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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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Soni N, Ora M, Mangla R, Singh R, Ellika S, Agarwal A, Meyers SP, Bathla G. Radiological abnormalities in progressive multifocal leukoencephalopathy: Identifying typical and atypical imaging patterns for early diagnosis and differential considerations. Mult Scler Relat Disord 2023; 77:104830. [PMID: 37418930 DOI: 10.1016/j.msard.2023.104830] [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: 03/29/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 07/09/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare viral central nervous system (CNS) demyelinating disease primarily associated with a compromised immune system. PML is seen mainly in individuals with human immunodeficiency virus, lymphoproliferative disease, and multiple sclerosis. Patients on immunomodulators, chemotherapy, and solid organ or bone marrow transplants are predisposed to PML. Recognition of various PML-associated typical and atypical imaging abnormalities is critical for early diagnosis and differentiating it from other conditions, especially in high-risk populations. Early PML recognition should expedite efforts at immune-system restoration, allowing for a favorable outcome. This review aims to provide a practical overview of radiological abnormalities in PML patients and address differential considerations.
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Affiliation(s)
- Neetu Soni
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA.
| | - Manish Ora
- Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Rohit Singh
- Division of Hematology-Oncology at the University of Vermont Medical Center, Burlington, VT, USA
| | - Shehanaz Ellika
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
| | - Amit Agarwal
- Radiology, Mayo Clinic in Florida, San Pablo Dr, Jacksonville, FL 32224-1865, USA
| | - Steven P Meyers
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
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Kaiserman J, O’Hara BA, Haley SA, Atwood WJ. An Elusive Target: Inhibitors of JC Polyomavirus Infection and Their Development as Therapeutics for the Treatment of Progressive Multifocal Leukoencephalopathy. Int J Mol Sci 2023; 24:8580. [PMID: 37239927 PMCID: PMC10218015 DOI: 10.3390/ijms24108580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease caused by infection with JC Polyomavirus (JCPyV). Despite the identification of the disease and isolation of the causative pathogen over fifty years ago, no antiviral treatments or prophylactic vaccines exist. Disease onset is usually associated with immunosuppression, and current treatment guidelines are limited to restoring immune function. This review summarizes the drugs and small molecules that have been shown to inhibit JCPyV infection and spread. Paying attention to historical developments in the field, we discuss key steps of the virus lifecycle and antivirals known to inhibit each event. We review current obstacles in PML drug discovery, including the difficulties associated with compound penetrance into the central nervous system. We also summarize recent findings in our laboratory regarding the potent anti-JCPyV activity of a novel compound that antagonizes the virus-induced signaling events necessary to establish a productive infection. Understanding the current panel of antiviral compounds will help center the field for future drug discovery efforts.
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Affiliation(s)
| | | | | | - Walter J. Atwood
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI 02912, USA
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Chatterjee T, Roy M, Lin RC, Almoujahed MO, Ahmad S. Pembrolizumab for the treatment of Progressive Multifocal Leukoencephalopathy (PML) in a patient with AIDS: A Case Report and Literature Review. IDCases 2022; 28:e01514. [PMID: 35637642 PMCID: PMC9144385 DOI: 10.1016/j.idcr.2022.e01514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022] Open
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Innovative therapeutic concepts of progressive multifocal leukoencephalopathy. J Neurol 2022; 269:2403-2413. [PMID: 34994851 PMCID: PMC8739669 DOI: 10.1007/s00415-021-10952-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 02/04/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral disease of the brain-caused by human polyomavirus 2. It affects patients whose immune system is compromised by a corresponding underlying disease or by drugs. Patients with an underlying lymphoproliferative disease have the worst prognosis with a mortality rate of up to 90%. Several therapeutic strategies have been proposed but failed to show any benefit so far. Therefore, the primary therapeutic strategy aims to reconstitute the impaired immune system to generate an effective endogenous antiviral response. Recently, anti-PD-1 antibodies and application of allogeneic virus-specific T cells demonstrated promising effects on the outcome in individual PML patients. This article aims to provide a detailed overview of the literature with a focus on these two treatment approaches.
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Corey S, Smith BR, Cortese ICM. Promise and Challenges of Checkpoint Inhibitor Therapy for Progressive Multifocal Leukoencephalopathy in HIV. Curr HIV/AIDS Rep 2022; 19:580-591. [PMID: 36181625 PMCID: PMC9759507 DOI: 10.1007/s11904-022-00626-w] [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] [Accepted: 08/29/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Progressive multifocal leukoencephalopathy (PML) is a severe opportunistic infection that remains an important cause of morbidity and mortality in people living with HIV (PLWH). Immune checkpoint molecules are negative regulators of the immune response that have been targeted as a strategy to bolster anti-viral immunity in PML, with varied outcomes reported. While initiation and optimization of antiretroviral therapy remains the standard of care in HIV-related PML, the specific opportunities and risks for checkpoint blockade in these cases should be explored. RECENT FINDINGS As of April 15, 2022, only 5 of the 53 total published cases of PML treated with checkpoint blockade had underlying HIV infection; four of these had a favorable outcome. The risk of promoting immune reconstitution inflammatory syndrome is a major concern and underscores the importance of patient selection and monitoring. Checkpoint blockade warrants further exploration as a potentially promising option for treatment escalation in HIV-related PML.
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Affiliation(s)
- Sydney Corey
- grid.416870.c0000 0001 2177 357XExperimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, 5C103, Bethesda, MD 20892-1684 USA
| | - Bryan R. Smith
- grid.416870.c0000 0001 2177 357XSection of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD USA
| | - Irene C. M. Cortese
- grid.416870.c0000 0001 2177 357XExperimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, 5C103, Bethesda, MD 20892-1684 USA
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Darcy S, Alexander M, McCarthy A, O'Dowd S. Pembrolizumab treatment of inflammatory progressive multifocal leukoencephalopathy: a report of two cases. J Neurovirol 2021; 28:145-150. [PMID: 34874539 DOI: 10.1007/s13365-021-01028-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/03/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare but devastating neurological disease caused by reactivation of the JC virus in susceptible individuals. The illness has classically been associated with the human immunodeficiency virus (HIV) and multiple sclerosis (MS) patients who are treated with natalizumab. It is also associated with haematological malignancies, organ transplantation, autoimmune disease and immunodeficiency. Aside from natalizumab, a range of other immunomodulators including obinutuzumab and rituximab have been associated with PML. The nature of these associations is unclear due to the overall low incidence of PML associated with these drugs and the fact that most patients will have other confounding risk factors for developing the disease. There is no known effective treatment available for PML in the non-HIV, non-MS cohort. Recent case studies and series have proposed that pembrolizumab, an anti-PD-1 immune checkpoint inhibitor, may be a potentially efficacious option for these patients. We present two cases of non-HIV, non-MS patients with PML who were treated with pembrolizumab with little clinical benefit. The literature surrounding pembrolizumab use in PML is discussed, with a focus on potential indicators of successful outcomes for patients who receive this therapy.
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Affiliation(s)
- Sarah Darcy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland.
| | - Michael Alexander
- Department of Neurophysiology, Tallaght University Hospital, Dublin 24, Ireland
| | - Allan McCarthy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland
| | - Seán O'Dowd
- Department of Neurology, Tallaght University Hospital, Dublin 24, Ireland
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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: 2] [Impact Index Per Article: 0.7] [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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Mackenzie S, Shafat M, Roddy H, Hyare H, Neill L, Marzolini MAV, Gilhooley M, Marafioti T, Kara E, Sanchez E, Rees J, Lynch DS, Thomson K, Ardeshna KM, Laurence A, Peggs KS, O'Reilly M, Roddie C. Pembrolizumab for the treatment of progressive multifocal leukoencephalopathy following anti‐CD19 CAR‐T therapy: a case report. EJHAEM 2021; 2:848-853. [PMID: 35845220 PMCID: PMC9281485 DOI: 10.1002/jha2.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 11/12/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic brain infection with few treatment options and poor survival when reversal of the underlying immune dysfunction is not achievable. JC polyomavirus reactivation resulting in PML can rarely complicate chimeric antigen receptor T‐cell (CAR‐T) therapy. We describe successful treatment of PML with Programmed death‐1 (PD‐1) blockade using pembrolizumab, 4 months following axicabtagene ciloleucel. Radiological features of immune reconstitution inflammatory syndrome without clinical deterioration were seen. Evidence of anti‐viral immune reconstitution by in vitro detection of JC‐specific T‐cells and sustained neurological recovery in this patient suggest PD‐1 blockade may be an effective treatment approach for PML post‐CAR‐T.
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Affiliation(s)
- Strachan Mackenzie
- UCL Cancer Institute Paul O'Gorman Building University College London London UK
- UCL Great Ormond Street Institute of Child Health University College London London UK
| | - Manar Shafat
- UCL Cancer Institute Paul O'Gorman Building University College London London UK
| | - Harriet Roddy
- UCL Cancer Institute Paul O'Gorman Building University College London London UK
| | - Harpreet Hyare
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
- Department of Radiology University College London Hospital NHS Foundation Trust London UK
| | - Lorna Neill
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Maria A. V. Marzolini
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Michael Gilhooley
- The Institute of Ophthalmology University College London Bath Street London UK
| | - Teresa Marafioti
- Department of Histopathology University College London 60 Whitfield Street London UK
| | - Eleanna Kara
- Department of Neuropathology National Hospital of Neurology and Neurosurgery University College London Hospital NHS Foundation Trust Queen Square London UK
| | - Emilie Sanchez
- Department of Virology University College London Hospital NHS Foundation Trust London UK
| | - Jeremy Rees
- Institute of Neurology National Hospital of Neurology and Neurosurgery University College London Queen Square London UK
| | - David S. Lynch
- Institute of Neurology National Hospital of Neurology and Neurosurgery University College London Queen Square London UK
| | - Kirsty Thomson
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Kirit M. Ardeshna
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Arian Laurence
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Karl S. Peggs
- UCL Cancer Institute Paul O'Gorman Building University College London London UK
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Maeve O'Reilly
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
| | - Claire Roddie
- UCL Cancer Institute Paul O'Gorman Building University College London London UK
- Department of Haematology University College London Hospital NHS Foundation Trust London UK
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Bernard-Valnet R, Koralnik IJ, Du Pasquier R. Advances in Treatment of Progressive Multifocal Leukoencephalopathy. Ann Neurol 2021; 90:865-873. [PMID: 34405435 PMCID: PMC9291129 DOI: 10.1002/ana.26198] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 12/19/2022]
Abstract
Progressive multifocal encephalopathy (PML) is a severe demyelinating disease of the central nervous system (CNS) caused by JC virus (JCV), which occurs in immunocompromised individuals. Management of PML relies on restoration of immunity within the CNS. However, when this restoration cannot be readily achieved, PML has a grim prognosis. Innovative strategies have shown promise in promoting anti‐JCV immune responses, and include T‐cell adoptive transfer or immune checkpoint inhibitor therapies. Conversely, management of immune reconstitution inflammatory syndrome, particularly in iatrogenic PML, remains a major challenge. In this paper, we review recent development in the treatment of PML. ANN NEUROL 2021;90:865–873
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Affiliation(s)
- Raphaël Bernard-Valnet
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Igor J Koralnik
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Renaud Du Pasquier
- Service of Neurology, Department of Clinical Neurosciences, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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Lambert N, El Moussaoui M, Maquet P. Immune checkpoint inhibitors for progressive multifocal leukoencephalopathy: Identifying relevant outcome factors. Eur J Neurol 2021; 28:3814-3819. [PMID: 34251719 DOI: 10.1111/ene.15021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/09/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Progressive multifocal leukoencephalopathy (PML) is an infectious brain disease caused by JC virus in immunocompromised individuals. Immune checkpoint inhibitors (ICIs) recently emerged as a therapeutic hope for these patients but identification of those likely to respond to the treatment is still an unmet need. METHOD We performed a systematic PubMed search for reports of patients treated for PML using an ICI. Clinical, biological and radiological characteristics were contrasted between patients who responded to the treatment (RP) and those who did not (NRP). RESULTS Thirty-five patients were included in the present study. Twenty-one of them reportedly benefited from the treatment. Age, blood CD4+ cells count, pretreatment viral load in the cerebrospinal fluid (CSF), PML lesions localization, treatment delay since first PML symptoms, type of ICI used and immune-related adverse events (irAEs) occurrence did not significantly differ between RP and NRP. By contrast, a history of therapeutic immune suppression and the use of an immunosuppressive therapy at treatment initiation were significantly associated with a poor response. Besides, reaching an undetectable viral load in the CSF and reduction of the lesion load on magnetic resonance imaging after ICI administration was associated with a good clinical response. CONCLUSION Current data suggest that patients with PML under immunosuppressive therapy are less likely to respond to ICIs and raises the issue of the optimal management of irAEs during ICI treatment in this setting.
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Affiliation(s)
- Nicolas Lambert
- Department of Neurology, Liège University Hospital, Liège, Belgium.,GIGA-Stem Cells, Molecular Regulation of Neurogenesis, University of Liège, Liège, Belgium
| | - Majdouline El Moussaoui
- Department of General Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
| | - Pierre Maquet
- Department of Neurology, Liège University Hospital, Liège, Belgium.,GIGA-CRC in Vivo Imaging, University of Liège, Liège, Belgium
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Volk T, Warnatz K, Marks R, Urbach H, Schluh G, Strohmeier V, Rojas-Restrepo J, Grimbacher B, Rauer S. Pembrolizumab for treatment of progressive multifocal leukoencephalopathy in primary immunodeficiency and/or hematologic malignancy: a case series of five patients. J Neurol 2021; 269:973-981. [PMID: 34196768 PMCID: PMC8782776 DOI: 10.1007/s00415-021-10682-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/21/2021] [Indexed: 12/30/2022]
Abstract
Progressive multifocal leukoencephalopathy is a rare opportunistic infection of the brain by John Cunningham polyomavirus in immune-compromised patients. In cases where no overt option for immune reconstitution is available [e.g., in patients with primary immunodeficiency (PID)], the disease is lethal in the majority of patients. Immune checkpoint inhibition has been applied in recent years with mixed outcomes. We present four novel patients and the follow-up of a previously published patient suffering from progressive multifocal leukoencephalopathy (PML) due to PID and/or hematologic malignancy who were treated with the immune checkpoint inhibitor pembrolizumab. In two patients with PID, symptoms improved and stabilized. One patient died because of worsening PML another of intracranial hemorrhage which was unrelated to PML or its treatment with pembrolizumab. The fifth patient suffered from PID and died of a pre-existing immune dysregulation, possibly exacerbated by pembrolizumab. The long-term follow-up of the first patient provides support for therapeutic decisions during this therapy and is the longest published clinical course of a patient with checkpoint inhibition for PML. We conclude that pembrolizumab can control PML symptoms long term in a subgroup of patients with PID, in our cases for 21 and 36 months. However, therapy must be started early because symptoms are only partially reversible. In light of severe adverse events, application of pembrolizumab is only justified if the prognosis for the individual patient is very poor.
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Affiliation(s)
- Timo Volk
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacherstr. 64, 79106, Freiburg, Germany
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany
| | - Reinhard Marks
- Department of Hematology and Oncology, University Medical Center, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
| | - Gisela Schluh
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacherstr. 64, 79106, Freiburg, Germany
| | - Valentina Strohmeier
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Jessica Rojas-Restrepo
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany.,Institute for Immunodeficiency, University Medical Center, Medical Faculty, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.,RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center, Freiburg, Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), University Medical Center Freiburg, Freiburg, Germany.,Institute for Immunodeficiency, University Medical Center, Medical Faculty, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.,RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center, Freiburg, Germany.,DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany.,CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany
| | - Sebastian Rauer
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacherstr. 64, 79106, Freiburg, Germany.
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13
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Möhn N, Wattjes MP, Adams O, Nay S, Tkachenko D, Salge F, Heine J, Pars K, Höglinger G, Respondek G, Stangel M, Skripuletz T, Jacobs R, Sühs KW. PD-1-inhibitor pembrolizumab for treatment of progressive multifocal leukoencephalopathy. Ther Adv Neurol Disord 2021; 14:1756286421993684. [PMID: 34035834 PMCID: PMC8129640 DOI: 10.1177/1756286421993684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
The reactivation of human JC polyoma virus (JCPyV) results in lytic infection of oligodendrocytes and neuronal cells. The corresponding clinical picture is called progressive multifocal leukoencephalopathy (PML) and results mostly from a disease-related or drug-induced immunosuppression. The opportunistic brain infection leads to a progressive demyelination of multiple areas of the central nervous system. Patients can present with various neurological deficits ranging from slight motoric symptoms to marked aphasia or reduced vigilance. Currently, there is no effective causal therapy for PML. Survival depends on the ability to achieve timely immune reconstitution. If the immune system cannot be restored, PML progresses rapidly and often ends fatally within months. Recently, some evidence for positive response has been reported in patients treated with immune checkpoint inhibitor therapy. Here, we provide a case series of three PML patients with underlying hematological malignancies who were treated with anti-PD-1-antibody pembrolizumab at Hannover Medical School. All patients received an extensive diagnostic follow-up including cerebrospinal fluid analysis, brain imaging, and lymphocyte-phenotyping via flow cytometry. Our patients had very different outcomes, with the only patient showing a specific anti-JCPyV immune response in the sense of an increased JCPyV antibody index clearly benefiting most from the treatment. Our results partly support the hypothesis that anti-PD-1 therapy may represent a promising treatment option for patients with PML. However, there is a current lack of pre-therapeutic stratification regarding the therapeutic response rates. Before larger studies can be initiated to further evaluate the efficacy of anti-PD-1 antibodies in PML, it is imperative to develop a reliable strategy for selecting suitable patients.
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Affiliation(s)
- Nora Möhn
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Mike P Wattjes
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Ortwin Adams
- Department of Virology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Sandra Nay
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Daria Tkachenko
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Friederike Salge
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanne Heine
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Kaweh Pars
- Department of Neurology, European Medical School, University Oldenburg, Oldenburg, Germany
| | - Günter Höglinger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Gesine Respondek
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Roland Jacobs
- Department of Rheumatology & Clinical Immunology, Hannover Medical School, Hannover, Germany
| | - Kurt-Wolfram Sühs
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, 30625, Germany
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14
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Clifford DB. Checkpoint therapy for progressive multifocal leukoencephalopathy: pointless? Eur J Neurol 2020; 27:2114-2116. [PMID: 32644212 DOI: 10.1111/ene.14434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- D B Clifford
- Melba and Forest Seay Professor of Clinical Neuropharmacology in Neurology, Department of Neurology, Washington University in St Louis, St Louis, MO, USA
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