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Cruz A, Pereira D, Batista S. [Use of Gadolinium in Follow-Up MRI of Multiple Sclerosis Patients: Current Recommendations]. ACTA MEDICA PORT 2024; 37:53-63. [PMID: 38183232 DOI: 10.20344/amp.20467] [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: 07/30/2023] [Accepted: 10/30/2023] [Indexed: 01/07/2024]
Abstract
Multiple sclerosis is the most frequent demyelinating disease of the central nervous system and is characterized by early onset and progressive disability. Magnetic resonance imaging, due to its high sensitivity and specificity in the detection of demyelinating lesions, is the most useful diagnostic test for this disease, with the administration of gadolinium-based contrast agents being an important contribution to imaging interpretation. Although contrast is essential for diagnostic purposes, its routine use in monitoring disease activity, response to treatment, and related complications is controversial. This article aims to collate current recommendations regarding the use of gadolinium in the imaging follow-up of multiple sclerosis and establish effective and safe guidelines for clinical practice. The literature review was conducted in PubMed, using the terms 'multiple sclerosis', 'magnetic resonance imaging' and 'gadolinium', or 'contrast media'. Articles published between January 2013 and January 2023 concerning the safety of gadolinium and the use of these contrast agents in follow-up scans of adult patients diagnosed with multiple sclerosis were selected. Although no biological or clinical consequences have been unequivocally attributed to the retention of gadolinium in the brain, which were mostly reported with linear agents, health authorities have been recommending the restriction of contrast to essential clinical circumstances. In multiple sclerosis, the detection of subclinical contrast-enhancing lesions with no corresponding new/ enlarging T2-WI lesions is rare and has a questionable impact on therapeutic decisions. On the other hand, gadolinium has a higher sensitivity in the differential diagnosis of relapses, in the detection of recent disease activity, before and after treatment initiation, and in patients with a large lesion burden or diffuse/confluent T2-WI lesions. Contrary to progressive multifocal leukoencephalopathy screening, monitoring of immune restitution inflammatory syndrome also benefits from the administration of gadolinium. It is feasible and safe to exclude gadolinium-based contrast agents from routine follow-up scans of multiple sclerosis, despite their additional contribution in specific clinical circumstances that should be acknowledged by the neurologist and neuroradiologist.
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Affiliation(s)
- Andreia Cruz
- Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
| | - Daniela Pereira
- Área Funcional de Neurorradiologia. Serviço de Imagem Médica. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Sónia Batista
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Serviço de Neurologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
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2
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Moser T, Zimmermann G, Baumgartner A, Berger T, Bsteh G, Di Pauli F, Enzinger C, Fertl E, Heller T, Koppi S, Rommer PS, Safoschnik G, Seifert-Held T, Stepansky R, Sellner J. Long-term outcome of natalizumab-associated progressive multifocal leukoencephalopathy in Austria: a nationwide retrospective study. J Neurol 2024; 271:374-385. [PMID: 37728757 PMCID: PMC10770206 DOI: 10.1007/s00415-023-11924-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/28/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND/OBJECTIVE The use of natalizumab (NAT) in multiple sclerosis (MS) may be complicated by progressive multifocal leukoencephalopathy (PML), a rare and life-threatening opportunistic brain infection. We aimed to analyze the course of MS after PML recovery together with the long-term outcome of NAT-associated PML (NAT-PML) in Austria. METHODS Retrospective study based on identification of cases in the nationwide Austrian MS treatment registry (AMSTR) and MS centers with review of patient records. The expanded disability status scale (EDSS) was used to measure neurological disability and outcome. RESULTS As of December 2022, we identified 15 NAT-PML cases in Austria; only 20% occurred after 2016, when increased vigilance commenced. Two patients did not survive acute PML, and an additional patient died five years later, yielding a mortality rate of 20%. Seizures occurred exclusively in patients with pronounced EDSS increase. Gadolinium (Gd)-enhancement on brain magnetic resonance imaging (MRI) on PML suspicion was associated with minor changes of post-PML neurological disability. Long-term follow-up of up to 132 months (median 76 months) was available in 11/15. The overall median EDSS increased from 3.5 at pre-PML to 6.5 at the last assessment. Regarding inflammatory MS-related disease activity during the observation period, one single individual experienced an MS relapse and another patient had two Gd-enhancing brain lesions. Three patients converted to progressive MS within three years from PML and the EDSS further increased in 6/11. CONCLUSIONS The number of NAT-PML cases is decreasing over time. While many patients accumulated severe persistent neurological deficits compared to pre-PML, inflammatory MS-related disease activity after PML recovery was rare.
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Affiliation(s)
- Tobias Moser
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria
- Department of Research and Innovation, Paracelsus Medical University, Salzburg, Austria
| | - Anna Baumgartner
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Thomas Berger
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Gabriel Bsteh
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elisabeth Fertl
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Thomas Heller
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Stefan Koppi
- Rehabilitation Clinic Montafon, Schruns, Austria
| | - Paulus S Rommer
- Department of Neurology, Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Johann Sellner
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria.
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstrasse 67, 2130, Mistelbach, Austria.
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3
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Experiences in treatment of multiple sclerosis with natalizumab from a real-life cohort over 15 years. Sci Rep 2021; 11:23317. [PMID: 34857795 PMCID: PMC8639988 DOI: 10.1038/s41598-021-02665-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
Natalizumab (NTZ) has been used for treatment of highly active relapsing–remitting multiple sclerosis (MS). When stopping NTZ the risk of severe rebound phenomenon has to be considered. We aimed to investigate the use of NTZ in clinical routine and focused on identification of potential risk factors for disease reactivation after treatment discontinuation. At the Medical University of Innsbruck, Austria, we identified all MS patients who were treated with NTZ and performed a retrospective analysis on therapeutic decision making, disease course before, during and after treatment with NTZ and on risk factors for disease reactivation after NTZ discontinuation. 235 NTZ treated MS patients were included, of whom 105 had discontinued treatment. At NTZ start disease duration was 5.09 (IQR 2.09–10.57) years, average number of total relapses was 4 (IQR 3–6) and median EDSS 2.0 (range 0–6.5), whereby these values significantly decreased over time. Reduction of annualized relapse rate (ARR) on treatment was 93% and EDSS remained stable in 64%. In multivariate regression models only conversion to secondary progressive MS (SPMS) on treatment was significantly associated with lower risk of disease reactivation after NTZ, while ARR before treatment was associated with earlier disease reactivation. We could confirm the high therapeutic efficacy of NTZ which trends to be used earlier in the disease course nowadays. Discontinuation of NTZ seems safe only in patients who convert to SPMS during treatment, while higher ARR before NTZ increases the risk of disease reactivation after treatment discontinuation.
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4
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Karanasios P, Karachalios G, Gourgioti R, Alexopoulou A, Mastorodemos V. Patient and treatment characteristics and safety outcomes of patients with relapsing-remitting multiple sclerosis treated with natalizumab in Greece: Results from the multicenter, 5-year prospective observational study 'TOPICS greece'. Mult Scler J Exp Transl Clin 2021; 7:20552173211035803. [PMID: 34377528 PMCID: PMC8327250 DOI: 10.1177/20552173211035803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022] Open
Abstract
Background Natalizumab is a highly efficacious treatment for relapsing-remitting multiple sclerosis (RRMS). Objective To assess the real-world long-term safety of natalizumab in RRMS. Methods This multicenter, 5-year prospective observational study, included adults with RRMS newly initiated on natalizumab as per the approved product label in the routine care in Greece. Safety was evaluated by collecting serious adverse events (SAEs) following study enrollment. Results Between 19-Apr-2012 and 18-Dec-2014, 304 eligible patients (median age at natalizumab initiation: 38.0 years; median disease duration: 6.2 years) were enrolled by 20 hospital-based neurologists. Over a median treatment duration period of 58.7 months, 50.7% of the patients discontinued natalizumab, mainly due to anti-JCV antibody detection (59.1%). The adverse event treatment discontinuation rate was 5.2%. The SAE incidence rate during the safety data collection period (median: 48.7 months) was 4.6%. The most common SAEs were infections (1.0%), including 2 cases (0.7%) of progressive multifocal leukoencephalopathy (PML), and no other opportunistic infections. PML diagnoses occurred 6.2-6.7 years after natalizumab initiation, and approximately 2 years after first detection of anti-JCV antibody for both patients. The incidence rate of malignancies was 0.7%. Conclusion In real-world settings in Greece, natalizumab displayed an acceptable safety profile, with no new safety signals emerging.
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Affiliation(s)
- Panagiotis Karanasios
- Department of Neurology, "Saint Andrew's" General Hospital of Patras Agios Andreas, Patras, Greece
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5
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Schultz TJ, Thomas A, Georgiou P, Juaton MS, Cusack L, Simon L, Naidoo K, Webb K, Karnon J, Ravindran J. Home infusions of natalizumab for people with multiple sclerosis: a pilot randomised crossover trial. Ann Clin Transl Neurol 2021; 8:1610-1621. [PMID: 34288591 PMCID: PMC8351394 DOI: 10.1002/acn3.51410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/27/2021] [Accepted: 05/30/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The delivery of healthcare at home has expanded to intravenous infusions of monoclonal antibodies. A recently developed model of care for home infusions of natalizumab for people with relapsing‐remitting multiple sclerosis was evaluated. This pilot study of home infusions of natalizumab and usual care (attendance in a hospital out‐patients’ clinic) compared safety, feasibility, patient satisfaction, effectiveness and costs. Methods In this randomised AB/BA crossover trial, 37 adults were randomised to usual care (n = 19) or home infusions (n = 18). After three infusions, patients crossed over to the alternate treatment for another three infusions. Patient safety outcomes and adherence, satisfaction, quality of life, disability and costs were compared. Results No adverse events were recorded from 207 infusions from 35 patients across both home and clinic infusions. There was no difference in adherence (p = 0.71) and infection rates (p = 0.84) between home and clinic settings. Satisfaction with “convenience” of home infusions was significantly greater (p = 0.008) but there were no differences in quality of life measures. Excluding pharmacy, costs were A$74 lower per infusion at home, including A$16 of patients” out‐of‐pocket costs. Interpretation There were no differences in safety and effectiveness between clinic and home infusions of natalizumab. The home infusions were shown to be feasible, more convenient and less expensive than usual care. Larger scale studies are required to verify these preliminary findings, particularly around safety and management of hypersensitivity adverse events in the home setting and for equivalence of clinical outcomes.
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Affiliation(s)
- Timothy J Schultz
- Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Anne Thomas
- Post Op Care at Home (Pty Ltd), Adelaide, South Australia, Australia
| | - Paul Georgiou
- Medical Day Treatment Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mahasen S Juaton
- Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Lynette Cusack
- Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia
| | - Lorraine Simon
- Medical Day Treatment Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kerisha Naidoo
- Biogen Australia and New Zealand, Sydney, New South Wales, Australia
| | - Kevin Webb
- Neurology & Stroke Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Janakan Ravindran
- Neurology & Stroke Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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6
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Chisari CG, Comi G, Filippi M, Paolicelli D, Iaffaldano P, Zaffaroni M, Brescia Morra V, Cocco E, Marfia GA, Grimaldi LM, Inglese M, Bonavita S, Lugaresi A, Salemi G, De Luca G, Cottone S, Conte A, Sola P, Aguglia U, Maniscalco GT, Gasperini C, Ferrò MT, Pesci I, Amato MP, Rovaris M, Solaro C, Lus G, Maimone D, Bergamaschi R, Granella F, Di Sapio A, Bertolotto A, Totaro R, Vianello M, Cavalla P, Bellantonio P, Lepore V, Patti F. PML risk is the main factor driving the choice of discontinuing natalizumab in a large multiple sclerosis population: results from an Italian multicenter retrospective study. J Neurol 2021; 269:933-944. [PMID: 34181077 DOI: 10.1007/s00415-021-10676-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Natalizumab (NTZ) is an effective treatment for relapsing-remitting multiple sclerosis (RRMS). However, patients and physicians may consider discontinuing NTZ therapy due to safety or efficacy issues. The aim of our study was to evaluate the NTZ discontinuation rate and reasons of discontinuation in a large Italian population of RRMS patients. MATERIALS AND METHODS The data were extracted from the Italian MS registry in May 2018 and were collected from 51,845 patients in 69 Italian multiple sclerosis centers. MS patients with at least one NTZ infusion in the period between June 1st 2012 to May 15th 2018 were included. Discontinuation rates at each time point were calculated. Reasons for NTZ discontinuation were classified as "lack of efficacy", "progressive multifocal leukoencephalopathy (PML) risk" or "other". RESULTS Out of 51,845, 5151 patients, 3019 (58.6%) females, with a mean age of 43.6 ± 10.1 years (median 40), were analyzed. Out of 2037 (39.5%) who discontinued NTZ, a significantly higher percentage suspended NTZ because of PML risk compared to lack of efficacy [1682 (32.7% of 5151) vs 221 (4.3%), p < 0.001]; other reasons were identified for 99 (1.9%) patients. Patients discontinuing treatment were older, had longer disease duration and worse EDSS at the time of NTZ initiation and at last follow-up on NTZ treatment. The JCV index and EDSS at baseline were predictors for stopping therapy (HR 2.94, 95% CI 1.22-4.75; p = 0.02; HR 1.36, 95% CI 1.18-5.41; p = 0.04). CONCLUSIONS Roughly 60% of MS patients stayed on NTZ treatment during the observation period. For those patients in whom NTZ discontinuation was required, it was mainly due to PML concerns.
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Affiliation(s)
- Clara G Chisari
- Department "GF. Ingrassia", Section of Neurosciences, University of Catania, via S. Sofia 78, 95129, Catania, Italy
| | - Giancarlo Comi
- Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neurology Unit and MS Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, Neurophysiology Unit, IRCCS San Raffaele Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, School of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, ASST Della Valle Olona, Gallarate Hospital, Gallarate (VA), Italy
| | - Vincenzo Brescia Morra
- Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Science and Odontostomatology, Multiple Sclerosis Centre, University Federico II, Naples, Italy
| | - Eleonora Cocco
- Multiple Sclerosis Centre Binaghi Hospital, ATS Sardegna-University of Cagliari, Cagliari, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,Unit of Neurology, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy
| | | | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,San Martino Hospital-IRCCS, Genoa, Italy
| | - Simona Bonavita
- Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, MRI Research Center SUN-FISM, AOU-University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandra Lugaresi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedic and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Salemi
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Giovanna De Luca
- Multiple Sclerosis Center, Neurology Clinic, Policlinico SS Annunziata, University of Chieti-Pescara, Chieti, Italy
| | - Salvatore Cottone
- Department of Neurology, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed Pozzili, Pozzili (IS), Italy
| | - Patrizia Sola
- Department of Neuroscience, UO of Neurology, AOU Policlinico OB, Modena, Italy
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy.,Great Metropolitan Hospital, Reggio Calabria, Italy
| | | | - Claudio Gasperini
- Department of Neurology, Multiple Sclerosis Centre, San Camillo-Forlanini Hospital, Rome, Italy
| | - Maria Teresa Ferrò
- Neuroimmunology Center for Multiple Sclerosis, Cerebrovascular Department, ASST Crema, Crema, Italy
| | - Ilaria Pesci
- Multiple Sclerosis Center, Fidenza-S. Secondo Hospital, Fidenza, Parma, Italy
| | - Maria Pia Amato
- Division Neurological Rehabilitation, Department of NEUROFARBA, University of Florence, Florence, Italy.,Department of Neurorehabilitation, IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | | | - Claudio Solaro
- Rehabilitation Department, CRRF Mons L Novarese, Moncrivello VC, Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of Neurology, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Davide Maimone
- Multiple Sclerosis Center, Neurology Unit, ARNAS Garibaldi, Catania, Italy
| | | | - Franco Granella
- Neurosciences Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alessia Di Sapio
- Department of Neurology, Regina Montis Regalis Hospital, Mondovì, Italy
| | - Antonio Bertolotto
- Neurologia & CRESM (Centro Riferimento Regionale SM), AOU San Luigi Gonzaga, Orbassano, Italy
| | - Rocco Totaro
- Demyelinating Disease Center, Department of Neurology, San Salvatore Hospital, L'Aquila, Italy
| | | | - Paola Cavalla
- Multiple Sclerosis Center, Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Turin, Torino, Italy
| | - Paolo Bellantonio
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli, IS, Italy
| | - Vito Lepore
- Coreserach Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy.,Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Francesco Patti
- Department "GF. Ingrassia", Section of Neurosciences, University of Catania, via S. Sofia 78, 95129, Catania, Italy.
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7
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Vivekanandan G, Abubacker AP, Myneni R, Chawla HV, Iqbal A, Grewal A, Ndakotsu A, Khan S. Risk of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patient Treated With Natalizumab: A Systematic Review. Cureus 2021; 13:e14764. [PMID: 34094729 PMCID: PMC8169000 DOI: 10.7759/cureus.14764] [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] [Indexed: 11/21/2022] Open
Abstract
Natalizumab, a monoclonal antibody acting on alpha4 integrin receptors, is frequently used to treat multiple sclerosis patients. The biggest downside is the risk of development of progressive multifocal leukoencephalopathy, an immune-related condition affecting mainly the central nervous system. The presence of the John Cunningham virus (JCV) and its reactivation is an important factor in the development of progressive multifocal leukoencephalopathy (PML). This study highlights its different proposed mechanism and risk factors strongly related to natalizumab-induced progressive multifocal leukoencephalopathy. The pieces of literature will also be reviewed to look for a relation between the JCV and natalizumab-induced progressive multifocal leukoencephalopathy in multiple sclerosis treated patients. The articles were searched from three databases and reviewed systematically. The inclusion criteria for this study were patients aged 20-50 years, English language paper, full-text availability, and human studies, whereas articles on patients with AIDS and cancer-related disease prior to natalizumab treatment were excluded. Out of 6531 articles identified after applying the search strategy on three main databases PubMed, Google Scholar, and ResearchGate, a total of 32 articles were finalized for the review. This study follows the guidelines listed in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009. The data collected from these finalized articles were pertaining to the risk factor related to natalizumab induced progressive multifocal leukoencephalopathy and the mechanism related to its pathogenesis. Natalizumab is known to have the potential to cause progressive multifocal leukoencephalopathy in treated patients; here, we evaluate a close relationship of its related risk factors. The articles studied exhibit a close relationship between the length of natalizumab treatment and the presence of the JCV before infusion of natalizumab. From our analysis, it seems that the mechanism related to natalizumab-induced PML is strongly related to antigen-specific T cells and its effects. The frequency of monitoring and vigilance on the management of patients treated with natalizumab will help detect progressive multifocal leukoencephalopathy.
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Affiliation(s)
- Govinathan Vivekanandan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ansha P Abubacker
- Emergency Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Revathi Myneni
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Harsh V Chawla
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Aimen Iqbal
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amit Grewal
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Andrew Ndakotsu
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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8
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De Mercanti SF, Gned D, Matta M, Iudicello M, Franchin E, Clerico M. Atypical Multiple Sclerosis Lesions or Progressive Multifocal Leukoencephalopathy Lesions: That Is the Question. J Investig Med High Impact Case Rep 2021; 8:2324709620939802. [PMID: 32646245 PMCID: PMC7357099 DOI: 10.1177/2324709620939802] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a serious infective disease of the central nervous system that may occur in case of severe immunosuppression or after some treatment for multiple sclerosis (MS) with natalizumab, dimethyl fumarate, and fingolimod. In these case reports, we highlight the importance of differential diagnosis between PML and MS lesions in order to provide rapidly the best treatment option, by discussing the finding of brain (magnetic resonance imaging) MRI suggestive for PML in 2 MS patients, one treated with dimethyl fumarate and the other during natalizumab withdrawal. In both cases, although brain MRI was highly suggestive for PML, the detection of John Cunningham virus-DNA copies in cerebrospinal fluid resulted in negative result. These case reports illustrate the diagnostic process in case of suspected PML, as both patients were diagnosed with suspected PML during a routine brain MRI control, and highlights the importance of providing a strict brain MRI follow-up during dimethyl fumarate treatment, although only a few cases of PML during this therapy have been detected, and during natalizumab suspension phase. In clinical practice, in case of a radiologically suspected case of PML, although not confirmed by the cerebrospinal fluid analysis, the best approach could be to perform a close radiological and clinical monitoring before starting a new MS therapy.
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Affiliation(s)
- Stefania Federica De Mercanti
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
- Stefania Federica De Mercanti, Clinical and Biological Sciences Department, San Luigi Gonzaga Hospital, Regione Gonzole, 10, Orbassano 10043, Italy.
| | - Dario Gned
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Manuela Matta
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Marco Iudicello
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Emanuele Franchin
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Marinella Clerico
- University of Torino, Orbassano, Italy
- San Luigi Gonzaga Hospital, Orbassano, Italy
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9
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Wijburg MT, Warnke C, McGuigan C, Koralnik IJ, Barkhof F, Killestein J, Wattjes MP. Pharmacovigilance during treatment of multiple sclerosis: early recognition of CNS complications. J Neurol Neurosurg Psychiatry 2021; 92:177-188. [PMID: 33229453 DOI: 10.1136/jnnp-2020-324534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/27/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
An increasing number of highly effective disease-modifying therapies for people with multiple sclerosis (MS) have recently gained marketing approval. While the beneficial effects of these drugs in terms of clinical and imaging outcome measures is welcomed, these therapeutics are associated with substance-specific or group-specific adverse events that include severe and fatal complications. These adverse events comprise both infectious and non-infectious complications that can occur within, or outside of the central nervous system (CNS). Awareness and risk assessment strategies thus require interdisciplinary management, and robust clinical and paraclinical surveillance strategies. In this review, we discuss the current role of MRI in safety monitoring during pharmacovigilance of patients treated with (selective) immune suppressive therapies for MS. MRI, particularly brain MRI, has a pivotal role in the early diagnosis of CNS complications that potentially are severely debilitating and may even be lethal. Early recognition of such CNS complications may improve functional outcome and survival, and thus knowledge on MRI features of treatment-associated complications is of paramount importance to MS clinicians, but also of relevance to general neurologists and radiologists.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands .,Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Clemens Warnke
- Department of Neurology, University Hospital Köln, University of Cologne, Köln, Germany.,Department of Neurology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany
| | - Christopher McGuigan
- Department of Neurology, St Vincent's University Hospital & University College Dublin, Dublin, Ireland
| | - Igor J Koralnik
- Department of Neurological Sciences, Division of Neuroinfectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology & Nuclear Medicine, MS Center Amsterdam, Neuroscience Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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Jalkh G, Abi Nahed R, Macaron G, Rensel M. Safety of Newer Disease Modifying Therapies in Multiple Sclerosis. Vaccines (Basel) 2020; 9:12. [PMID: 33375365 PMCID: PMC7823546 DOI: 10.3390/vaccines9010012] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022] Open
Abstract
In the past decade, the therapeutic arsenal for multiple sclerosis has expanded greatly. Newer more potent disease modifying therapies (DMTs) with varying mechanisms of actions are increasingly used early in the disease course. These newer DMTs include oral therapies (teriflunomide, dimethyl fumarate, fingolimod, siponimod, ozanimod, and cladribine) and infusion therapies (natalizumab, alemtuzumab, and ocrelizumab), and are associated with better control of disease activity and long-term outcomes in patients with MS compared to older injectable therapies (interferon beta and glatiramer acetate). However, they are associated with safety concerns and subsequent monitoring requirements. Adverse events are initially observed in phase 2 and 3 clinical trials, and further long-term data are collected in phase 3 extension studies, case series, and post-marketing reports, which highlight the need to periodically re-evaluate and adjust monitoring strategies to optimize treatment safety in an individualized approach.
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Affiliation(s)
- Georges Jalkh
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Rachelle Abi Nahed
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
| | - Gabrielle Macaron
- Department of Neurology, Faculty of Medicine, Université Saint Joseph, Beirut B.P. 11-5076, Lebanon; (G.J.); (R.A.N.); (G.M.)
- Department of Neurology, Hotel-Dieu de France Hospital, Beirut 16-6830, Lebanon
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mary Rensel
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Cortese I, Reich DS, Nath A. Progressive multifocal leukoencephalopathy and the spectrum of JC virus-related disease. Nat Rev Neurol 2020; 17:37-51. [PMID: 33219338 PMCID: PMC7678594 DOI: 10.1038/s41582-020-00427-y] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a devastating CNS infection caused by JC virus (JCV), a polyomavirus that commonly establishes persistent, asymptomatic infection in the general population. Emerging evidence that PML can be ameliorated with novel immunotherapeutic approaches calls for reassessment of PML pathophysiology and clinical course. PML results from JCV reactivation in the setting of impaired cellular immunity, and no antiviral therapies are available, so survival depends on reversal of the underlying immunosuppression. Antiretroviral therapies greatly reduce the risk of HIV-related PML, but many modern treatments for cancers, organ transplantation and chronic inflammatory disease cause immunosuppression that can be difficult to reverse. These treatments — most notably natalizumab for multiple sclerosis — have led to a surge of iatrogenic PML. The spectrum of presentations of JCV-related disease has evolved over time and may challenge current diagnostic criteria. Immunotherapeutic interventions, such as use of checkpoint inhibitors and adoptive T cell transfer, have shown promise but caution is needed in the management of immune reconstitution inflammatory syndrome, an exuberant immune response that can contribute to morbidity and death. Many people who survive PML are left with neurological sequelae and some with persistent, low-level viral replication in the CNS. As the number of people who survive PML increases, this lack of viral clearance could create challenges in the subsequent management of some underlying diseases. In this Review, Cortese et al. provide an overview of the pathobiology and evolving presentations of progressive multifocal leukoencephalopathy and other diseases caused by JC virus, and discuss emerging immunotherapeutic approaches that could increase survival. Progressive multifocal leukoencephalopathy (PML) is a rare, debilitating and often fatal disease of the CNS caused by JC virus (JCV). JCV establishes asymptomatic, lifelong persistent or latent infection in immune competent hosts, but impairment of cellular immunity can lead to reactivation of JCV and PML. PML most commonly occurs in patients with HIV infection or lymphoproliferative disease and in patients who are receiving natalizumab for treatment of multiple sclerosis. The clinical phenotype of PML varies and is shaped primarily by the host immune response; changes in the treatment of underlying diseases associated with PML have changed phenotypes over time. Other clinical manifestations of JCV infection have been described, including granule cell neuronopathy. Survival of PML depends on reversal of the underlying immunosuppression; emerging immunotherapeutic strategies include use of checkpoint inhibitors and adoptive T cell transfer.
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Affiliation(s)
- Irene Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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12
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Kolcava J, Hulova M, Rihova L, Bednarik J, Stourac P. The impact of lymphocytosis and CD4/CD8 ratio on the anti-JCV antibody index and clinical data in patients treated with natalizumab. Neurol Sci 2020; 42:2847-2853. [PMID: 33201361 DOI: 10.1007/s10072-020-04897-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Natalizumab is an effective therapy in the treatment of relapsing-remitting multiple sclerosis; it induces lymphocytosis (NIL, natalizumab-induced lymphocytosis) and changes the peripheral lymphocyte pattern. METHODS This study aims to evaluate NIL, peripheral blood lymphocyte subsets, CD4/CD8 ratio, and their impacts on JCV index and clinical data-No Evidence of Disease Activity (NEDA-3) and annualized relapse rate (ARR) in patients treated with natalizumab. RESULTS Forty-one patients (33 women) were included in the study. The mean duration of follow-up on natalizumab treatment was 6.7 ± 3.2 years. Significant increases in relative lymphocytosis after 1 month, with a median of 40.4% (- 34.1 to + 145.5%) (p < 0.001), and after 1 year (49.0% (- 9.3 to + 127.6%)) (p < 0.001) were found. Significant differences were found after 1 month when comparing NIL between patients JCV-seroconverting (20.6% (- 17.7 to 72.7%)) and stable JCV-seronegative ones (43.5% (- 6.3 to +96.3%)) (p = 0.04). No significant difference NIL level was found between the patients exhibiting NEDA-3 status and those without it. ARR on natalizumab treatment correlated with CD4/CD8 ratio (r = 0.356; p = 0.021); patients who maintained NEDA-3 status over the whole treatment period exhibited a lower CD4/CD8 ratio (1.89 ± 1.08 vs. 2.5 ± 0.73; p < 0.04). CONCLUSION This contribution reports the CD4/CD8 ratio as a possible biomarker for better clinical efficacy of natalizumab in patients exhibiting a lower CD4/CD8 ratio. NIL did not correlate with long-term therapeutic efficacy in patients treated with natalizumab, but was demonstrated as lower in patients JCV-seroconverting in the course of follow-up.
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Affiliation(s)
- Jan Kolcava
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Jihlavská 340/20, 625 00, Brno, Czech Republic
| | - Monika Hulova
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Jihlavská 340/20, 625 00, Brno, Czech Republic
| | - Lucie Rihova
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Josef Bednarik
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Jihlavská 340/20, 625 00, Brno, Czech Republic
| | - Pavel Stourac
- Faculty of Medicine, Masaryk University, Brno, Czech Republic. .,Department of Neurology, University Hospital Brno, Jihlavská 340/20, 625 00, Brno, Czech Republic.
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Progressive multifocal leukoencephalopathy: MRI findings in HIV-infected patients are closer to rituximab- than natalizumab-associated PML. Eur Radiol 2020; 31:2944-2955. [PMID: 33155106 PMCID: PMC7644389 DOI: 10.1007/s00330-020-07362-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 08/26/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
Objectives To compare brain MRI findings in progressive multifocal leukoencephalopathy (PML) associated to rituximab and natalizumab treatments and HIV infection. Materials and methods In this retrospective, multicentric study, we analyzed brain MRI exams from 72 patients diagnosed with definite PML: 32 after natalizumab treatment, 20 after rituximab treatment, and 20 HIV patients. We compared T2- or FLAIR-weighted images, diffusion-weighted images, T2*-weighted images, and contrast enhancement features, as well as lesion distribution, especially gray matter involvement. Results The three PML entities affect U-fibers associated with low signal intensities on T2*-weighted sequences. Natalizumab-associated PML showed a punctuate microcystic appearance in or in the vicinity of the main PML lesions, a potential involvement of the cortex, and contrast enhancement. HIV and rituximab-associated PML showed only mild contrast enhancement, punctuate appearance, and cortical involvement. The CD4/CD8 ratio showed a trend to be higher in the natalizumab group, possibly mirroring a more efficient immune response. Conclusion Imaging features of rituximab-associated PML are different from those of natalizumab-associated PML and are closer to those observed in HIV-associated PML. Key Points • Nowadays, PML is emerging as a complication of new effective therapies based on monoclonal antibodies. • Natalizumab-associated PML shows more inflammatory signs, a perivascular distribution “the milky way,” and more cortex involvement than rituximab- and HIV-associated PML. • MRI differences are probably related to higher levels of immunosuppression in HIV patients and those under rituximab therapy.
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14
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Lauver MD, Lukacher AE. JCPyV VP1 Mutations in Progressive MultifocalLeukoencephalopathy: Altering Tropismor Mediating Immune Evasion? Viruses 2020; 12:v12101156. [PMID: 33053912 PMCID: PMC7600905 DOI: 10.3390/v12101156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022] Open
Abstract
Polyomaviruses are ubiquitous human pathogens that cause lifelong, asymptomatic infections in healthy individuals. Although these viruses are restrained by an intact immune system, immunocompromised individuals are at risk for developing severe diseases driven by resurgent viral replication. In particular, loss of immune control over JC polyomavirus can lead to the development of the demyelinating brain disease progressive multifocal leukoencephalopathy (PML). Viral isolates from PML patients frequently carry point mutations in the major capsid protein, VP1, which mediates virion binding to cellular glycan receptors. Because polyomaviruses are non-enveloped, VP1 is also the target of the host's neutralizing antibody response. Thus, VP1 mutations could affect tropism and/or recognition by polyomavirus-specific antibodies. How these mutations predispose susceptible individuals to PML and other JCPyV-associated CNS diseases remains to be fully elucidated. Here, we review the current understanding of polyomavirus capsid mutations and their effects on viral tropism, immune evasion, and virulence.
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15
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Khachanova NV, Bakhtiyarova KZ, Boyko AN, Vlasov YV, Davydovskaya MV, Evdoshenko EP, Zakharova MN, Kotov SV, Popova EV, Sivertseva SA, Totolyan NA, Khabirov FA. [Updated recommendations of the Council of Experts on the use and safety of alemtuzumab (Lemtrada)]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:82-91. [PMID: 32323949 DOI: 10.17116/jnevro202012003182] [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: 11/17/2022]
Abstract
Alemtuzumab (Lemtrada) is a recombinant humanized IgG1 kappa monoclonal antibody to the surface cell glycoprotein, a CD52 differentiation cluster. The drug is approved for use in more than 65 countries, including the Russian Federation. The drug is one of the most effective methods of treating patients with aggressive multiple sclerosis, but the risk management plan should be followed. The safety profile of the drug includes infusion-associated reactions, thyroid dysfunction, immune cytopenia, acute cardiovascular events, infections, and other autoimmune diseases. This publication provides updated practical recommendations for the use of the drug and ensuring the safety of patients treated with alemtuzumab.
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Affiliation(s)
- N V Khachanova
- Russian National Medical Research University named after N.I. Pirogov, Moscow, Russia
| | | | - A N Boyko
- Russian National Medical Research University named after N.I. Pirogov, Moscow, Russia.,Federal Center for Cerebrovascular Pathology and Stroke, Moscow, Russia
| | - Y V Vlasov
- Samara State Medical University, Samara, Russia
| | - M V Davydovskaya
- Russian National Medical Research University named after N.I. Pirogov, Moscow, Russia.,State Budgetary Institution of the Moscow region «Clinical and Economic Analysis Scientific-Practical Center of the Moscow Region Healthcare Ministry, Moscow, Russia
| | - E P Evdoshenko
- SPb Centre of Multiple Sclerosis and AID (City Clinical Hospital No31), St. Petersburg, Russia
| | | | - S V Kotov
- State Budgetary Healthcare Institution of Moscow Region Moscow Regional Scientific Research Clinical Institute named after M.F. Vladimirsky, Moscow, Russia
| | - E V Popova
- Russian National Medical Research University named after N.I. Pirogov, Moscow, Russia.,Interdistrict Division of Multiple Sclerosis a the 24th City Hospital of Moscow, Moscow, Russia
| | - S A Sivertseva
- Tyumen Regional Centre of the Multiple Sclerosis, Tyumen, Russia
| | - N A Totolyan
- Federal State Budgetary Educational Institution of Higher Education First Saint Petersburg State Medical University named after Academician I.P. Pavlov of the Ministry of Healthcare of the Russian Federation, Saint Petersburg, Russia
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16
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Hanaei S, Sahraian MA, Mohammadifar M, Ramagopalan SV, Ghajarzadeh M, Ghajarzadeh M. Prevalence of Anti-JC Virus Antibody Seropositivity in Patients with Multiple Sclerosis: A Systematic Review and Meta-Analysis. Intervirology 2020; 62:169-173. [PMID: 32623436 DOI: 10.1159/000507367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 03/17/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The John Cunningham virus (JCV) is the causative agent of progressive multifocal leukoencephalopathy. Anti-JCV antibody seropositivity is an important consideration in patients with multiple sclerosis (MS). The reported prevalence of JCV in MS patients has been conflicting. OBJECTIVE We aimed to conduct a systematic review and meta-analysis to estimate the pooled prevalence of anti-JCV antibody seropositivity in cases with MS. METHODS We searched PubMed, Scopus, EMBASE, CINAHL, Web of Science, Ovid, ProQuest, Google Scholar, and gray literature including reference of included studies, and conference abstracts which were published up to April 2019. Two independent researchers independently assessed the articles. RESULTS The literature search found 181 articles. After eliminating duplicates, reviews, case reports, and trials, 15 articles remained. Finally, 8 articles were included for the final analysis (from Asia, Europe, the USA, and Canada). In total, 16,041 MS cases were analyzed. The prevalence of anti-JCV antibody seropositivity varied between 40 and 80%, and the pooled estimate was calculated as 60% (95% CI: 56-64%), though with significant heterogeneity (I2 = 95%, p = 0.01). CONCLUSION The prevalence of anti-JCV antibody seropositivity is variable among MS patients in different countries, and the pooled estimate showed that this is 60% overall.
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Affiliation(s)
- Sara Hanaei
- Research Center for Immunodeficiencies (RCID), Tehran University of Medical Sciences (TUMS), Tehran, Iran, Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammad Ali Sahraian
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohammadifar
- Department of Radiology, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | | | - Mahsa Ghajarzadeh
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran,
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Brisset JC, Kremer S, Hannoun S, Bonneville F, Durand-Dubief F, Tourdias T, Barillot C, Guttmann C, Vukusic S, Dousset V, Cotton F, Ameli R, Anxionnat R, Audoin B, Attye A, Bannier E, Barillot C, Ben Salem D, Boncoeur-Martel MP, Bonhomme G, Bonneville F, Boutet C, Brisset J, Cervenanski F, Claise B, Commowick O, Constans JM, Cotton F, Dardel P, Desal H, Dousset V, Durand-Dubief F, Ferre JC, Gaultier A, Gerardin E, Glattard T, Grand S, Grenier T, Guillevin R, Guttmann C, Krainik A, Kremer S, Lion S, Champfleur NMD, Mondot L, Outteryck O, Pyatigorskaya N, Pruvo JP, Rabaste S, Ranjeva JP, Roch JA, Sadik JC, Sappey-Marinier D, Savatovsky J, Stankoff B, Tanguy JY, Tourbah A, Tourdias T, Brochet B, Casey R, Cotton F, De Sèze J, Douek P, Guillemin F, Laplaud D, Lebrun-Frenay C, Mansuy L, Moreau T, Olaiz J, Pelletier J, Rigaud-Bully C, Stankoff B, Vukusic S, Debouverie M, Edan G, Ciron J, Lubetzki C, Vermersch P, Labauge P, Defer G, Berger E, Clavelou P, Gout O, Thouvenot E, Heinzlef O, Al-Khedr A, Bourre B, Casez O, Cabre P, Montcuquet A, Créange A, Camdessanché JP, Bakchine S, Maurousset A, Patry I, De Broucker T, Pottier C, Neau JP, Labeyrie C, Nifle C. New OFSEP recommendations for MRI assessment of multiple sclerosis patients: Special consideration for gadolinium deposition and frequent acquisitions. J Neuroradiol 2020; 47:250-258. [DOI: 10.1016/j.neurad.2020.01.083] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 01/04/2023]
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Diagnosis and management of multiple sclerosis: MRI in clinical practice. J Neurol 2020; 267:2917-2925. [PMID: 32472179 PMCID: PMC7501096 DOI: 10.1007/s00415-020-09930-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 12/22/2022]
Abstract
Background Recent changes in the understanding and management of multiple sclerosis (MS) have increased the role of MRI in supporting diagnosis and disease monitoring. However, published guidelines on the use of MRI in MS do not translate easily into different clinical settings and considerable variation in practice remains. Here, informed by published guidelines for the use of MRI in MS, we identified a clinically informative MRI protocol applicable in a variety of clinical settings, from district general hospitals to tertiary centres. Methods MS specialists geographically representing the UK National Health Service and with expertise in MRI examined existing guidelines on the use of MRI in MS and identification of challenges in their applications in various clinical settings informed the formulation of a feasible MRI protocol. Results We identified a minimum set of MRI information, based on clinical relevance, as well as on applicability to various clinical settings. This informed the selection of MRI acquisitions for scanning protocols, differentiated on the basis of their purpose and stage of the disease, and indication of timing for scans. Advice on standardisation of MRI requests and reporting, and proposed timing and frequency of MRI scans were generated. Conclusions The proposed MRI protocol can adapt to a range of clinical settings, aiding the impetus towards standardisation of practice and offering an example of research-informed service improvement to support optimisation of resources. Other neurological conditions, where a gap still exists between published guidelines and their clinical implementation, may benefit from this same approach.
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Developing a Model of Care for Home Infusions of Natalizumab for People With Multiple Sclerosis. JOURNAL OF INFUSION NURSING 2020; 42:289-296. [PMID: 31693562 PMCID: PMC7328856 DOI: 10.1097/nan.0000000000000343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Natalizumab is an effective treatment for multiple sclerosis that requires 4-weekly infusions that are usually provided in hospital outpatient clinics. In this study, a model of care (MOC), an overarching design for the provision of a health care service, was developed to permit home infusions of natalizumab. The proposed new MOC comprised 9 dimensions, in addition to the central concept of patient-centered care at home. The new MOC is responsive to patient needs and prioritizes the nurse-patient therapeutic relationship. It provides practical examples of patient-centered care to guide clinical practice for this patient population in the home setting.
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20
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Eis PS, Bruno CD, Richmond TA, Koralnik IJ, Hanson BA, Major EO, Chow CR, Hendel-Chavez H, Stankoff B, Gasnault J, Taoufik Y, Hatchwell E. Germline Genetic Risk Variants for Progressive Multifocal Leukoencephalopathy. Front Neurol 2020; 11:186. [PMID: 32256442 PMCID: PMC7094807 DOI: 10.3389/fneur.2020.00186] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/27/2020] [Indexed: 12/18/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disorder of the brain caused by reactivation of the JC virus (JCV), a polyomavirus that infects at least 60% of the population but is asymptomatic or results in benign symptoms in most people. PML occurs as a secondary disease in a variety of disorders or as a serious adverse event from immunosuppressant agents, but is mainly found in three groups: HIV-infected patients, patients with hematological malignancies, or multiple sclerosis (MS) patients on the immunosuppressant therapy natalizumab. It is severely debilitating and is deadly in ~50% HIV cases, ~90% of hematological malignancy cases, and ~24% of MS-natalizumab cases. A PML risk prediction test would have clinical utility in all at risk patient groups but would be particularly beneficial in patients considering therapy with immunosuppressant agents known to cause PML, such as natalizumab, rituximab, and others. While a JC antibody test is currently used in the clinical decision process for natalizumab, it is suboptimal because of its low specificity and requirement to periodically retest patients for seroconversion or to assess if a patient's JCV index has increased. Whereas a high specificity genetic risk prediction test comprising host genetic risk variants (i.e., germline variants occurring at higher frequency in PML patients compared to the general population) could be administered one time to provide clinicians with additional risk prediction information that is independent of JCV serostatus. Prior PML case reports support the hypothesis that PML risk is greater in patients with a genetically caused immunodeficiency disorder. To identify germline PML risk variants, we performed exome sequencing on 185 PML cases (70 in a discovery cohort and 115 in a replication cohort) and used the gnomAD variant database for interpretation. Our study yielded 19 rare variants (maximum allele frequency of 0.02 in gnomAD ethnically matched populations) that impact 17 immune function genes (10 are known to cause inborn errors of immunity). Modeling of these variants in a PML genetic risk test for MS patients considering natalizumab treatment indicates that at least a quarter of PML cases may be preventable.
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Affiliation(s)
- Peggy S Eis
- Population Bio, Inc., New York, NY, United States
| | | | - Todd A Richmond
- Richmond Bioinformatics Consulting, Seattle, WA, United States
| | - Igor J Koralnik
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Barbara A Hanson
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Eugene O Major
- Laboratory of Molecular Medicine and Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | | | - Houria Hendel-Chavez
- Department of Hematology and Immunology, Hôpitaux Universitaires Paris-Sud, INSERM 1184, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre, France
| | - Bruno Stankoff
- Department of Neurology, Hôpital Saint-Antoine, Paris, France
| | - Jacques Gasnault
- Department of Internal Medicine, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
| | - Yassine Taoufik
- Department of Hematology and Immunology, Hôpitaux Universitaires Paris-Sud, INSERM 1184, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre, France
| | - Eli Hatchwell
- Population Bio UK, Inc., Oxfordshire, United Kingdom
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Forryan J, Yong J. Rapid cognitive decline in a patient with chronic lymphocytic leukaemia: a case report. J Med Case Rep 2020; 14:39. [PMID: 32127027 PMCID: PMC7055117 DOI: 10.1186/s13256-020-2360-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/05/2020] [Indexed: 11/30/2022] Open
Abstract
Background The use of monoclonal antibodies in various settings has been linked to the development of progressive multifocal leukoencephalopathy (PML). Whilst this association is well-described with agents such as rituximab and natalizumab, the literature describing the occurrence of PML with ofatumumab therapy (especially in a haematology setting) is sparse. This case aims to draw attention to the above association with a particular focus on the mechanisms by which B-cell-depleting therapy can precipitate PML during the treatment of haematological malignancy. Case presentation A 68-year-old Caucasian man presented with acute-on-subacute confusion and reduced mobility. He had a history of chronic lymphocytic leukaemia for which he had completed six cycles of ofatumumab and chlorambucil 2 months prior to presentation. Biochemistry, physical examination and imaging were unremarkable on admission. Subsequent neurological examination demonstrated diminished reflexes and an extensor right plantar, while magnetic resonance imaging (MRI) assessment revealed white matter hyperintensities in the frontal lobes with restricted diffusion surrounding these areas. Cerebrospinal fluid (CSF) analysis demonstrated normal cell counts and chemistry but detected John Cunningham virus (JCV) via polymerase chain reaction (PCR), with a quantitative value of 41,850 gEg/ml. CSF immunophenotyping excluded malignant processes. A diagnosis of PML was confirmed, and with the support of palliative care, the patient was discharged to a hospice for ongoing care with the family’s agreement. Conclusion PML remains a rare complication of ofatumumab treatment. Nevertheless, clinicians should maintain a certain level of suspicion for this risk, especially in the context of patients presenting with clinical syndromes of encephalopathy and focal neurologic deficits. Furthermore, research to better our understanding of the manifold links between B-cell function and JCV regulation could provide valuable information for use in the future prevention and treatment of PML.
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Affiliation(s)
- James Forryan
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK. .,Haematology Department, Duncan Building, Liverpool, UK.
| | - Jun Yong
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.,Haematology Department, Duncan Building, Liverpool, UK
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Kartau M, Sipilä JO, Auvinen E, Palomäki M, Verkkoniemi-Ahola A. Progressive Multifocal Leukoencephalopathy: Current Insights. Degener Neurol Neuromuscul Dis 2019; 9:109-121. [PMID: 31819703 PMCID: PMC6896915 DOI: 10.2147/dnnd.s203405] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022] Open
Abstract
Cases of PML should be evaluated according to predisposing factors, as these subgroups differ by incidence rate, clinical course, and prognosis. The three most significant groups at risk of PML are patients with hematological malignancies mostly previously treated with immunotherapies but also untreated, patients with HIV infection, and patients using monoclonal antibody (mAb) treatments. Epidemiological data is scarce and partly conflicting, but the distribution of the subgroups appears to have changed. While there is no specific anti-JCPyV treatment, restoration of the immune function is the most effective approach to PML treatment. Research is warranted to determine whether immune checkpoint inhibitors could benefit certain PML subgroups. There are no systematic national or international records of PML diagnoses or a risk stratification algorithm, except for MS patients receiving natalizumab (NTZ). These are needed to improve PML risk assessment and to tailor better prevention strategies.
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Affiliation(s)
- Marge Kartau
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Jussi Ot Sipilä
- Department of Neurology, Siun Sote, North Carelia Central Hospital, Joensuu, Finland.,Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland.,Clinical Neurosciences, University of Turku, Turku, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Palomäki
- Neuroradiology, HUS Medical Imaging Center, Helsinki, Finland
| | - Auli Verkkoniemi-Ahola
- Clinical Neurosciences, Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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23
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Wijburg MT, Kleerekooper I, Lissenberg-Witte BI, de Vos M, Warnke C, Uitdehaag BMJ, Barkhof F, Killestein J, Wattjes MP. Association of Progressive Multifocal Leukoencephalopathy Lesion Volume With JC Virus Polymerase Chain Reaction Results in Cerebrospinal Fluid of Natalizumab-Treated Patients With Multiple Sclerosis. JAMA Neurol 2019. [PMID: 29532061 DOI: 10.1001/jamaneurol.2018.0094] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance The JC virus (JCV) was named after the first patient to be described with progressive multifocal leukoencephalopathy (PML), John Cunningham. Detection of JC virus DNA in cerebrospinal fluid (CSF) by polymerase chain reaction (PCR), and of specific lesions by brain magnetic resonance imaging (MRI), are both considered essential for the diagnosis of natalizumab-associated PML (NTZ-PML) in patients with multiple sclerosis. However, strict pharmacovigilance by MRI can result in detection of patients with small lesions and undetectable JCV DNA in CSF. Objective To investigate the association of PML lesion characteristics on MRI with both qualitative and quantitative JCV PCR results in CSF of patients with NTZ-PML. Design, Setting and Participants This was a retrospective, cross-sectional study conducted from January 2007 to December 2014 in patients considered to have NTZ-PML based on a set of predefined criteria. Follow-up was at least 6 months. Data of patients from the Dutch-Belgian NTZ-PML cohort and patients treated at multiple medical centers in Belgium and the Netherlands and selected for research purposes were included as a convenience sample. Main Outcomes and Measures Brain MRI scans were analyzed for PML lesion volume, location, dissemination, and signs of inflammation. Associations of the qualitative and quantitative CSF JCV PCR results with PML MRI characteristics were calculated. Results Of the 73 patients screened, 56 were included (37 were women). At inclusion, 9 patients (16.1%) had undetectable JCV DNA in CSF. Patients with a positive PCR had larger total PML lesion volumes than those with undetectable JCV DNA (median volume, 22.9 mL; interquartile range, 9.2-60.4 mL vs median volume, 6.7 mL; interquartile range, 4.9-14.7 mL; P = .008), and logistic regression showed that a lower PML lesion volume significantly increased the probability for undetectable JCV DNA. There was a positive correlation between PML lesion volume and JCV copy numbers (Spearman ρ, 0.32; P = .03). Progressive multifocal leukoencephalopathy lesion volume was higher in patients with PML symptoms and in patients with more widespread lesion dissemination. No association was found between PCR results and PML lesion dissemination, signs of inflammation, or PML symptoms. Conclusions and Relevance Smaller NTZ-PML lesions are associated with a higher likelihood of undetectable JCV DNA in CSF. This may preclude a formal diagnosis of PML and can complicate patient treatment in patients with small MRI lesions highly suggestive of PML detected early through pharmacovigilance.
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Affiliation(s)
- Martijn T Wijburg
- Department of Neurology, Neuroscience Amsterdam, VUmc Multiple Sclerosis Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Iris Kleerekooper
- Department of Neurology, Neuroscience Amsterdam, VUmc Multiple Sclerosis Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
| | - Marlieke de Vos
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.,Department of Neurology, Medical Faculty, University of Köln, Köln, Germany
| | - Bernard M J Uitdehaag
- Department of Neurology, Neuroscience Amsterdam, VUmc Multiple Sclerosis Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.,Institutes of Neurology and Healthcare Engineering, University College London, London, United Kingdom
| | - Joep Killestein
- Department of Neurology, Neuroscience Amsterdam, VUmc Multiple Sclerosis Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
| | - Mike P Wattjes
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.,Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
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24
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Rommer PS, Milo R, Han MH, Satyanarayan S, Sellner J, Hauer L, Illes Z, Warnke C, Laurent S, Weber MS, Zhang Y, Stuve O. Immunological Aspects of Approved MS Therapeutics. Front Immunol 2019; 10:1564. [PMID: 31354720 PMCID: PMC6637731 DOI: 10.3389/fimmu.2019.01564] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Multiple sclerosis (MS) is the most common neurological immune-mediated disease leading to disability in young adults. The outcome of the disease is unpredictable, and over time, neurological disabilities accumulate. Interferon beta-1b was the first drug to be approved in the 1990s for relapsing-remitting MS to modulate the course of the disease. Over the past two decades, the treatment landscape has changed tremendously. Currently, more than a dozen drugs representing 1 substances with different mechanisms of action have been approved (interferon beta preparations, glatiramer acetate, fingolimod, siponimod, mitoxantrone, teriflunomide, dimethyl fumarate, cladribine, alemtuzumab, ocrelizumab, and natalizumab). Ocrelizumab was the first medication to be approved for primary progressive MS. The objective of this review is to present the modes of action of these drugs and their effects on the immunopathogenesis of MS. Each agent's clinical development and potential side effects are discussed.
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Affiliation(s)
- Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ron Milo
- Department of Neurology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - May H. Han
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Sammita Satyanarayan
- Neuroimmunology Division, Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, United States
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Sarah Laurent
- Department of Neurology, Medical Faculty, University of Köln, Cologne, Germany
| | - Martin S. Weber
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Yinan Zhang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Olaf Stuve
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität, Munich, Germany
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Neurology Section, VA North Texas Health Care System, Medical Service Dallas, VA Medical Center, Dallas, TX, United States
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25
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Auer M, Hegen H, Sellner J, Oppermann K, Bsteh G, Di Pauli F, Berger T, Deisenhammer F. Conversion and reversion of anti-John Cunningham virus antibody serostatus: A prospective study. Brain Behav 2019; 9:e01332. [PMID: 31168964 PMCID: PMC6625483 DOI: 10.1002/brb3.1332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/05/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Determination of antibodies against the John Cunningham virus (JCV) is an important tool for risk stratification in Natalizumab-treated multiple sclerosis (MS) patients. Six-monthly testing has been suggested for anti-JCV antibody negative patients and patients with low antibody index in order to detect changes of serostatus. We conducted a prospective study with predefined testing intervals in order to investigate the predictability of anti-JCV antibody status and the intervals for repetitive testing. METHODS Our study included 109 patients at the MS Clinic of the Departments of Neurology, Medical Universities of Innsbruck and Salzburg. Blood withdrawals were performed at five time points: baseline, month 1, 3, 6, and 12. Patients' sera were sent to Unilabs, Copenhagen, Denmark, where anti-JCV antibodies were tested by a two-step enzyme-linked immunosorbent assay. Qualitative (negative/positive) and quantitative results (anti-JCV antibody index) were used for statistical analyses. RESULTS In our cohort, 52.3% of the patients were positive for anti-JCV antibodies at baseline, with a significant correlation with age, but no association with sex or prior disease-modifying therapy. Seven patients converted and reverted from negative to positive status and vice versa around the cut-off index of 0.4, but no patient showed a permanent seroconversion from negative to highly positive anti-JCV antibody status. CONCLUSION Long-term anti-JCV antibody status, including seroconverters/-reverters around the cut-off index, is highly predictable by testing three times within short intervals, however, we cannot suggest clearly defined intervals for repetitive testing. The rate of real seroconverters, i.e., new infections with JCV, per year seems lower than previously described.
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Affiliation(s)
- Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Katrin Oppermann
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Gabriel Bsteh
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Franziska Di Pauli
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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26
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Abstract
Pediatric-onset multiple sclerosis (MS) comprises 2-5% of MS cases, and is known to be associated with high disease activity and the accumulation of disability at an earlier age than their adult-onset counterparts. Appropriate therapy leading to disease control has the potential to alter the known trajectory of adverse long-term physical, cognitive, and psychosocial outcomes in this population. Thus, optimizing treatment for children and adolescents with MS is of paramount importance. The last decade has seen a growing number of disease-modifying therapies approved for relapsing MS in adults, and available agents now include oral, injectable, and infusion therapies. Recently, the development of randomized controlled MS trials in youth has led to the first agent approved by the US FDA for the treatment of pediatric MS-fingolimod. With this, we have entered a new era of knowledge and treatment in this population and ongoing pediatric trials are expected to further inform clinical management. With the emergence of highly effective therapies targeting the inflammatory component of the disease, there has been increased interest in identifying treatment strategies that instead target mechanisms such as remyelination/repair, neuroprotection, or rehabilitation. The potential role for such emerging therapies in the treatment of pediatric MS remains an important area of study. In this review, we discuss current evidence for MS therapies in children including the treatment of acute relapses, disease-modifying therapies, and symptomatic management. We will also discuss evidence for emerging therapies, including remyelinating and neuroprotective agents.
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Affiliation(s)
- Colin Wilbur
- Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Division of Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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27
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Haghi Navand A, Teimoori A, Makvandi M, Nisi N, Seyedian SS, Ranjbari N, Ahmadi Angali K, Keyani H, Tabasi M, Pourjabari K. Study on JV Virus in Patients with Colon Cancer Type
Adenocarcinoma. Asian Pac J Cancer Prev 2019; 20:1147-1151. [PMID: 31030488 PMCID: PMC6948910 DOI: 10.31557/apjcp.2019.20.4.1147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Introduction: Colorectal cancer is the most repetitious malignancies with high mortality worldwide. JC virus (JCV) is ubiquitous Polyomavirus, with seroprevalence rates ranging from 70% to 90% in adult population. Recently the role of JCV have been reported in many malignant tumors worldwide. The association of JCV was reported in patients with colon and rectum cancers. Thus this study was conducted to evaluate the association of JCV DNA in patients with colon cancer type Adenocarcinoma. Material and Methods: A total of 120 formalin-fixed paraffin-embedded tissue blocks samples were collected including 20/40(50%) males, 20/40(50%) females patients with Colorectal Cancer(CRC), and 80 (50% males, 50% females) patients with benign tumor as a control. DNA was extracted for all the samples. Nested PCR was carried out for detection of Vp1/T-Ag junction genome in JCV genome by Nested-PCR assay. Randomly, PCR products of 6 samples were sequenced to analysis the partial JCV DNA. The phylogeny tree was constructed to determine homology identity with other JCV. Results: 4/40(10%) samples of test group and 10/80 (12.5%) of control samples were positive for JCV DNA (P= 0.69). Out of 4 samples positive for JC DNA, 3(7.5%) were males and 1(2.4%) female (P=0.29). The frequency of JCV DNA in age group> 50 years was 4/32(10%), while in age group <50 years was 0/8 (0%) (p= 0.29). Conclusion: prevalence of JCV DNA was among 10% patients with CRC and 12.5% benign tumors (p=0.69). The distribution of JCV DNA was among 7.5% male and 2.5% female (p= 0.29). The frequency of JCV DNA was among 10% cases of age group >50 years and 0% of age group <50 years (P= 0.29). The subsequent T-Ag protein expression might explain the increased risk of colorectal cancer and requires further investigation.
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Affiliation(s)
- Azadeh Haghi Navand
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Teimoori
- Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Manoochehr Makvandi
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nilofar Nisi
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed Saeid Seyedian
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nastarn Ranjbari
- Department of Pathology, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kambiz Ahmadi Angali
- Department of Biostatistic, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hadis Keyani
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com
| | - Maryam Tabasi
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com
| | - Keyvan Pourjabari
- Infectious and Tropical Diseases Research Center Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. manoochehrmakvandi299@ gmail.com
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28
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Monoclonal Antibodies in Multiple Sclerosis: Present and Future. Biomedicines 2019; 7:biomedicines7010020. [PMID: 30875812 PMCID: PMC6466331 DOI: 10.3390/biomedicines7010020] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 01/09/2023] Open
Abstract
The global incidence of multiple sclerosis (MS) appears to be increasing. Although it may not be associated with a high mortality rate, this disease has a high morbidity rate which affects the quality of life of patients and reduces their ability to do their activities of daily living. Thankfully, the development of novel disease modifying therapies continues to increase. Monoclonal antibodies (MABs) have become a mainstay of MS treatment and they are likely to continue to be developed for the treatment of this disease. Specifically, MABs have proven to be some of the most efficacious treatments at reducing relapses and the inflammation in MS patients, including the first treatment for primary progressive MS and are being explored as reparative/remyelinating agents as well. These relatively new treatments will be reviewed here to help evaluate their efficacy, adverse events, immunogenicity, and benefit-risk ratios in the treatment of the diverse spectrum of MS. The focus will be on MABs that are currently approved or may be approved in the near future.
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29
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Scarpazza C, Signori A, Prosperini L, Sormani MP, Cosottini M, Capra R, Gerevini S. Early diagnosis of progressive multifocal leucoencephalopathy: longitudinal lesion evolution. J Neurol Neurosurg Psychiatry 2019; 90:261-267. [PMID: 30389778 DOI: 10.1136/jnnp-2018-319208] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Early diagnosis of natalizumab-related progressive multifocal leucoencephalopathy (NTZ-PML) in multiple sclerosis has been deemed a major priority by the regulatory agencies but has yet to become a reality. The current paper aims to: (1) investigate whether patients with NTZ-PML pass through a prolonged presymptomatic phase with MRI abnormalities, (2) estimate the longitudinal PML lesion volume increase during the presymptomatic phase and (3) estimate the presymptomatic phase length and its impact on therapy duration as a risk stratification parameter. METHODS All Italian patients who developed NTZ-PML between 2009 and 2018 were included. The data of patients with available prediagnostic MRI were analysed (n=41). Detailed clinical and neuroradiological information was available for each participant. RESULTS (1) PML lesions were detectable in the presymptomatic phase in 32/41 (78%) patients; (ii) the lesion volume increased by 62.8 % for each month spent in the prediagnostic phase; (3) the prediagnostic phase length was 150.8±74.9 days; (4) PML MRI features were detectable before the 24th month of therapy in 31.7 % of patients in our cohort. CONCLUSIONS Considering the latency of PML clinical manifestation, the presymptomatic phase length supports the usefulness of MRI surveillance every 3-4 months. Early diagnosis could prompt a better outcome for patients due to the relationship between lesion volume and JC virus infection. The insight from this study might also have an impact on risk stratification algorithms, as therapy duration as a parameter of stratification appears to need reassessment.
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Affiliation(s)
- Cristina Scarpazza
- Multiple Sclerosis Centre, Spedali Civili, Brescia, Italy .,Department of General Psychology, University of Padova, Padova, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Luca Prosperini
- Department of Neurosciences, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Mirco Cosottini
- Department of Translational Research and New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, Spedali Civili, Brescia, Italy
| | - Simonetta Gerevini
- Department of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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30
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Progressive multifocal leukoencephalopathy in Finland: a cross-sectional registry study. J Neurol 2019; 266:515-521. [PMID: 30612143 PMCID: PMC6373365 DOI: 10.1007/s00415-018-09167-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/18/2018] [Accepted: 12/21/2018] [Indexed: 01/31/2023]
Abstract
Objective To investigate if progressive multifocal leucoencephalopathy (PML) incidence has increased in Finland like in the neighbouring Sweden. Methods National administrative registries were searched for all PML admissions aged 16 years or more in 2004–2014 on all neurological and internal medicine wards in Finland. The mortality data of the patients was extracted from the national causes of death registry. National level data on annual predisposing drug use was obtained from the national pharmaceutical authority. Results We identified 35 PML cases (57% male) with a peak in 2010–2011 that amounted to 49% of all cases. The annual incidence for the entire study period was 0.072/100,000 person-years (95% CI 0.050–0.10) with no temporal trend (p = 0.18). Mean age was 57 years (22–88 years) with no sex difference (p = 0.42). Neoplasms (60%), HIV infection (17%) and systemic connective tissue disorders (CTD, 14%) were the most common predisposing conditions. MS was recorded in three cases (9%). The national level use of drugs that predispose to PML increased during the study period, with the exceptions of alemtuzumab and fludarabine. Overall survival was 85% at 90 days, 79% at 1 year, and 66% at 5 years. Survival was worst in patients with malignancy and best in patients with CTD. Conclusions PML most often occurs in patients with malignancies and patients with HIV or CTD cover a third. PML incidence in Finland is lower than in Sweden and shows no temporal trend despite increasing use of predisposing drugs. Mortality after PML varies according to the predisposing condition. Electronic supplementary material The online version of this article (10.1007/s00415-018-09167-y) contains supplementary material, which is available to authorized users.
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31
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Progressive Multifocal Leukoencephalopathy in Primary Immunodeficiencies. J Clin Immunol 2018; 39:55-64. [PMID: 30552536 DOI: 10.1007/s10875-018-0578-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Progressive multifocal leukoencephalopathy (PML) is a rare but severe demyelinating disease caused by the polyomavirus JC (JCV) in immunocompromised patients. We report a series of patients with primary immune deficiencies (PIDs) who developed PML. METHODS Retrospective observational study including PID patients with PML. Clinical, immunological, imaging features, and outcome are provided for each patient. RESULTS Eleven unrelated patients with PIDs developed PML. PIDs were characterized by a wide range of syndromic or genetically defined defects, mostly with combined B and T cell impairment. Genetic diagnosis was made in 7 patients. Before the development of PML, 10 patients had recurrent infections, 7 had autoimmune and/or inflammatory manifestations, and 3 had a history of malignancies. Immunologic investigations showed CD4+ lymphopenia (median 265, range 50-344) in all cases. Six patients received immunosuppressive therapy in the year before PML onset, including prolonged steroid therapy in 3 cases, rituximab in 5 cases, anti-TNF-α therapy, and azathioprine in 1 case each. Despite various treatments, all but 1 patient died after a median of 8 months following PML diagnosis. CONCLUSION PML is a rare but fatal complication of PIDs. Many cases are secondary to immunosuppressive therapy warranting careful evaluation before initiation subsequent immunosuppression during PIDs.
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Gholamzad M, Ebtekar M, Ardestani MS, Azimi M, Mahmodi Z, Mousavi MJ, Aslani S. A comprehensive review on the treatment approaches of multiple sclerosis: currently and in the future. Inflamm Res 2018; 68:25-38. [DOI: 10.1007/s00011-018-1185-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022] Open
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Epstein DJ, Dunn J, Deresinski S. Infectious Complications of Multiple Sclerosis Therapies: Implications for Screening, Prophylaxis, and Management. Open Forum Infect Dis 2018; 5:ofy174. [PMID: 30094293 PMCID: PMC6080056 DOI: 10.1093/ofid/ofy174] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/12/2018] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis therapies include interferons, glatiramer, and multiple immunosuppressive drugs. Discerning infectious risks of immunosuppressive drugs requires understanding their mechanisms of action and analyzing interventional studies and postmarketing observational data. Though identical immunosuppressive therapies are sometimes used in non-neurologic conditions, infectious risks may differ in this population. Screening for and treatment of latent tuberculosis (TB) infection should be prioritized for patients receiving alemtuzumab; ocrelizumab is likely not associated with an increased risk of TB. Hepatitis B virus (HBV) reactivation can be devastating for patients treated with ocrelizumab and alemtuzumab, whereas the small molecule oral agents do not likely pose substantial risk of HBV. Progressive multifocal leukoencephalopathy is a particular concern with natalizumab. Alemtuzumab, and possibly natalizumab and fingolimod, risks herpes virus reactivation and may warrant prophylaxis. Unusual opportunistic infections have been described. Vaccination is an important tool in preventing infections, though vaccine timing and contraindications can be complex.
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Affiliation(s)
- David J Epstein
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jeffrey Dunn
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, California
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Zhang Y, Wright C, Flores A. Asymptomatic progressive multifocal leukoencephalopathy: a case report and review of the literature. J Med Case Rep 2018; 12:187. [PMID: 29960601 PMCID: PMC6026501 DOI: 10.1186/s13256-018-1727-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/28/2018] [Indexed: 11/30/2022] Open
Abstract
Background We report the development of asymptomatic progressive multifocal leukoencephalopathy in a patient with multiple sclerosis on natalizumab therapy. Progressive multifocal leukoencephalopathy often presents with debilitating neurologic symptoms. Very few cases have documented a completely asymptomatic course of the disease. Case presentation A 26-year-old white woman with multiple sclerosis was treated with natalizumab. She was diagnosed as having progressive multifocal leukoencephalopathy based on characteristic magnetic resonance imaging lesions after 27 infusions of natalizumab. She had no neurologic deficits at the time of diagnosis and John Cunningham virus in cerebrospinal fluid was detected at 15 copies/ml. She was initially treated with mefloquine and mirtazapine and remained asymptomatic for 3 months. She later developed worsening magnetic resonance imaging lesions related to immune reconstitution inflammatory syndrome. At that time, she received intravenously administered immunoglobulin and high-dose intravenously administered methylprednisolone with radiologic improvement of the lesions. Conclusions Our case report illustrates that early detection of asymptomatic progressive multifocal leukoencephalopathy and its subsequent treatment resulted in a benign clinical course. In consideration of the additional small number of cases of asymptomatic progressive multifocal leukoencephalopathy that have been reported, we conclude that routine magnetic resonance imaging surveillance is important for patients with multiple sclerosis who are at high risk for developing natalizumab-associated progressive multifocal leukoencephalopathy.
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Affiliation(s)
- Yinan Zhang
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Crystal Wright
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Angela Flores
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Koolaji S, Allahabadi NS, Ahmadi A, Eskandarieh S, Moghadasi AN, Azimi AR, Sahraian MA. Anti-JC virus antibody sera positivity and index value among patients with multiple sclerosis may be correlated with age, sex, and area of residence. J Neurovirol 2018; 24:570-576. [PMID: 29785581 DOI: 10.1007/s13365-018-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/05/2018] [Accepted: 04/26/2018] [Indexed: 11/26/2022]
Abstract
Anti-JC virus (JCV) antibody index is the predictive factor of progressive multifocal leukoencephalopathy (PML) for multiple sclerosis (MS) patients treating with natalizumab. The aim of this study is to evaluate the prevalence of anti-JCV antibody positivity and index among Iranian patients who are the candidate for natalizumab and its correlation with their demographic data and previous therapies. A cross-sectional design was assessed for receiving anti-JCV antibody test results between January 2014 and December 2016. Demographic data and disease characteristics were also obtained. Statistical analysis and logistic regression were done using SPSS. Among 803 MS patients that were observed, the prevalence of anti-JCV antibody positivity was 67.9% (mean of index = 2.23 ± 1.16) and 67.6% of positive patients had an index ≥ 1.5. Males were more antibody positive than females (81.7 and 64% respectively; significance (sig.) < 0.001, OR = 2.51, CI 1.65-3.81). The rate of positivity was lower in patients under the age of 18. Patients who lived in cold regions had significantly more prevalence of positivity (Num. = 403; sig. = 0.043 and OR = 1.86; CI 1.02-3.39) and with higher rate of index ≥ 1.5 (sig. = 0.017; OR = 3.99, CI 1.79-8.88). Disease onset age between 28 and 37 years were more positive compared to 18-27 years (N = 480; sig. = 0.02; OR = 1.85, CI 1.09-3.14). Age, male gender, onset age, and cold area of residency significantly influenced anti-JCV antibody sera positivity. Only age of onset and cold area of residency were related to the index. No significant difference was observed between type, dosage, and duration of previous immunosuppressant drugs and anti-JCV antibody positivity and index value.
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Affiliation(s)
- Sogol Koolaji
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Narges Sistany Allahabadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Arash Ahmadi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Sharareh Eskandarieh
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Abdorreza Naser Moghadasi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Amir Reza Azimi
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran.
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Wattjes MP, Wijburg MT, van Eijk J, Frequin S, Uitdehaag BMJ, Barkhof F, Warnke C, Killestein J. Inflammatory natalizumab-associated PML: baseline characteristics, lesion evolution and relation with PML-IRIS. J Neurol Neurosurg Psychiatry 2018; 89:535-541. [PMID: 29142146 DOI: 10.1136/jnnp-2017-316886] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVE Natalizumab-associated progressive multifocal leukoencephalopathy (NTZ-PML) patients may show imaging signs suggestive of inflammation at diagnosis ('inflammatory PML'), reminiscent of PML-immune reconstitution inflammatory syndrome (PML-IRIS). We investigated the imaging characteristics of inflammatory NTZ-PML lesions and PML-IRIS to determine differentiating and overlapping features. METHODS We scored the presence, localisation and pattern of imaging characteristics of inflammation on brain MRI scans of inflammatory NTZ-PML patients. The imaging characteristics were followed up until the occurrence of PML-IRIS. RESULTS Ten out of the 44 NTZ-PML patients included showed signs suggestive of inflammation at the time of diagnosis. The inflammation pattern at diagnosis was similar to the pattern seen at PML-IRIS, with contrast enhancement representing the most frequent sign of inflammation (90% at diagnosis, 100% at PML-IRIS). However, the severity of inflammation differed, with absence of swelling and low frequency of perilesional oedema (10%) at diagnosis, as compared with the PML-IRIS stage (40%). CONCLUSION Patterns of inflammation at the time of PML diagnosis and at the PML-IRIS stage overlap but differ in their severity of inflammation. This supports histopathological evidence that the inflammation seen at both stages of the same disease shares a similar underlying pathophysiology, representing the immune response to the JC virus to a variable extend.
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Affiliation(s)
- Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany.,Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn T Wijburg
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Jeroen van Eijk
- Department of Neurology, Jeroen Bosch Ziekenhuis, s'Hertogenbosch, The Netherlands
| | - Stephan Frequin
- Department of Neurology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Bernard M J Uitdehaag
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Institutes of Neurology and Healthcare Engineering, UCL, London, UK
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.,Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Joep Killestein
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Redelman-Sidi G, Michielin O, Cervera C, Ribi C, Aguado JM, Fernández-Ruiz M, Manuel O. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Immune checkpoint inhibitors, cell adhesion inhibitors, sphingosine-1-phosphate receptor modulators and proteasome inhibitors). Clin Microbiol Infect 2018; 24 Suppl 2:S95-S107. [PMID: 29427804 DOI: 10.1016/j.cmi.2018.01.030] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/18/2018] [Accepted: 01/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The present review is part of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections in Compromised Hosts (ESGICH) consensus document on the safety of targeted and biological therapies. AIMS To review, from an infectious diseases perspective, the safety profile of immune checkpoint inhibitors, LFA-3-targeted agents, cell adhesion inhibitors, sphingosine-1-phosphate receptor modulators and proteasome inhibitors, and to suggest preventive recommendations. SOURCES Computer-based Medline searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT T-lymphocyte-associated antigen 4 (CTLA-4) and programmed death (PD)-1/PD-1 ligand 1 (PD-L1)-targeted agents do not appear to intrinsically increase the risk of infection but can induce immune-related adverse effects requiring additional immunosuppression. Although CD4+ T-cell lymphopenia is associated with alefacept, no opportunistic infections have been observed. Progressive multifocal leukoencephalopathy (PML) may occur during therapy with natalizumab (anti-α4-integrin monoclonal antibody (mAb)) and efalizumab (anti-CD11a mAb), but no cases have been reported to date with vedolizumab (anti-α4β7 mAb). In patients at high risk for PML (positive anti-JC polyomavirus serology with serum antibody index >1.5 and duration of therapy ≥48 months), the benefit-risk ratio of continuing natalizumab should be carefully considered. Fingolimod induces profound peripheral blood lymphopenia and increases the risk of varicella zoster virus (VZV) infection. Prophylaxis with (val)acyclovir and VZV vaccination should be considered. Proteasome inhibitors also increase the risk of VZV infection, and antiviral prophylaxis with (val)acyclovir is recommended. Anti-Pneumocystis prophylaxis may be considered in myeloma multiple patients with additional risk factors (i.e. high-dose corticosteroids). IMPLICATIONS Clinicians should be aware of the risk of immune-related adverse effects and PML in patients receiving immune checkpoint and cell adhesion inhibitors respectively.
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Affiliation(s)
- G Redelman-Sidi
- Service of Infectious Disease, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA.
| | - O Michielin
- Department of Oncology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - C Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - C Ribi
- Department of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - O Manuel
- Department of Infectious Diseases, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
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Tur C, Moccia M, Barkhof F, Chataway J, Sastre-Garriga J, Thompson AJ, Ciccarelli O. Assessing treatment outcomes in multiple sclerosis trials and in the clinical setting. Nat Rev Neurol 2018; 14:75-93. [PMID: 29326424 DOI: 10.1038/nrneurol.2017.171] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Increasing numbers of drugs are being developed for the treatment of multiple sclerosis (MS). Measurement of relevant outcomes is key for assessing the efficacy of new drugs in clinical trials and for monitoring responses to disease-modifying drugs in individual patients. Most outcomes used in trial and clinical settings reflect either clinical or neuroimaging aspects of MS (such as relapse and accrual of disability or the presence of visible inflammation and brain tissue loss, respectively). However, most measures employed in clinical trials to assess treatment effects are not used in routine practice. In clinical trials, the appropriate choice of outcome measures is crucial because the results determine whether a drug is considered effective and therefore worthy of further development; in the clinic, outcome measures can guide treatment decisions, such as choosing a first-line disease-modifying drug or escalating to second-line treatment. This Review discusses clinical, neuroimaging and composite outcome measures for MS, including patient-reported outcome measures, used in both trials and the clinical setting. Its aim is to help clinicians and researchers navigate through the multiple options encountered when choosing an outcome measure. Barriers and limitations that need to be overcome to translate trial outcome measures into the clinical setting are also discussed.
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Affiliation(s)
- Carmen Tur
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK
| | - Marcello Moccia
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Federico II University, Via Sergio Pansini 5, Naples 80131, Italy
| | - Frederik Barkhof
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,Institute of Healthcare Engineering, University College London, Engineering Front Building, Room 2.01, 2nd Floor, Torrington Place, WC1E 7JE London, UK.,Vrije Universiteit (VU) University Medical Centre - Radiology and Nuclear Medicine, Van der Boechorststraat 7 F/A-114, 1081 BT Amsterdam, Netherlands.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
| | - Jaume Sastre-Garriga
- Multiple Sclerosis Centre of Catalonia, Department of Neurology and Neuroimmunology, Vall d'Hebron University Hospital, 119-129, 08035 Barcelona, Spain
| | - Alan J Thompson
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK.,University College London Faculty of Brain Sciences, Institute of Neurology, Department of Brain Repair and Rehabilitation, Queen Square, London WC1N 3BG, UK
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, University College of London Institute of Neurology, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals Biomedical Research Centre, 170 Tottenham Court Rd, W1T 7HA London, UK
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Paz SPC, Branco L, Pereira MADC, Spessotto C, Fragoso YD. Systematic review of the published data on the worldwide prevalence of John Cunningham virus in patients with multiple sclerosis and neuromyelitis optica. Epidemiol Health 2018; 40:e2018001. [PMID: 29370683 PMCID: PMC5900441 DOI: 10.4178/epih.e2018001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/05/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES John Cunningham virus (JCV) is a polyoma virus that infects humans, mainly in childhood or adolescence, and presents no symptomatic manifestations. JCV can cause progressive multifocal leukoencephalopathy (PML) in immunosuppressed individuals, including those undergoing treatment for multiple sclerosis (MS) and neuromyelitis optica (NMO). PML is a severe and potentially fatal disease of the brain. The prevalence of JCV antibodies in human serum has been reported to be between 50.0 and 90.0%. The aim of the present study was to review worldwide data on populations of patients with MS and NMO in order to establish the rates of JCV seropositivity in these individuals. METHODS The present review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and used the following search terms: “JCV” OR “JC virus” AND “multiple sclerosis” OR “MS” OR “NMO” OR “neuromyelitis optica” AND “prevalence.” These terms were searched for both in smaller and in larger clusters of words. The databases searched included PubMed, MEDLINE, SciELO, LILACS, Google Scholar, and Embase. RESULTS After the initial selection, 18 papers were included in the review. These articles reported the prevalence of JCV antibodies in the serum of patients with MS or NMO living in 26 countries. The systematic review identified data on 29,319 patients with MS/NMO and found that 57.1% of them (16,730 individuals) were seropositive for the anti-JCV antibody (range, 40.0 to 69.0%). CONCLUSIONS The median worldwide prevalence of JCV among adults with MS or NMO was found to be 57.1%.
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Affiliation(s)
| | | | | | | | - Yara Dadalti Fragoso
- Reference Center for Multiple Sclerosis, Santos, Brazil.,Department of Neurology, Universidade Metropolitana de Santos, Santos, Brazil
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Progressive multifocal leukoencephalopathy and hematologic malignancies: a single cancer center retrospective review. Blood Adv 2017; 1:2041-2045. [PMID: 29296850 DOI: 10.1182/bloodadvances.2017008201] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/22/2017] [Indexed: 11/20/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is an uncommon opportunistic infection with high morbidity and mortality. This is an institutional review board-approved retrospective review of medical records identified by diagnostic coding for PML or John Cunningham virus (JCV) from 2000 to 2015. Inclusion criteria were cerebrospinal fluid (CSF) positive for JCV by polymerase chain reaction or brain biopsy-proven PML in non-HIV patients. There were 16 patients, 12 of whom were men (75%); the median age was 56 years (range, 31-71 years). All had hematologic malignancies (5 [31%] had chronic lymphocytic leukemia, 3 [19%] had acute myeloid leukemia, 3 had [19%] mantle cell lymphoma, and 1 patient each had acute lymphoblastic leukemia, Hodgkin lymphoma, myeloma, or B-cell lymphoma). One patient received no cancer-directed therapy. Of the remaining 15 patients, all received conventional chemotherapy, and 9 (60%) underwent transplant. Thirteen patients (87%) received immunomodulating therapy (predominantly rituximab). The median time from cancer diagnosis to PML diagnosis was 48.5 months. PML was diagnosed a median of 2.1 months from symptom onset; however, the median time to PML diagnosis was 5.4 months for the 4 patients presenting with a cerebellar syndrome. PML was diagnosed by CSF in 12 patients and brain biopsy in 4 following negative CSF test results. Median survival from PML diagnosis was 4.3 months for the 11 patients on treatment and 0.87 months for the 5 without treatment. PML still occurs in patients with hematologic malignancies in the absence of treatment. Twenty-five percent of our patients required brain biopsy for diagnosis, and diagnosis was delayed when the clinical presentation was unusual, such as a cerebellar syndrome.
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Scholten P, Kralt P, Jacobs B. Posterior fossa progressive multifocal leukoencephalopathy: first presentation of an unknown autoimmune disease. BMJ Case Rep 2017; 2017:bcr-2017-220990. [PMID: 29025774 PMCID: PMC5652366 DOI: 10.1136/bcr-2017-220990] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We present a case of a 57-year-old man who presented with progressive cerebellar dysarthria and cerebellar ataxia. Additional investigations confirmed the diagnosis of progressive multifocal leukoencephalopathy (PML) in the posterior fossa. This is a demyelinating disease of the central nervous system, caused by an opportunistic infection with John Cunningham virus. PML has previously been considered a lethal condition, but because of careful monitoring of patients with HIV and of patients using immunosuppressive drugs it is discovered in earlier stages and prognosis can be improved. Our patient had no known immune-compromising state, but further work-up revealed that the PML was most likely the first presentation of a previous untreated autoimmune disorder: sarcoidosis.
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Affiliation(s)
| | - Peter Kralt
- Radiology, The Rotherham NHS Foundation Trust, Rotherham, UK
| | - Bram Jacobs
- Neurology, Universitair Medisch Centrum Groningen, Groningen, Netherlands
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MRI and multiple sclerosis-the evolving role of MRI in the diagnosis and management of MS: a clinician's perspective. Ir J Med Sci 2017; 187:493-498. [PMID: 29019147 DOI: 10.1007/s11845-017-1691-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/03/2017] [Indexed: 01/26/2023]
Abstract
The diagnosis of multiple sclerosis (MS) is based on a history consistent with demyelination of the central nervous system and corresponding physical signs on examination. However, this diagnosis is supported radiologically using magnetic resonance imaging (MRI). At present, MRI serves as the most reliable and widely available biomarker for the practising clinician to measure disease activity and treatment response in MS. As MRI remains central to both the diagnosis and management of MS, this paper provides proposed guidelines for its use in routine clinical practice.
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Groppo E, Baglio F, Cattaneo D, Tavazzi E, Bergsland N, Di Tella S, Parelli R, Carpinella I, Grosso C, Capra R, Rovaris M. Multidisciplinary Rehabilitation is Efficacious and Induces Neural Plasticity in Multiple Sclerosis even when Complicated by Progressive Multifocal Leukoencephalopathy. Front Neurol 2017; 8:491. [PMID: 28974941 PMCID: PMC5610687 DOI: 10.3389/fneur.2017.00491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/01/2017] [Indexed: 11/13/2022] Open
Abstract
A 48-year-old woman with multiple sclerosis (MS), treated with natalizumab for more than one year without clinical and magnetic resonance imaging (MRI) signs of disease activity, was diagnosed with definite progressive multifocal leukoencephalopathy (PML). She presented with subacute motor deficit of the right upper limb (UL), followed by involvement of the homolateral leg and urinary urgency. The patient was treated with steroids and plasma exchange. On follow-up MRI scans, the PML lesion remained stable and no MS rebounds were observed, but the patient complained of a progressive worsening of the right UL motor impairment, becoming dependent in most activities of daily living. A cycle of multidisciplinary rehabilitation (MDR) was then started, including daily sessions of UL robot therapy and occupational therapy. Functional MRI (fMRI) was acquired before and at the end of the MDR cycle using a motor task which consisted of 2 runs: in one run the patient was asked to observe while the second one consisted of hand grasping movements. At the end of the rehabilitation period, both the velocity and the smoothness of arm trajectories during robot-based reaching movements were significantly improved. After MDR, compared with baseline, fMRI showed significantly increased functional activation within the sensory-motor network in the active, motor task, while no significant differences were found in the observational task. MDR in MS, including robot-assisted UL training, seems to be clinically efficacious and to have a significant impact on brain functional reorganization on a short-term, even in the presence of superimposed tissue damage provoked by PML.
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Affiliation(s)
| | | | | | | | - Niels Bergsland
- IRCCS Fondazione Don Gnocchi ONLUS, Milan, Italy.,Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo SUNY, Buffalo, NY, United States
| | | | | | | | | | - Ruggero Capra
- ASST Spedali Civili of Brescia, MS Regional Center, Montichiari, Italy
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Bohra C, Sokol L, Dalia S. Progressive Multifocal Leukoencephalopathy and Monoclonal Antibodies: A Review. Cancer Control 2017; 24:1073274817729901. [PMID: 28975841 PMCID: PMC5937251 DOI: 10.1177/1073274817729901] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/03/2017] [Indexed: 11/27/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a viral infection predominantly seen in patients with HIV infection. However, with the increased use of monoclonal antibodies (MAB) for various lymphoproliferative disorders, we are now seeing this infection in non-HIV patients on drugs such as natalizumab, rituximab, and so on. The aim of this article is to review the relationship between the occurrence of PML and MAB used in the treatment of hematological malignancies and autoimmune diseases. Review of articles from PubMed-indexed journals which study PML in relation to the use of MAB. Relevant literature demonstrated an increased risk of reactivation of latent John Cunningham polyomavirus (JCV) resulting in development of PML in patients on long-term therapy with MAB. The highest incidence of 1 PML case per 1000 treated patients and 1 case per 32 000 was observed in patients treated with natalizumab and rituximab, respectively. Serological and polymerase chain reaction tests for the detection of JCV can be helpful in risk stratification of patients for the development of PML before and during therapy with MAB. Treatment with MAB can result in development of PML. Clinicians should include PML in differential diagnosis in patients treated with these agents if they manifest central nervous system symptoms.
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Affiliation(s)
- Chandrashekar Bohra
- Internal Medicine Program, University of South Florida, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center &
Research Institute, Tampa, FL, USA
- Mercy Oncology and Hematology–Joplin, Joplin, MO, USA
| | - Lubomir Sokol
- Internal Medicine Program, University of South Florida, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center &
Research Institute, Tampa, FL, USA
- Mercy Oncology and Hematology–Joplin, Joplin, MO, USA
| | - Samir Dalia
- Internal Medicine Program, University of South Florida, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center &
Research Institute, Tampa, FL, USA
- Mercy Oncology and Hematology–Joplin, Joplin, MO, USA
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Leurs CE, van Kempen ZLE, Dekker I, Balk LJ, Wattjes MP, Rispens T, Uitdehaag BM, Killestein J. Switching natalizumab to fingolimod within 6 weeks reduces recurrence of disease activity in MS patients. Mult Scler 2017; 24:1453-1460. [PMID: 28823223 PMCID: PMC6174622 DOI: 10.1177/1352458517726381] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Natalizumab is an effective treatment in relapsing-remitting multiple sclerosis (MS). Mainly because of the risk of progressive multifocal leukoencephalopathy (PML), a substantial proportion of John Cunningham (JC) virus-positive patients switch to fingolimod. Previous reports show a clear benefit when the duration of a washout (WO) period of natalizumab is 0-3 months in comparison to longer WO periods. However, there is no consensus regarding the optimal duration of a WO period under 3 months. OBJECTIVE We compared MS disease activity after different WO periods. In addition, we investigated several factors that possibly influence recurrence of disease activity, including serum natalizumab concentration and lymphocyte counts. METHODS From a prospective observational cohort study of natalizumab-treated patients, we selected 52 patients who switched to fingolimod. We divided the patients in three groups (<6 weeks, 6-8 weeks, >8 weeks WO). Serum natalizumab concentration and lymphocyte count were assessed during and after natalizumab treatment. RESULTS Patients with a WO period of >8 weeks had a significant higher recurrence of disease activity (odds ratio, 6.8; 95% confidence interval, 1.4-32.8) compared to patients with a WO period of <6 weeks. Serum natalizumab concentration and lymphocyte count did not predict recurrence of disease activity. INTERPRETATION A short WO period decreases the risk of recurrence of disease activity. The possible impact of a short WO period on the risk of carry-over PML in JC virus-positive patients remains uncertain.
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Affiliation(s)
- Cyra E Leurs
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Zoé LE van Kempen
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Iris Dekker
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands / Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Lisanne J Balk
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Mike P Wattjes
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Theo Rispens
- Department of Immunology, Landsteiner Laboratory Sanquin Research, Amsterdam, The Netherlands
| | - Bernard Mj Uitdehaag
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
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Age as a risk factor for early onset of natalizumab-related progressive multifocal leukoencephalopathy. J Neurovirol 2017; 23:742-749. [PMID: 28791614 DOI: 10.1007/s13365-017-0561-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/21/2017] [Accepted: 07/26/2017] [Indexed: 10/19/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare but potentially fatal opportunistic infection that arises almost exclusively in immunocompromised patients or in those treated with monoclonal antibodies, especially natalizumab. Here, we aimed at exploring if age at treatment start affects the time to onset of natalizumab-related PML. PubMed was searched for the terms "natalizumab and progressive multifocal leukoencephalopathy" in articles published from January 2005 to March 2017. We collected information on each identified PML case, including demographic and clinical variables at natalizumab start and at PML onset. The number of natalizumab infusions until PML onset was investigated in time-to-event analyses. We identified 238 cases who developed PML after a median number of 33 natalizumab infusions (range 6 to 103). Risk factors for an earlier onset of natalizumab-related PML were prior immunosuppressant exposure (hazard ratio [HR] = 1.43, p = 0.017) and older age at treatment start (HR = 1.02, p = 0.016). In particular, patients older than 50 years had a more than doubled-increased risk for an earlier PML onset (HR = 2.11, p = 0.006). Our findings suggest that the age at natalizumab start may represent a risk factor for an earlier PML onset, thus claiming further investigations about the interplay between immunosenescence and MS treatments.
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Paužuolis M, Eich T, Burman J. Quantification of γδ T cells and HLA-DR+ NK cells does not predict emergence of new contrast enhancing lesions in MS patients suspending natalizumab treatment. PLoS One 2017; 12:e0179095. [PMID: 28586378 PMCID: PMC5460885 DOI: 10.1371/journal.pone.0179095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/23/2017] [Indexed: 11/19/2022] Open
Abstract
Background Natalizumab (NTZ) is a drug that has been widely used in the treatment of multiple sclerosis (MS). NTZ is very effective in suppressing inflammation, but if treatment is suspended many patients will experience relapses. Objective To investigate if quantification of γδ T cells and HLA-DR+ NK cells could predict early disease reactivation after NTZ suspension. Methods Absolute counts of γδ T cells and HLA-DR+ NK cells in whole blood were determined with flow cytometry in fifteen patients treated with NTZ. NTZ treatment was then withdrawn and patients were followed with clinical visits and MR investigations. Results Patients with recurrent disease had higher absolute counts of γδ T cells 129 (±156) cells/μl in comparison to patients with stable disease 50.0 (±51.0) cells/μl but the difference was not statistically significant and largely driven by outliers. Patients with recurrent and stable disease had similar absolute counts of HLA-DR+ NK cells. Conclusion Quantification of γδ T cells and HLA-DR+ NK cells could not predict active disease after NTZ suspension.
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Affiliation(s)
| | - Torsten Eich
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
- * E-mail:
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Chacińska W, Brzostowska M, Nojszewska M, Podlecka-Piętowska A, Jędrzejczak WW, Snarski E. "Cure" for multiple sclerosis (MS)-Evolving views of therapy goals in patients on different stages of the disease: A pilot study in a cohort of Polish MS patients. Brain Behav 2017; 7:e00701. [PMID: 28638709 PMCID: PMC5474707 DOI: 10.1002/brb3.701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION New aggressive treatments promise improvement of results in the treatment of multiple sclerosis (MS), however, with high risk of serious complications. In this study, we analyzed patients' acceptance for risks connected with the MS treatment. METHODS The study was designed as a prospective nonanonymous online questionnaire. Responders were asked about the definition of the "cure" for MS and crucial goals in the treatment. RESULTS One hundred and eighty patients filled in the questionnaire (129 women and 51 men), and the mean age was 33 years (SD = 10.29). The MS forms were as follows: relapsing-remitting (65%), secondary progressive (14%), primary progressive (10%), and other (11%), with mean EDSS score of 3 points (SD = 2.6). For 50% of the patients, relief of symptoms such as fatigue (72%), paresis (66%), and balance disorders (65%) was synonymous with "cure." The patients with faster progression of the disease were likely to accept risky "curative" treatments-with average 68% accepted mortality risk (p = .003). Over 81% of patients accepted mortality rates over 1% for the treatment that achieves self-defined cure. CONCLUSION The study shows that the MS patients are likely to accept even very risky treatments as long as they promise patient-defined "cure."
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Affiliation(s)
- Weronika Chacińska
- Department of Hematology Oncology and Internal Diseases Medical University of Warsaw Warsaw Poland
| | - Marta Brzostowska
- Department of Hematology Oncology and Internal Diseases Medical University of Warsaw Warsaw Poland
| | | | | | - Wiesław W Jędrzejczak
- Department of Hematology Oncology and Internal Diseases Medical University of Warsaw Warsaw Poland
| | - Emilian Snarski
- Department of Hematology Oncology and Internal Diseases Medical University of Warsaw Warsaw Poland
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Gieselbach RJ, Muller-Hansma AH, Wijburg MT, de Bruin-Weller MS, van Oosten BW, Nieuwkamp DJ, Coenjaerts FE, Wattjes MP, Murk JL. Progressive multifocal leukoencephalopathy in patients treated with fumaric acid esters: a review of 19 cases. J Neurol 2017; 264:1155-1164. [PMID: 28536921 DOI: 10.1007/s00415-017-8509-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 11/25/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare and potentially fatal condition caused by a brain infection with JC polyomavirus (JCV). PML develops almost exclusively in immunocompromised patients and has recently been associated with use of fumaric acid esters (FAEs), or fumarates. We reviewed the literature and the Dutch and European pharmacovigilance databases in order to identify all available FAE-associated PML cases and distinguish possible common features among these patients. A total of 19 PML cases associated with FAE use were identified. Five cases were associated with FAE use for multiple sclerosis and 14 for psoriasis. Ten patients were male and nine were female. The median age at PML diagnosis was 59 years. The median duration of FAE therapy to PML symptom onset or appearance of first PML lesion on brain imaging was 31 months (range 6-110). In all cases a certain degree of lymphocytopenia was reported. The median duration of lymphocytopenia to PML symptom onset was 23 months (range 6-72). The median lymphocyte count at PML diagnosis was 414 cells/µL. CD4 and CD8 counts were reported in ten cases, with median cell count of 137 and 39 cells/µL, respectively. Three patients died (16% mortality). The association between occurrence of PML in patients with low CD4 and CD8 counts is reminiscent of PML cases in the HIV population and suggests that loss of T cells is the most important risk factor.
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Affiliation(s)
- Robbert-Jan Gieselbach
- Department of Medical Microbiology and Infection Control, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Martijn T Wijburg
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Bob W van Oosten
- Department of Neurology, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Dennis J Nieuwkamp
- Department of Neurology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Frank E Coenjaerts
- Department of Medical Microbiology and Infection Control, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mike P Wattjes
- Department of Radiology and Nuclear Medicine, Neuroscience Amsterdam, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Jean-Luc Murk
- Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands.
- Laboratory of Medical Microbiology and Immunology, St. Elisabeth TweeSteden ziekenhuis (ETZ), Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
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Kaunzner UW, Gauthier SA. MRI in the assessment and monitoring of multiple sclerosis: an update on best practice. Ther Adv Neurol Disord 2017; 10:247-261. [PMID: 28607577 DOI: 10.1177/1756285617708911] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/09/2017] [Indexed: 01/14/2023] Open
Abstract
Magnetic resonance imaging (MRI) has developed into the most important tool for the diagnosis and monitoring of multiple sclerosis (MS). Its high sensitivity for the evaluation of inflammatory and neurodegenerative processes in the brain and spinal cord has made it the most commonly used technique for the evaluation of patients with MS. Moreover, MRI has become a powerful tool for treatment monitoring, safety assessment as well as for the prognostication of disease progression. Clinically, the use of MRI has increased in the past couple decades as a result of improved technology and increased availability that now extends well beyond academic centers. Consequently, there are numerous studies supporting the role of MRI in the management of patients with MS. The aim of this review is to summarize the latest insights into the utility of MRI in MS.
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Affiliation(s)
- Ulrike W Kaunzner
- Judith Jaffe Multiple Sclerosis Center, Weill Cornell Medicine, New York, NY, USA
| | - Susan A Gauthier
- Judith Jaffe Multiple Sclerosis Center, Weill Cornell Medicine, 1305 York Avenue, New York, NY 10021, USA
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