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Memon AB, Javed A, Caon C, Srivastawa S, Bao F, Bernitsas E, Chorostecki J, Tselis A, Seraji-Bozorgzad N, Khan O. Long-term safety of rituximab induced peripheral B-cell depletion in autoimmune neurological diseases. PLoS One 2018; 13:e0190425. [PMID: 29309416 PMCID: PMC5757948 DOI: 10.1371/journal.pone.0190425] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 12/14/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND B-cells play a pivotal role in several autoimmune diseases, including patients with immune-mediated neurological disorders (PIMND), such as neuromyelitis optica (NMO), multiple sclerosis (MS), and myasthenia gravis (MG). Targeting B-cells has been an effective approach in ameliorating both central and peripheral autoimmune diseases. However, there is a paucity of literature on the safety of continuous B-cell depletion over a long period of time. OBJECTIVE The aim of this study was to examine the long-term safety, incidence of infections, and malignancies in subjects receiving continuous therapy with a B-cell depleting agent rituximab over at least 3 years or longer. METHODS This was a retrospective study involving PIMND who received continuous cycles of rituximab infusions every 6 to 9 months for up to 7 years. The incidence of infection related adverse events (AE), serious adverse events (SAE), and malignancies were observed. RESULTS There were a total of 32 AE and 4 SAE with rituximab treatment. The 3 SAE were noted after 9 cycles (48 months) and 1 SAE was observed after 11 cycles (60 months) of rituximab. There were no cases of Progressive multifocal leukoencephalopathy (PML) and malignancies observed throughout the treatment period. Rituximab was well tolerated without any serious infusion reactions. Also, rituximab was found to be beneficial in treating PIMND over a 7-year period. CONCLUSIONS This study demonstrates that long-term depletion of peripheral B-cells appears safe and efficacious in treating PIMND. Longer and larger prospective studies with rituximab are needed to carefully ascertain risks associated with chronic B-cell depletion, including malignancies. Recognizing that this is a small, retrospective study, such data nonetheless complement the growing literature documenting the safety and tolerability of B-cell depleting agents in neurological diseases.
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Affiliation(s)
- Anza B Memon
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Adil Javed
- Multiple Sclerosis Center, Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States of America
| | - Christina Caon
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Shitiz Srivastawa
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Fen Bao
- The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Evanthia Bernitsas
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Jessica Chorostecki
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America.,The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Alexandros Tselis
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Navid Seraji-Bozorgzad
- The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
| | - Omar Khan
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America.,The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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Bernitsas E, Khan O, Razmjou S, Tselis A, Bao F, Caon C, Millis S, Seraji-Bozorgzad N. Cerebrospinal fluid humoral immunity in the differential diagnosis of multiple sclerosis. PLoS One 2017; 12:e0181431. [PMID: 28727770 PMCID: PMC5519077 DOI: 10.1371/journal.pone.0181431] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/30/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The diagnostic accuracy of cerebrospinal fluid oligoclonal bands (CSF-OCB) detected by isoelectric focusing (IEF) in patients with multiple sclerosis (MS) was evaluated in our study. METHODS Three hundred and twenty-one patients with MS and other central nervous system (CNS) immune mediated disorders were assessed (CIMD). Cerebrospinal fluid and matched serum samples were examined for the presence of OCB by IEF-IB (isoelectric focusing with immunoblotting). RESULTS Isolated oligoclonal bands (ISO-OCB) were the only predictor of MS diagnosis independent of age, gender and CSF-OCB. ISO-OCB ≥ 3.5 detected by IEF yielded a sensitivity of 98% and specificity of 87% in distinguishing MS from MS mimickers. CONCLUSIONS For the neurologist, a score of ≥ 4 ISO-OCB supports the diagnosis of MS. On the other hand, ISO-OCB ≤3 favors CIMD. Further studies with larger population samples are warranted to confirm these findings.
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Affiliation(s)
- Evanthia Bernitsas
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
- * E-mail:
| | - Omar Khan
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
| | - Sara Razmjou
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
| | - Alexandros Tselis
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
| | - Fen Bao
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
| | - Christina Caon
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
| | - Scott Millis
- Department of Physical Medicine and Rehabilitation; Wayne State University School of Medicine, Detroit, MI, United States of America
| | - Navid Seraji-Bozorgzad
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States of America
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Seraji-Bozorgzad N, Khan O, Cree BA, Bao F, Caon C, Zak I, Razmjou S, Tselis A, Millis S, Bernitsas E. Cerebral Gray Matter Atrophy Is Associated with the CSF IgG index in African American with Multiple Sclerosis. J Neuroimaging 2017; 27:476-480. [DOI: 10.1111/jon.12435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/09/2017] [Indexed: 02/01/2023] Open
Affiliation(s)
- Navid Seraji-Bozorgzad
- Sastry Foundation Advanced Imaging Laboratory, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Omar Khan
- Sastry Foundation Advanced Imaging Laboratory, Department of Neurology; Wayne State University School of Medicine; Detroit MI
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Bruce A.C. Cree
- Multiple Sclerosis Center, Department of Neurology; University of California; San Francisco CA
| | - Fen Bao
- Sastry Foundation Advanced Imaging Laboratory, Department of Neurology; Wayne State University School of Medicine; Detroit MI
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Christina Caon
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Imad Zak
- Department of Radiology; Wayne State University School of Medicine; Detroit MI
| | - Sara Razmjou
- Sastry Foundation Advanced Imaging Laboratory, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Alexandros Tselis
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - Scott Millis
- Division of Biostatistics, Department of Physical Medicine & Rehabilitation; Wayne State University School of Medicine; Detroit MI
| | - Evanthia Bernitsas
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
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Affiliation(s)
- Richa Tripathi
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Alexandros Tselis
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Evanthia Bernitsas
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA
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Affiliation(s)
- Monica B Dhakar
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, Mich.
| | - Mahmoud Rayes
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, Mich
| | - William Kupsky
- Department of Pathology, Wayne State University, Detroit Medical Center, Detroit, Mich
| | - Alexandros Tselis
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, Mich
| | - Gregory Norris
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, Mich
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Jani-Acsadi A, Tselis A, Taraman S. Central nervous system vasculitis and pediatric stroke. J Pediatr Neurol 2015. [DOI: 10.3233/jpn-2010-0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Agnes Jani-Acsadi
- Department of Neurology, Wayne State University, School of Medicine, Detroit, MI, USA
| | - Alexandros Tselis
- Department of Neurology, Wayne State University, School of Medicine, Detroit, MI, USA
| | - Sharief Taraman
- Division of Pediatric Neurology, Department of Pediatrics, Carman and Ann Adams, Children's Hospital of Michigan, Wayne State University, School of Medicine, Detroit, MI, USA
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Bernitsas E, Bao F, Seraji-Bozorgzad N, Chorostecki J, Santiago C, Tselis A, Caon C, Zak I, Millis S, Khan O. Spinal cord atrophy in multiple sclerosis and relationship with disability across clinical phenotypes. Mult Scler Relat Disord 2014; 4:47-51. [PMID: 25787052 DOI: 10.1016/j.msard.2014.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/28/2014] [Accepted: 11/07/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies have shown a relationship between spinal cord atrophy and clinical disability in patients with multiple sclerosis (MS). OBJECTIVES We examined the correlation between cervical cord cross-sectional area at the C2 vertebral level (CSA-C2) and the expanded disability status scale (EDSS) in patients with relapsing-remitting and progressive forms of MS. The latter included both secondary and primary progressive MS patients. METHODS A total of 150 patients with MS were recruited from the Wayne State University MS clinic. Ninety-three had relapsing-remitting MS and 57 patients had progressive MS. MRI scan of the cervical cord was obtained for each patient. Correlation studies and multivariate regression analysis was performed, blinded to clinical status. RESULTS The mean age was 41.3 year old, 64.6% were women, mean disease duration was 11.2 years, CSA-C2 was 80.2mm(2) and mean EDSS was 3.8. There was significant correlation between CSA-C2 and EDSS (r -0.75, p<0.0001). Sub-group analysis showed CSA-C2 was 68.6mm(2) and 87.3mm(2) in the progressive and relapsing-remitting groups, respectively (p<0.0001). Multivariable regression showed that CSA-C2 was a significant predictor of disability independent of disease duration, and phenotype. CONCLUSIONS Our study demonstrates that CSA-C2 has a strong correlation with clinical disability in both RRMS and progressive MS. Greater spinal cord atrophy was seen in patients with progressive than relapsing-remitting MS. CSA-C2, disease duration, and phenotype are independent predictors of disability.
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Affiliation(s)
- Evanthia Bernitsas
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA
| | - Fen Bao
- The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Navid Seraji-Bozorgzad
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA; The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Jessica Chorostecki
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA; The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Carla Santiago
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA; The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Alexandros Tselis
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA
| | - Christina Caon
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA
| | - Imad Zak
- Department of Radiology, Wayne State University School of Medicine, Detroit, USA
| | - Scott Millis
- Division of Clinical Research & Biostatistics, Department of Physical Medicine and Rehabilitation, Wayne State University School of Medicine, Detroit, USA
| | - Omar Khan
- Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, USA; The Sastry Foundation Advanced Imaging Laboratory, Department of Neurology, Wayne State University School of Medicine, Detroit, USA.
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Figueroa M, Guo Y, Tselis A, Pittock SJ, Lennon VA, Lucchinetti CF, Lisak RP. Paraneoplastic neuromyelitis optica spectrum disorder associated with metastatic carcinoid expressing aquaporin-4. JAMA Neurol 2014; 71:495-8. [PMID: 24733266 DOI: 10.1001/jamaneurol.2013.6331] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Reports of neuromyelitis optica spectrum disorder (NMOSD) occurring in the setting of neoplasia suggest that aquaporin-4 autoimmunity may in some cases have a paraneoplastic basis. OBSERVATIONS In this case report, we describe a patient with NMOSD whose test results were seropositive for aquaporin-4 IgG and who had a hepatic metastasis from a small-bowel neuroendocrine tumor. The tumor cells expressed aquaporin-4 immunoreactivity. She presented to the Neurology Department at Wayne State University with bilateral leg weakness, ascending paresthesias, and decreased sensation. CONCLUSIONS AND RELEVANCE This case extends the context of NMOSD as a paraneoplastic disorder.
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Affiliation(s)
- Michelle Figueroa
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan
| | - Yong Guo
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Alexandros Tselis
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Vanda A Lennon
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota3Department of Laboratory Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota4Department of Pathology and Immunology, Mayo Clinic College of Medicine, Rochester, Min
| | | | - Robert P Lisak
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan5Department of Immunology and Microbiology, Wayne State University School of Medicine, Detroit, Michigan
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Sundal C, Fujioka S, Van Gerpen J, Wider C, Aasly J, Roeber S, Shuster E, Ghetti B, Garbern J, Tselis A, Swerdlow R, Miller B, Rademakers R, Dickson D, Broderick D, Wszolek Z. Observational Study for MRI Characteristics in HDLS with a Known Gene Mutation on Chromosome 5 (P06.180). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p06.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bernitsas E, Caon C, Lulu S, Tselis A, Lisak R, Khan O. Longitudinal Characterization of Lymphocyte Subsets and Clinical Follow-Up of MS Patients Receiving Fingolimod (P06.160). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p06.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lulu S, Bernitsas E, Bao F, Shah M, Tselis A, Caon C, Aronov R, Khan O. Radiologically Isolated Syndrome: Long-Term Follow Up in 75 Patients (S50.005). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s50.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sundal C, Van Gerpen J, Fujioka S, Aasly J, Wider C, Roeber S, Shuster E, Ghetti B, Garbern J, Tselis A, Swerdlow R, Rademakers R, Dickson D, Broderick D, Wszolek Z. HDLS: Due to CSF1R Gene Mutation; Clinical Characteristics (P05.119). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p05.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Puntambekar P, Santhakumar S, Kupsky WJ, Tselis A, Mittal S. Primary intracranial plasma cell granulomas presenting as malignant neoplasms. J Neurooncol 2011; 106:327-37. [PMID: 21786175 DOI: 10.1007/s11060-011-0667-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 07/07/2011] [Indexed: 12/22/2022]
Abstract
Plasma cell granuloma (PCG) is an uncommon non-neoplastic mass lesion of unknown etiology. It is characterized by a polyclonal proliferation of chronic inflammatory cells, mostly mature plasma and other mononuclear cells. PCGs arising in the central nervous system are particularly rare. We report two additional cases of intracranial PCG exclusively involving the brain parenchyma. A 47 year-old woman, presenting with partial motor seizures and fluent aphasia, underwent complete excision of a well-demarcated, enhancing left parietal mass. The second patient was a 56 year-old man presenting with headaches and right-sided weakness who underwent stereotactic biopsy of an ill-defined, heterogeneously enhancing lesion in the left basal ganglia. Immunohistochemical analysis of surgical specimens showed polyclonal plasma cells and mature lymphocytes but no etiological agent. A histopathologic diagnosis of intracranial PCG was made in both cases. PCG should be part of the differential diagnosis of enhancing mass lesions of the brain. The etiology and natural history of these tumor-like lesions is not fully understood. Complete surgical excision appears to be curative. Lesions where total resection is not possible may benefit from adjuvant treatment including corticosteroids and possibly radiation therapy.
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Affiliation(s)
- Preeti Puntambekar
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, MI, USA
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Zvartau-Hind M, Caon C, Zabad R, Tselis A, Lisak R, Khan O. Glatiramer acetate for multiple sclerosis: a comprehensive review of mechanisms and clinical efficacy. Expert Rev Neurother 2010; 2:285-94. [PMID: 19810859 DOI: 10.1586/14737175.2.3.285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 'Decade of the Brain' (1990-2000) saw unprecedented advances in neurosciences including multiple sclerosis. It could have not been more aptly named, as it produced a shift in the paradigm of multiple sclerosis management, making multiple sclerosis a treatable disorder with the availability of several therapeutic options. For a chronic progressive neurological disorder like multiple sclerosis, this change in the understanding and treatment touched the lives of hundreds of thousands of patients worldwide and many more who provided care and counsel as family and friends. Of the four agents available for the treatment of the most common type of multiple sclerosis - relapsing-remitting - three are beta-interferons and one is a noninterferon polypeptide of four amino acids (glatiramer acetate) with a distinct immunomodulating profile. Glatiramer acetate is now approved and available in North America, Europe and many other countries. It has been tested in pivotal trials as well as long term extension trials for almost 10 years (8 years published) providing remarkable evidence of efficacy and safety. This review will highlight the immune mechanisms and clinical data reported with glatiramer acetate in multiple sclerosis over the past three decades.
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Affiliation(s)
- Marina Zvartau-Hind
- Department of Neurology, 8D-University Health Center, 4201 St. Antoine, Detroit, MI 48201, USA.
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Khan O, Perumal J, Bao I, Zak I, Shah M, Caon C, Tselis A. FP33-WE-05 CNS immune reconstitution syndrome (CIRIS) in patients who discontinue natalizumab therapy: clinical and MRI findings. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hreha S, Bao F, Zak I, Tselis A, Shah M, Millis S, Khan O, Caon C. FP14-TU-04 Gray matter atrophy, gadolinium enhancing lesions, and brain MTR correlate with CSF humoral immune response in clinically aggressive African-American and not Caucasian patients with MS. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Boster A, Hreha S, Berger JR, Bao F, Penmesta R, Tselis A, Endress C, Zak I, Perumal J, Caon C, Vazquez J, Tyler KL, Racke MK, Millis S, Khan O. Progressive multifocal leukoencephalopathy and relapsing-remitting multiple sclerosis: a comparative study. ACTA ACUST UNITED AC 2009; 66:593-9. [PMID: 19433659 DOI: 10.1001/archneurol.2009.31] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To identify clinical and magnetic resonance imaging (MRI) features that distinguish progressive multifocal leukoencephalopathy (PML) from relapsing-remitting multiple sclerosis (RRMS). DESIGN Retrospective medical record review. SETTING Two urban teaching hospitals in Detroit, Michigan. Patients Forty-five confirmed PML cases and 100 patients with RRMS. MAIN OUTCOME MEASURES Clinical and MRI features distinguishing PML from RRMS. RESULTS Overall, monosymptomatic presentations were more common in multiple sclerosis (MS) than PML (85% vs 47%; P < .01). However, patients with PML presented more often with hemiparesis (24% vs 5%; P = .001) and altered mentation (19% vs 0%; P < .0001), whereas brainstem (2% vs 18%; P = .007) presentations were more common in patients with RRMS. Spinal cord and optic neuritis presentations were seen in 18% and 33% of patients with RRMS, respectively, but not in patients with PML (m < .0001). Brain MRI scans, available in 35 (78%) PML cases, revealed 7 lesion types. Large, confluent T2-weighted lesions (74% vs 2%; P < .0001) and deep gray matter lesions (31% vs 7%; P < .001) were more frequent in patients with PML than patients with RRMS. Crescentic cerebellar lesions (23% vs 0%; P < .001) were seen only in patients with PML. Gadolinium-enhancing (23%), transcallosal (9%), and periventricular (9%) lesions were noted in patients with PML. Brain magnetization transfer ratio (MTR) was low in both PML and MS lesions. However, normal-appearing brain tissue MTR in PML was higher than normal-appearing brain tissue MTR in RRMS (44.15% vs 41.04%; P = .002), suggesting that PML may be relatively more focal than MS. CONCLUSIONS There appear to be differences between the clinical and MRI characteristics of PML and RRMS, which may help distinguish new MS activity from PML. Magnetization transfer ratio studies may provide additional clues in improving early detection of PML in patients with preexisting MS and warrant further investigation.
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Affiliation(s)
- Aaron Boster
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Khan OA, Tselis A, Boster A, Fazekas F, Lublin F, Li D, Freedman M, Hartung HP, Rieckmann P, Soelberg Sorensen P, Maas-Enriquez M, Hanna K. INTRAVENOUS IMMUNOGLOBULIN IN RELAPSING-REMITTING MULTIPLE SCLEROSIS: A DOSE-FINDING TRIAL. Neurology 2009; 72:2134; author reply 2134-5. [DOI: 10.1212/01.wnl.0000349656.65459.5f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Khan O, Shen Y, Bao F, Caon C, Tselis A, Latif Z, Zak I. Long-term study of brain 1H-MRS study in multiple sclerosis: effect of glatiramer acetate therapy on axonal metabolic function and feasibility of long-Term H-MRS monitoring in multiple sclerosis. J Neuroimaging 2009; 18:314-9. [PMID: 18304034 DOI: 10.1111/j.1552-6569.2007.00206.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Glatiramer acetate (GA) has several putative mechanisms of action with the potential of limiting sublethal axonal injury in the central nervous system (CNS). Brain proton magnetic resonance spectroscopy ((1)H-MRS) allows in vivo examination of axonal integrity by quantifying the neuronal marker N-acetylaspartate (NAA), often expressed as a ratio to creatine (Cr). We showed that treatment with GA led to improvement in NAA/Cr over a 2-year period. We now report the results of this ongoing study after 4 years of annual brain (1)H-MRS examinations. Compared to baseline, at year 4, patients receiving continuous GA therapy showed a 12.7% increase in NAA/Cr and (P= .03) in the multivoxel brain volume of interest (VOI) studied and by 9.6% (P= .04) in the normal-appearing white matter within the VOI. Three patients in the control group who began therapy with GA during the course of the study showed similar increases in NAA/Cr after the first year of therapy. These data support the long-term effect of GA on maintaining axonal metabolic function and protection from sublethal injury as well as the feasibility of employing brain (1)H-MRS in long-term investigative studies in MS.
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Affiliation(s)
- Omar Khan
- Multiple Sclerosis Clinical Research Center, Department of Neurology, The Detroit Medical Center, Wayne State University School of Medicine, Detroit, Michigan 48201, USA.
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Tselis A, Perumal J, Caon C, Hreha S, Ching W, Din M, Van Stavern G, Khan O. Treatment of corticosteroid refractory optic neuritis in multiple sclerosis patients with intravenous immunoglobulin. Eur J Neurol 2008; 15:1163-7. [PMID: 18727675 DOI: 10.1111/j.1468-1331.2008.02258.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with severe visual loss because of optic neuritis refractory to high dose corticosteroids have limited therapeutic options. The use of intravenous immunoglobulin (IVIG) has been advocated in the past, but data are scarce. In this study, we use a protocol different from those used in other studies, with different timing and dosage. METHODS Consecutive patients with corticosteroid-refractive optic neuropathy were treated with IVIG and compared with control patients who received only corticosteroids in an open-label, non-randomized, controlled prospective study. RESULTS Twenty-three patients received treatment with IVIG and 24 matched patients who did not receive treatment with IVIG were followed as controls. All patients had visual acuity 20/400 or worse in the affected eye. There was significant improvement in the IVIG group with 18/23 (78%) subjects reaching near normal vision (20/30 or better), compared with the control group with only 3/24 (12.5%) responding similarly. CONCLUSIONS The use of IVIG, following corticosteroids, may be useful using the protocol described herein, with sustained pulsed dosing. A larger controlled trial is indicated to confirm these results.
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Affiliation(s)
- A Tselis
- Department of Neurology, Multiple Sclerosis Clinical Research Center, Detroit, MI, USA
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Boster A, Caon C, Perumal J, Hreha S, Zabad R, Zak I, Tselis A, Lisak R, Khan O. Failure to develop multiple sclerosis in patients with neurologic symptoms without objective evidence. Mult Scler 2008; 14:804-8. [PMID: 18573830 DOI: 10.1177/1352458507088156] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Many patients referred to multiple sclerosis (MS) centers with symptoms suggestive of MS are found to have normal neurologic examinations, normal or non-specific brain magnetic resonance imaging (MRI) scan findings, and normal cerebrospinal fluid (CSF). Persistent symptoms often lead to multiple consultations and repeated diagnostic investigations. We performed a study to evaluate the diagnostic utility of repeated evaluations in patients with normal initial assessments and persistent neurologic symptoms. METHODS 143 patients were evaluated initially and 109 returned for a second evaluation after a mean interval of 4.4 years. RESULTS All 143 patients had normal initial examinations, brain MRI scans, screening blood tests, and CSF studies. Spinal cord imaging was normal in all patients tested (cervical cord, n = 126; 88.1%; thoracic cord, n = 58; 40.6%). Evoked potential studies were abnormal in a small percentage of patients: visual evoked potentials, VEP (8.1%), somatosensory evoked potentials, SSEP (4.9%), and brainstem auditory evoked potentials, BAEP (2.8%). All follow-up patients (n = 109) had normal examinations and MRI scans. Repeat CSF studies (n = 35; 32.1%) and spinal cord imaging (cervical cord n = 57; 52.3%; thoracic cord n = 32; 29.4%) were normal in all follow-up patients tested. No patients at initial presentation or at follow-up fulfilled diagnostic criteria for MS. CONCLUSIONS PATIENTS and clinicians may be reassured that persistent neurologic symptoms in the absence of objective clinical evidence do not lead to the development of MS. Costly serial investigations should be carefully considered, particularly in the presence of normal neurologic examination at follow-up.
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Affiliation(s)
- A Boster
- Multiple Sclerosis Clinical Research Center, Department of Neurology, Wayne State University School Medicine, Detroit, MI 48201, USA
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Perumal JS, Caon C, Hreha S, Zabad R, Tselis A, Lisak R, Khan O. Oral prednisone taper following intravenous steroids fails to improve disability or recovery from relapses in multiple sclerosis. Eur J Neurol 2008; 15:677-80. [PMID: 18459972 DOI: 10.1111/j.1468-1331.2008.02146.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A short course of intravenous methylprednisolone (IVMP) followed by oral prednisone taper (OPT) is often used for the treatment of relapses in multiple sclerosis (MS). We examined the effect of IVMP plus OPT compared with IVMP only on neurologic disability 1 year after treatment of a relapse in patients with relapsing-remitting multiple sclerosis. METHODS Two hundred eighty-five consecutive relapses were analyzed in a retrospective fashion. One hundred fifty-two patients with a total of 171 relapses received IVMP plus an OPT at the time of relapse whilst 112 patients who experienced 114 relapses received IVMP without OPT. RESULTS There was no difference between the two groups in the baseline characteristics as well as the mean or categorical EDSS at baseline, at the time of relapse confirmation, and at months 3, 6 and 12 after relapse confirmation. CONCLUSION Our observations suggest that OPT following treatment with IVMP for an MS relapse does not lead to improved neurologic outcome after 12 months compared with treatment with IVMP only. Moreover, our findings raise concerns regarding the common practice of using OPT following IVMP. Further studies are indicated to validate our findings and minimize exposure to systemic corticosteroids, well known for systemic toxicity.
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Affiliation(s)
- J S Perumal
- Department of Neurology, Multiple Sclerosis Clinical Research Center, Wayne State University School of Medicine, Detroit & The Detroit Medical Center, Detroit, MI 48201, USA
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25
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Boster A, Edan G, Frohman E, Javed A, Stuve O, Tselis A, Weiner H, Weinstock-Guttman B, Khan O. Intense immunosuppression in patients with rapidly worsening multiple sclerosis: treatment guidelines for the clinician. Lancet Neurol 2008; 7:173-83. [PMID: 18207115 DOI: 10.1016/s1474-4422(08)70020-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Several lines of evidence link immunosuppression to inflammation in patients with multiple sclerosis (MS) and provide a rationale for the increasing use of immunosuppressive drugs in the treatment of MS. Treatment-refractory, clinically active MS can quickly lead to devastating and irreversible neurological disability and treating these patients can be a formidable challenge to the clinician. Patients with refractory MS have been treated with intense immunosuppression, such as cyclophosphamide or mitoxantrone, or with autologous haematopoeitic stem cell transplants. Evidence shows that intense immunosuppression might be effective in patients who are unresponsive to immunomodulating therapy, such as interferon beta and glatiramer acetate. Natalizumab, a new addition to the armamentarium for treating MS, might also have a role in the treatment of this MS phenotype. This Review describes the use of intense immunosuppressant drugs and natalizumab in patients with rapidly worsening MS and provides clinicians with guidelines for the use of these drugs in this patient group.
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Affiliation(s)
- Aaron Boster
- The Multiple Sclerosis Clinical Research Center, Department of Neurology, Wayne State University School of Medicine, and The Detroit Medical Center, Detroit, MI 48201, USA
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26
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Sheth SG, Rao CV, Tselis A, Lewis RA. HIV-Related Peripheral Neuropathy and Glucose Dysmetabolism: Study of a Public Dataset. Neuroepidemiology 2007; 29:121-4. [DOI: 10.1159/000109826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Perumal J, Filippi M, Ford C, Johnson K, Lisak R, Metz L, Tselis A, Tullman M, Khan O. Glatiramer acetate therapy for multiple sclerosis: a review. Expert Opin Drug Metab Toxicol 2006; 2:1019-29. [PMID: 17125414 DOI: 10.1517/17425255.2.6.1019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The past decade has witnessed a revolution in the treatment of multiple sclerosis (MS), the most common demyelinating disorder of the human CNS. After being considered as an untreatable disease for more than a century, six disease-modifying treatments have been approved between 1993 and 2006. Glatiramer acetate (GA) is a worldwide drug approved for the treatment of relapsing-remitting MS in 1996. The drug is a synthetic copolymer of four amino acids based on the composition of myelin basic protein, one of several putative autoantigens implicated in the pathogenesis of MS. Three separate double-blind, placebo-controlled trials have established its efficacy in relapsing-remitting MS. Observations from an ongoing study, the longest prospective study in MS therapeutics so far, suggest that the effect of GA in reducing the relapse rate and neurological disability is maintained over a 10-year period. Independent investigators have identified several putative immunological mechanisms of action of GA, with the unique observation of the generation of GA-reactive T-helper 2 (anti-inflammatory) polarised lymphocytes within days to weeks of initiating therapy and sustaining an anti-inflammatory milieu for years in the peripheral immune system and, presumably, in the CNS. Emerging data from immunological and imaging studies quantifying axonal injury in the brain point towards neuroprotective abilities of GA. Combined with its remarkable safety and tolerability, long-term efficacy and neuroprotective effect, GA presents it self as a first-line choice in relapsing-remitting MS, and holds immense promise in developing its potential as a combination therapy in MS, as well as extending its indications to other neurodegenerative diseases.
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Affiliation(s)
- Jai Perumal
- Wayne State University School of Medicine, Department of Neurology, 8D-UHC, Detroit, MI 48201, USA
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Abstract
We examined the clinical course after switching disease-modifying therapy (DMT) in patients with relapsing-remitting multiple sclerosis (RRMS). Eighty-five consecutive RRMS patients who received weekly interferon beta-1a (IFN beta-1a) 6 MU i.m. for at least 18 months were enrolled. Baseline annualized relapse rate (ARR) for the 2 years prior to initiating therapy with IFN beta-1a was obtained from charts. All 85 patients received treatment with IFN beta-1a at 6 MU i.m. weekly for 18-24 months (mean 19.7 months). Treatment with IFN beta-1a reduced the mean ARR from 1.41 to 1.23 (P=0.005). All 85 patients were then switched to glatiramer acetate (GA) 20 mg s.c. daily and prospectively followed up for 36-42 months (mean 37.5 months). Patients were switched because of persistent clinical disease activity (n=62) or persistently unacceptable toxicity (n=23) as determined by the treating neurologist. Treatment with GA reduced the mean ARR from 1.23 to 0.53 (P=0.0001). Subgroup analysis showed that in patients who were switched because of lack of efficacy (n=62), the mean ARR was reduced from 1.32 on IFN beta-1a to 0.52 on GA (P=0.0001). In contrast, in patients who switched because of persistent toxicity (n=23), the mean ARR was reduced from 0.61 on IFN beta-1a to 0.47 on GA (P, non-significant). Our observations suggest that clinical observations such as relapse rate and tolerability may be used as criteria for switching DMT in clinical practice. More definitive consensus criteria incorporating magnetic resonance imaging and clinical observations for defining optimal response and tolerability need to be developed for the routine clinical management of RRMS patients receiving DMT.
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Affiliation(s)
- C Caon
- Multiple Sclerosis Center, Department of Neurology, Wayne State University School of Medicine, Detroit, MI, USA
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Khan O, Shen Y, Caon C, Bao F, Ching W, Reznar M, Buccheister A, Hu J, Latif Z, Tselis A, Lisak R. Axonal metabolic recovery and potential neuroprotective effect of glatiramer acetate in relapsing-remitting multiple sclerosis. Mult Scler 2006; 11:646-51. [PMID: 16320723 DOI: 10.1191/1352458505ms1234oa] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Glatiramer acetate (GA) is a disease-modifying therapy for relapsing-remitting multiple sclerosis (RRMS) with several putative mechanisms of action. Currently, there is paucity of in vivo human data linking the well-established peripheral immunologic effects of therapy with GA to its potential effects inside the central nervous system (CNS). Brain proton magnetic resonance spectroscopy (MRS) allows in vivo examination of axonal integrity by quantifying the resonance intensity of the neuronal marker N-acetylaspartate (NAA). In a pilot study to investigate the effect of GA on axonal injury, we performed combined brain magnetic resonance imaging (MRI) and MRS studies in 18 treatment naïve RRMS patients initiating therapy with GA at baseline and annually for two years on therapy. A small group of four treatment naïve RRMS patients, electing to remain untreated, served as controls. NAA/Cr was measured in a large central brain volume of interest (VOI) as well as the normal appearing white matter (NAWM) within the VOI. After two years, NAA/Cr in the GA-treated group increased significantly by 10.7% in the VOI (2.17 +/- 0.26 versus 1.96 +/- 0.24, P = 0.03) and by 71% in the NAWM (2.23 +/- 0.26 versus 2.08 +/- 0.31, P = 0.04). In the untreated group, NAA/Cr decreased by 8.9% at two years in the VOI (2.01 +/- 0.16 versus 1.83 +/- 0.21, P = 0.03) and 8.2% in the NAWM (2.07 +/- 0.24 versus 1.90 +/- 0.29, P = 0.03). Our data shows that treatment with GA leads to axonal metabolic recovery and protection from sub-lethal axonal injury. These results support an in situ effect of GA therapy inside the CNS and suggest potential neuroprotective effects of GA.
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Affiliation(s)
- Omar Khan
- Department of Neurology, Multiple Sclerosis Center, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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30
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Abstract
The past decade has seen unprecedented advances in the development of disease-modifying therapies for relapsing-remitting multiple sclerosis (RRMS), a disease that has a worldwide prevalence of two million patients. Four agents with the ability to modulate the immune system are now being widely used for RRMS. Of these, three are forms of interferon (IFN)-beta [IFNbeta-1b and two preparations of IFNbeta-1a (Avonex and Rebif], and one is a polypeptide of four amino acids (glatiramer acetate) with a unique mechanism of action. The administration regimens for the IFNbeta-1a products differ, with Avonex being given as 30 microg intramuscularly once a week and Rebif being given as 22 or 44 microg subcutaneously three times a week. It appears safe to predict that both forms of IFNbeta and glatiramer acetate will remain standard treatments for MS for years to come. However, with four therapeutic options available for RRMS, selecting a single therapy is often difficult and necessitates comparisons of the agents, which can be contentious. All four agents have shown superiority over placebo in pivotal phase III trials. Three recent prospective comparative studies have indicated that IFNbeta-1b, Rebif and glatiramer acetate may be more optimal choices than Avonex for patients with RRMS. In a pharmaceutical environment with an estimated worldwide market of $US2.5 billion annually for RRMS, comparative studies are understandably provocative, but at the same time provide meaningful information to clinicians and patients.
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Affiliation(s)
- Omar Khan
- Department of Neurology, Multiple Sclerosis Center, Wayne State University School of Medicine, *D-University Health Center, 4201 St. Antoine, Detroit, MI 48201, USA.
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Abstract
There is no standard therapy for acute disseminated encephalomyelitis (ADEM), and treatments are based on the analogy of the pathogenesis of ADEM with that of multiple sclerosis (MS), namely an inflammatory perivenular demyelination. High-dose intravenous corticosteroids, such as methylprednisolone, at a dosage standard for MS relapses have been commonly used. Plasmapheresis, beginning with a course of four to six plasma exchanges, has also been used, particularly when intravenous methylprednisolone has failed. Intravenous immunoglobulin is a third potential therapeutic modality.
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Affiliation(s)
- Alexandros Tselis
- Department of Neurology, Wayne State University Detroit Medical Center, 4201 Saint Antoine Street, UHC-8D, Detroit, MI 48201, USA.
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32
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Chaturvedi S, Sohrab S, Tselis A. Carotid stent thrombosis: report of 2 fatal cases. Stroke 2001; 32:2700-2. [PMID: 11692038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Carotid stenting is receiving increased attention as an alternative to carotid endarterectomy. Carotid stent thrombosis is a rare complication of this procedure. CASE DESCRIPTIONS We present 2 case reports from a university medical center. Two patients had angiographically confirmed carotid stent (CS) thrombosis with subsequent fatal strokes. The first was a 63-year-old woman who developed stent thrombosis after the procedure was performed for a postendarterectomy intimal flap. The second patient was a 57-year-old man who underwent CS placement for transient ischemic attacks and developed internal carotid artery occlusion at the level of the stent 3 days later. Neither patient was treated with combination antiplatelet therapy before or after CS placement. Both patients died. CONCLUSIONS CS thrombosis can be a cause of fatal iatrogenic stroke. Combination antiplatelet therapy should be administered to decrease the incidence of this complication.
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Affiliation(s)
- S Chaturvedi
- Department of Neurology and Stroke Program, Wayne State University, Detroit, Michigan, USA.
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33
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Abstract
Background
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Carotid stenting is receiving increased attention as an alternative to carotid endarterectomy. Carotid stent thrombosis is a rare complication of this procedure.
Case Descriptions
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We present 2 case reports from a university medical center. Two patients had angiographically confirmed carotid stent (CS) thrombosis with subsequent fatal strokes. The first was a 63-year-old woman who developed stent thrombosis after the procedure was performed for a postendarterectomy intimal flap. The second patient was a 57-year-old man who underwent CS placement for transient ischemic attacks and developed internal carotid artery occlusion at the level of the stent 3 days later. Neither patient was treated with combination antiplatelet therapy before or after CS placement. Both patients died.
Conclusions
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CS thrombosis can be a cause of fatal iatrogenic stroke. Combination antiplatelet therapy should be administered to decrease the incidence of this complication.
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Affiliation(s)
- Seemant Chaturvedi
- From the Department of Neurology and Stroke Program, Wayne State University, Detroit, Mich
| | - Sayyed Sohrab
- From the Department of Neurology and Stroke Program, Wayne State University, Detroit, Mich
| | - Alexandros Tselis
- From the Department of Neurology and Stroke Program, Wayne State University, Detroit, Mich
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MESH Headings
- Adult
- Anti-Inflammatory Agents/therapeutic use
- Body Water
- Combined Modality Therapy
- Diagnosis, Differential
- Diffusion
- Encephalomyelitis, Acute Disseminated/cerebrospinal fluid
- Encephalomyelitis, Acute Disseminated/diagnosis
- Encephalomyelitis, Acute Disseminated/pathology
- Encephalomyelitis, Acute Disseminated/therapy
- Female
- Gastroenteritis/complications
- Humans
- Infant, Newborn
- Labor, Induced
- Magnetic Resonance Imaging
- Male
- Methylprednisolone/therapeutic use
- Multiple Sclerosis/diagnosis
- Optic Neuritis/cerebrospinal fluid
- Optic Neuritis/etiology
- Optic Neuritis/pathology
- Plasma Exchange
- Pregnancy
- Pregnancy Complications, Infectious/cerebrospinal fluid
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/drug therapy
- Pregnancy Complications, Infectious/pathology
- Pregnancy Complications, Infectious/therapy
- Pregnancy Outcome
- Vision Disorders/etiology
- Visual Fields
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Affiliation(s)
- A K Shah
- Department of Neurology, Wayne State University, Detroit Medical Center, Detroit, MI 48201, USA.
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35
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Price RW, Yiannoutsos CT, Clifford DB, Zaborski L, Tselis A, Sidtis JJ, Cohen B, Hall CD, Erice A, Henry K. Neurological outcomes in late HIV infection: adverse impact of neurological impairment on survival and protective effect of antiviral therapy. AIDS Clinical Trial Group and Neurological AIDS Research Consortium study team. AIDS 1999; 13:1677-85. [PMID: 10509569 DOI: 10.1097/00002030-199909100-00011] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In a large multi-center clinical trial of combination reverse transcriptase inhibitors (RTIs), we assessed the impact of antiretroviral therapy on neurological function, the relationship between neurological and systemic benefit, and the prognostic value of neurological performance in late HIV-1 infection. DESIGN Neurological evaluations incorporated in a randomized, multi-center trial of combination antiretroviral therapy. SETTING Forty-two AIDS Clinical Trials Group sites and seven National Hemophilia Foundation sites. PATIENTS Adult HIV-infected patients (n = 1313) with CD4 counts < 50 x 10(6) cells/l. INTERVENTIONS Four combinations of reverse transcriptase inhibitors consisting of zidovudine (ZDV), alternating monthly with didanosine (ddl), or in combination with zalcitabine (ddC), ddl or ddl and nevirapine. MAIN OUTCOME MEASURES Mean change from baseline of a four-item quantitative neurological performance battery score, the QNPZ-4, administered to 1031 subjects. RESULTS Triple therapy and ZDV/ddl combination preserved or improved neurological performance over time compared with the alternating ZDV/ddl and ZDV/ddC regimens (P < 0.001), paralleling their impact on survival in the same trial as previously reported. QNPZ-4 scores were predictive of survival (P < 0.001), after adjusting for CD4 counts and HIV-1 plasma RNA concentrations. CONCLUSIONS Combination antiretroviral therapy can have a salutary effect on preserving or improving neurological function. Superior systemic treatments may likewise better preserve neurological function. The significant association of poor neurological performance with mortality, independent of CD4 counts and HIV-1 RNA levels indicates that neurological dysfunction is an important cause or a strong marker of poor prognosis in late HIV-1 infection. This study demonstrates the value of adjunctive neurological measures in large therapeutic trials of late HIV-1 infection.
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Affiliation(s)
- R W Price
- University of California, San Francisco, USA
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36
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Tselis A, Shannon KM. Neurological Complications of HIV and AIDS. Neurology 1999. [DOI: 10.1212/wnl.52.6.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Tselis A, Duman R, Storch GA, Lisak RP. Epstein-Barr virus encephalomyelitis diagnosed by polymerase chain reaction: detection of the genome in the CSF. Neurology 1997; 48:1351-5. [PMID: 9153472 DOI: 10.1212/wnl.48.5.1351] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A case of encephalomyelitis with polymerase chain reaction detection of Epstein-Barr virus (EBV) in the CSF, and concurrent serologic changes consistent with acute systemic EBV infection is presented and discussed. We document involvement of the brain, spinal cord, and nerve roots, summarize some unusual imaging findings, and note the evolution of CSF oligoclonal bands.
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Affiliation(s)
- A Tselis
- Department of Neurology, Wayne State University School of Medicine, Detroit Medical Center, MI 48201, USA
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