphoma: a case report. Mod Rheumatol Case Rep 2021; 5:272-277. [PMID: 33719867 DOI: 10.1080/24725625.2021.1899763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare opportunistic infection of the central nervous system caused by reactivation of JC virus (JCV). Typical PML shows confluent, bilateral but asymmetric, subcortical lesions in the supratentorial white matter on magnetic resonance imaging (MRI). We report here a 50-year-old woman with systemic lupus erythematosus complicated with lymphoma who developed PML with atypical brain MRI findings limited to the infratentorial area at presentation. She presented with numbness on the right side of the face, including her tongue, clumsiness of the right hand, and gait disturbance, after completion of remission induction therapy for lymphoma, including rituximab. Brain MRI demonstrated a solitary lesion limited to the cerebellum and brainstem, but a definitive diagnosis could not be made from cerebrospinal fluid study or tentative histologic evaluation of brain biopsy specimens. Despite methylprednisolone pulse therapy, her neurological deficits progressively worsened. One month later, in-depth analysis of her cerebrospinal fluid and brain biopsy specimens confirmed the presence of JCV. Eventually, the localised unilateral crescent-shaped cerebellar lesions on MRI expanded to the contralateral cerebellum, middle cerebellar hemisphere, pons, and midbrain and finally developed multifocal invasion into the white matter of the cerebral hemispheres. Our case suggests that PML could first present with a solitary infratentorial lesion in immunocompromised patients.
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Affiliation(s)
- Mita Sakuraba
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Shinji Watanabe
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yasuhiro Nishiyama
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Kenta Takahashi
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Mikito Suzuki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Takashi Nawata
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Kota Komai
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Tadaki Suzuki
- Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Abstract
The risk of JC polyomavirus encephalopathy varies among biologic classes and among agents within the same class. Of currently used biologics, the highest risk is seen with natalizumab followed by rituximab. Multiple other agents have also been implicated. Drug-specific causality is difficult to establish because many patients receive multiple immunomodulatory medications concomitantly or sequentially, and have other immunocompromising factors related to their underlying disease. As use of biologic therapies continues to expand, further research is needed into pathogenesis, treatment, and prevention of JC polyomavirus encephalopathy such that risk for its development is better understood and mitigated, if not eliminated altogether.
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21
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Complications neurologiques de l’infection par le virus JC : revue générale. Rev Med Interne 2021; 42:177-185. [DOI: 10.1016/j.revmed.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/28/2020] [Accepted: 08/27/2020] [Indexed: 12/11/2022]
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22
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McEntire CR, Fong KT, Jia DT, Cooper ER, Cervantes-Arslanian AM, Mateen FJ, Anand P, Thakur KT. Central nervous system disease with JC virus infection in adults with congenital HIV. AIDS 2021; 35:235-244. [PMID: 33394671 PMCID: PMC7945987 DOI: 10.1097/qad.0000000000002734] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to describe the natural history of individuals with congenital HIV who develop JC virus (JCV) infection of the central nervous system (CNS). METHODS We retrospectively evaluated individuals with congenital HIV who met criteria for progressive multifocal leukoencephalopathy (PML) or JCV granule cell neuronopathy (JCV GCN) at three major healthcare centres in the northeast USA. Data on adherence to combined antiretroviral therapy (cART), neurologic symptoms, serum markers of immunity and HIV infection, cerebrospinal fluid (CSF) analyses, radiographic features, modified Rankin Scale (mRS) scores and survival were collected from the electronic medical record up to a censoring date of 1 August 2020. RESULTS Among 10 adults with congenitally acquired HIV, nine were diagnosed with definitive PML and one was diagnosed with probable JCV GCN. Individuals presented at the time of their PML or JCV GCN diagnosis with a mean mRS of 2.0 (standard deviation 1.0). A premorbid mRS was documented for six patients and was zero in all cases. The most common risk factor was confirmed cART nonadherence in nine individuals. Five individuals with PML and one with JCV GCN died, with a latency from symptom onset to death of approximately 3 months for three individuals, and approximately 2 years for the remaining two. CONCLUSION Youth-adulthood transition is a high-risk point for dropping off from medical care. The study of this timepoint in people living with HIV could help inform effective care in these individuals.
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Affiliation(s)
| | - Kathryn T. Fong
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032
| | - Dan Tong Jia
- Department of Neurology, Northwestern Memorial Hospital, Chicago, IL 60611
| | - Ellen R. Cooper
- Department of Pediatrics, Boston University School of Medicine, Boston, MA 02215
| | - Anna M. Cervantes-Arslanian
- Departments of Neurology, Neurosurgery, and Medicine (Infectious Disease), Boston Medical Center, Boston, MA 02118
| | - Farrah J. Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114
| | - Pria Anand
- Departments of Neurology, Neurosurgery, and Medicine (Infectious Disease), Boston Medical Center, Boston, MA 02118
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032
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23
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Mascitti H. Infections de l’immunodéprimé (hors VIH). Med Mal Infect 2020; 50:8S6-8S11. [PMID: 33357973 DOI: 10.1016/s0399-077x(20)30777-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- H Mascitti
- Service d'infectiologie, CHU Raymond-Poincaré (AP-HP), Université Paris-Saclay, 104, boulevard Raymond-Poincaré, 92380 Garches, France..
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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: 158] [Impact Index Per Article: 39.5] [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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Focosi D, Tuccori M, Maggi F. Progressive multifocal leukoencephalopathy and anti‐CD20 monoclonal antibodies: What do we know after 20 years of rituximab. Rev Med Virol 2019; 29:e2077. [DOI: 10.1002/rmv.2077] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/11/2019] [Accepted: 07/14/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Daniele Focosi
- North‐Western Tuscany Blood Bank Pisa University Hospital Pisa Italy
| | - Marco Tuccori
- Unit of Pharmacology and Pharmacovigilance, Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
- Unit of Adverse Drug Reaction Monitoring Pisa University Hospital Pisa Italy
| | - Fabrizio Maggi
- Department of Translational Research University of Pisa Pisa Italy
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26
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Pruitt AA. Central Nervous System Infections Complicating Immunosuppression and Transplantation. Continuum (Minneap Minn) 2019; 24:1370-1396. [PMID: 30273244 DOI: 10.1212/con.0000000000000653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This article reviews infections associated with cancer treatments and immunosuppressive/immunomodulatory therapies used in both neoplastic and non-neoplastic conditions, including hematopoietic cell transplantation and solid organ transplantation. It provides a clinical approach to the most commonly affected patient groups based on clinicoanatomic presentation and disease-specific risks resulting from immune deficits and drugs received. RECENT FINDINGS The clinical presentations, associated neuroimaging findings, and CSF abnormalities of patients with central nervous system infections who are immunocompromised may differ from those of patients with central nervous system infections who are immunocompetent and may be confused with noninfectious processes. Triggering of brain autoimmunity with emergence of neurotropic antibodies has emerged as a recognized parainfectious complication. New unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. SUMMARY Despite evidence-based prophylactic regimens and organism-specific antimicrobials, central nervous system infections continue to cause significant morbidity and mortality in an increasing range of patients who are immunocompromised by their conditions and therapies. Multiple new drugs put patients at risk for progressive multifocal leukoencephalopathy, which has numerous imaging and clinical manifestations; patients at risk include those with multiple sclerosis, for whom infection risk is becoming one of the most important factors in therapeutic decision making. Efficient, early diagnosis is essential to improve outcomes in these often-devastating diseases.
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27
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Zhong M, Kempster PA, Phan TG. John Cunningham virus granule cell neuronopathy in a mildly immunosuppressed patient with systemic lupus erythematosus. Intern Med J 2019; 49:804-805. [PMID: 31185530 DOI: 10.1111/imj.14318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/31/2018] [Accepted: 08/05/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Zhong
- Neurosciences Department, Monash Health, Melbourne, Victoria, Australia
| | - Peter A Kempster
- Neurosciences Department, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Thanh G Phan
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Stroke Unit, Monash Health, Melbourne, Victoria, Australia
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Ono D, Shishido-Hara Y, Mizutani S, Mori Y, Ichinose K, Watanabe M, Tanizawa T, Yokota T, Uchihara T, Fujigasaki H. Development of demyelinating lesions in progressive multifocal leukoencephalopathy (PML): Comparison of magnetic resonance images and neuropathology of post-mortem brain. Neuropathology 2019; 39:294-306. [PMID: 31155757 PMCID: PMC6852116 DOI: 10.1111/neup.12562] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/19/2019] [Accepted: 04/18/2019] [Indexed: 01/13/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disorder caused by opportunistic infection of JC polyomavirus (JCV). Today, increased attention has been focused on PML development in multiple sclerosis (MS) patients under disease-modifying therapies (DMT). Although in the acquired immunodeficiency syndrome (AIDS) era, PML was thought to be a rapidly progressive disease with poor prognosis, drug-associated PML is relatively slow in progress, and a favorable outcome may be expected with early diagnosis. However, early PML diagnosis on magnetic resonance imaging (MRI) is frequently difficult, and JCV DNA copy number in cerebrospinal fluid (CSF) is usually low. To facilitate early PML diagnosis on MRI, the pre-mortem images were compared with neuropathology of the post-mortem brain, and underlying pathology corresponding to the MRI findings was evaluated. As a result, PML lesions of the autopsied brain were divided into three parts, based on the disease extension patterns: (A) Progressive white matter lesion in the right frontoparietal lobe including the precentral gyrus. Huge demyelinated lesions were formed with fusions of numerous small lesions. (B) Central lesion including deep gray matters, such as the putamen and thalamus. The left thalamic lesion was contiguous with the pontine tegmentum. (C) Infratentorial lesion of brainstem and cerebellum. Demyelination in the pontine basilar region and in cerebellar white matter was contiguous via middle cerebellar peduncles (MCPs). In addition, (D) satellite lesions were scattered all over the brain. These observations indicate that PML lesions likely evolve with three steps in a tract-dependent manner: (1) initiation; (2) extension/expansion of demyelinating lesions; and (3) fusion. Understanding of the PML disease evolution patterns would enable confident early diagnosis on MRI, which is essential for favorable prognosis with good functional outcome.
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Affiliation(s)
- Daisuke Ono
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Laboratory of Structural Neuropathology, Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Yukiko Shishido-Hara
- Laboratory of Structural Neuropathology, Metropolitan Institute of Medical Science, Tokyo, Japan.,Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Saneyuki Mizutani
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yoko Mori
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Neurology, Nitobe Memorial Nakano General Hospital, Tokyo, Japan
| | - Keiko Ichinose
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mutsufusa Watanabe
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tohru Tanizawa
- Department of Pathology, Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiki Uchihara
- Laboratory of Structural Neuropathology, Metropolitan Institute of Medical Science, Tokyo, Japan.,Department of Neurology, Nitobe Memorial Nakano General Hospital, Tokyo, Japan
| | - Hiroto Fujigasaki
- Department of Internal Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan
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29
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Lapides DA, Batchala PP, Donahue JH, Lisak RP, Meltzer EI, Narayan RN, Nath A, Frohman TC, Costello K, Goldman MD, Zamvil SS, Frohman EM. Cerebellar syndrome in a man treated with natalizumab: From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:e546. [PMID: 30882020 PMCID: PMC6410929 DOI: 10.1212/nxi.0000000000000546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 11/15/2022]
Affiliation(s)
- David A Lapides
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Prem P Batchala
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Joseph H Donahue
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Robert P Lisak
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ethan I Meltzer
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Ram N Narayan
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Avi Nath
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Teresa C Frohman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Kathleen Costello
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Myla D Goldman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Scott S Zamvil
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
| | - Elliot M Frohman
- Departments of Neurology (D.A.L., M.D.G.), and Radiology and Medical Imaging (P.P.B., J.H.D.), Charlottesville, VA; Department of Neurology (R.P.L.), Wayne State University, Detroit, MI; Department of Neurology (E.I.M.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.N.N.), Barrows Neuroscience Institute, Phoenix, AZ; Neuroimmunology Branch (A.N.), National Institutes of Health, Bethesda, MD; Department of Neurology and Ophthalmology (T.C.F., E.M.F.), Dell Medical School at the University of Texas at Austin; The National Multiple Sclerosis Society (K.C.), New York; and Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco
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Abstract
JC virus is the etiological agent of progressive multifocal leukoencephalopathy, a white matter demyelinating disease that mostly affects immunocompromised patients. JC virus can also infect neurons and meningeal cells and cause encephalitis, meningitis and granule cell neuronopathy. We report a patient with JC virus granule cell neuronopathy, without concomitant progressive multifocal leukoencephalopathy, presenting as inaugural acquired immune deficiency syndrome-related illness. This patient's human immunodeficiency virus infection remained undiagnosed for several months after neurological symptoms onset. We review JC virus pathophysiology, clinical manifestations, treatment and prognosis, and emphasize the importance of considering human immunodeficiency virus infection and related opportunistic infections in the differential diagnosis of new-onset isolated cerebellar disease.
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31
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HIV-associated opportunistic CNS infections: pathophysiology, diagnosis and treatment. Nat Rev Neurol 2018; 12:662-674. [PMID: 27786246 DOI: 10.1038/nrneurol.2016.149] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nearly 30 years after the advent of antiretroviral therapy (ART), CNS opportunistic infections remain a major cause of morbidity and mortality in HIV-positive individuals. Unknown HIV-positive disease status, antiretroviral drug resistance, poor drug compliance, and recreational drug abuse are factors that continue to influence the morbidity and mortality of infections. The clinical and radiographic pattern of CNS opportunistic infections is unique in the setting of HIV infection: opportunistic infections in HIV-positive patients often have characteristic clinical and radiological presentations that can differ from the presentation of opportunistic infections in immunocompetent patients and are often sufficient to establish the diagnosis. ART in the setting of these opportunistic infections can lead to a paradoxical worsening caused by an immune reconstitution inflammatory syndrome (IRIS). In this Review, we discuss several of the most common CNS opportunistic infections: cerebral toxoplasmosis, progressive multifocal leukoencephalopathy (PML), tuberculous meningitis, cryptococcal meningitis and cytomegalovirus infection, with an emphasis on clinical pearls, pathological findings, MRI findings and treatment. Moreover, we discuss the risk factors, pathophysiology and management of IRIS. We also summarize the challenges that remain in management of CNS opportunistic infections, which includes the lack of phase II and III clinical trials, absence of antimicrobials for infections such as PML, and controversy regarding the use of corticosteroids for treatment of IRIS.
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Demas A, Bennani O, Vandendriessche A, de Menibus LH, Langlois V, Gasnault J. JC Virus Granule Cell Neuronopathy and Lymphoma. Open Forum Infect Dis 2018; 5:ofy112. [PMID: 29977966 PMCID: PMC6016421 DOI: 10.1093/ofid/ofy112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/16/2018] [Indexed: 12/03/2022] Open
Abstract
Neurological opportunistic infections are going to increase. Clinicians should be aware of the neurological spectrum of JC virus manifestations, including granule cell neuronopathy. Detection of JC virus DNA by polymerase chain reaction in cerebrospinal fluid should be realized in the assessment of a progressive cerebellar ataxia in an immunocompromised patient.
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Affiliation(s)
- Alexis Demas
- Department of Neurology, Hospital Jacques Monod, Le Havre, France
| | - Omar Bennani
- Department of Neurology, Hospital Jacques Monod, Le Havre, France
| | - Anne Vandendriessche
- Department of Infectious Diseases and Internal Medicine, Hospital Jacques Monod, Le Havre, France
| | | | - Vincent Langlois
- Department of Infectious Diseases and Internal Medicine, Hospital Jacques Monod, Le Havre, France
| | - Jacques Gasnault
- UF SSR des Maladies Neurovirales, Médecine Interne & Immunologie Clinique, Centre Hospitalier Universitaire de Bicetre, IMVA INSERM, Le Kremlin-Bicêtre, France
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DeCaprio JA. Merkel cell polyomavirus and Merkel cell carcinoma. Philos Trans R Soc Lond B Biol Sci 2018; 372:rstb.2016.0276. [PMID: 28893943 DOI: 10.1098/rstb.2016.0276] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2017] [Indexed: 12/27/2022] Open
Abstract
Merkel cell polyomavirus (MCPyV) causes the highly aggressive and relatively rare skin cancer known as Merkel cell carcinoma (MCC). MCPyV also causes a lifelong yet relatively innocuous infection and is one of 14 distinct human polyomaviruses species. Although polyomaviruses typically do not cause illness in healthy individuals, several can cause catastrophic diseases in immunocompromised hosts. MCPyV is the only polyomavirus clearly associated with human cancer. How MCPyV causes MCC and what oncogenic events must transpire to enable this virus to cause MCC is the focus of this essay.This article is part of the themed issue 'Human oncogenic viruses'.
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Affiliation(s)
- James A DeCaprio
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA .,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
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Maillart E, Taoufik Y, Gasnault J, Stankoff B. Leucoencefalopatia multifocale progressiva. Neurologia 2018. [DOI: 10.1016/s1634-7072(18)89404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Susceptibility of Primary Human Choroid Plexus Epithelial Cells and Meningeal Cells to Infection by JC Virus. J Virol 2018; 92:JVI.00105-18. [PMID: 29437972 DOI: 10.1128/jvi.00105-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022] Open
Abstract
JC polyomavirus (JCPyV) establishes a lifelong persistence in roughly half the human population worldwide. The cells and tissues that harbor persistent virus in vivo are not known, but renal tubules and other urogenital epithelial cells are likely candidates as virus is shed in the urine of healthy individuals. In an immunosuppressed host, JCPyV can become reactivated and cause progressive multifocal leukoencephalopathy (PML), a fatal demyelinating disease of the central nervous system. Recent observations indicate that JCPyV may productively interact with cells in the choroid plexus and leptomeninges. To further study JCPyV infection in these cells, primary human choroid plexus epithelial cells and meningeal cells were challenged with virus, and their susceptibility to infection was compared to the human glial cell line, SVG-A. We found that JCPyV productively infects both choroid plexus epithelial cells and meningeal cells in vitro Competition with the soluble receptor fragment LSTc reduced virus infection in these cells. Treatment of cells with neuraminidase also inhibited both viral infection and binding. Treatment with the serotonin receptor antagonist, ritanserin, reduced infection in SVG-A and meningeal cells. We also compared the ability of wild-type and sialic acid-binding mutant pseudoviruses to transduce these cells. Wild-type pseudovirus readily transduced all three cell types, but pseudoviruses harboring mutations in the sialic acid-binding pocket of the virus failed to transduce the cells. These data establish a novel role for choroid plexus and meninges in harboring virus that likely contributes not only to meningoencephalopathies but also to PML.IMPORTANCE JCPyV infects greater than half the human population worldwide and causes central nervous system disease in patients with weakened immune systems. Several recent reports have found JCPyV in the choroid plexus and leptomeninges of patients with encephalitis. Due to their role in forming the blood-cerebrospinal fluid barrier, the choroid plexus and leptomeninges are also poised to play roles in virus invasion of brain parenchyma, where infection of macroglial cells leads to the development of progressive multifocal leukoencephalopathy, a severely debilitating and often fatal infection. In this paper we show for the first time that primary choroid plexus epithelial cells and meningeal cells are infected by JCPyV, lending support to the association of JCPyV with meningoencephalopathies. These data also suggest that JCPyV could use these cells as reservoirs for the subsequent invasion of brain parenchyma.
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Mills EA, Mao-Draayer Y. Understanding Progressive Multifocal Leukoencephalopathy Risk in Multiple Sclerosis Patients Treated with Immunomodulatory Therapies: A Bird's Eye View. Front Immunol 2018; 9:138. [PMID: 29456537 PMCID: PMC5801425 DOI: 10.3389/fimmu.2018.00138] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/16/2018] [Indexed: 12/14/2022] Open
Abstract
The increased use of newer potent immunomodulatory therapies for multiple sclerosis (MS), including natalizumab, fingolimod, and dimethyl fumarate, has expanded the patient population at risk for developing progressive multifocal leukoencephalopathy (PML). These MS therapies shift the profile of lymphocytes within the central nervous system (CNS) leading to increased anti-inflammatory subsets and decreased immunosurveillance. Similar to MS, PML is a demyelinating disease of the CNS, but it is caused by the JC virus. The manifestation of PML requires the presence of an active, genetically rearranged form of the JC virus within CNS glial cells, coupled with the loss of appropriate JC virus-specific immune responses. The reliability of metrics used to predict risk for PML could be improved if all three components, i.e., viral genetic strain, localization, and host immune function, were taken into account. Advances in our understanding of the critical lymphocyte subpopulation changes induced by these MS therapies and ability to detect viral mutation and reactivation will facilitate efforts to develop these metrics.
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Affiliation(s)
- Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States.,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, United States
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Abstract
Merkel cell carcinoma (MCC) is a rare but highly aggressive skin cancer with neuroendocrine features. MCC pathogenesis is associated with either the presence of Merkel cell polyomavirus or chronic exposure to ultraviolet light (UV), which can cause a characteristic pattern of multiple DNA mutations. Notably, in the Northern hemisphere, the majority of MCC cases are of viral aetiology; by contrast, in areas with high UV exposure, UV-mediated carcinogenesis is predominant. The two aetiologies share similar clinical, histopathological and prognostic characteristics. MCC presents with a solitary cutaneous or subcutaneous nodule, most frequently in sun-exposed areas. In fact, UV exposure is probably involved in both viral-mediated and non-viral-mediated carcinogenesis, by contributing to immunosuppression or DNA damage, respectively. Confirmation of diagnosis relies on analyses of histological features and immunological marker expression profiles of the lesion. At primary diagnosis, loco-regional metastases are already present in ∼30% of patients. Excision of the tumour is the first-line therapy; if not feasible, radiotherapy can often effectively control the disease. Chemotherapy was the only alternative in advanced-stage or refractory MCC until several clinical trials demonstrated the efficacy of immune-checkpoint inhibitors.
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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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41
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Assetta B, Atwood WJ. The biology of JC polyomavirus. Biol Chem 2017; 398:839-855. [PMID: 28493815 DOI: 10.1515/hsz-2016-0345] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/20/2017] [Indexed: 02/06/2023]
Abstract
JC polyomavirus (JCPyV) is the causative agent of a fatal central nervous system demyelinating disease known as progressive multifocal leukoencephalopathy (PML). PML occurs in people with underlying immunodeficiency or in individuals being treated with potent immunomodulatory therapies. JCPyV is a DNA tumor virus with a double-stranded DNA genome and encodes a well-studied oncogene, large T antigen. Its host range is highly restricted to humans and only a few cell types support lytic infection in vivo or in vitro. Its oncogenic potential in humans has not been firmly established and the international committee on oncogenic viruses lists JCPyV as possibly carcinogenic. Significant progress has been made in understanding the biology of JCPyV and here we present an overview of the field and discuss some important questions that remain unanswered.
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Holroyd KB, Sotirchos ES, DeBoer SR, Mills KA, Newsome SD. JC virus granule cell neuronopathy onset two months after chemotherapy for low-grade lymphoma. CEREBELLUM & ATAXIAS 2017; 4:8. [PMID: 28652923 PMCID: PMC5481904 DOI: 10.1186/s40673-017-0066-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/14/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Granule cell neuronopathy (GCN) is a rare disease caused by the JC virus, leading to degeneration of cerebellar granule cell neurons. Primarily described in patients with AIDS, it has also been diagnosed in patients with lymphoproliferative diseases and after long-term treatment with immune-suppressing medications such as natalizumab. CASE PRESENTATION A 69 year old woman presented with progressive ataxia which began 2 months after initiation of treatment for follicular low-grade B cell lymphoma with rituximab/bendamustine, and progressed for 2 years prior to admission. Extensive prior evaluation included MRI that showed atrophy of the cerebellum but normal CSF analysis and serum studies. Neurologic exam on admission was notable for severe appendicular ataxia and fatigable end-gaze direction-changing horizontal nystagmus. FDG-PET/CT scan was unremarkable and repeat lumbar puncture revealed 2 WBCs/mm3, 148 RBCs/mm3, glucose 70 mg/dL, protein 37.7 mg/dL and negative flow cytometry/cytopathology. Standard CSF JC virus PCR testing was negative, but ultrasensitive TaqMan real-time JC virus PCR testing was positive, consistent with JC virus-related GCN. CONCLUSIONS Because of the diagnostic challenges in identifying GCN, a high threshold of suspicion should be maintained in patients with an immune-suppressing condition such as lymphoma or on immune-suppressing agents such as rituximab, even shortly after initiation of therapy.
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Affiliation(s)
| | - Elias S Sotirchos
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Scott R DeBoer
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Kelly A Mills
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA.,Division of Neuroimmunology and Neurological Infections, Johns Hopkins Hospital, 600 North Wolfe St., Pathology 627, Baltimore, MD 21287 USA
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Hoyer C, Alonso A, Schlotter-Weigel B, Platten M, Fatar M. HIV-Associated Cerebellar Dysfunction and Improvement with Aminopyridine Therapy: A Case Report. Case Rep Neurol 2017. [PMID: 28626409 PMCID: PMC5471757 DOI: 10.1159/000475544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Apart from infectious causes and cerebellar dysfunction associated with acquired immune deficiency syndrome dementia or HIV-associated neurocognitive disorder, cerebellar dysfunction in HIV-positive individuals has been ascribed to granule cell neuronopathy as well as primary cerebellar atrophy without identifiable etiology. We report the case of a patient with progressive cerebellar dysfunction as the primary manifestation of HIV infection. No symptom improvement was seen under combination antiretroviral therapy, which had been established upon diagnosis, but the patient improved rapidly under 4-aminopyridine treatment, which was recommended 1 year later. Our report, adding to the rather small number of reports of HIV-associated cerebellar atrophy and dysfunction as a primary manifestation of HIV infection, draws attention to HIV as a possible differential etiology of a cerebellar syndrome. Further, rapid improvement of symptom severity under 4-aminopyridine treatment warrants further investigation with longer-term follow-up into the effectiveness of this compound in gait disorder associated with HIV infection.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, University Medical Centre Mannheim, Mannheim, Germany
| | - Angelika Alonso
- Department of Neurology, University Medical Centre Mannheim, Mannheim, Germany
| | - Beate Schlotter-Weigel
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Platten
- Department of Neurology, University Medical Centre Mannheim, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology, University Medical Centre Mannheim, Mannheim, Germany
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Clavel G, Moulignier A, Semerano L. Progressive multifocal leukoencephalopathy and rheumatoid arthritis treatments. Joint Bone Spine 2017; 84:671-675. [PMID: 28323224 DOI: 10.1016/j.jbspin.2017.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 12/15/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system due to reactivation of the JC virus (JCV). PML is extremely uncommon despite the high prevalence of the virus in the general population. No specific treatment is available, and the prognosis is bleak. The diagnosis is based on brain imaging findings, detection of the JCV genome in cerebrospinal fluid samples and, in some cases, histological studies of the brain lesions. The pathophysiological mechanisms that drive the development of PML are incompletely understood. However, a consistent feature is the presence of a predisposing factor, most notably immunosuppression. The risk of developing PML varies with the underlying disease (e.g., HIV infection or autoimmune disease) and with the drugs used to treat them. Biologics have been ranked according to the risk of PML during their use. Natalizumab, a monoclonal antibody given to treat multiple sclerosis, is among the drugs associated with a high risk of PML. Patients given natalizumab are now closely monitored based on anti-JCV antibody titers and index values. In rheumatology, the expanding use of biologics has led to an increase in cases of PML, with rituximab being associated with the highest risk. Given the absence of specific recommendations, exhaustive registries and postmarketing observational studies are urgently needed to gauge the risk of PML according to the underlying disease and drug treatments, with the goal of defining optimal monitoring protocols.
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Affiliation(s)
- Gaëlle Clavel
- Service de médecine interne, Fondation A. de Rothschild, 25-29, rue Manin, 75019 Paris, France; Inserm UMR 1125, 74, rue Marcel-Cachin, 93017 Bobigny, France; Sorbonne Paris Cité, université Paris 13, 74, rue Marcel-Cachin, 93017 Bobigny, France.
| | | | - Luca Semerano
- Inserm UMR 1125, 74, rue Marcel-Cachin, 93017 Bobigny, France; Sorbonne Paris Cité, université Paris 13, 74, rue Marcel-Cachin, 93017 Bobigny, France; Service de rhumatologie, groupe hospitalier Avicenne Jean-Verdier-René-Muret, Assistance publique-Hopitaux de Paris (AP-HP), 93017 Bobigny, France
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Warnke C, Wattjes MP, Adams O, Hartung HP, Martin R, Weber T, Stangel M. [Progressive multifocal leukoencephalopathy]. DER NERVENARZT 2016; 87:1300-1304. [PMID: 27730274 DOI: 10.1007/s00115-016-0225-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a disease of immunosuppressed patients caused by the JC polyomavirus (JCPyV). Due to the elevated risk in patients treated with natalizumab for multiple sclerosis (MS) and also treatment with other biologicals for different indications, the relevance of PML has increased in recent years. This article summarizes the published knowledge on the biology and pathogenesis of PML with a focus on the role of cerebrospinal fluid diagnostics in the work-up for PML and the current PML case definition. Current recommendations regarding risk management are discussed, as are possible therapies and prevention.
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Affiliation(s)
- C Warnke
- Klinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - M P Wattjes
- Abteilung für Radiologie und Nuklearmedizin, VU University Medical Center, Amsterdam, Niederlande
| | - O Adams
- Institut für Virologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - H-P Hartung
- Klinik für Neurologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - R Martin
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Schweiz
| | - T Weber
- Klinik für Neurologie, Kath. Marienkrankenhaus, Hamburg, Deutschland
| | - M Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Wijburg MT, Witte BI, Vennegoor A, Roosendaal SD, Sanchez E, Liu Y, Martins Jarnalo CO, Uitdehaag BM, Barkhof F, Killestein J, Wattjes MP. MRI criteria differentiating asymptomatic PML from new MS lesions during natalizumab pharmacovigilance. J Neurol Neurosurg Psychiatry 2016; 87:1138-45. [PMID: 27530808 DOI: 10.1136/jnnp-2016-313772] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Differentiation between progressive multifocal leukoencephalopathy (PML) and new multiple sclerosis (MS) lesions on brain MRI during natalizumab pharmacovigilance in the absence of clinical signs and symptoms is challenging but is of substantial clinical relevance. We aim to define MRI characteristics that can aid in this differentiation. METHODS Reference and follow-up brain MRIs of natalizumab-treated patients with MS with asymptomatic PML (n=21), or asymptomatic new MS lesions (n=20) were evaluated with respect to characteristics of newly detected lesions by four blinded raters. We tested the association with PML for each characteristic and constructed a multivariable prediction model which we analysed using a receiver operating characteristic (ROC) curve. RESULTS Presence of punctate T2 lesions, cortical grey matter involvement, juxtacortical white matter involvement, ill-defined and mixed lesion borders towards both grey and white matter, lesion size of >3 cm, and contrast enhancement were all associated with PML. Focal lesion appearance and periventricular localisation were associated with new MS lesions. In the multivariable model, punctate T2 lesions and cortical grey matter involvement predict for PML, while focal lesion appearance and periventricular localisation predict for new MS lesions (area under the curve: 0.988, 95% CI 0.977 to 1.0, sensitivity: 100%, specificity: 80.6%). INTERPRETATION The MRI characteristics of asymptomatic natalizumab-associated PML lesions proved to differ from new MS lesions. This led to a prediction model with a high discriminating power. Careful assessment of the presence of punctate T2 lesions, cortical grey matter involvement, focal lesion appearance and periventricular localisation allows for an early diagnosis of PML.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Birgit I Witte
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Anke Vennegoor
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Stefan D Roosendaal
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Esther Sanchez
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Yaou Liu
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, P. R. China
| | - Carine O Martins Jarnalo
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Radiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Bernard Mj Uitdehaag
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Saylor D, Venkatesan A. Progressive Multifocal Leukoencephalopathy in HIV-Uninfected Individuals. Curr Infect Dis Rep 2016; 18:33. [PMID: 27686675 DOI: 10.1007/s11908-016-0543-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS) caused by the human neurotropic polyomavirus JC (JCV). The disease occurs virtually exclusively in immunocompromised individuals, and, prior to the introduction of antiretroviral therapy, was seen most commonly in the setting of HIV/AIDS. More recently, however, the incidence of PML in HIV-uninfected persons has increased with broader use of immunosuppressive and immunomodulatory medications utilized in a variety of systemic and neurologic autoimmune disorders. In this review, we discuss the epidemiology and clinical characteristics of PML in HIV-uninfected individuals, as well as diagnostic modalities and the limited treatment options. Moreover, we describe recent findings regarding the neuropathogenesis of PML, with specific focus on the unique association between PML and natalizumab, a monoclonal antibody that prevents trafficking of activated leukocytes into the CNS that is used for the treatment of multiple sclerosis.
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Affiliation(s)
- Deanna Saylor
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Arun Venkatesan
- Division of Neuroimmunology and Neuro-Infectious Diseases, Department of Neurology, The Johns Hopkins University School of Medicine, Meyer 6-113, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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Wüthrich C, Batson S, Anderson MP, White LR, Koralnik IJ. JC Virus Infects Neurons and Glial Cells in the Hippocampus. J Neuropathol Exp Neurol 2016; 75:712-717. [PMID: 27297673 PMCID: PMC5909865 DOI: 10.1093/jnen/nlw050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The human polyomavirus JC (JCV) infects glial cells and is the etiologic agent of the CNS demyelinating disease progressive multifocal leukoencephalopathy. JCV can infect granule cell neurons of the cerebellum, causing JCV granule cell neuronopathy and cortical pyramidal neurons in JCV encephalopathy. Whether JCV also infects neurons in other areas of the CNS is unclear. We determined the prevalence and pattern of JCV infection of the hippocampus in archival samples from 28 patients with known JCV infection of the CNS and 66 control subjects. Among 28 patients, 11 (39.3%) had JCV infection of hippocampus structures demonstrated by immunohistochemistry. Those included gray matter (dentate gyrus and cornu ammonis, subiculum) in 11/11 and afferent or efferent white matter tracts (perforant path, alveus, fimbria) in 10/11. In the hippocampus, JCV infected granule cell and pyramidal neurons, astrocytes, and oligodendrocytes. Although glial cells expressed either JCV regulatory T Antigen or JCV VP1 capsid protein, infected neurons expressed JCV T Antigen only, suggesting an abortive/restrictive infection. None of the 66 control subjects had evidence of hippocampal JCV protein expression by immunohistochemistry or JCV DNA by in situ hybridization. These results greatly expand our understanding of JCV pathogenesis in the CNS.
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Affiliation(s)
- Christian Wüthrich
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Stephanie Batson
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Matthew P Anderson
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Lon R White
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW)
| | - Igor J Koralnik
- From the Division of Neuro-Immunology (CW, SB, IJK); Department of Neurology (CW, SB, MPA, IJK); Center for Virology and Vaccine Research, Department of Medicine(CW, SB, IJK); Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (MPA); and John a. Burns School of Medicine, University of Hawaii, Honolulu, and the Pacific Health Research and Education Institute, Honolulu, Hawaii (LRW).
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Darbinyan A, Major EO, Morgello S, Holland S, Ryschkewitsch C, Monaco MC, Naidich TP, Bederson J, Malaczynska J, Ye F, Gordon R, Cunningham-Rundles C, Fowkes M, Tsankova NM. BK virus encephalopathy and sclerosing vasculopathy in a patient with hypohidrotic ectodermal dysplasia and immunodeficiency. Acta Neuropathol Commun 2016; 4:73. [PMID: 27411570 PMCID: PMC4944483 DOI: 10.1186/s40478-016-0342-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/26/2016] [Indexed: 02/02/2023] Open
Abstract
Human BK polyomavirus (BKV) is reactivated under conditions of immunosuppression leading most commonly to nephropathy or cystitis; its tropism for the brain is rare and poorly understood. We present a unique case of BKV-associated encephalopathy in a man with hypohidrotic ectodermal dysplasia and immunodeficiency (HED-ID) due to IKK-gamma (NEMO) mutation, who developed progressive neurological symptoms. Brain biopsy demonstrated polyomavirus infection of gray and white matter, with predominant involvement of cortex and distinct neuronal tropism, in addition to limited demyelination and oligodendroglial inclusions. Immunohistochemistry demonstrated polyoma T-antigen in neurons and glia, but expression of VP1 capsid protein only in glia. PCR analysis on both brain biopsy tissue and cerebrospinal fluid detected high levels of BKV DNA. Sequencing studies further identified novel BKV variant and disclosed unique rearrangements in the noncoding control region of the viral DNA (BKVN NCCR). Neuropathological analysis also demonstrated an unusual form of obliterative fibrosing vasculopathy in the subcortical white matter with abnormal lysosomal accumulations, possibly related to the patient's underlying ectodermal dysplasia. Our report provides the first neuropathological description of HED-ID due to NEMO mutation, and expands the diversity of neurological presentations of BKV infection in brain, underscoring the importance of its consideration in immunodeficient patients with unexplained encephalopathy. We also document novel BKVN NCCR rearrangements that may be associated with the unique neuronal tropism in this patient.
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Progressive Multifocal Leukoencephalopathy: Recent Advances and a Neuro-Ophthalmological Review. J Neuroophthalmol 2016; 35:296-305. [PMID: 26132966 DOI: 10.1097/wno.0000000000000271] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a severe often fatal opportunistic infection of the central nervous system caused by reactivation of a ubiquitous polyoma virus, JC virus. Although typically characterized by multifocal asymmetric subcortical white matter lesions, it may be monofocal and affect the cortical gray matter. Among the broad spectrum of clinical manifestations that occurs with PML, visual complaints are common. EVIDENCE ACQUISITION Combination of representative personally observed cases of PML and comprehensive review of case series of PML from 1958 through 2014. RESULTS Neuro-ophthalmic signs and symptoms were reported in approximately 20%-50% of patients with PML and can be the presenting manifestation in half of these. A majority of these presentations occur from damage to cerebral visual pathways resulting in visual field defects, cortical blindness, and other disorders of visual association. Given the decreased frequency of infratentorial and cerebellar involvement, ocular motility disorders are less common. CONCLUSIONS Visual complaints occur in patients with PML and are often the presenting sign. Awareness of this condition is helpful in avoiding unnecessary delays in the diagnosis of PML and management of the underlying condition. Recent guidelines have established criteria for diagnosis of PML in the high-risk patient population and strategies to mitigate the risk in these populations.
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