1
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Shishido-Hara Y, Akimoto J, Fukami S, Kohno M, Matsubayashi J, Nagao T. Pathology for severe inflammatory PML with PD1/PD-L1 expression of favorable prognosis: What's a prognostic factor for PML-IRIS? Neuropathology 2024; 44:47-58. [PMID: 37424276 DOI: 10.1111/neup.12929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023]
Abstract
A 72-year-old woman with dermatomyositis (DM) developed neurological manifestation, and magnetic resonance imaging (MRI) revealed multiple T2/fluid-attenuated inversion recovery (FLAIR)-hyperintense lesions predominantly in the deep white matter of the cerebral hemisphere. Punctate or linear contrast enhancement was observed surrounding the T1-hypointense area. Multiple T2/FLAIR-hyperintense lesions were aligned along with the corona radiata. Malignant lymphoma was first suspected, and a brain biopsy was performed. Pathological investigation suggested the provisional diagnosis of "suspicious of malignant lymphoma." Owing to emergent clinical conditions, high-dose methotrexate (MTX) therapy was conducted, and then T2/FLAIR-hyperintense lesions were dramatically reduced. However, the diagnosis of malignant lymphoma was concerning since multiplex PCR demonstrated clonal restriction of the Ig H gene for B cells and TCR beta genes for T cells. Histopathology revealed the infiltration of both CD4+ and CD8+ T cells, and the CD4+ /CD8+ ratio was 4.0. Moreover, prominent plasma cells were observed, in addition to CD20+ B cells. Atypical cells with enlarged nuclei were present, and they were not hematopoietic but found as glial cells. JC virus (JCV) infection was verified with both immunohistochemistry and in situ hybridization; the final diagnosis was progressive multifocal leukoencephalopathy (PML). The patient was treated with mefloquine and discharged. This case is informative in understanding the host anti-viral response. Variable inflammatory cells were observed, including CD4+ and CD8+ T cells, plasma cells, and a small amount of perivascular CD20+ B cells. PD-1 and PD-L1 expression was observed in lymphoid cells and macrophages, respectively. PML with inflammatory reactions was thought fatal, and autopsy cases of PML with immune reconstitution inflammatory syndrome (IRIS) demonstrated excessive infiltration of only CD8+ T cells. However, this case revealed infiltration of variable inflammatory cells, and a favorable prognosis would be expected under PD-1/PD-L1 immune-checkpoint regulation.
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Affiliation(s)
- Yukiko Shishido-Hara
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
- Department of Pathology and Applied Neurobiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jiro Akimoto
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Shinjiro Fukami
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Matsubayashi
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Toshitaka Nagao
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
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2
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Lombardo-Del Toro P, Bragado-Trigo I, Arroyo P, Tena-Cucala R, Bau L, Matas E, Muñoz-Vendrell A, Simó M, Pons-Escoda A, Martínez-Yélamos A, Martínez-Yélamos S, Romero-Pinel L. Fingolimod-associated progressive multifocal leukoencephalopathy in a multiple sclerosis patient with a good response to filgrastim. J Neurol 2023; 270:5196-5200. [PMID: 37460853 DOI: 10.1007/s00415-023-11865-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Paula Lombardo-Del Toro
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Irene Bragado-Trigo
- Department of Neurology, Hospital Residència Sant Camil - Consorci Sanitari Alt Penedès-Garraf, Sant Pere de Ribes, Barcelona, Spain
| | - Pablo Arroyo
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raquel Tena-Cucala
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Bau
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Elisabet Matas
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Muñoz-Vendrell
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Simó
- Neuro-Oncology Unit, Hospital Universitari de Bellvitge-Institut Català d'Oncologia L'Hospitalet, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Pons-Escoda
- Department of Neuroradiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Antonio Martínez-Yélamos
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Sergio Martínez-Yélamos
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Lucía Romero-Pinel
- Multiple Sclerosis Unit, Department of Neurology, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
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3
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Okamoto K, Takeda A, Hatsuta H, Sano T, Takao M, Ohsawa M, Miki Y, Nakamichi K, Itoh Y. An autopsy case of progressive multifocal leukoencephalopathy with massive iron deposition in juxtacortical lesions. Neuropathology 2023; 43:396-402. [PMID: 36847459 DOI: 10.1111/neup.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease caused by JC virus infection of oligodendrocytes. Little has been reported on iron deposits in patients with PML. Herein, we report a case of PML with massive iron deposition in the juxtacortical regions attaching white matter lesions in a 71-year-old woman who developed bilateral visual disturbance and progressive aphasia after 16 months of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone treatment for follicular lymphoma. Magnetic resonance imaging revealed white matter lesions in the left parietal and other lobes with massive iron deposition in the juxtacortical lesions. A PCR test for JC virus was positive, confirming the diagnosis of PML. Despite treatment with mefloquine and mirtazapine, the patient died six months later. At autopsy, demyelination was found dominantly in the left parietal lobe. Moreover, hemosiderin-laden macrophages and reactive astrocytes containing ferritin were abundant in the juxtacortical regions adjacent to the white matter lesions. This is a previously unreported case of PML after lymphoma, in which iron deposition was confirmed both radiologically and pathologically.
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Grants
- 22H04923 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 18K06506 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 21K06417 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 21K07450 Research Committee of Prion Disease and Slow Virus Infection, Research on Policy Planning and Evaluation for Rare and Intractable Diseases, Health and Labour Sciences Research Grants, the Ministry of Health, Labour and Welfare, Japan, KAKENHI
- 22dk0307115h0001 AMED
- JP21wm0425019 AMED
- intramural fund National Center of Neurology and Psychiatry
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Affiliation(s)
- Kosuke Okamoto
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akitoshi Takeda
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Hatsuta
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
- Hatsuta Neurology Clinic, Osaka, Japan
| | - Terunori Sano
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaki Takao
- Department of Pathology and Laboratory Medicine, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masahiko Ohsawa
- Department of Pathology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshiaki Itoh
- Department of Neurology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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4
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Soni N, Ora M, Mangla R, Singh R, Ellika S, Agarwal A, Meyers SP, Bathla G. Radiological abnormalities in progressive multifocal leukoencephalopathy: Identifying typical and atypical imaging patterns for early diagnosis and differential considerations. Mult Scler Relat Disord 2023; 77:104830. [PMID: 37418930 DOI: 10.1016/j.msard.2023.104830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 07/09/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare viral central nervous system (CNS) demyelinating disease primarily associated with a compromised immune system. PML is seen mainly in individuals with human immunodeficiency virus, lymphoproliferative disease, and multiple sclerosis. Patients on immunomodulators, chemotherapy, and solid organ or bone marrow transplants are predisposed to PML. Recognition of various PML-associated typical and atypical imaging abnormalities is critical for early diagnosis and differentiating it from other conditions, especially in high-risk populations. Early PML recognition should expedite efforts at immune-system restoration, allowing for a favorable outcome. This review aims to provide a practical overview of radiological abnormalities in PML patients and address differential considerations.
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Affiliation(s)
- Neetu Soni
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA.
| | - Manish Ora
- Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | - Rohit Singh
- Division of Hematology-Oncology at the University of Vermont Medical Center, Burlington, VT, USA
| | - Shehanaz Ellika
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
| | - Amit Agarwal
- Radiology, Mayo Clinic in Florida, San Pablo Dr, Jacksonville, FL 32224-1865, USA
| | - Steven P Meyers
- Radiodiagnosis (Neuroradiology and Nuclear Medicine), University of Rochester Medical Center, Rochester, NY 14618, USA
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5
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Barritt AW, Das E, Morley N, Seymour M, Saha R, Vera J, Vundavalli S, Dizdarevic S, Nicholas R, Berger JR, Fisniku LK. Management approach including pembrolizumab for fingolimod-associated progressive multifocal leukoencephalopathy in a patient with relapsing-remitting multiple sclerosis. Mult Scler 2023; 29:301-306. [PMID: 36451581 DOI: 10.1177/13524585221137279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
A 62-year-old man with relapsing-remitting multiple sclerosis developed progressive multifocal leukencephalopathy (PML) after 6 years on fingolimod. The fingolimod was immediately discontinued and preexisting mirtazepine increased. Three weeks later, with brain magnetic resonance imaging (MRI) appearances worsening and cerebrospinal fluid (CSF) JC virus (JCV) titres increasing, maraviroc was introduced. At 6 weeks, subtle punctate contrast enhancement raised the possibility of immune reconstitution inflammatory syndrome (IRIS), followed by a single focal-to-generalised tonic clonic seizure and a further deterioration in clinical disability. Mefloquine was commenced alongside three doses of pembrolizumab administered a month apart. Serial CSF examinations and several imaging modalities including spectroscopy and fused FDG-PET-MRI (18F-fluoro-deoxy-glucose-positron emission tomography-magnetic resonance imaging) were used to help distinguish between PML, PML-IRIS and rebound MS activity and guide optimal management at each stage. A handful of small, enhancing ovoid lesions developed between the first two doses of pembrolizumab, probably representative of a mild rebound phenomenon. A sustained improvement became obvious thereafter with CSF JCV-DNA undetectable 16 weeks following fingolimod withdrawal. To our knowledge, this is the first case of combined therapy and use of pembrolizumab in a fingolimod-associated PML.
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Affiliation(s)
- Andrew W Barritt
- Hurstwood Park Neurological Centre, Haywards Heath, UK/Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, Brighton, UK
| | - Esther Das
- Hurstwood Park Neurological Centre, Haywards Heath, UK
| | | | | | - Romi Saha
- Hurstwood Park Neurological Centre, Haywards Heath, UK
| | - Jaime Vera
- Hurstwood Park Neurological Centre, Haywards Heath, UK/Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | | | - Sabina Dizdarevic
- Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, Brighton, UK/Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Nicholas
- Department of Brain Sciences, Imperial College London, London, UK
| | - Joseph R Berger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Leonora K Fisniku
- Hurstwood Park Neurological Centre, Haywards Heath, UK/Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Agarwal A, Garg D, Joy S, Garg A, Srivastava AK. Milky Way Sign in Progressive Multifocal Leukoencephalopathy. Ann Indian Acad Neurol 2022; 25:1177-1178. [PMID: 36911493 PMCID: PMC9996468 DOI: 10.4103/aian.aian_650_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shiny Joy
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K. Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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7
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Sriwastava S, Chaudhary D, Srivastava S, Beard K, Bai X, Wen S, Khalid SH, Lisak RP. Progressive multifocal leukoencephalopathy and sphingosine 1-phosphate receptor modulators used in multiple sclerosis: an updated review of literature. J Neurol 2021; 269:1678-1687. [PMID: 34800168 DOI: 10.1007/s00415-021-10910-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Progressive multifocal leukoencephalopathy (PML) is a serious viral infection associated with disease-modifying therapies (DMT) for multiple sclerosis (MS) including sphingosine 1-phosphate receptor (S1PR) modulators. The objective of this review was to investigate the characteristics of PML in MS patients associated with drugs of the S1PR modulator. METHODS We conducted a literature review and analysis of 24 patients from 12 publications in PubMed, SCOPUS and EMBASE. This is a descriptive analysis and study of characteristics of PML associated fingolimod and related S1PR modulator group of DMT. RESULTS A total of 24 cases of PML in MS patients treated with fingolimod were identified. Of these, 21 cases contained data regarding changes in the expanded disability status scale (EDSS). One case of PML in association with ozanimod treatment in a clinical trial was also identified. In PML cases associated with fingolimod, the mean age at the time of PML diagnosis was 50.91 ± 11.5 years. All patients were treated with fingolimod for more than 24 months. Compared to patients who improved or were stable, in terms of EDSS, after symptomatic management of PML, the non-improved groups were significantly older. There were no fatalities in either group during the reported follow-up period. CONCLUSION The incidence of PML appears to be extremely low in MS patients treated with S1PR modulators. Risk of PML increases with increase in duration of treatment with S1PR modulators like fingolimod, and increased age at the time of PML diagnosis is associated with worse prognosis.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, 26506, USA.
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA.
- Department of Neurology, Wayne State University, Detroit, MI, USA.
- School of Medicine, West Virginia University, Morgantown, WV, USA.
| | | | | | - Katherine Beard
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Xue Bai
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Syed Hassan Khalid
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Robert P Lisak
- Department of Neurology, Wayne State University, Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA
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8
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Baldassari LE, Wattjes MP, Cortese ICM, Gass A, Metz I, Yousry T, Reich DS, Richert N. The neuroradiology of progressive multifocal leukoencephalopathy: a clinical trial perspective. Brain 2021; 145:426-440. [PMID: 34791056 DOI: 10.1093/brain/awab419] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/29/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the central nervous system caused by the JC virus, which infects white and grey matter cells and leads to irreversible demyelination and neuroaxonal damage. Brain magnetic resonance imaging (MRI), in addition to the clinical presentation and demonstration of JC virus DNA either in the CSF or by histopathology, is an important tool in the detection of PML. In clinical practice, standard MRI pulse sequences are utilized for screening, diagnosis, and monitoring of PML, but validated imaging-based outcome measures for use in prospective, interventional clinical trials for PML have yet to be established. We review the existing literature regarding the use of MRI and positron emission tomography imaging in PML and discuss the implications of PML histopathology for neuroradiology. MRI not only demonstrates the localization and extent of PML lesions, but also mirrors the tissue destruction, ongoing viral spread, and resulting inflammation. Finally, we explore the potential for imaging measures to serve as an outcome in PML clinical trials and provide recommendations for current and future imaging outcome measure development in this area.
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Affiliation(s)
- Laura E Baldassari
- Division of Neurology 2, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland, 20993, USA
| | - Mike P Wattjes
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, 30625 Hannover, Germany
| | - Irene C M Cortese
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, 20892, USA
| | - Achim Gass
- Department of Neurology/Neuroimaging, Mannheim Center of Translational Neuroscience, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Imke Metz
- Institute of Neuropathology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Tarek Yousry
- Neuroradiological Academic Unit, UCL IoN; Lysholm Department of Neuroradiology, UCLH National Hospital for Neurology and Neurosurgery, London, UK
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, 20892, USA
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9
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Ruiz Romagnoli E, Akly MP, Miquelini LA, Funes J, Gillanders T, Besada C. Understanding progressive multifocal leukoencephalopathy: links between milky-way appearance and mismatch T2/FLAIR. Neuroradiol J 2021; 34:646-655. [PMID: 34048309 DOI: 10.1177/19714009211019374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Magnetic resonance imaging is essential to diagnose progressive multifocal leukoencephalopathy. The broad radiological spectrum may partially be explained by genetic viral mutations and their differential neurotropism. Recent pharmacovigilance-magnetic resonance imaging studies have provided new insight into pathophysiology and radiological markers of early stages. However, how lesions evolve and why certain anatomical locations are more frequently affected remains unknown. We aim to describe a new sign - T2/fluid-attenutated inversion recovery mismatch - as a complementary marker of cavitated lesions and propose a link with the milky-way appearance, a key early sign. Furthermore, we hypothesise viral dissemination routes. METHODS We conducted a retrospective longitudinal study from January 2010 to January 2020, to analyse clinical and magnetic resonance imaging features of 13 progressive multifocal leukoencephalopathy individuals at the symptomatic stage (mean age 58.3 years (SD ± 16.8) - 61.5% were women). RESULTS The most prevalent pathology was HIV (61.5%) and motor deficit prevailed regarding other symptoms (76.9%). Frontal lobes (76.9%), middle cerebellar peduncle (61.5%), cerebellum (61.5%), and pons (53.8%) were most commonly affected, and the cortico-ponto-cerebellar pathway seemed involved in these patients. Five patients had a pure radiological pattern. Milky-way appearance was the most frequent radiological sign (58.3%). Five patients with milky-way appearance had concomitantly T2/fluid-attenuated inversion recovery mismatch (P = 0.02). This sign showed high sensitivity and specificity (100-71%, P = 0.02) to assess evolved lesions besides diffusion. CONCLUSION The possible tract-dependent spread, as well as clinical and genetic, have implications on the MRI variability of progressive multifocal leukoencephalopathy. The milky-way appearance could reflect a transitional phase towards evolved lesions, the latter demonstrated by T2/fluid-attenuated inversion recovery mismatch. Both could be key magnetic resonance imaging signs to diagnose progressive multifocal leukoencephalopathy at the symptomatic stage.
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Affiliation(s)
| | | | | | - Jorge Funes
- 37533Hospital Italiano de Buenos Aires, Argentina
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10
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Mahajan KR, Amin M, Poturalski M, Lee J, Herman D, Zheng Y, Androjna C, Howell M, Fox RJ, Trapp BD, Jones SE, Nakamura K, Ontaneda D. Juxtacortical susceptibility changes in progressive multifocal leukoencephalopathy at the gray-white matter junction correlates with iron-enriched macrophages. Mult Scler 2021; 27:2159-2169. [PMID: 33749379 DOI: 10.1177/1352458521999651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Describe magnetic resonance imaging (MRI) susceptibility changes in progressive multifocal leukoencephalopathy (PML) and identify neuropathological correlates. METHODS PML cases and matched controls with primary central nervous system lymphoma (PCNSL) were retrospectively identified. MRI brain at 3 T and 7 T were reviewed. MRI-pathology correlations in fixed brain autopsy tissue were conducted in three subjects with confirmed PML. RESULTS With PML (n = 26 total, n = 5 multiple sclerosis natalizumab-associated), juxtacortical changes on susceptibility-weighted imaging (SWI) or gradient echo (GRE) sequences were noted in 3/3 cases on 7 T MRI and 14/22 cases (63.6%) on 1.5 T or 8/22 (36.4%) 3 T MRI. Similar findings were only noted in 3/25 (12.0%) of PCNSL patients (odds ratio (OR) 12.83, 95% confidence interval (CI), 2.9-56.7, p < 0.001) on 1.5 or 3 T MRI. On susceptibility sequences available prior to diagnosis of PML, 7 (87.5%) had changes present on average 2.7 ± 1.8 months (mean ± SD) prior to diagnosis. Postmortem 7 T MRI showed SWI changes corresponded to areas of increased iron density along the gray-white matter (GM-WM) junction predominantly in macrophages. CONCLUSION Susceptibility changes in PML along the GM-WM junction can precede noticeable fluid-attenuated inversion recovery (FLAIR) changes and correlates with iron accumulation in macrophages.
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Affiliation(s)
- Kedar R Mahajan
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA/Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Poturalski
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan Lee
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Danielle Herman
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yufan Zheng
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caroline Androjna
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Howell
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce D Trapp
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen E Jones
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kunio Nakamura
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Abstract
Radiology signs have long been described in ways that communicate the imagery around us to enhance our cognitive perception. Here, we describe the use and limitations of 10 such signs in neuroradiology, divided into three groups. The first are signs that are reliable for a specific diagnosis, such as the Medusa head sign indicating a developmental venous anomaly, or a racing car sign in agenesis of corpus callosum. The second group of signs helps us to diagnose rare conditions, such as the onion skin sign in Balo's concentric sclerosis. The third group is of unreliable signs that may lead clinicians astray. For example, the absence of a swallow-tail sign in Parkinson's disease or the presence of a hummingbird sign and Mickey Mouse sign in progressive supranuclear palsy. The appropriate use of these signs in clinical practice is essential.
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Affiliation(s)
- Inna Page
- Radiology Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Frank Gaillard
- Radiology Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia .,Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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