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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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Kim J, Kim C, Lee JA, Lee SJ, Lee KH, Kim JH, Ahn JY, Jeong SJ, Ku NS, Choi JY, Yeom JS, Song YG. Long-term prognosis and overall mortality in patients with progressive multifocal leukoencephalopathy. Sci Rep 2023; 13:14291. [PMID: 37652945 PMCID: PMC10471597 DOI: 10.1038/s41598-023-41147-9] [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: 02/12/2023] [Accepted: 08/22/2023] [Indexed: 09/02/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare but fatal opportunistic infection and mainly occurs in patients with immunosuppressive conditions. Despite the increasing number of patients receiving immunosuppressive treatments, studies on PML are still lacking due to its low prevalence and incidence. We retrospectively reviewed patients diagnosed with PML in two tertiary hospitals in South Korea from 1999 to 2021. Total of 47 PML patients were included. Of 27 patients (57.4%) were diagnosed with human immunodeficiency virus (HIV). Median last follow-up modified Rankin Scale (mRS) score was higher in the non-HIV PML group than that in the HIV group (5 vs. 4, p = 0.020). Median survival duration was lower in the non-HIV group (184 vs. 1,564 days). The 1-year and overall mortality rates of PML patients were significantly higher in the non-HIV group than that in HIV group (60.0% vs. 25.9%, p = 0.019; 80.0% vs. 40.7%, p = 0.007). Initial mRS score (HR 1.685, p = 0.038) and highly active antiretroviral therapy (HAART) in HIV patients (HR 0.374, p = 0.013) had a significant effect on overall mortality. Our findings suggest that early detection of PML with low mRS score and early initiation of HAART in patients with HIV may improve prognosis.
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Affiliation(s)
- Jinnam Kim
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Changhyup Kim
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ah Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Se Ju Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Hyun Lee
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea.
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Jin Young Ahn
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
- AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
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3
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McEntire CRS, Fletcher A, Toledano M, Epstein S, White E, Tan CS, Mao-Draayer Y, Banks SA, Aksamit AJ, Gelfand JM, Thakur KT, Anand P, Cortese I, Bhattacharyya S. Characteristics of Progressive Multifocal Leukoencephalopathy Associated With Sarcoidosis Without Therapeutic Immune Suppression. JAMA Neurol 2023; 80:624-633. [PMID: 37093609 PMCID: PMC10126944 DOI: 10.1001/jamaneurol.2023.0841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/17/2023] [Indexed: 04/25/2023]
Abstract
Importance Progressive multifocal leukoencephalopathy can occur in the context of systemic sarcoidosis (S-PML) in the absence of therapeutic immune suppression and can initially be mistaken for neurosarcoidosis or other complications of sarcoidosis. Earlier recognition of S-PML could lead to more effective treatment of the disease. Objective To describe characteristics of patients with S-PML. Design, Setting, and Participants For this case series, records from 8 academic medical centers in the United States were reviewed from 2004 to 2022. A systematic review of literature from 1955 to 2022 yielded data for additional patients. Included were patients with S-PML who were not receiving therapeutic immune suppression. The median follow-up time for patients who survived the acute range of illness was 19 months (range, 2-99). Data were analyzed in February 2023. Exposures Sarcoidosis without active therapeutic immune suppression. Main Outcomes and Measures Clinical, laboratory, and radiographic features of patients with S-PML. Results Twenty-one patients with S-PML not receiving therapeutic immune suppression were included in this study, and data for 37 patients were collected from literature review. The median age of the 21 study patients was 56 years (range, 33-72), 4 patients (19%) were female, and 17 (81%) were male. The median age of the literature review patients was 49 years (range, 21-74); 12 of 34 patients (33%) with reported sex were female, and 22 (67%) were male. Nine of 21 study patients (43%) and 18 of 31 literature review patients (58%) had simultaneous presentation of systemic sarcoidosis and PML. Six of 14 study patients (43%) and 11 of 19 literature review patients (58%) had a CD4+ T-cell count greater than 200/μL. In 2 study patients, a systemic flare of sarcoidosis closely preceded S-PML development. Ten of 17 study patients (59%) and 21 of 35 literature review patients (60%) died during the acute phase of illness. No meaningful predictive differences were found between patients who survived S-PML and those who did not. Conclusions and Relevance In this case series, patients with sarcoidosis developed PML in the absence of therapeutic immune suppression, and peripheral blood proxies of immune function were often only mildly abnormal. Systemic sarcoidosis flares may rarely herald the onset of S-PML. Clinicians should consider PML in any patient with sarcoidosis and new white matter lesions on brain magnetic resonance imaging.
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Affiliation(s)
| | - Anita Fletcher
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Michel Toledano
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Samantha Epstein
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Emily White
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - C. Sabrina Tan
- Division of Infectious Diseases, Center for Virology and Vaccines Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, University of Iowa, Iowa City
| | | | - Samantha A. Banks
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Allen J. Aksamit
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Kiran T. Thakur
- Department of Neurology, Columbia University Irving Medical Center–New York Presbyterian Hospital, New York
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Irene Cortese
- Experimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Hatchwell E, Smith EB, Jalilzadeh S, Bruno CD, Taoufik Y, Hendel-Chavez H, Liblau R, Brassat D, Martin-Blondel G, Wiendl H, Schwab N, Cortese I, Monaco MC, Imberti L, Capra R, Oksenberg JR, Gasnault J, Stankoff B, Richmond TA, Rancour DM, Koralnik IJ, Hanson BA, Major EO, Chow CR, Eis PS. Progressive multifocal leukoencephalopathy genetic risk variants for pharmacovigilance of immunosuppressant therapies. Front Neurol 2022; 13:1016377. [PMID: 36588876 PMCID: PMC9795231 DOI: 10.3389/fneur.2022.1016377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is a rare and often lethal brain disorder caused by the common, typically benign polyomavirus 2, also known as JC virus (JCV). In a small percentage of immunosuppressed individuals, JCV is reactivated and infects the brain, causing devastating neurological defects. A wide range of immunosuppressed groups can develop PML, such as patients with: HIV/AIDS, hematological malignancies (e.g., leukemias, lymphomas, and multiple myeloma), autoimmune disorders (e.g., psoriasis, rheumatoid arthritis, and systemic lupus erythematosus), and organ transplants. In some patients, iatrogenic (i.e., drug-induced) PML occurs as a serious adverse event from exposure to immunosuppressant therapies used to treat their disease (e.g., hematological malignancies and multiple sclerosis). While JCV infection and immunosuppression are necessary, they are not sufficient to cause PML. Methods We hypothesized that patients may also have a genetic susceptibility from the presence of rare deleterious genetic variants in immune-relevant genes (e.g., those that cause inborn errors of immunity). In our prior genetic study of 184 PML cases, we discovered 19 candidate PML risk variants. In the current study of another 152 cases, we validated 4 of 19 variants in both population controls (gnomAD 3.1) and matched controls (JCV+ multiple sclerosis patients on a PML-linked drug ≥ 2 years). Results The four variants, found in immune system genes with strong biological links, are: C8B, 1-57409459-C-A, rs139498867; LY9 (alias SLAMF3), 1-160769595-AG-A, rs763811636; FCN2, 9-137779251-G-A, rs76267164; STXBP2, 19-7712287-G-C, rs35490401. Carriers of any one of these variants are shown to be at high risk of PML when drug-exposed PML cases are compared to drug-exposed matched controls: P value = 3.50E-06, OR = 8.7 [3.7-20.6]. Measures of clinical validity and utility compare favorably to other genetic risk tests, such as BRCA1 and BRCA2 screening for breast cancer risk and HLA-B*15:02 pharmacogenetic screening for pharmacovigilance of carbamazepine to prevent Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Conclusion For the first time, a PML genetic risk test can be implemented for screening patients taking or considering treatment with a PML-linked drug in order to decrease the incidence of PML and enable safer use of highly effective therapies used to treat their underlying disease.
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Affiliation(s)
- Eli Hatchwell
- Population Bio UK, Inc., Oxfordshire, United Kingdom,*Correspondence: Eli Hatchwell
| | | | | | | | - Yassine Taoufik
- Department of Hematology and Immunology, Hôpitaux Universitaires Paris-Saclay and INSERM 1186, Institut Gustave Roussy, Villejuif, France
| | - Houria Hendel-Chavez
- Department of Hematology and Immunology, Hôpitaux Universitaires Paris-Saclay and INSERM 1186, Institut Gustave Roussy, Villejuif, France
| | - Roland Liblau
- Infinity, Université Toulouse, CNRS, INSERM, UPS, Toulouse, France,Department of Immunology, CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - David Brassat
- Infinity, Université Toulouse, CNRS, INSERM, UPS, Toulouse, France,Department of Immunology, CHU Toulouse, Hôpital Purpan, Toulouse, France
| | - Guillaume Martin-Blondel
- Infinity, Université Toulouse, CNRS, INSERM, UPS, Toulouse, France,Department of Infectious and Tropical Diseases, Toulouse University Hospital Center, Toulouse, France
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Nicholas Schwab
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Irene Cortese
- Experimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Maria Chiara Monaco
- Viral Immunology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Luisa Imberti
- Centro di Ricerca Emato-Oncologica AIL (CREA) and Diagnostic Department, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Ruggero Capra
- Lombardia Multiple Sclerosis Network, Brescia, Italy
| | - Jorge R. Oksenberg
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Jacques Gasnault
- Department of Internal Medicine, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
| | - Bruno Stankoff
- Department of Neurology, Hôpital Saint-Antoine, Paris, France
| | | | | | - 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
| | | | - Peggy S. Eis
- Population Bio, Inc., New York, NY, United States,Peggy S. Eis
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Gomes ABAGR, Feo LB, Silva GD, Disserol CCD, Paolilo RB, Lara AN, Tonácio AC, Mendes MF, Pereira SLA, Callegaro D. Reducing infection risk in multiple sclerosis and neuromyelitis optica spectrum disorders: a Brazilian reference center's approach. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1057-1066. [PMID: 36261129 PMCID: PMC9770084 DOI: 10.1055/s-0042-1754348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are the most common autoimmune diseases of the central nervous system (CNS). They present chronic relapsing courses that demand treatment with disease-modifying drugs (DMDs) to prevent inflammatory activity. Disease-modifying drugs lead to immunomodulation or immunosuppression through diverse mechanisms (e.g., shifting lymphocyte and cytokine profile, suppressing specific lymphocyte subpopulations). Thus, patients are more prone to infectious complications and associated worsening of disease. OBJECTIVE To present feasible strategies for mitigating the infection risk of MS and NMOSD treated patients. METHODS Targeted literature review concerning the management of infection risk with an emphasis on vaccination, therapy-specific measures, and particularities of the Brazilian endemic infectious diseases' scenario. CONCLUSION We propose a vaccination schedule, infectious screening routine, and prophylactic measures based on the current scientific evidence. Awareness of emergent tropical diseases is necessary due to evidence of demyelinating events and possible parainfectious cases of MS and NMOSD.
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Affiliation(s)
| | - Lucas Bueno Feo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Caio César Diniz Disserol
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Renata Barbosa Paolilo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
| | - Amanda Nazareth Lara
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Doenças Infecciosas e Parasitárias, São Paulo SP, Brazil
| | - Adriana Coracini Tonácio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Doenças Infecciosas e Parasitárias, São Paulo SP, Brazil
| | - Maria Fernanda Mendes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil,Faculdade de Ciências Mídicas, Santa Casa de São Paulo, Divisão de Neurologia, São Paulo SP, Brazil,Address for correspondence Maria Fernanda Mendes
| | | | - Dagoberto Callegaro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurologia,, São Paulo SP, Brazil
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Mickeviciene D, Baltusiene A, Afanasjeva B, Afanasjevas D, Gleizniene R, Rastenyte D, Berger JR. Progressive multifocal leukoencephalopathy or immune reconstitution inflammatory syndrome after fingolimod cessation? A case report. BMC Neurol 2022; 22:306. [PMID: 35986243 PMCID: PMC9392231 DOI: 10.1186/s12883-022-02839-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 08/14/2022] [Indexed: 12/04/2022] Open
Abstract
Background Fingolimod is associated with an increased risk of developing progressive multifocal leukoencephalopathy (PML); however, its discontinuation may cause severe immune reconstitution inflammatory syndrome (IRIS). As both of these conditions (especially fingolimod induced PML) are rarely described in medical case reports distinguishing between PML-IRIS and MS-IRIS may be diagnostically challenging. Case presentation We report a patient with severe clinical decline (Expanded Disability Status Scale (EDSS) increasing from 3.5 to 7.5) and multiple, large, contrast-enhancing lesions on brain magnetic resonance imaging (MRI) a few months after fingolimod withdrawal. The diagnostic possibilities included IRIS due to fingolimod withdrawal versus PML-IRIS. The JC virus (JCV) antibody index was positive (2.56); however, cerebrospinal fluid (CSF) JCV real-time polymerase chain reaction (JCV-PCR) was negative and brain biopsy was not performed. After a long course of aggressive treatment (several pulsed methylprednisolone infusions, plasmapheresis, intravenous dexamethasone, oral mirtazapine) the patient gradually recovered (EDSS 2.5) and MRI lesions decreased. Conclusions This case report demonstrates the importance of monitoring patients carefully after the discontinuation of fingolimod for PML-IRIS and rebound MS with IRIS as these conditions may manifest similarly.
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Lambert-Jenkins K, Rossman I, Watson KL. Treatment of Inflammatory Bowel Disease and Pediatric Onset Multiple Sclerosis With Ocrelizumab and Ustekinumab in a JC-virus Positive Adolescent. JPGN REPORTS 2022; 3:e214. [PMID: 37168621 PMCID: PMC10158457 DOI: 10.1097/pg9.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/02/2022] [Indexed: 05/13/2023]
Abstract
Inflammatory bowel disease (IBD) and multiple sclerosis (MS) are known to co-occur. Many disease modifying therapies for MS may exacerbate IBD and several carry risk of progressive multifocal leukoencephalopathy in JC-virus (JCV) positive patients. Some biologics used for IBD can exacerbate MS. These factors make comanagement of these diseases difficult. We report a 17-year-old female who presented with right leg weakness and paresthesia and was diagnosed with pediatric onset MS (POMS). She then had worsening abdominal pain and diarrhea, accompanied by weight loss, and was subsequently diagnosed with Crohn's disease. She was weakly JCV positive, so a short trial of natalizumab was initiated, which controlled her POMS well but not her IBD. Ustekinumab and ocrelizumab were initiated and achieved remission of both diseases. In the absence of established treatment guidelines, we recommend considering this combination of therapies for cases where standard treatment modalities are not viable options.
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Affiliation(s)
| | - Ian Rossman
- Neurology, Akron Children's Hospital, Akron, OH
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8
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Mao-Draayer Y, Cohen JA, Bar-Or A, Han MH, Singer B, Williams IM, Meng X, Elam C, Weiss JL, Cox GM, Ziehn M, Cree BAC. Immune cell subset profiling in multiple sclerosis after fingolimod initiation and continued treatment: The FLUENT study. Mult Scler J Exp Transl Clin 2022; 8:20552173221115023. [PMID: 35936922 PMCID: PMC9346260 DOI: 10.1177/20552173221115023] [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: 01/26/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022] Open
Abstract
Background Fingolimod is a sphingosine 1-phosphate receptor modulator approved for
relapsing MS. Long-term effects on the immunological profile are not fully
understood. Objective Investigate fingolimod's temporal effects on immune cell subsets, and safety
outcomes. Methods In FLUENT, a 12-month, prospective, non-randomized, open-label, phase IV
study, adult participants received fingolimod 0.5 mg/day. Changes in immune
cell subsets, anti-John Cunningham virus (JCV) antibody index, and serum
neurofilament levels were assessed. Results 165 fingolimod-naive and 217 participants treated for 2–12 years in routine
clinical practice were enrolled. Levels of all monitored peripheral
lymphocyte subsets were reduced from month 3 in fingolimod-naive
participants. Greatest reductions occurred in naive and central memory
CD4+ and CD8+ T cells, and in naive and memory B cells. Most lymphocyte
subset levels remained stable in the continuous fingolimod group. Components
of the innate immune system remained within reference ranges. No increase in
JCV seropositivity was observed. No single cellular subset correlated with
anti-JCV antibody index at any time point. Neurofilament levels remained
within healthy adult reference limits throughout. No opportunistic
infections were reported; no new or unexpected safety signals were
observed. Conclusion FLUENT provides insights into the utility of immunological profiling to
evaluate therapy response and potential infection risk.
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Affiliation(s)
- Yang Mao-Draayer
- Autoimmunity Center of Excellence, Multiple Sclerosis Center, University of Michigan, Ann Arbor, MI, USA
| | | | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, and the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - May H Han
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Barry Singer
- Missouri Baptist Medical Center, St Louis, MO, USA
| | | | | | | | | | | | - Marina Ziehn
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Bruce AC Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Giovannoni G, Mathews J. Cladribine Tablets for Relapsing-Remitting Multiple Sclerosis: A Clinician's Review. Neurol Ther 2022; 11:571-595. [PMID: 35318617 PMCID: PMC8940595 DOI: 10.1007/s40120-022-00339-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/25/2022] [Indexed: 01/22/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic neurodegenerative disease characterized by inflammation and demyelination for which there is currently no cure; therefore, the aim of therapy is to reduce the risk of relapse and disability progression. The treatment options for MS have increased greatly in recent years with the development of several disease-modifying therapies (DMTs) and the advent of immune reconstitution therapy (IRT). IRTs are administered in short-dosing periods to produce long-term effects on the immune system. Treatment with an IRT is based on the 3Rs: reduction, repopulation, and reconstitution of lymphocytes, which leads to restoration of immune effector functions. Cladribine tablets represent a selective, high-efficacy, oral form of IRT for patients with MS that targets lymphocytes and spares innate immune cells. Patients require only two weekly treatment courses, with each course comprising two treatment weeks, in Years 1 and 2; therefore, cladribine tablets are associated with a lower monitoring burden than many other DMTs, while short dosing periods can help to improve adherence. This review provides an overview of IRT and offers the clinician's perspective on the current MS treatment landscape, with a focus on practical advice for the management of patients undergoing treatment with cladribine tablets based on the most recent evidence available, including risks associated with COVID-19 and recommendations for vaccination in patients with MS.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark St, Whitechapel, London, E1 2AT, UK.
| | - Joela Mathews
- Royal London Hospital, Barts Health NHS Trust, London, UK
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Infection Mitigation Strategies for Multiple Sclerosis Patients on Oral and Monoclonal Disease-Modifying Therapies. Curr Neurol Neurosci Rep 2021; 21:36. [PMID: 34009478 PMCID: PMC8132488 DOI: 10.1007/s11910-021-01117-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The newer, higher-efficacy disease-modifying therapies (DMTs) for multiple sclerosis (MS)-orals and monoclonals-have more profound immunomodulatory and immunosuppressive properties than the older, injectable therapies and require risk mitigation strategies to reduce the risk of serious infections. This review will provide a systematic framework for infectious risk mitigation strategies relevant to these therapies. RECENT FINDINGS We classify risk mitigation strategies according to the following framework: (1) screening and patient selection, (2) vaccinations, (3) antibiotic prophylaxis, (4) laboratory and MRI monitoring, (5) adjusting dose and frequency of DMT, and (6) behavioral modifications to limit the risk of infection. We systematically apply this framework to the infections for which risk mitigations are available: hepatitis B, herpetic infections, progressive multifocal leukoencephalopathy, and tuberculosis. We also discuss up-to-date recommendations regarding COVID-19 vaccinations for patients on DMTs. We offer a practical, comprehensive, DMT-specific framework of derisking strategies designed to minimize the risk of infections associated with the newer MS therapies.
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11
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Kataria H, Hart CG, Alizadeh A, Cossoy M, Kaushik DK, Bernstein CN, Marrie RA, Yong VW, Karimi-Abdolrezaee S. Neuregulin-1 beta 1 is implicated in pathogenesis of multiple sclerosis. Brain 2021; 144:162-185. [PMID: 33313801 PMCID: PMC7880664 DOI: 10.1093/brain/awaa385] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/10/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis is characterized by immune mediated neurodegeneration that results in progressive, life-long neurological and cognitive impairments. Yet, the endogenous mechanisms underlying multiple sclerosis pathophysiology are not fully understood. Here, we provide compelling evidence that associates dysregulation of neuregulin-1 beta 1 (Nrg-1β1) with multiple sclerosis pathogenesis and progression. In the experimental autoimmune encephalomyelitis model of multiple sclerosis, we demonstrate that Nrg-1β1 levels are abated within spinal cord lesions and peripherally in the plasma and spleen during presymptomatic, onset and progressive course of the disease. We demonstrate that plasma levels of Nrg-1β1 are also significantly reduced in individuals with early multiple sclerosis and is positively associated with progression to relapsing-remitting multiple sclerosis. The functional impact of Nrg-1β1 downregulation preceded disease onset and progression, and its systemic restoration was sufficient to delay experimental autoimmune encephalomyelitis symptoms and alleviate disease burden. Intriguingly, Nrg-1β1 therapy exhibited a desirable and extended therapeutic time window of efficacy when administered prophylactically, symptomatically, acutely or chronically. Using in vivo and in vitro assessments, we identified that Nrg-1β1 treatment mediates its beneficial effects in EAE by providing a more balanced immune response. Mechanistically, Nrg-1β1 moderated monocyte infiltration at the blood-CNS interface by attenuating chondroitin sulphate proteoglycans and MMP9. Moreover, Nrg-1β1 fostered a regulatory and reparative phenotype in macrophages, T helper type 1 (Th1) cells and microglia in the spinal cord lesions of EAE mice. Taken together, our new findings in multiple sclerosis and experimental autoimmune encephalomyelitis have uncovered a novel regulatory role for Nrg-1β1 early in the disease course and suggest its potential as a specific therapeutic target to ameliorate disease progression and severity.
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Affiliation(s)
- Hardeep Kataria
- Department of Physiology and Pathophysiology, Regenerative Medicine Program, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Christopher G Hart
- Department of Physiology and Pathophysiology, Regenerative Medicine Program, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Department of Physiology and Pathophysiology, Regenerative Medicine Program, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Cossoy
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deepak K Kaushik
- Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - V Wee Yong
- Hotchkiss Brain Institute and the Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Soheila Karimi-Abdolrezaee
- Department of Physiology and Pathophysiology, Regenerative Medicine Program, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Children Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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12
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Prevention and management of adverse effects of disease modifying treatments in multiple sclerosis. Curr Opin Neurol 2021; 33:286-294. [PMID: 32374570 DOI: 10.1097/wco.0000000000000824] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To summarize the currently known side effects of the approved therapies of multiple sclerosis and to suggest monitoring procedures. RECENT FINDINGS The progress in the treatment of multiple sclerosis with new very effective therapies is accompanied by a number of side effects. Some of these have already been described in the approval studies, but some only after approval in a real world situation. The reason for this is the short duration of the clinical studies, the very heterogeneous patient profile in the real world setting with a number of comorbidities, pretherapies, and wider age range. The side effects may occur during application of therapies or afterwards during the course of the treatment. The side effects may range from mild infections, mild laboratory abnormalities, secondary autoimmune diseases to life-threatening side effects such as progressive multifocal leukoencephalopathy. SUMMARY It has to be pointed out that these side effects are not to be considered as final and neurologists should be vigilant against new unknown side effects. The doctor should be aware of these undesirable effects, should weigh the benefits of the therapies against the risks, but at the same time she/he should keep in mind that multiple sclerosis can be a very disabling disease if not treated properly.
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13
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Guzman BB, Schauer AP, Dunn JA, Cottrell ML, Sykes C. A quantitative LC-MS/MS method for the determination of tissue brincidofovir and cidofovir diphosphate in a MuPyV-infected mouse model. Biomed Chromatogr 2021; 35:e5061. [PMID: 33398885 DOI: 10.1002/bmc.5061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 11/06/2022]
Abstract
Brincidofovir (BCV) is an investigational lipid conjugate of the nucleotide analog cidofovir (CDV), which is being developed as a medical countermeasure for the treatment of smallpox. BCV is active against double-stranded DNA viruses including BK and JC viruses. Here, we validated procedures for quantifying BCV and its pharmacologically active moiety cidofovir diphosphate (CDV-PP) in mouse kidney, brain and spleen tissue homogenates. Following homogenization, BCV and CDV-PP were extracted from the tissues by protein precipitation with their stable, isotopically labeled internal standards, BCV-d6 and 13 C3 15 N2 -CDV-PP. Then, samples were analyzed for BCV by reverse-phase chromatography on a Waters Xterra MS C18 (50 × 2.1 mm, 3.5 μm particle size) column while CDV-PP was analyzed on a Thermo BioBasic AX (50 × 2.1 mm, 5 μm particle size) column using anion exchange chromatography. Detection was achieved by electrospray ionization in positive ion mode on an AB Sciex API-5000 triple quadrupole mass spectrometer. The calibration curves were linear over a range of 1.00-1,000 ng/ml homogenate and 0.050-50.0 ng/ml homogenate for BCV and CDV-PP, respectively. These methods were validated according to US Food and Drug Administration guidance for industry and may be used to characterize the tissue pharmacology of both analytes to advance its preclinical development.
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Affiliation(s)
- Bryan B Guzman
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda P Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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14
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Toboso I, Tejeda-Velarde A, Alvarez-Lafuente R, Arroyo R, Hegen H, Deisenhammer F, Sainz de la Maza S, Alvarez-Cermeño JC, Izquierdo G, Paramo D, Oliva P, Casanova B, Agüera-Morales E, Franciotta D, Gastaldi M, Fernández O, Urbaneja P, Garcia-Dominguez JM, Romero F, Laroni A, Uccelli A, Perez-Sempere A, Saiz A, Blanco Y, Galimberti D, Scarpini E, Espejo C, Montalban X, Rasche L, Paul F, González I, Álvarez E, Ramo C, Caminero AB, Aladro Y, Calles C, Eguía P, Belenguer-Benavides A, Ramió-Torrentà L, Quintana E, Martínez-Rodríguez JE, Oterino A, López de Silanes C, Casanova LI, Landete L, Frederiksen J, Bsteh G, Mulero P, Comabella M, Hernández MA, Espiño M, Prieto JM, Pérez D, Otano M, Padilla F, García-Merino JA, Navarro L, Muriel A, Frossard LC, Villar LM. New Algorithms Improving PML Risk Stratification in MS Patients Treated With Natalizumab. Front Neurol 2020; 11:579438. [PMID: 33408681 PMCID: PMC7780851 DOI: 10.3389/fneur.2020.579438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/15/2020] [Indexed: 12/22/2022] Open
Abstract
Overview: We assessed the role of age and disease activity as new factors contributing to establish the risk of progressive multifocal leucoencephalopathy in multiple sclerosis patients treated with natalizumab in 36 University Hospitals in Europe. We performed the study in 1,307 multiple sclerosis patients (70.8% anti-John Cunninghan virus positive antibodies) treated with natalizumab for a median time of 3.28 years. Epidemiological, clinical, and laboratory variables were collected. Lipid-specific IgM oligoclonal band status was available in 277 patients. Factors associated with progressive multifocal leucoencephalopathy onset were explored by uni- and multivariate logistic regression. Results: Thirty-five patients developed progressive multifocal leucoencephalopathy. The multivariate analysis identified anti-John Cunninghan virus antibody indices and relapse rate as the best predictors for the onset of this serious opportunistic infection in the whole cohort. They allowed to stratify progressive multifocal leucoencephalopathy risk before natalizumab initiation in individual patients [area under the curve (AUC) = 0.85]. The risk ranged from <1/3,300 in patients with anti-John Cunninghan virus antibody indices <0.9 and relapse rate >0.5, to 1/50 in the opposite case. In patients with lipid-specific IgM oligoclonal bands assessment, age at natalizumab onset, anti-John Cunninghan virus antibody indices, and lipid-specific IgM oligoclonal band status predicted progressive multifocal leucoencephalopathy risk (AUC = 0.92). The absence of lipid-specific IgM oligoclonal bands was the best individual predictor (OR = 40.94). The individual risk ranged from <1/10,000 in patients younger than 45 years at natalizumab initiation, who showed anti John Cunningham virus antibody indices <0.9 and lipid-specific IgM oligoclonal bands to 1/33 in the opposite case. Conclusions: In a perspective of personalized medicine, disease activity, anti-lipid specific IgM oligoclonal bands, anti Jonh Cunninghan virus antibody levels, and age can help tailor natalizumab therapy in multiple sclerosis patients, as predictors of progressive multifocal leucoencephalopathy.
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Affiliation(s)
- Inmaculada Toboso
- Immunology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | | | - Roberto Alvarez-Lafuente
- Instituto de Investigación Sanitaria San Carlos (IDISSC), Hospital Clinico San Carlos, Madrid, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Universitario Quiron Salud, Madrid, Spain
| | - Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | | | | | | | - Guillermo Izquierdo
- Neurology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Dolores Paramo
- Neurology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Pedro Oliva
- Neurology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Diego Franciotta
- Istituti di Recovero e Cura a Carattere Scientifico (IRCCS) Mondino Foundation, Pavia, Italy
| | - Matteo Gastaldi
- Istituti di Recovero e Cura a Carattere Scientifico (IRCCS) Mondino Foundation, Pavia, Italy
| | - Oscar Fernández
- Neurology Department, Hospital Regional Universitario, Malaga, Spain
| | - Patricia Urbaneja
- Neurology Department, Hospital Regional Universitario, Malaga, Spain
| | | | - Fernando Romero
- Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alicia Laroni
- University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Uccelli
- University of Genoa, Ospedale Policlinico San Martino, Genoa, Italy
| | - Angel Perez-Sempere
- Neurology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Albert Saiz
- Neurology Service, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Yolanda Blanco
- Neurology Service, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Daniela Galimberti
- Centro Dino Ferrari, Fondazione Ca' Granda, Istituti di Recovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico, University of Milan, Milan, Italy
| | - Elio Scarpini
- Centro Dino Ferrari, Fondazione Ca' Granda, Istituti di Recovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico, University of Milan, Milan, Italy
| | - Carmen Espejo
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ludwig Rasche
- Department of Neurology, NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Friedemann Paul
- Department of Neurology, NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Inés González
- Neurology Department, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Elena Álvarez
- Neurology Department, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Cristina Ramo
- Neurology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ana B Caminero
- Neurology Department, Hospital Nuestra Señora de Sonsoles, Avila, Spain
| | - Yolanda Aladro
- Neurology Department, Hospital Universitario Getafe, Getafe, Spain
| | - Carmen Calles
- Neurology Department, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Pablo Eguía
- Neurology Department, Hospital Doctor Jose Molina Orosa, Arrecife, Spain
| | | | | | - Ester Quintana
- Neurology Department, Hospital Universitario Doctor Josep Trueta, Girona, Spain
| | | | - Agustín Oterino
- Neurology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Luis I Casanova
- Neurology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Lamberto Landete
- Neurology Department, Hospital Universitario Dr. Peset, Valencia, Spain
| | | | - Gabriel Bsteh
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Patricia Mulero
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Comabella
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel A Hernández
- Neurology Department, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Mercedes Espiño
- Immunology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - José M Prieto
- Neurology Department, Hospital Clínico de Santiago, Santiago de Compostela, Spain
| | - Domingo Pérez
- Neurology Department, Hospital del Bierzo, Ponferrada, Spain
| | - María Otano
- Neurology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | | | - Laura Navarro
- Neurology Department, Hospital General de Elche, Elche, Spain
| | - Alfonso Muriel
- Biostatistics Unit, Hospital Univesitario Ramon y Cajal, Instituto Ramon y Cajal para la Investigación Sanitaria (IRYCIS), Madrid, Spain
| | | | - Luisa M Villar
- Immunology Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
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15
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The Role of Extracellular Vesicles in Demyelination of the Central Nervous System. Int J Mol Sci 2020; 21:ijms21239111. [PMID: 33266211 PMCID: PMC7729475 DOI: 10.3390/ijms21239111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 12/21/2022] Open
Abstract
It is being increasingly demonstrated that extracellular vesicles (EVs) are deeply involved in the physiology of the central nervous system (CNS). Processes such as synaptic activity, neuron-glia communication, myelination and immune response are modulated by EVs. Likewise, these vesicles may participate in many pathological processes, both as triggers of disease or, on the contrary, as mechanisms of repair. EVs play relevant roles in neurodegenerative disorders such as Alzheimer’s or Parkinson’s diseases, in viral infections of the CNS and in demyelinating pathologies such as multiple sclerosis (MS). This review describes the involvement of these membrane vesicles in major demyelinating diseases, including MS, neuromyelitis optica, progressive multifocal leukoencephalopathy and demyelination associated to herpesviruses.
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16
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Liang G, Chai J, Ng HS, Tremlett H. Safety of dimethyl fumarate for multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2020; 46:102566. [PMID: 33296968 DOI: 10.1016/j.msard.2020.102566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The safety profile of dimethyl fumarate (DMF) for multiple sclerosis (MS) is not fully understood. OBJECTIVE To systematically review the literature for adverse events (AE) associated with DMF for MS. METHODS We searched MEDLINE, EMBASE, CINAHL, Web of Science, CENTRAL, and clinicaltrials.gov for articles published from database inception to May/2019. Studies (observational and randomized controlled trials (RCTs)) reporting AEs, serious AEs (SAE), or discontinuation due to AEs were included. We summarized the proportion of DMF-exposed patients affected and calculated the risk ratios (RR) and number needed to treat for an additional harmful outcome (NNTH) and 95% confidence intervals (CI) for the DMF relative to placebo-exposed participants. RCT findings were pooled via meta-analyses. RESULTS Twenty-one observational studies, 4 RCTs, 1 RCT extension study, and 2 open-label studies were included, totalling 12,380 MS patients on DMF followed for an average of 19.8 months. Compared to placebo, DMF-exposed patients had a higher risk of grade III/IV lymphopenia (NNTH = 28.8;95%CI:20.2-50.5), pruritus (NNTH = 22.1;95%CI:14.0-52.3), flushing (NNTH = 3.7;95%CI:3.3-4.1), gastrointestinal related events (NNTH = 5.7;95%CI:3.5-15.7), nausea (NNTH = 23.4;95%CI:14.9-54.7), diarrhea (NNTH = 21.2;95%CI:13.6-47.6), and abdominal pain (NNTH = 19.2;95%CI:12.9-37.9). Patients discontinued DMF because of GI symptoms (498/5619;8.9%), lymphopenia (163/4003;4.1%), and flushing (173/4779;3.6%). From pooled analyses of 4 RCTs, AE risks were higher in the DMF versus placebo groups (RR = 1.37;95%CI:1.27-1.48), but SAEs were similar (RR = 1.01;95%CI:0.77-1.33). CONCLUSION Over the short-term, DMF was associated with a higher risk of AEs. The NNTH included 4 for flushing, 6 for gastrointestinal complaints, and 29 for severe or life-threatening (grade III/IV) lymphopenia. The longer-term safety of DMF, including consequences of lymphopenia remain unknown.
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Affiliation(s)
- Geoffrey Liang
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Julia Chai
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada; Faculty of Science, University of British Columbia, Vancouver, BC, Canada.
| | - Huah Shin Ng
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Helen Tremlett
- Faculty of Medicine (Neurology), University of British Columbia and The Djavad Mowafaghian Centre for Brain Health, 2215 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
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17
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Karimi Dehcheshmeh L, Makvandi M, Timori A. Prevalence of Human Polyomavirus JC and BK in Normal Population. Asian Pac J Cancer Prev 2020; 21:2877-2882. [PMID: 33112543 PMCID: PMC7798155 DOI: 10.31557/apjcp.2020.21.10.2877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Indexed: 11/25/2022] Open
Abstract
JC virus (JCV) , and BK virus (BKV) can remain latency in kidney and excrete via urine asymptomatically. JCV has been associated with colorectal and bladder cancers. BKV has been linked with lung, pancreas, liver, urogenital tract, head and neck cancers. Therefore, the frequency of JCV DNA and BKV DNA are essential to evaluate in urine samples of healthy individuals. MATERIALS AND METHODS Hundred sixty four urine samples were collected from healthy subjects [96 females and 68 males]. DNA was extracted and detection of JCV DNA and BKV DNA was carried out by PCR . The analysis of sequencing and construction of phylogenetic tree were performed for the samples positive for JCV DNA and BKV DNA. RESULTS Ten (6.09%) urine samples [5/96(5.2%) females and 5/68( 8.82) males] were tested positive for JCV DNA (P= 0.814). The results of sequencing and phylogenetic tree showed the isolated JCV DNA were cluster with 3A genotype. 21/164 (12.8%) samples were tested positive for BKV DNA [11/96(11.45%) females and males 10/68(14.7%)] ( P= 0.63). The results of sequencing and phylogenetic tree showed that the isolated BKV was cluster with genotype III. CONCLUSION In the present study 6.09% and 12.8% of the healthy individuals showed positive for JCV DNA (genotype 3A) and BKV DNA(genotype III) respectively. With regard to life threating diseases by BKV and JCV in immunocomprsied patients , the screening BKV DNA and JCV DNA should be implemented for patients with cancer /autoimmune diseases /organ recipient/ multiple sclerosis (MS), prior to immunosuppression therapy or immunomodulatory agents treatment.<br />.
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Affiliation(s)
- Lila Karimi Dehcheshmeh
- Infectious and Tropical Diseases Research Center, Health Research Institute, 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.,Virology Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Timori
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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18
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Michel L, Grasmuck C, Charabati M, Lécuyer MA, Zandee S, Dhaeze T, Alvarez JI, Li R, Larouche S, Bourbonnière L, Moumdjian R, Bouthillier A, Lahav B, Duquette P, Bar-Or A, Gommerman JL, Peelen E, Prat A. Activated leukocyte cell adhesion molecule regulates B lymphocyte migration across central nervous system barriers. Sci Transl Med 2020; 11:11/518/eaaw0475. [PMID: 31723036 DOI: 10.1126/scitranslmed.aaw0475] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 07/10/2019] [Accepted: 10/21/2019] [Indexed: 12/19/2022]
Abstract
The presence of B lymphocyte-associated oligoclonal immunoglobulins in the cerebrospinal fluid is a classic hallmark of multiple sclerosis (MS). The clinical efficacy of anti-CD20 therapies supports a major role for B lymphocytes in MS development. Although activated oligoclonal populations of pathogenic B lymphocytes are able to traffic between the peripheral circulation and the central nervous system (CNS) in patients with MS, molecular players involved in this migration have not yet been elucidated. In this study, we demonstrated that activated leukocyte cell adhesion molecule (ALCAM/CD166) identifies subsets of proinflammatory B lymphocytes and drives their transmigration across different CNS barriers in mouse and human. We also showcased that blocking ALCAM alleviated disease severity in animals affected by a B cell-dependent form of experimental autoimmune encephalomyelitis. Last, we determined that the proportion of ALCAM+ B lymphocytes was increased in the peripheral blood and within brain lesions of patients with MS. Our findings indicate that restricting access to the CNS by targeting ALCAM on pathogenic B lymphocytes might represent a promising strategy for the development of next-generation B lymphocyte-targeting therapies for the treatment of MS.
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Affiliation(s)
- Laure Michel
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Camille Grasmuck
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Marc Charabati
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Marc-André Lécuyer
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Stephanie Zandee
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Tessa Dhaeze
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Jorge I Alvarez
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Rui Li
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sandra Larouche
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Lyne Bourbonnière
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | | | | | - Boaz Lahav
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Pierre Duquette
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Evelyn Peelen
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada.,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
| | - Alexandre Prat
- Department of Neuroscience, Faculty of Medicine, Université de Montréal, Montréal, QC Canada. .,Neuroimmunology Unit, Centre de recherche du CHUM (CRCHUM), Montréal, QC H2X 0A9, Canada
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19
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Jordan AL, Yang J, Fisher CJ, Racke MK, Mao-Draayer Y. Progressive multifocal leukoencephalopathy in dimethyl fumarate-treated multiple sclerosis patients. Mult Scler 2020; 28:7-15. [PMID: 32808554 DOI: 10.1177/1352458520949158] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Dimethyl fumarate (DMF), a fumaric acid with antioxidant and immunomodulatory properties, is among the most commonly used oral therapies for relapsing multiple sclerosis (MS). Progressive multifocal leukoencephalopathy (PML) has been associated with several disease-modifying therapies (DMTs), including DMF in treating MS. We present detailed clinical characteristics of nine PML cases and show that the PML incidence in DMF-treated patients is 0.02 per 1000 patients. In addition to persistent severe lymphopenia, older age appears to be a potential risk for PML. However, younger patients without lymphopenia were also observed to develop PML. DMF-associated PML has occurred in patients with absolute lymphocyte counts (ALCs) above the guideline threshold, suggesting that changes in specific subsets might be more important than total ALC. Furthermore, since DMF has been found to decrease immune cell migration by decreasing the expression of adhesive molecules, the cerebrospinal fluid (CSF) immune profile may also be useful for assessing PML risk in DMF-treated patients. This review provides an up-to-date assessment of PML cases occurring in DMF-treated patients and discusses other potential considerations in light of our current understanding of DMF's mechanism of action on the immune system in the periphery and in the central nervous system (CNS).
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Affiliation(s)
- Allison Lm Jordan
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jennifer Yang
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Caitlyn J Fisher
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael K Racke
- The Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA
| | - Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA/Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
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20
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Tawara T, Kai H, Kageyama M, Akiyama T, Matsunaga T, Sakuma A, Ishii R, Tsunoda R, Kawamura T, Fujita A, Kaneko S, Morito N, Saito C, Usui J, Yamagata K. A case report of progressive multifocal leukoencephalopathy during steroid treatment for ANCA-associated renal vasculitis. CEN Case Rep 2020; 9:354-358. [PMID: 32388828 DOI: 10.1007/s13730-020-00482-w] [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] [Received: 02/10/2020] [Accepted: 04/15/2020] [Indexed: 11/29/2022] Open
Abstract
CASE REPORT an 80-year-old woman presented with rapidly progressive glomerulonephritis and was admitted to our hospital. Myeloperoxidase-specific antineutrophil cytoplasmic antibody (MPO-ANCA) was positive. We diagnosed ANCA-associated renal vasculitis (ANCA-RV). Treatment was initiated with intravenous methylprednisolone pulse therapy, followed by prednisolone (PSL) at 30 mg/day. We gradually reduced the PSL dose to 7.5 mg/day over 6 months. At that time, the patient developed disturbances of consciousness which progressed subacutely. MRI revealed regions of patchy white matter with an increased signal on T2-weighted, fluid attenuated inversion recovery (FLAIR) sequences and diffusion-weighted sequences. JC virus DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR), leading to a diagnosis of progressive multifocal leukoencephalopathy (PML). PML is a rare infectious demyelinating disease of the central nervous system caused by JC virus infection, occurring in highly immunosuppressed individuals such as HIV-infected patients and patients using some biological agents, and having a very poor prognosis. In the present case, PML may have been associated with steroid use, although there are very few case reports of PML in patients taking only steroids. We report progressive multifocal leukoencephalopathy during steroid treatment of ANCA-RV. When patients show progressive disturbance of consciousness during treatment for ANCA-RV, we need to take PML into consideration for differential diagnosis.
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Affiliation(s)
- Takashi Tawara
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hirayasu Kai
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Mikiko Kageyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tomoki Akiyama
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takahiro Matsunaga
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Aki Sakuma
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryota Ishii
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Ryouya Tsunoda
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tetusya Kawamura
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akiko Fujita
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shuzo Kaneko
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Morito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Chie Saito
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Joichi Usui
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kunihiro Yamagata
- Division of Clinical Medicine, Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan.
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21
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Rempe T, Wang Q, Wu Q, Ballur Narayana Reddy V, Newcomer Z, Miravalle A, Mao-Draayer Y. Progressive multifocal leukoencephalopathy and granule cell neuronopathy with novel mutation flanking VP1 C-terminus in natalizumab-extended interval dosing. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/3/e709. [PMID: 32198230 PMCID: PMC7136058 DOI: 10.1212/nxi.0000000000000709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Torge Rempe
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor.
| | - Qin Wang
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor
| | - Qi Wu
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor
| | - Varalakshmi Ballur Narayana Reddy
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor
| | - Zachary Newcomer
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor
| | - Augusto Miravalle
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor
| | - Yang Mao-Draayer
- From the Department of Neurology (T.R., V.B.N.R., Z.N., A.M.), University of Florida, Gainesville; and Department of Neurology (Q. Wang, Q. Wu, Y.M.-D.), University of Michigan, Ann Arbor.
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22
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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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23
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Shivaji UN, Nardone OM, Cannatelli R, Smith SC, Ghosh S, Iacucci M. Small molecule oral targeted therapies in ulcerative colitis. Lancet Gastroenterol Hepatol 2020; 5:850-861. [PMID: 32171056 DOI: 10.1016/s2468-1253(19)30414-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 02/08/2023]
Abstract
The incidence and prevalence of ulcerative colitis are increasing globally. Although the exact cause and pathogenesis of this disease is unclear, research has led to a better understanding of the condition and to identification of new targets for therapy, which in turn has encouraged the development of new therapies. As well as biologic therapies, which have changed the way inflammatory bowel disease is managed, small molecules have been developed for the treatment of ulcerative colitis. These small molecule treatments are orally administered and are likely to bring a substantial shift in the way this chronic disease is treated. Oral therapies offer many advantages over infusion therapies, such as ease of use, increased acceptability by patients, and reduction of cost. This Review focuses not only on oral therapies that have been approved for use in ulcerative colitis, but also on those that are in development, providing a comprehensive overview for clinicians of available oral therapies and drugs that are likely to become available. We have also reviewed drugs that have shown promise in preclinical studies and could be effective future therapies.
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Affiliation(s)
- Uday N Shivaji
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK
| | - Olga Maria Nardone
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, Birmingham, UK
| | - Rosanna Cannatelli
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, Birmingham, UK
| | - Samuel Cl Smith
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, Birmingham, UK
| | - Subrata Ghosh
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, Birmingham, UK; Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK.
| | - Marietta Iacucci
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Institute of Translational Medicine, Birmingham, UK; Department of Gastroenterology, University Hospitals Birmingham, Birmingham, UK
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24
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Ciardi MR, Zingaropoli MA, Iannetta M, Prezioso C, Perri V, Pasculli P, Lichtner M, d'Ettorre G, Altieri M, Conte A, Pietropaolo V, Mastroianni CM, Vullo V. JCPyV NCCR analysis in PML patients with different risk factors: exploring common rearrangements as essential changes for neuropathogenesis. Virol J 2020; 17:23. [PMID: 32046748 PMCID: PMC7014659 DOI: 10.1186/s12985-020-1295-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/29/2020] [Indexed: 01/25/2023] Open
Abstract
Background During severe immunosuppression or treatment with specific biological drugs, human polyomavirus JC (JCPyV) may establish a lytic infection in oligodendrocytes, leading to progressive multifocal leukoencephalopathy (PML). Beyond AIDS, which represents the most common predisposing condition, several biological drugs have been associated to the development of PML, such as natalizumab, fingolimod and dimethyl fumarate, which have been showed to increase the risk of PML in the multiple sclerosis (MS) population. JCPyV non-coding control region (NCCR) can be found in two different forms: a virulent neurotropic pathogenic form and a latent non-pathogenic form. The neurotropic forms contain a rearranged NCCR and are typically found in the cerebrospinal fluid, brain or blood of PML patients. Case presentation We sequenced and critically examined JCPyV NCCR from isolates detected in the cerebrospinal fluid of four newly diagnosed progressive multifocal leukoencephalopathy patients: two HIV-positive and two HIV-negative multiple sclerosis patients. More complex NCCR rearrangements were observed in the two HIV-positive patients compared to the HIV-negative multiple sclerosis patients with PML. Conclusions The comparison of HIV-positive and HIV-negative MS patients with PML, allowed us to evidence the presence of a common pattern of JCPyV NCCR rearrangement, characterized by the deletion of the D-block, which could be one of the initial rearrangements of JCPyV NCCR needed for the development of PML.
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Affiliation(s)
- Maria Rosa Ciardi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Maria Antonella Zingaropoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy.
| | - Marco Iannetta
- Department of System Medicine, Tor Vergata University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - Carla Prezioso
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Valentina Perri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Patrizia Pasculli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Miriam Lichtner
- Infectious Diseases Unit, Sapienza University of Rome, Santa Maria Goretti Hospital, Via Canova, 04100, Latina, Italy
| | - Gabriella d'Ettorre
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Marta Altieri
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00161, Rome, Italy
| | - Antonella Conte
- Department of Human Neurosciences, Sapienza University of Rome, Viale dell'Università, 30, 00161, Rome, Italy
| | - Valeria Pietropaolo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Claudio Maria Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
| | - Vincenzo Vullo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, Italy
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25
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Zanghì A, D'Amico E, Patti F. Immunosuppression in relapsing remitting multiple sclerosis: moving towards personalized treatment. Expert Rev Neurother 2020; 20:771-782. [PMID: 31971026 DOI: 10.1080/14737175.2020.1721282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Therapeutic armamentarium in Multiple Sclerosis (MS) has radically changed in the last few decades due to the development of disease modifying treatments (DMTs) with highly selective mechanisms of action. AREAS COVERED In this review, the authors will focus on the current role of immunosuppressive DMTs in the management of the relapsing-remitting form of MS (RRMS), moving from the rationale of its use and looking at the possibility to design an idealistic scenario of a personalized approach for each single patient. EXPERT OPINION Questions remain open about whether initial high-efficacy immunosuppressive DMTs improve long-term outcomes, whether prolonged exposure to these agents increases adverse events and what the strongest early surrogate markers are for predicting long-term treatment responses to high-efficacy drugs. In this way, the immunosuppressive DMTs, are used to hit the immune system early and hard with the idealistic goal of striking the autoimmune activities before the neurological damage becomes irreversible.
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Affiliation(s)
- Aurora Zanghì
- Department "G.F. Ingrassia", MS Center, University of Catania , Catania, Italy
| | - Emanuele D'Amico
- Department "G.F. Ingrassia", MS Center, University of Catania , Catania, Italy
| | - Francesco Patti
- Department "G.F. Ingrassia", MS Center, University of Catania , Catania, Italy
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26
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Meira M, Sievers C, Hoffmann F, Bodmer H, Derfuss T, Kuhle J, Haghikia A, Kappos L, Lindberg RL. PARP-1 deregulation in multiple sclerosis. Mult Scler J Exp Transl Clin 2019; 5:2055217319894604. [PMID: 31897308 PMCID: PMC6918498 DOI: 10.1177/2055217319894604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/27/2019] [Accepted: 11/14/2019] [Indexed: 12/29/2022] Open
Abstract
Background Poly (ADP-ribose) polymerase 1 (PARP-1) plays pivotal roles in immune and inflammatory responses. Accumulating evidence suggests PARP-1 as a promising target for immunomodulation in multiple sclerosis and natalizumab-associated progressive multifocal leukoencephalopathy. Objective This study explores expression of PARP-1 and downstream effectors in multiple sclerosis and during natalizumab treatment. Methods Transcriptional expressions were studied by real-time reverse transcriptase polymerase chain reaction on CD4+T/CD8+T/CD14+/B cells and peripheral blood mononuclear cells from healthy volunteers, untreated and natalizumab-treated non-progressive multifocal leukoencephalopathy and progressive multifocal leukoencephalopathy multiple sclerosis patients. Results PARP-1 expression was higher in CD4+T, CD8+T and B cells from untreated patients compared to healthy volunteers. Natalizumab treatment restored deregulated PARP-1 expression in T cells but not in B cells. Sustained upregulation of PARP-1 was associated with decreased expression of downstream PARP-1 factors such as TGFBR1/TGFBR2/BCL6 in B cells. Notably, a higher expression of PARP-1 was detected in progressive multifocal leukoencephalopathy patients. Conclusions Given the importance of PARP-1 in inflammatory processes, its upregulation in multiple sclerosis lymphocyte populations suggests a potential role in the immune pathogenesis of multiple sclerosis. Strikingly higher PARP-1 expression in progressive multifocal leukoencephalopathy cases suggests its involvement in progressive multifocal leukoencephalopathy disease pathomechanisms. These results further support the value of PARP-1 inhibitors as a potential novel therapeutic strategy for multiple sclerosis and natalizumab-associated progressive multifocal leukoencephalopathy.
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Affiliation(s)
- Maria Meira
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Claudia Sievers
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Francine Hoffmann
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Heidi Bodmer
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Tobias Derfuss
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Jens Kuhle
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Aiden Haghikia
- Department of Neurology, Ruhr-University Bochum, Germany
| | - Ludwig Kappos
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
| | - Raija Lp Lindberg
- Departments of Biomedicine and Neurology, University Hospital Basel, Switzerland
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27
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The Role of Vesicle Trafficking and Release in Oligodendrocyte Biology. Neurochem Res 2019; 45:620-629. [PMID: 31782103 DOI: 10.1007/s11064-019-02913-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/11/2019] [Accepted: 11/16/2019] [Indexed: 12/11/2022]
Abstract
Oligodendrocytes are a subtype of glial cells found within the central nervous system (CNS), responsible for the formation and maintenance of specialized myelin membranes which wrap neuronal axons. The development of myelin requires tight coordination for the cell to deliver lipid and protein building blocks to specific myelin segments at the right time. Both internal and external cues control myelination, thus the reception of these signals also requires precise regulation. In late years, a growing body of evidence indicates that oligodendrocytes, like many other cell types, may use extracellular vesicles (EVs) as a medium for transferring information. The field of EV research has expanded rapidly over the past decade, with new contributions that suggest EVs might have direct involvement in communications with neurons and other glial cells to fine tune oligodendroglial function. This functional role of EVs might also be maladaptive, as it has likewise been implicated in the spreading of toxic molecules within the brain during disease. In this review we will discuss the field's current understanding of extracellular vesicle biology within oligodendrocytes, and their contribution to physiologic and pathologic conditions.
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Bertoli D, Sottini A, Capra R, Scarpazza C, Bresciani R, Notarangelo LD, Imberti L. Lack of specific T- and B-cell clonal expansions in multiple sclerosis patients with progressive multifocal leukoencephalopathy. Sci Rep 2019; 9:16605. [PMID: 31719595 PMCID: PMC6851145 DOI: 10.1038/s41598-019-53010-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/26/2019] [Indexed: 01/11/2023] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a rare, potentially devastating myelin-degrading disease caused by the JC virus. PML occurs preferentially in patients with compromised immune system, but has been also observed in multiple sclerosis (MS) patients treated with disease-modifying drugs. We characterized T and B cells in 5 MS patients that developed PML, 4 during natalizumab therapy and one after alemtuzumab treatment, and in treated patients who did not develop the disease. Results revealed that: i) thymic and bone marrow output was impaired in 4 out 5 patients at the time of PML development; ii) T-cell repertoire was restricted; iii) clonally expanded T cells were present in all patients. However, common usage or pairings of T-cell receptor beta variable or joining genes, specific clonotypes or obvious “public” T-cell response were not detected at the moment of PML onset. Similarly, common restrictions were not found in the immunoglobulin heavy chain repertoire. The data indicate that no JCV-related specific T- and B-cell expansions were mounted at the time of PML. The current results enhance our understanding of JC virus infection and PML, and should be taken into account when choosing targeted therapies.
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Affiliation(s)
- Diego Bertoli
- Centro di Ricerca Emato-oncologica AIL (CREA), Diagnostic Department, ASST Spedali Civili, Brescia, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Alessandra Sottini
- Centro di Ricerca Emato-oncologica AIL (CREA), Diagnostic Department, ASST Spedali Civili, Brescia, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, ASST Spedali Civili, Brescia, Italy
| | - Cristina Scarpazza
- Multiple Sclerosis Center, ASST Spedali Civili, Brescia, Italy.,Department of General Psychology, University of Padova, Padova, Italy
| | - Roberto Bresciani
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Luisa Imberti
- Centro di Ricerca Emato-oncologica AIL (CREA), Diagnostic Department, ASST Spedali Civili, Brescia, Italy.
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Early reduction of the splicing factor2/alternative splicing factor: a cellular inhibitor of the JC polyomavirus in natalizumab-treated MS patients long before developing progressive multifocal leukoencephalopathy. J Neurovirol 2019; 26:133-137. [PMID: 31468472 DOI: 10.1007/s13365-019-00793-4] [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: 04/25/2019] [Revised: 08/03/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Abstract
Natalizumab is effective against relapsing-remitting multiple sclerosis (MS) but increases the risk of progressive multifocal leukoencephalopathy (PML), which is caused by the activation of the JCV polyomavirus. SF2/ASF (splicing factor2/alternative splicing factor) is a potent cellular inhibitor of JCV replication and large T-antigen (T-Ag) expression. We reported that SF2/ASF levels in blood cells increase during the first year of natalizumab therapy and decrease thereafter, inversely related to T-Ag expression, and suggested a correlation with JCV reactivation. Here, we report SF2/ASF levels of longitudinal blood samples of two patients undergoing natalizumab therapy, who developed PML while monitored, in comparison to natalizumab-treated controls and to one-off PML samples. After 6 months of therapy, SF2/ASF levels of the two cases were reduced, instead of increased, and their overall SF2/ASF levels were lower than those from natalizumab controls. Since SF2/ASF inhibits JCV, its early reduction might have a role in subsequent PML. We are aware of the limitations of the study, but the uniqueness of serial blood samples collected before and after PML onset in natalizumab-treated patients must be stressed. If confirmed in other patients, SF2/ASF evaluation could be a new and early biomarker of natalizumab-associated PML risk, allowing an 18-24-month interval before PML onset (presently ~ 5 months), in which clinicians could evaluate other risk factors and change therapy.
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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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Benefit-risk Assessment of Cladribine Using Multi-criteria Decision Analysis (MCDA) for Patients With Relapsing-remitting Multiple Sclerosis. Clin Ther 2019; 41:249-260.e18. [DOI: 10.1016/j.clinthera.2018.12.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 12/03/2018] [Accepted: 12/28/2018] [Indexed: 11/21/2022]
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Anti-JC virus antibody index changes in rituximab-treated multiple sclerosis patients. J Neurol 2018; 265:2342-2345. [DOI: 10.1007/s00415-018-8996-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/14/2022]
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Mao Z, Álvarez-Gonzalez C, De Trane S, Yildiz O, Albor C, Doctor G, Soon D, Pepper G, Turner BP, Marta M, Mathews J, Giovannoni G, Baker D, Schmierer K. Cladribine: Off-label disease modification for people with multiple sclerosis in resource-poor settings? Mult Scler J Exp Transl Clin 2018; 4:2055217318783767. [PMID: 30090639 PMCID: PMC6077935 DOI: 10.1177/2055217318783767] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/19/2018] [Accepted: 05/04/2018] [Indexed: 01/13/2023] Open
Abstract
Background A considerable number of people with multiple sclerosis (pwMS) live in low- and middle-income countries (LMIC), where lack of resource adversely affects access to effective disease-modifying treatment. Objective The objective of this commentary is to propose a useful cost-effective disease-modifying treatment option for pwMS in LMIC with potential high efficacy and high convenience to the pwMS and treating physician. Viewpoint: We propose using generic 2-chloro-2’-deoxyadenosine (cladribine), a small molecule licensed for treatment of people with hairy cell leukaemia, as a solution of this significant equity imbalance. Cladribine has been shown in phase II and III trials to be a highly effective disease-modifying treatment for pwMS, and its adverse effect profile is comparable with any DMT currently licensed in high-income economies where an oral preparation has recently been licensed by the European Medicines Agency. Conclusion Our viewpoint takes into account experience we have gathered over the past three years in the use of generic cladribine to treat pwMS. Whilst here we focus on MS, there is significant potential for use of cladribine in other conditions that could benefit from its mechanism of action.
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Affiliation(s)
- Zhifeng Mao
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-Sen University, China.,BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - César Álvarez-Gonzalez
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Stefania De Trane
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Ozlem Yildiz
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Christo Albor
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Gabriel Doctor
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Derek Soon
- Division of Neurology, National University Hospital, Singapore
| | | | - Benjamin P Turner
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Monica Marta
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Emergency Care & Acute Medicine Clinical Academic Group Neuroscience, The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - Joela Mathews
- Barts Health NHS Trust, Pharmacy, The Royal London Hospital, United Kingdom
| | - Gavin Giovannoni
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, United Kingdom
| | - David Baker
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom
| | - Klaus Schmierer
- BartsMS, Blizard Institute, Queen Mary University of London, United Kingdom.,Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, United Kingdom
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Rommer PS, Zettl UK. Managing the side effects of multiple sclerosis therapy: pharmacotherapy options for patients. Expert Opin Pharmacother 2018. [PMID: 29528247 DOI: 10.1080/14656566.2018.1446944] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Multiple sclerosis (MS) is an immune-mediated and neurodegenerative disease with an unpredictable outcome. Immune-modulatory treatment aims at decreasing long-term disability. With the increasing number of treatment options, it is essential to fully digest the possible side effects of the available therapeutics and to monitor patients is essential. AREAS COVERED All approved disease-modifying drugs (DMD) for MS are discussed in this review. Mode of action, adverse effects, reported risks for infections and malignancies, and pregnancy related issues are discussed in the review. The authors also provide suggestions for monitoring therapy. For all approved DMDs the pivotal studies have been included for possible side effects, as well as reports by health authorities. For this manuscript, PubMed was checked for reports on side effects for various drugs. EXPERT OPINION Treatment options in MS are manifold, each carrying different risks. The safety-risk profile for approved agents is favorable. Knowing and monitoring these possible side effects is essential to minimize risks associated with treatment. Presently, the long-term experience for some of these therapies is missing and this must be addressed.
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Affiliation(s)
- Paulus S Rommer
- a Department of Neurology , Medical University of Vienna , Vienna , Austria
| | - Uwe K Zettl
- b Department of Neurology, Neuroimmunological Section , University of Rostock , Rostock , Germany
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