Efficacy and Safety Results from Comparison of Alemtuzumab and Rebif(R) Efficacy in Multiple Sclerosis II (CARE-MS II): A Phase 3 Study in Relapsing-Remitting Multiple Sclerosis Patients Who Relapsed on Prior Therapy (S01.004)

Alemtuzumab Associated Listeria Monocytogenes Meningitis

Purpose Describe a case of Listeria monocytogenes meningitis following initiation of alemtuzumab therapy in a patient diagnosed with relapsing–remitting multiple sclerosis (RRMS). Summary A 44-year-old female presented with headache and fever seven days after completion of an initial course of alemtuzumab for the treatment of RRMS. Blood cultures were positive for gram-positive bacilli. A lumbar puncture revealed cell counts, consistent with bacterial meningitis and magnetic resonance imaging (MRI) revealed abnormal signal enhancement of the left cingulate gyrus. Vancomycin, ceftriaxone, and ampicillin were initiated empirically. Both blood and cerebrospinal fluid cultures resulted positive for Listeria monocytogenes. Antibiotics were narrowed to ampicillin for a treatment duration of 21 days, after which symptoms resolved and she was transitioned home. Alemtuzumab is a CD52-directed cytolytic monoclonal antibody that has previously been implicated in association with cases of Listeria monocytogenes meningitis in other countries. Based on its mechanism of action, previous association, and positive temporal relationship, we hypothesize that alemtuzumab played a substantial role in the development of L. monocytogenes meningitis in this patient. Conclusion To our knowledge, this is the first reported case of alemtuzumab associated Listeria meningitis in the United States. This case highlights the severe lymphopenia associated with alemtuzumab therapy and risk of subsequent opportunistic infection. Heightened vigilance in counseling and monitoring of dietary restrictions is critical both prior to and during alemtuzumab therapy. A greater role of prophylactic antibiotics may also be warranted.

Benefits versus risks of latest therapies in multiple sclerosis: a perspective review

Disease-modifying treatments for multiple sclerosis (MS) have now been available for almost 20 years. Interferon β (IFN-β) products and glatiramer acetate (GA) were the first available options and are now considered first-line agents for the treatment of MS. These medications have several years of favorable safety data, but are not effective in completely controlling disease activity in all patients. Alternate medications with increased efficacy have been developed and identified; however, these newer medications have known or potential safety concerns which have prompted clinicians to view them as second-line agents. Highly efficacious and safe medications are continuously being searched for and developed; however, time is needed to establish the long-term safety of any new therapeutic agent. MS practitioners are faced with the clinical dilemma of treating patients with very safe modestly effective medications or using more efficacious and potentially riskier agents. The risk-benefit profile of every medication will have to be weighed carefully and clinicians will need to gage the risk tolerance of each patient in order to tailor treatment. This review will summarize benefits and risks of recently approved therapies in MS and will provide a perspective view on the placement of these medications within the MS treatment algorithm in the near future.