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Paolucci M, Gentile L, Gentile M, Borghi A, Merli E, Marchionni E, Guerra L, Galluzzo S, Cilloni N, Simonetti L, Zini A. Progressive multifocal leukoencephalopathy in multiple myeloma: a case report of a patient with SARS-CoV-2 infection and an updated systematic literature review. Neurol Sci 2023; 44:2995-2998. [PMID: 37421487 DOI: 10.1007/s10072-023-06944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/04/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a reactivation of the human polyomavirus 2 (HPyV-2, previously known as JCV) in immunosuppressed individuals. Few cases of PML have been described in multiple myeloma (MM) patients. METHODS We described a case of PML in a patient with MM with fatal worsening that occurred during SARS-CoV-2 infection. We also performed a literature review to update the 16 cases series of MM patients with PML already collected until April 2020. RESULTS A 79-year-old female patient with refractory IgA lambda MM in Pomalidomide- Cyclophosphamide-Dexamethasone regimen developed gradual lower limbs and left arm paresis along with a decreased consciousness 3.5 years after the MM diagnosis. Symptoms developed shortly after the recognition of hypogammaglobulinemia. After SARS-CoV-2 infection, her neurological status quickly worsened until she deceased. MRI features and JCV-positive PCR on CSF confirmed the PML diagnosis. Our literature review adds sixteen clinical cases of PML in MM published between May 2020 and March 2023 to the 16 cases already collected in the previously published review by Koutsavlis. DISCUSSION PML has been increasingly described in MM patients. It remains questionable if the HPyV-2 reactivation is determined by the severity of MM itself, by the effect of drugs or by a combination of both. SARS-CoV-2 infection may have a role in worsening PML in affected patients.
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Affiliation(s)
- Matteo Paolucci
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy.
| | - Luana Gentile
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Mauro Gentile
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Annamaria Borghi
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Elena Merli
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
| | - Elisa Marchionni
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna Bologna, Bologna, Italy
| | - Luca Guerra
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna Bologna, Bologna, Italy
| | - Simone Galluzzo
- UOSI Neuroradiologia Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Nicola Cilloni
- Intensive Care Unit, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Luigi Simonetti
- UOSI Neuroradiologia Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- UOC Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, IRCCS Istituto delle Scienze Neurologiche di Bologna, Largo Bartolo Nigrisoli, 2, Bologna, 40133, Italy
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Tawara T, Kai H, Kageyama M, Akiyama T, Matsunaga T, Sakuma A, Ishii R, Tsunoda R, Kawamura T, Fujita A, Kaneko S, Morito N, Saito C, Usui J, Yamagata K. A case report of progressive multifocal leukoencephalopathy during steroid treatment for ANCA-associated renal vasculitis. CEN Case Rep 2020; 9:354-358. [PMID: 32388828 DOI: 10.1007/s13730-020-00482-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/15/2020] [Indexed: 11/29/2022] Open
Abstract
CASE REPORT an 80-year-old woman presented with rapidly progressive glomerulonephritis and was admitted to our hospital. Myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA) was positive. We diagnosed ANCA-associated renal vasculitis (ANCA-RV). Treatment was initiated with intravenous methylprednisolone pulse therapy, followed by prednisolone (PSL) at 30 mg/day. We gradually reduced the PSL dose to 7.5 mg/day over 6 months. At that time, the patient developed disturbances of consciousness which progressed subacutely. MRI revealed regions of patchy white matter with an increased signal on T2-weighted, fluid attenuated inversion recovery (FLAIR) sequences and diffusion-weighted sequences. JC virus DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR), leading to a diagnosis of progressive multifocal leukoencephalopathy (PML). PML is a rare infectious demyelinating disease of the central nervous system caused by JC virus infection, occurring in highly immunosuppressed individuals such as HIV-infected patients and patients using some biological agents, and having a very poor prognosis. In the present case, PML may have been associated with steroid use, although there are very few case reports of PML in patients taking only steroids. We report progressive multifocal leukoencephalopathy during steroid treatment of ANCA-RV. When patients show progressive disturbance of consciousness during treatment for ANCA-RV, we need to take PML into consideration for differential diagnosis.
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Affiliation(s)
- Takashi Tawara
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hirayasu Kai
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Mikiko Kageyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tomoki Akiyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takahiro Matsunaga
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Aki Sakuma
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryota Ishii
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryouya Tsunoda
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tetusya Kawamura
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akiko Fujita
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shuzo Kaneko
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Morito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Chie Saito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Joichi Usui
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kunihiro Yamagata
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
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Yuan C, Deberardinis C, Patel R, Shroff SM, Messina SA, Goldstein S, Mori S. Progressive multifocal leukoencephalopathy after allogeneic stem cell transplantation: Case report and review of the literature. Transpl Infect Dis 2018. [PMID: 29512846 DOI: 10.1111/tid.12879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare, yet typically fatal complication of allogeneic stem cell transplantation. It is caused by reactivation of the John Cunningham (JC) virus in an immunocompromised host. This report describes an unfortunate case of PML in a recipient of an allogeneic stem cell transplant for acute myelogenous leukemia. The JC virus was undetectable in the patient's cerebrospinal fluid by polymerase chain reaction (PCR); however, a positive diagnosis was made after a brain biopsy. This and other published cases demonstrate that recipients of allogeneic stem cells can develop PML. Moreover, early diagnosis of the disease is often difficult and, as demonstrated in this case, screening with PCR does not appear to have strong diagnostic significance. With no effective treatment presently available, restoration of immune function is the only intervention that can affect prognosis. Further prospective studies are needed to understand the pathophysiology and treatment of this disease.
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Affiliation(s)
- Cai Yuan
- Hematology and Oncology Fellowship, University of Florida, Gainesville, FL, USA
| | | | - Rushang Patel
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
| | - Seema M Shroff
- Pathology Department, Florida Hospital, Orlando, FL, USA
| | | | - Steven Goldstein
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
| | - Shahram Mori
- Blood & Marrow Transplant Center, Florida Hospital, Orlando, FL, USA
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Drug-associated progressive multifocal leukoencephalopathy: a clinical, radiological, and cerebrospinal fluid analysis of 326 cases. J Neurol 2016; 263:2004-21. [PMID: 27401179 PMCID: PMC5037162 DOI: 10.1007/s00415-016-8217-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 02/07/2023]
Abstract
The implementation of a variety of immunosuppressive therapies has made drug-associated progressive multifocal leukoencephalopathy (PML) an increasingly prevalent clinical entity. The purpose of this study was to investigate its diagnostic characteristics and to determine whether differences herein exist between the multiple sclerosis (MS), neoplasm, post-transplantation, and autoimmune disease subgroups. Reports of possible, probable, and definite PML according to the current diagnostic criteria were obtained by a systematic search of PubMed and the Dutch pharmacovigilance database. Demographic, epidemiologic, clinical, radiological, cerebrospinal fluid (CSF), and histopathological features were extracted from each report and differences were compared between the disease categories. In the 326 identified reports, PML onset occurred on average 29.5 months after drug introduction, varying from 14.2 to 37.8 months in the neoplasm and MS subgroups, respectively. The most common overall symptoms were motor weakness (48.6 %), cognitive deficits (43.2 %), dysarthria (26.3 %), and ataxia (24.1 %). The former two also constituted the most prevalent manifestations in each subgroup. Lesions were more often localized supratentorially (87.7 %) than infratentorially (27.4 %), especially in the frontal (64.1 %) and parietal lobes (46.6 %), and revealed enhancement in 27.6 % of cases, particularly in the MS (42.9 %) subgroup. Positive JC virus results in the first CSF sample were obtained in 63.5 %, while conversion after one or more negative outcomes occurred in 13.7 % of cases. 52.2 % of patients died, ranging from 12.0 to 83.3 % in the MS and neoplasm subgroups, respectively. In conclusion, despite the heterogeneous nature of the underlying diseases, motor weakness and cognitive changes were the two most common manifestations of drug-associated PML in all subgroups. The frontal and parietal lobes invariably constituted the predilection sites of drug-related PML lesions.
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Henegar CE, Eudy AM, Kharat V, Hill DD, Bennett D, Haight B. Progressive multifocal leukoencephalopathy in patients with systemic lupus erythematosus: a systematic literature review. Lupus 2016; 25:617-26. [PMID: 26743322 DOI: 10.1177/0961203315622819] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 11/24/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine risk factors for progressive multifocal leukoencephalopathy (PML) in systemic lupus erythematosus (SLE) patients, and understand how underlying disease or treatment for SLE may be associated with PML in this population. METHODS Studies published in English between January 1, 1984 and October 31, 2014 that reported PML in adult SLE patients were included. Immunosuppression was defined as exposure to ≥1 immunosuppressant drug of interest at PML diagnosis: belimumab, rituximab, mycophenolate mofetil, azathioprine, cyclophosphamide, methotrexate and high-dose corticosteroids (>15 mg/day). Minimal immunosuppression was defined as low-dose corticosteroids (≤15 mg/day) and/or anti-malarials. RESULTS Thirty-five publications met our inclusion criteria: four observational studies, two large case series, and 29 case reports that described 35 cases. Reported PML incidence rates among SLE patients based on observational studies ranged from 1.0 to 2.4 cases/100,000 person-years. Of the 35 case reports, three cases were exposed to no immunosuppressant drugs at PML diagnosis, five cases had minimal immunosuppression, 23 cases had immunosuppression, and four cases were indeterminate. CONCLUSIONS The evidence from this literature review suggests that, while PML is a very rare disease in SLE patients, there does appear to be an increased risk of PML associated with SLE compared to the general population, potentially due to immunosuppression, other contributing factors in their underlying disease, treatments prescribed to manage disease, or some combination of these factors. Additional large observational studies, designed to assess exposure to drugs of interest and complicated treatment histories, are needed to provide further evidence about potential mechanisms contributing to the onset of PML in SLE patients.
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Affiliation(s)
- C E Henegar
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - A M Eudy
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - V Kharat
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D D Hill
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - D Bennett
- Worldwide Epidemiology, GlaxoSmithKline, Research Triangle Park, USA
| | - B Haight
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Research Triangle Park, USA
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Abstract
Inflammatory bowel diseases (IBD) are chronic, relapsing and remitting inflammatory conditions affecting the digestive system, comprising two main distinctive diseases, ulcerative colitis (UC) and Crohn's disease (CD). Besides the classic gastrointestinal manifestations, a variable number of IBD patients present with extraintestinal manifestations, including central and peripheral nervous system involvement. Peripheral neuropathy is one of the most common complications. An inflammatory myopathy has also been found. Cranial neuropathies include the Melkersson-Rosenthal syndrome, optic neuritis, and sensorineural hearing loss. Patients with IBD have a remarkable thromboembolic tendency and are at increased risk of both venous and arterial thrombotic complications. The prothrombotic state in IBD has multiple contributors. Ischemic stroke occurs through several mechanisms, including large artery disease, small vessel disease, paradoxical embolism, endocarditis, vasculitis, and associated with anti-TNF-α therapy. Thrombosis of the dural sinus and cerebral veins are at least as frequent as arterial stroke in IBD. Multiple sclerosis has been repeatedly associated with IBD. Up to 50% of IBD present asymptomatic white matter lesions. Other central nervous system complications include a slowly progressive myelopathy, epidural and subdural spinal empyema secondary to fistulous extension from the rectum, seizures, and encephalopathy.
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Successful Treatment of Progressive Multifocal Leukoencephalopathy With Interferon. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2012. [DOI: 10.1097/ipc.0b013e318245d48f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bomback AS, Derebail VK, McGregor JG, Kshirsagar AV, Falk RJ, Nachman PH. Rituximab therapy for membranous nephropathy: a systematic review. Clin J Am Soc Nephrol 2009; 4:734-44. [PMID: 19279120 DOI: 10.2215/cjn.05231008] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The treatment of membranous nephropathy (MN) remains controversial. Rituximab, which selectively targets B cells, has emerged as a possible alternative treatment option with limited toxicity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The available data on rituximab therapy for MN were reviewed using the MEDLINE database (inception to August 1, 2008), Google Scholar, and selected reference lists. English-language studies investigating the use of rituximab in idiopathic and secondary MN, in native and transplanted kidneys, were included. Study design, subject number, clinical characteristics (diagnosis, previous and concomitant treatment courses, baseline proteinuria, baseline renal function), rituximab protocol, follow-up period, achievement of complete or partial remission, changes in proteinuria and renal function, and adverse effects of therapy were extracted. RESULTS Twenty-one articles were included for review; all were either case reports or case series without controls. More than half of the published cases (50 of 85) came from one center where rituximab was used as primary immunosuppression for idiopathic MN. The available data suggest that rituximab, dosed either as 375 mg/m(2) once weekly for 4 wk or as 1 g on days 1 and 15, achieves a 15 to 20% rate of complete remission and a 35 to 40% rate of partial remission. The drug was well tolerated with minimal adverse events. CONCLUSIONS Although rituximab may prove to be a better treatment option for MN than alkylating agents or calcineurin inhibitors, the current literature only supports using the drug in research protocols. Whether, when, how, and why to use rituximab in MN remains to be determined.
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Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina Kidney Center, Chapel Hill, North Carolina 27599-7155, USA.
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Stoner GL. Implications of progressive multifocal leukoencephalopathy and JC virus for the etiology of MS. Acta Neurol Scand 2009. [DOI: 10.1111/j.1600-0404.1991.tb03954.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shprecher D, Frech T, Chin S, Eskandari R, Steffens J. Progressive multifocal leucoencephalopathy associated with lupus and methotrexate overdose. Lupus 2008; 17:1029-32. [DOI: 10.1177/0961203308089435] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Progressive multifocal leucoencephalopathy (PML) is a CNS infection of oligodendrocytes by JC virus, which rarely occurs in lupus, and can be mistaken for antiphospholipid antibody syndrome or neuropsychiatric systemic lupus erythematosus (NSLE). This case of PML in a patient with systemic lupus erythematosus on supra-therapeutic doses of methotrexate emphasises that CNS infection is an important diagnostic consideration before empiric treatment with immunosuppresants for NSLE.
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Affiliation(s)
- D Shprecher
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - T Frech
- Department of Rheumatology, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - S Chin
- Department of Neurology, University of Utah Medical Center, Salt Lake City, Utah, USA; Department of Pathology, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - R Eskandari
- Department of Neurosurgery, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - J Steffens
- Department of Neurology, University of Utah Medical Center, Salt Lake City, Utah, USA
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Kimura M, Aramaki K, Wada T, Nishi K, Matsushita R, Iizuka N, Hashimoto A, Tanaka S, Ishikawa A, Endo H, Hirohata S. Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature. J Neurol Sci 2008; 272:71-6. [PMID: 18538345 DOI: 10.1016/j.jns.2008.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/11/2008] [Accepted: 04/22/2008] [Indexed: 11/26/2022]
Abstract
We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.
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Affiliation(s)
- Miho Kimura
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa 228-8555, Japan
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Boren EJ, Cheema GS, Naguwa SM, Ansari AA, Gershwin ME. The emergence of progressive multifocal leukoencephalopathy (PML) in rheumatic diseases. J Autoimmun 2008; 30:90-8. [DOI: 10.1016/j.jaut.2007.11.013] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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13
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Calabrese LH, Molloy ES, Huang D, Ransohoff RM. Progressive multifocal leukoencephalopathy in rheumatic diseases: evolving clinical and pathologic patterns of disease. ACTA ACUST UNITED AC 2007; 56:2116-28. [PMID: 17599729 DOI: 10.1002/art.22657] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Leonard H Calabrese
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Terrier B, Martinez V, Seilhean D, Chapelon-Abric C, Vaghefi P, Sanson M, Bricaire F, Piette JC, Caumes E. Progressive multifocal leukoencephalopathy mimicking cerebral vasculitis in systemic granulomatosis. J Infect 2007; 54:e133-5. [PMID: 17052759 DOI: 10.1016/j.jinf.2006.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Revised: 08/22/2006] [Accepted: 09/09/2006] [Indexed: 11/16/2022]
Abstract
We describe the case of a 69-year-old man with systemic granulomatosis who presented with left-sided hemiplegia. Initial diagnosis concerning the neurological troubles was cerebral vasculitis. Corticosteroids associated with antituberculosis therapy showed a rapid but transient amelioration followed by neurological aggravation. Two weeks later, JC virus was detected in cerebrospinal fluid by PCR and the diagnosis of progressive multifocal leukoencephalopathy (PML) was made. Treatment with cytarabine and cidofovir was initiated but the patient died three months after the first neurological signs. In the presence of central neurological symptoms occurring during systemic granulomatosis before specific therapy, PML should be evoked.
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Affiliation(s)
- Benjamin Terrier
- Department of Infectious Diseases, Université Pierre et Marie Curie, APHP, Service de Maladies Infectieuses et Tropicales, Groupe Hospitalier Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75651 Paris Cedex 13, France
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15
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Vandecasteele SJ, Maes B, Claes K, Sciot R, Vanrenterghem Y. High anti-double-stranded DNA antibodies and progressive multifocal leukoencephalopathy in a patient with systemic lupus erythematosus. Nephrol Dial Transplant 2005; 20:1246-7. [PMID: 15769818 DOI: 10.1093/ndt/gfh756] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Warnatz K, Peter HH, Schumacher M, Wiese L, Prasse A, Petschner F, Vaith P, Volk B, Weiner SM. Infectious CNS disease as a differential diagnosis in systemic rheumatic diseases: three case reports and a review of the literature. Ann Rheum Dis 2003; 62:50-7. [PMID: 12480669 PMCID: PMC1754279 DOI: 10.1136/ard.62.1.50] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Immunosuppressive treatment of rheumatic diseases may be associated with several opportunistic infections of the brain. The differentiation between primary central nervous system (CNS) involvement and CNS infection may be difficult, leading to delayed diagnosis. OBJECTIVE To differentiate between CNS involvement and CNS infection in systemic rheumatic diseases. METHODS AND RESULTS Three patients with either longstanding or suspected systemic rheumatic diseases (systemic lupus erythematodes, Wegener's granulomatosis, and cerebral vasculitis) who presented with various neuropsychiatric symptoms are described. All three patients were pretreated with different immunosuppressive drugs (leflunomide, methotrexate, cyclophosphamide) in combination with corticosteroids. Magnetic resonance imaging of the brain was suggestive of infectious disease, which was confirmed by cerebrospinal fluid analysis or stereotactic brain biopsy (progressive multifocal leucoencephalopathy (PML) in two and nocardiosis in one patient). DISCUSSION More than 20 cases of PML or cerebral nocardiosis in patients receiving corticosteroids and cytotoxic drugs for rheumatic disease have been reported. The clinical aspects of opportunistic CNS infections and the role of brain imaging, cerebrospinal fluid analysis and stereotactic brain biopsy in the differential diagnosis are reviewed.
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Affiliation(s)
- K Warnatz
- Department of Rheumatology and Clinical Immunology, Medizinische Klinik, University Hospital, Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
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Abstract
Immunocompromised patients with rheumatic diseases have an increased risk of infections. A major risk factor for infection seems to be the immunosuppressive therapy used. Newer therapies for RA may lead to increased rates of infection by opportunistic pathogens such as Mycobacteria tuberculosis. Because disease manifestation may mimic signs and symptoms of infection, prompt diagnosis may be difficult. Familiarity with the likely infections and their causes should aid in obtaining the appropriate culture specimens.
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Affiliation(s)
- Stephen B Greenberg
- Departments of Medicine, Molecular Virology, and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
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18
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Bouza E, Moya JG, Muñoz P. Infections in systemic lupus erythematosus and rheumatoid arthritis. Infect Dis Clin North Am 2001; 15:335-61, vii. [PMID: 11447699 DOI: 10.1016/s0891-5520(05)70149-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with systemic lupus erythematosus have a higher infection rate than the general population. It is estimated that at least 50% of them will suffer a severe infectious episode during the course of the disease. Improvements in the control of the disease are discussed in this article.
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Affiliation(s)
- E Bouza
- Clinical Microbiology and Infectious Disease Service, Hospital General Universitario Gregorio Marañón, University of Madrid, Madrid, Spain.
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19
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Abstract
The improved survival of SLE patients since the 1950s is the result of not only better treatment, but also supportive treatment of renal failure and the wealth of antibiotics now available. Ironically, the wider use of immunosuppressives, especially the alkylating drugs, and the longer survival of patients with renal insufficiency and renal failure have made the identification and appropriate treatment of infection in SLE an ongoing challenge.
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Affiliation(s)
- M Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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A case of systemic lupus erythematosus complicated by progressive multifocal leukoencephalopathy: case report and review of the literature. ACTA ACUST UNITED AC 1997. [DOI: 10.1007/bf03041233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Matsumoto R, Nakano I, Shiga J, Akaoka I. Systemic lupus erythematosus with multiple perivascular spongy changes in the cerebral deep structures, midbrain and cerebellar white matter: a case report. J Neurol Sci 1997; 145:147-53. [PMID: 9094042 DOI: 10.1016/s0022-510x(96)00238-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A 42-year-old woman with systemic lupus erythematosus developed an episode of tonic seizures and progressive disturbance of consciousness at the terminal stage. Neuropathological examination of the brain revealed a nearly symmetrical distribution of multiple spongy foci in the internal capsules, thalami, globus pallidus, mesencephalic tegmentum, cerebral peduncles and hilus of the dentate nuclei. The spongy lesions were obviously distributed along apparently intact medium-sized veins, and contained large numbers of macrophages, and axonal spheroids and a few reactive astrocytes, without inflammatory cell infiltration. In addition, the perivenous spongy lesions exhibited IgG immunoreactivity, so it is surmised that some neurotoxic factor(s) that exuded from the veins in the center of the perivenous lesions may have brought about such a unique pathology.
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Affiliation(s)
- R Matsumoto
- Department of Neuropathology, Tokyo Metropolitan Institute for Neuroscience, Japan
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22
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Dong X, Hamilton KJ, Satoh M, Wang J, Reeves WH. Initiation of autoimmunity to the p53 tumor suppressor protein by complexes of p53 and SV40 large T antigen. J Exp Med 1994; 179:1243-52. [PMID: 8145041 PMCID: PMC2191430 DOI: 10.1084/jem.179.4.1243] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Antinuclear antibodies (ANAs) reactive with a limited spectrum of nuclear antigens are characteristic of systemic lupus erythematosus (SLE) and other collagen vascular diseases, and are also associated with certain viral infections. The factors that initiate ANA production and determine ANA specificity are not well understood. In this study, high titer ANAs specific for the p53 tumor suppressor protein were induced in mice immunized with purified complexes of murine p53 and the Simian virus 40 large T antigen (SVT), but not in mice immunized with either protein separately. The autoantibodies to p53 in these mice were primarily of the IgG1 isotype, were not cross-reactive with SVT, and were produced at titers up to 1:25,000, without the appearance of other autoantibodies. The high levels of autoantibodies to p53 in mice immunized with p53/SVT complexes were transient, but low levels of the autoantibodies persisted. The latter may have been maintained by self antigen, since the anti-p53, but not the SVT, response in these mice could be boosted by immunizing with murine p53. Thus, once autoimmunity to p53 was established by immunizing with p53/SVT complexes, it could be maintained without a requirement for SVT. These data may be explained in at least two ways. First, altered antigen processing resulting from the formation of p53/SVT complexes might activate autoreactive T helper cells specific for cryptic epitopes of murine p53, driving anti-p53 autoantibody production. Alternatively, SVT-responsive T cells may provide intermolecular-intrastructural help to B cells specific for murine p53. In a second stage, these activated B cells might themselves process self p53, generating p53-responsive autoreactive T cells. The induction of autoantibodies during the course of an immune response directed against this naturally occurring complex of self and nonself antigens may be relevant to the generation of specific autoantibodies in viral infections, and may also have implications for understanding the pathogenesis of ANAs in SLE. In particular, our results imply that autoimmunity can be initiated by a "hit and run" mechanism in which the binding of a viral antigen to a self protein triggers an immune response that subsequently can be perpetuated by self antigen.
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Affiliation(s)
- X Dong
- Department of Medicine, University of North Carolina, Chapel Hill 27599-7280
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23
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Abstract
Multiple sclerosis (MS) is generally considered to be an autoimmune disorder with myelin as the target and with several unidentified viruses playing ancillary roles, possibly through molecular mimicry. Although this paradigm has led to important progress on potential mechanisms of myelin loss, neither a target antigen in myelin nor a triggering mechanism has yet been identified, leaving the etiology of MS still unknown. Animal models of viral demyelination and studies showing that JC virus (JCV), the polyomavirus which causes progressive multifocal leukoencephalopathy (PML), may be latent in some normal human brains suggest another possibility. A host immune response targeting proteins expressed at low levels from viral DNA latent in the central nervous system (CNS) might underlie a focal demyelinating disease such as MS. A shift from autoimmunity to a latent-virus model is not a trivial substitution of target antigens. This shift would expand the search for a definitive laboratory test for MS and could lead to improved therapeutic and preventive approaches.
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Affiliation(s)
- G L Stoner
- Laboratory of Experimental Neuropathology, National Institute of Neurological and Communicative Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892
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24
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Kaye BR, Neuwelt CM, London SS, DeArmond SJ. Central nervous system systemic lupus erythematosus mimicking progressive multifocal leucoencephalopathy. Ann Rheum Dis 1992; 51:1152-6. [PMID: 1444628 PMCID: PMC1012422 DOI: 10.1136/ard.51.10.1152] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The case is reported of a patient with central nervous system systemic lupus erythematosus (SLE) with features of progressive multifocal leucoencephalopathy (PML) seen clinically and by magnetic resonance imaging. A brain biopsy sample showed microinfarcts. The use of magnetic resonance imaging and IgG synthesis rates in evaluating central nervous system lupus, the co-occurrence of SLE and PML, and the differentiation of these entities by magnetic resonance imaging and by histology are considered.
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Affiliation(s)
- B R Kaye
- East Bay Rheumatology Medical Group, Oakland, CA
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25
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Teo CG, Wong SY, Best PV. JC virus genomes in progressive multifocal leukoencephalopathy: detection using a sensitive non-radioisotopic in situ hybridization method. J Pathol 1989; 157:135-40. [PMID: 2537894 DOI: 10.1002/path.1711570208] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
JC virus genomes have been localized in formalin-fixed, paraffin-embedded brain tissues of two cases of known progressive multifocal leukoencephalopathy by in situ hybridization utilizing a biotinylated JC virus DNA probe. A three-stage immunoperoxidase system with gold-silver amplification of the diaminobenzidine substrate was used to visualize biotinylated nucleic acid hybrids. Dot-blot quantification of this visualization system indicates that subpicogramme amounts of biotinylated DNA can be detected. Optimal detection of the virus genomes in the brain tissues required a microwave irradiation step prior to hybridization. JC virus genomes were observed in the nuclei of enlarged oligodendrocytes and of some bizarre astrocytes. No other cell types were found to harbour the genomes.
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Affiliation(s)
- C G Teo
- Department of Virology, Royal Postgraduate Medical School, London, U.K
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