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Yamada H, Toko M, Nakamori M, Ueno H, Aoki S, Sugimoto T, Yasutomi H, Nakamichi K, Maruyama H. Progressive multifocal leukoencephalopathy associated with systemic lupus erythematosus: longitudinal observation of lymphocytes, JC virus in cerebrospinal fluid, and brain magnetic resonance imaging. J Neurovirol 2024:10.1007/s13365-024-01203-0. [PMID: 38502271 DOI: 10.1007/s13365-024-01203-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/29/2024] [Accepted: 03/13/2024] [Indexed: 03/21/2024]
Abstract
Progressive multifocal leukoencephalopathy (PML) rarely occurs in patients with systemic lupus erythematosus (SLE). This report presents the case of a patient who developed PML due to SLE-associated multiple factors. A 60-year-old woman diagnosed with SLE undergoing multiple immunosuppressive therapies, including azathioprine, presented with cerebral cortical symptoms, lymphocytopenia, and vitamin B12 deficiency and was subsequently diagnosed with SLE-associated PML. We evaluated the cause and disease activity of PML, focusing on the longitudinal assessment of lymphocytopenia, JC virus (JCV) DNA copy number in the cerebrospinal fluid, and magnetic resonance imaging (MRI) findings. Discontinuing azathioprine and initiating alternative immunosuppressive treatments with intramuscular vitamin B12 injections affected lymphocytopenia and disease management. However, despite recovery from lymphopenia and JCV DNA copy number being low, the large hyperintense and punctate lesions observed on the fluid-attenuated inversion recovery (FLAIR) images exhibited varying behaviors, indicating that the balance between contributing factors for PML may have fluctuated after the initial treatment. Clinicians should be meticulous when assessing the underlying pathology of the multifactorial causes of PML due to SLE. The difference in the transition pattern of these lesions on FLAIR images may be one of the characteristics of MRI findings in PML associated with SLE, reflecting fluctuations in disease activity and the progression stage of PML.
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Affiliation(s)
- Hidetada Yamada
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Megumi Toko
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.
| | - Masahiro Nakamori
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroko Yasutomi
- Department of Diagnostic Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Okamoto K, Takeda A, Hatsuta H, Sano T, Takao M, Ohsawa M, Miki Y, Nakamichi K, Itoh Y. An autopsy case of progressive multifocal leukoencephalopathy with massive iron deposition in juxtacortical lesions. Neuropathology 2023; 43:396-402. [PMID: 36847459 DOI: 10.1111/neup.12898] [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: 11/18/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease caused by JC virus infection of oligodendrocytes. Little has been reported on iron deposits in patients with PML. Herein, we report a case of PML with massive iron deposition in the juxtacortical regions attaching white matter lesions in a 71-year-old woman who developed bilateral visual disturbance and progressive aphasia after 16 months of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone treatment for follicular lymphoma. Magnetic resonance imaging revealed white matter lesions in the left parietal and other lobes with massive iron deposition in the juxtacortical lesions. A PCR test for JC virus was positive, confirming the diagnosis of PML. Despite treatment with mefloquine and mirtazapine, the patient died six months later. At autopsy, demyelination was found dominantly in the left parietal lobe. Moreover, hemosiderin-laden macrophages and reactive astrocytes containing ferritin were abundant in the juxtacortical regions adjacent to the white matter lesions. This is a previously unreported case of PML after lymphoma, in which iron deposition was confirmed both radiologically and pathologically.
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Grants
- 22H04923 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 18K06506 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 21K06417 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 21K07450 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 22dk0307115h0001 AMED
- JP21wm0425019 AMED
- intramural fund National Center of Neurology and Psychiatry
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Affiliation(s)
- Kosuke Okamoto
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akitoshi Takeda
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Hatsuta
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
- Hatsuta Neurology Clinic, Osaka, Japan
| | - Terunori Sano
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaki Takao
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masahiko Ohsawa
- Department of Pathology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshiaki Itoh
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Kareem SS, Viswanathan N, Sahebjam S, Tran ND, Gatewood T, Tobon K, Baz R, Piña Y, Shain KH, Mokhtari S. Leukoencephalopathy During Daratumumab-Based Therapy: A Case Series of Two Patients with Multiple Myeloma. Onco Targets Ther 2022; 15:953-962. [PMID: 36097632 PMCID: PMC9464026 DOI: 10.2147/ott.s365657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Leukoencephalopathy in the setting of multiple myeloma (MM) is a rare demyelinating condition, with few reported cases in literature. Daratumumab is a CD38 targeted monoclonal antibody that has been widely used for the management of MM. In the absence of central nervous system (CNS) disease, many medication-induced leukoencephalopathy cases reported with MM, including daratumumab-induced, are associated with progressive multifocal leukoencephalopathy (PML) and John Cunningham (JC) virus. Currently, there are no reported cases of daratumumab-induced leukoencephalopathy among patients without CNS involvement or PML. We discuss 2 patients who developed leukoencephalopathy while receiving daratumumab-based therapy without evidence of PML or CNS disease. Both patients had baseline MRIs without significant white matter changes before daratumumab-based therapy. Patients began experiencing neurological deficits about 6 to 8 months after daratumumab-based therapy initiation. One patient passed away before being assessed for improvement of symptoms with daratumumab cessation. The second patient had some stabilization of symptoms after cessation; however, the leukoencephalopathy remained irreversible. As the class of anti-CD38 monoclonal antibodies expands in MM therapy, we highlight a potential treatment complication and the importance of detecting leukoencephalopathy early among patients receiving anti-CD38 therapy. We recommend vigilant monitoring of any new or worsening neurological symptoms to avoid serious complications of irreversible leukoencephalopathy.
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Affiliation(s)
- Syeda Saba Kareem
- Malignant Hematology Department, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Solmaz Sahebjam
- Neuro-Oncology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Nam D Tran
- Neuro-Oncology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Tyra Gatewood
- Neuro-Oncology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Katherine Tobon
- Malignant Hematology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Rachid Baz
- Malignant Hematology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Yolanda Piña
- Neuro-Oncology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth H Shain
- Malignant Hematology Department, Moffitt Cancer Center, Tampa, FL, USA.,Tumor Biology Department, Moffitt Cancer Center, Tampa, FL, USA
| | - Sepideh Mokhtari
- Neuro-Oncology Department, Moffitt Cancer Center, Tampa, FL, USA
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Abstract
PURPOSE OF REVIEW This article reviews current epidemiologic trends, clinical presentations, and diagnostic strategies for central nervous system (CNS) infections in human immunodeficiency virus-negative (HIV) patients immunocompromised by their underlying disease or by receipt of immunosuppressive or immunomodulating therapies. Three patient groups are considered: (1) cancer patients; (2) hematopoietic or solid organ transplantation recipients; and (3) patients with autoimmune or inflammatory conditions requiring therapies that alter the host immune response. RECENT FINDINGS Clinical presentations, associated neuroimaging, and cerebrospinal fluid (CSF) abnormalities differ between immunocompromised and immunocompetent patients. Infections can trigger the emergence of neurotropic antibodies or inflammatory conditions due to treatment with cancer immunotherapies. Unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. Awareness of clinical presentations and disease and drug-specific risks is important for early diagnosis and intervention in these often life-threatening infections and their noninfectious mimes.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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Mahajan KR, Amin M, Poturalski M, Lee J, Herman D, Zheng Y, Androjna C, Howell M, Fox RJ, Trapp BD, Jones SE, Nakamura K, Ontaneda D. Juxtacortical susceptibility changes in progressive multifocal leukoencephalopathy at the gray-white matter junction correlates with iron-enriched macrophages. Mult Scler 2021; 27:2159-2169. [PMID: 33749379 DOI: 10.1177/1352458521999651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Describe magnetic resonance imaging (MRI) susceptibility changes in progressive multifocal leukoencephalopathy (PML) and identify neuropathological correlates. METHODS PML cases and matched controls with primary central nervous system lymphoma (PCNSL) were retrospectively identified. MRI brain at 3 T and 7 T were reviewed. MRI-pathology correlations in fixed brain autopsy tissue were conducted in three subjects with confirmed PML. RESULTS With PML (n = 26 total, n = 5 multiple sclerosis natalizumab-associated), juxtacortical changes on susceptibility-weighted imaging (SWI) or gradient echo (GRE) sequences were noted in 3/3 cases on 7 T MRI and 14/22 cases (63.6%) on 1.5 T or 8/22 (36.4%) 3 T MRI. Similar findings were only noted in 3/25 (12.0%) of PCNSL patients (odds ratio (OR) 12.83, 95% confidence interval (CI), 2.9-56.7, p < 0.001) on 1.5 or 3 T MRI. On susceptibility sequences available prior to diagnosis of PML, 7 (87.5%) had changes present on average 2.7 ± 1.8 months (mean ± SD) prior to diagnosis. Postmortem 7 T MRI showed SWI changes corresponded to areas of increased iron density along the gray-white matter (GM-WM) junction predominantly in macrophages. CONCLUSION Susceptibility changes in PML along the GM-WM junction can precede noticeable fluid-attenuated inversion recovery (FLAIR) changes and correlates with iron accumulation in macrophages.
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Affiliation(s)
- Kedar R Mahajan
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA/Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Poturalski
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan Lee
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Danielle Herman
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yufan Zheng
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caroline Androjna
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Howell
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce D Trapp
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen E Jones
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kunio Nakamura
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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