Cryptococcal Meningitis Reported With Fingolimod Treatment: Case Series

Choosing initial MS therapy; personal, disease, and medication factors

Initiating disease modifying therapy in a patient with newly diagnosed relapsing multiple sclerosis currently offers the best opportunity to influence their subsequent disease course. This article reviews personal factors, disease presentation characteristics, and data on current disease modifying therapies from the perspective of choosing initial treatment in this setting. Although metrics for prognostication at the individual level remain unreliable, particularly for those with mild presentations, currently available data on the relative efficacy of disease modifying therapies supports offering high efficacy therapy first line to most patients with newly diagnosed relapsing multiple sclerosis.

Cryptococcal meningoencephalitis in a patient on immunomodulatory drug: A case report

BACKGROUND

Cryptococcus neoformans is an important fungal pathogen causing pneumonia and central nervous system infections mainly in immunocompromised hosts. Fingolimod is an immunomodulatory drug approved in the US and Europe for the treatment of multiple sclerosis.

CASE PRESENTATION

We herein report a case of cryptococcal meningoencephalitis in a 46-year-old male with a history of fingolimod for five years. He suffered from a progressive headache and visual impairment. These symptoms led to a suspicion of a central nervous system infection and C. neoformans was identified with nucleic acid-based PCR method. Subsequently, appropriate treatment was initiated, and the patient recovered.

CONCLUSIONS

Our case underlines the importance of active diagnostic measures such as cerebrospinal fluid analysis in patients under fingolimod treatment with central nervous symptoms. While multiple sclerosis may cause headache and vision impairment, similar symptoms may be caused by central nervous system infections. It has been suggested that fingolimod may subject one to infections and this may occur even years after initiation of the treatment. For our case patient Cerebrospinal fluid sample combined with PCR-based identification provided a rapid diagnosis.

Investigating treatment alternatives for fingolimod in patients with multiple sclerosis developed refractory fingolimod-related genital Human Papilloma Virus (HPV) infection

INTRODUCTION

Genital human papillomavirus (HPV) infection is a rare skin complication in patients with relapse-remitting multiples sclerosis (RRMS) treated with fingolimod. Herein, we aimed to report a case series of 23 MS patients who had to discontinue fingolimod due to persistent HPV infection.

MATERIALS AND METHODS

This retrospective case series was conducted between September 2023 to September 2024 in six MS centers in Iran to identify the outcome of HPV infection who discontinued fingolimod.

RESULTS

23 patients with a mean age of 36.34 ± 6.90 -year-old. The majority of patients were female (78.3 %) with a mean disease duration of 3.83 ± 3.02 years, and a mean EDSS score of 1.26 ± 1.10 at the time of fingolimod initiation. Most patients (39.1%) were treatment naïve. They developed genital HPV infection after a mean 32.21± 25.15 months of using fingolimod. Most patients (78.3%) were affected by low risk HPV infection and received a mean 1.96± 1.43 cycles of cryotherapy. After a mean 14.30±11.05 months, all patients had to discontinue treatment, mainly switched to anti-CD20 agents (78.3%). The lesions were resolved after a mean 4.52± 3.11 months. In addition, except for two patients developing a rebound after fingolimod cessations, others were stable with no evidence of disease activity or progression over a one-year follow-up.

CONCLUSION

Our preliminary results revealed that anti-CD20s agents could be considered safe in patients treated with fingolimod who had to discontinue treatment due to persistent HPV infection. Larger studies are needed to warrant our data.

Fingolimod-associated cryptococcal meningitis in a patient with Multiple Sclerosis: A case report and literature review

A 65-year-old woman with Multiple Sclerosis treated with fingolimod developed headaches and convulsions. Cerebrospinal fluid (CSF) culture indicated Cryptococcus neoformans. A literature review of 20 cases of cryptococcal meningitis indicated that headache was the most common initial symptom, and all cases were positive for serum and/or CSF cryptococcal antigens.

Cryptococcosis Associated With Biologic Therapy: A Narrative Review

Cryptococcus is an opportunistic fungal pathogen that can cause disseminated infection with predominant central nervous system involvement in patients with compromised immunity. Biologics are increasingly used in the treatment of neoplasms and autoimmune/inflammatory conditions and the prevention of transplant rejection, which may affect human defense mechanisms against cryptococcosis. In this review, we comprehensively investigate the association between cryptococcosis and various biologics, highlighting their risks of infection, clinical manifestations, and clinical outcomes. Clinicians should remain vigilant for the risk of cryptococcosis in patients receiving biologics that affect the Th1/macrophage activation pathways, such as tumor necrosis factor α antagonists, Bruton tyrosine kinase inhibitors, fingolimod, JAK/STAT inhibitors (Janus kinase/signal transducer and activator of transcription), and monoclonal antibody against CD52. Other risk factors-such as age, underlying condition, and concurrent immunosuppressants, especially corticosteroids-should also be taken into account during risk stratification.

Survival after cryptococcosis in Germany: A retrospective multicenter cohort study of patients diagnosed between 2004 and 2021

Cryptococcosis is the most prevalent fungal infection of the central nervous system worldwide. We performed a retrospective multicenter cohort study to gain insights into the epidemiology of cryptococcosis in Germany. We describe the use of diagnostic tests, clinical management and patient outcome. We included 64 patients with underlying HIV infection (55%) or other predispositions. Molecular typing by MLST documented 20 individual sequence types among 42 typed isolates. A fatal outcome was documented in 14% of patients in the first two months after diagnosis.

An update on the use of sphingosine 1-phosphate receptor modulators for the treatment of relapsing multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated disorder of the CNS manifested by recurrent attacks of neurological symptoms (related to focal inflammation) and gradual disability accrual (related to progressive neurodegeneration and neuroinflammation). Sphingosine-1-phosphate-receptor (S1PR) modulators are a class of oral disease-modifying therapies (DMTs) for relapsing MS. The first S1PR modulator developed and approved for MS was fingolimod, followed by siponimod, ozanimod, and ponesimod. All are S1P analogues with different S1PR-subtype selectivity. They restrain the S1P-dependent lymphocyte egress from lymph nodes by binding the lymphocytic S1P-subtype-1-receptor. Depending on their pharmacodynamics and pharmacokinetics, they can also interfere with other biological functions.

AREAS COVERED

Our narrative review covers the PubMed English literature on S1PR modulators in MS until August 2022. We discuss their pharmacology, efficacy, safety profile, and risk management recommendations based on the results of phase II and III clinical trials. We briefly address their impact on the risk of infections and vaccines efficacy.

EXPERT OPINION

S1PR modulators decrease relapse rate and may modestly delay disease progression in people with relapsing MS. Aside their established benefit, their place and timing within the long-term DMT strategy in MS, as well as their immunological effects in the new and evolving context of the post-COVID-19 pandemic and vaccination campaigns warrant further study.

Immunomodulatory drug fingolimod (FTY720) restricts the growth of opportunistic yeast Candida albicans in vitro and in a mouse candidiasis model

Fingolimod (FTY720) is a drug derived from the fungicidal compound myriocin. As it was unclear whether FTY720 has antifungal effects as well, we aimed to characterize its effect on Candida albicans in vitro and in a mouse candidiasis model. First, antifungal susceptibility testing was performed in vitro. Then, a randomized, six-arm, parallel, open-label trial was conducted on 48 mice receiving oral FTY720 (0.3 mg/kg/day), intraperitoneal C. albicans inoculation, or placebo with different combinations and chorological patterns. The outcome measures of the trial included serum concentrations of interleukin-10 and interferon-gamma, absolute lymphocyte counts, and fungal burden values in the mice's livers, kidneys, and vaginas. Broth microdilution assay revealed FTY720's minimum inhibitory concentration (MIC99) to be 0.25 mg/mL for C. albicans. The infected mice treated with FTY720 showed lower fungal burden values than the ones not treated with FTY720 (p<0.05). As expected, the mice treated with FTY720 showed a less-inflammatory immune profile compared to the ones not treated with FTY720. We hypothesize that FTY720 synergizes the host's innate immune functions by inducing the production of reactive oxygen species. Further studies are warranted to unveil the mechanistic explanations of our observations and clarify further aspects of repurposing FTY720 for clinical antifungal usage.

Current status and new developments in sphingosine-1-phosphate receptor antagonism: fingolimod and more

INTRODUCTION

Fingolimod was the first oral disease-modifying treatment approved for relapsing-remitting multiple sclerosis (MS) that serves as a sphingosine-1-phosphate receptor (S1PR) agonist. The efficacy is primarily mediated by S1PR subtype 1 activation, leading to agonist-induced down-modulation of receptor expression and further functional antagonism, blocking the egression of auto-aggressive lymphocytes from the lymph nodes in the peripheral compartment. The role of S1P signaling in the regulation of other pathways in human organisms through different S1PR subtypes has received much attention due to its immune-modulatory function and its significance for the regeneration of the central nervous system (CNS). The more selective second-generation S1PR modulators have improved safety and tolerability profiles.

AREAS COVERED

This review has been carried out based on current data on S1PR modulators, emphasizing the benefits of recent advances in this emergent class of immunomodulatory treatment for MS.

EXPERT OPINION

Ongoing clinical research suggests that S1PR modulators represent an alternative to first-line therapies in selected cases of MS. A better understanding of the relevance of selective S1PR pathways and the ambition to optimize selective modulation has improved the safety and tolerability of S1PR modulators in MS therapy and opened new perspectives for the treatment of other diseases.