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Agnihotri SP, Dang X, Carter JL, Fife TD, Bord E, Batson S, Koralnik IJ. JCV GCN in a natalizumab-treated MS patient is associated with mutations of the VP1 capsid gene. Neurology 2014; 83:727-32. [PMID: 25037207 DOI: 10.1212/wnl.0000000000000713] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To describe the clinical, neuroimaging, immunologic, and virologic characteristics of JC virus-associated granule cell neuronopathy (JCV GCN) in a natalizumab-treated patient with multiple sclerosis (MS) who developed immune reconstitution inflammatory syndrome (IRIS) after natalizumab withdrawal. METHODS We obtained longitudinal clinical data as well as MRI and proton magnetic resonance spectroscopy from this patient with MS. We measured JCV-specific cellular immune response in his peripheral blood by intracellular cytokine staining and sequenced a fragment of JCV VP1 capsid gene detected in his CSF. We contrast our findings with the first recently reported case. RESULTS This patient presented with worsening cerebellar symptoms and progressive cerebellar atrophy without new MS lesions on MRI after 63 months of natalizumab monotherapy. JCV DNA was detected in his CSF by PCR and harbored novel GCN-type mutations in the VP1 gene. He developed IRIS upon discontinuation of natalizumab and plasma exchange, which manifested itself by a worsening of clinical symptoms and contrast enhancement in the cerebellum on MRI. Treatment with corticosteroids resulted in resolution of IRIS, as demonstrated by proton magnetic resonance spectroscopy. The patient had a strong JCV-specific T-cell response in his peripheral blood and remains alive after 15 months from onset of symptoms, although with significant disability. He did not have MS relapse on glatiramer acetate. CONCLUSIONS JCV GCN should be considered in patients on natalizumab presenting with progressive cerebellar symptoms and cerebellar atrophy, and is associated with mutations in the JCV VP1 gene. Natalizumab withdrawal may be complicated by JCV GCN IRIS, and require treatment with corticosteroids.
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Affiliation(s)
- Shruti P Agnihotri
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Xin Dang
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Jonathan L Carter
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Terry D Fife
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Evelyn Bord
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Stephanie Batson
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ
| | - Igor J Koralnik
- From the Division of Neurovirology, Department of Neurology (S.P.A., X.D., E.B., S.B., I.J.K.), Center for Virology and Vaccine Research (S.P.A., X.D., E.B., S.B., I.J.K.), and Department of Medicine (I.J.K.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.L.C., T.D.F.), University of Arizona College of Medicine, Tucson; and Barrow Neurological Institute (T.D.F.), Phoenix, AZ.
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Gheuens S, Ngo L, Wang X, Alsop DC, Lenkinski RE, Koralnik IJ. Metabolic profile of PML lesions in patients with and without IRIS: an observational study. Neurology 2012; 79:1041-8. [PMID: 22914832 DOI: 10.1212/wnl.0b013e318268465b] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To characterize progressive multifocal leukoencephalopathy (PML) lesions by contrast-enhanced MRI and evaluate their metabolism using proton magnetic resonance spectroscopy ((1)H- MRS) in the setting of immune reconstitution inflammatory syndrome (IRIS). METHODS A total of 42 patients with PML underwent a clinical evaluation as well as brain MRI and (1)H-MRS at baseline and 3, 6, and 12 months later. The presence of IRIS was determined based on clinical and laboratory criteria. Ratios of N-acetylaspartate (NAA), choline (Cho), myo-inositol (mI), and lipid/lactate (Lip1 and Lip2) to creatine (Cr) were measured and correlated with the presence of contrast enhancement (CE) in PML lesions. RESULTS IRIS occurred in 16 of 28 (57.1%) PML survivors (PML-S) and 1 of 14 (7.1%) PML progressors (PML-P). Lesions of patients with PML-IRIS showed significantly higher Cho/Cr (p = 0.0001), mI/Cr (p = 0.02), Lip1/Cr (p < 0.0001), and Lip2/Cr (p = 0.002) ratios and lower NAA/Cr (p = 0.02) ratios than patients with PML who did not have IRIS. An elevated Cho/Cr ratio was associated with CE within the (1)H-MRS voxel, whereas lipid/Cr ratios were elevated in PML-IRIS lesions independently of CE. Follow-up until 33 months from PML onset showed persistent elevation of the mI/Cr ratio in lesions of patients with PML-IRIS. A Lip1/Cr ratio greater than 1.5 combined with the presence of CE yielded a 79% probability of IRIS compared with 13% in the absence of these criteria. CONCLUSION (1)H-MRS is a valuable tool to recognize and track IRIS in PML and may prove useful in the clinical management of these patients.
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Affiliation(s)
- Sarah Gheuens
- Division of Neurovirology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA., USA
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Kaya A, Acikgoz M, Ustyol L, Avcu S, Sal E, Okur M, Caksen H. A case of acute disseminated encephalomyelitis mimicking leukodystrophy. Kurume Med J 2010; 57:85-9. [PMID: 21186344 DOI: 10.2739/kurumemedj.57.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is a monophasic, immune-mediated demyelinating disorder that can follow immunizations or more often infections including rubeola, rubella, varicella, herpes zoster, mumps, Mycoplasma pneumoniae, or, more commonly, other nonspecific upper respiratory tract infections. Documentation of a preceding illness is not required to make this diagnosis. This report examines the case of a 9-month-old male patient presenting with the features of an acute leukodystrophy following innoculation with the mixed vaccine Pentaxim (Sanofi Pasteur, Lyon- France) while suffering from a lower respiratory tract infection, and who was eventually diagnosed as ADEM. The case is presented as a reminder that ADEM can sometimes be linked to lower respiratory tract infection and vaccination, and that the features in such cases can be confused with leukodystrophy.
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Affiliation(s)
- Avni Kaya
- Department of Pediatrics, Women and Children's Hospital, Yüzüncü Yil University, Van, Turkey.
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Messina M, Meli G, Viglianesi A, Scavone G, Belfiore G, Di Bella D. Transient Bilateral Basal Ganglia Lesions in Rotavirus Encephalopathy. Neuroradiol J 2010; 23:42-7. [DOI: 10.1177/197140091002300107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 10/20/2009] [Indexed: 11/17/2022] Open
Abstract
Rotavirus gastroenteritis may be associated with the onset of an acute reversible encephalitis. We describe a case of transient bilateral basal ganglia lesions after a prodromal gastroenteritis which completely resolved four months later. Diffusion weighted images were determinant to depict the basal ganglia abnormalities and were helpful to evaluate the prognosis. A review of the literature indicates that many diseases may be accompanied by signal abnormalities within the basal ganglia and that differential diagnosis is possible only through the simultaneous evaluation of imaging, clinical and laboratory findings.
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Affiliation(s)
- M. Messina
- Department of Radiology, Catania University Hospital; Catania, Italy
| | - G.A. Meli
- Department of Radiology, “San Giovanni di Dio e Sant' Isidoro” Hospital of Giarre; Catania, Italy
| | - A. Viglianesi
- Department of Radiology, Catania University Hospital; Catania, Italy
| | - G. Scavone
- Department of Radiology, Catania University Hospital; Catania, Italy
| | - G. Belfiore
- Department of Paediatric Radiology, Catania University Hospital; Catania, Italy
| | - D. Di Bella
- Department of Paediatric Radiology, Catania University Hospital; Catania, Italy
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Magnetic resonance spectroscopy in pediatric neuroradiology: clinical and research applications. Pediatr Radiol 2010; 40:3-30. [PMID: 19937238 DOI: 10.1007/s00247-009-1450-z] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/01/2009] [Accepted: 10/19/2009] [Indexed: 10/20/2022]
Abstract
Magnetic resonance spectroscopy (MRS) offers a unique, noninvasive approach to assess pediatric neurological abnormalities at microscopic levels by quantifying cellular metabolites. The most widely available MRS method, proton ((1)H; hydrogen) spectroscopy, is FDA approved for general use and can be ordered by clinicians for pediatric neuroimaging studies if indicated. There are a multitude of both acquisition and post-processing methods that can be used in the implementation of MR spectroscopy. MRS in pediatric neuroimaging is challenging to interpret because of dramatic normal developmental changes that occur in metabolites, particularly in the first year of life. Still, MRS has been proven to provide additional clinically relevant information for several pediatric neurological disease processes such as brain tumors, infectious processes, white matter disorders, and neonatal injury. MRS can also be used as a powerful quantitative research tool. In this article, specific research applications using MRS will be demonstrated in relation to neonatal brain injury and pediatric brain tumor imaging.
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Balasubramanya KS, Kovoor JME, Jayakumar PN, Ravishankar S, Kamble RB, Panicker J, Nagaraja D. Diffusion-weighted imaging and proton MR spectroscopy in the characterization of acute disseminated encephalomyelitis. Neuroradiology 2006; 49:177-83. [PMID: 17131116 DOI: 10.1007/s00234-006-0164-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 09/13/2006] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Acute disseminated encephalomyelitis (ADEM) is usually a monophasic illness characterized by multiple lesions involving gray and white matter. Quantitative MR techniques were used to characterize and stage these lesions. METHODS Eight patients (seven males and one female; mean age 19 years, range 5 to 36 years) were studied using conventional MRI (T2- and T1-weighted and FLAIR sequences), diffusion-weighted imaging (DWI) and proton magnetic resonance spectroscopy (MRS). Apparent diffusion coefficient (ADC) values and MRS ratios were calculated for the lesion and for normal-appearing white matter (NAWM). Three patients were imaged in the acute stage (within 7 days of the onset of neurological symptoms) and five in the subacute stage (after 7 days from the onset of symptoms). RESULTS ADC values in NAWM were in the range 0.7-1.24 x 10(-3) mm/s2 (mean 0.937 +/- 0.17 mm/s2). ADC values of ADEM lesions in the acute stage were in the range 0.37-0.68 x 10(-3) mm/s2 (mean 0.56 +/- 0.16 mm/s2) and 1.01-1.31 x 10(-3) mm/s2 (mean 1.24 +/- 0.13 mm/s2) in the subacute stage. MRS ratios were obtained for all patients. NAA/Cho ratios were in the range 1.1-3.5 (mean 1.93 +/- 0.86) in the NAWM. NAA/Cho ratios within ADEM lesions in the acute stage were in the range 0.63-1.48 (mean 1.18 +/- 0.48) and 0.29-0.84 (mean 0.49 +/- 0.22) in the subacute stage. The ADC values, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the acute and subacute stages (P < 0.001, P < 0.027, P < 0.047, respectively). ADC values were significantly different between lesions in the acute (P < 0.009) and subacute stages (P < 0.005) with NAWM. In addition, NAA/Cho and Cho/Cr ratios were significantly different between lesions in the subacute stage and NAWM (P < 0.006, P < 0.007, respectively). CONCLUSION ADEM lesions were characterized in the acute stage by restricted diffusion and in the subacute stage by free diffusion and a decrease in NAA/Cho ratios. Restricted diffusion and progressive decrease in NAA/Cho ratios may help in staging the disease.
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Affiliation(s)
- K S Balasubramanya
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka 560029, India
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Kingsley PB, Shah TC, Woldenberg R. Identification of diffuse and focal brain lesions by clinical magnetic resonance spectroscopy. NMR IN BIOMEDICINE 2006; 19:435-62. [PMID: 16763970 DOI: 10.1002/nbm.1039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The purpose of this paper is to facilitate the comparison of magnetic resonance (MR) spectra acquired from unknown brain lesions with published spectra in order to help identify unknown lesions in clinical settings. The paper includes lists of references for published MR spectra of various brain diseases, including pyogenic abscesses, encephalitis (herpes simplex, Rasmussen's and subacute sclerosing panencephalitis), neurocysticercosis, tuberculoma, cysts (arachnoid, epidermoid and hydatid), acute disseminated encephalomyelitis (ADEM), adrenoleukodystrophy (ALD), Alexander disease, Canavan's disease, Krabbe disease (globoid cell leukodystrophy), Leigh's disease, megalencephalic leukoencephalopathy with cysts, metachromatic leukodystrophy (MLD), Pelizaeus-Merzbacher disease, Zellweger syndrome, HIV-associated lesions [cryptococcus, lymphoma, toxoplasmosis and progressive multifocal leukoencephalopathy (PML)], hydrocephalus and tuberous sclerosis. Each list includes information on the echo time(s) (TE) of the published spectra, whether a control spectrum is shown, whether the corresponding image and voxel position are shown and the patient ages if known. The references are listed in the approximate order of usefulness, based on spectral quality, number of spectra, range of echo times and whether the voxel positions are shown. Spectra of Zellweger syndrome, cryptococcal infection, toxoplasmosis and lymphoma are included, along with a spectrum showing propanediol (propylene glycol).
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Affiliation(s)
- Peter B Kingsley
- Department of Radiology, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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