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   DIR Return to: TYSABRI (natalizumab)
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       #Post#: 743--------------------------------------------------
       (AAN) Atypical presentation of PML in a Tysabri-treated patient
       By: agate Date: April 27, 2015, 5:32 pm
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       Another PML case presented at the annual AAN conference in
       Washington, DC:
       [quote][P4.033] Atypical Presentation of Progressive Multifocal
       Leukoencephalopathy in a Natalizumab-treated Patient
       Stefania De Mercanti, Carlo Alberto Artusi, Marinella Clerico,
       Marco Iudicello, Alessandro Vacca, Eleonora Virgilio, Luca
       Durelli
       Orbassano (TO), Italy.
       BACKGROUND:
       Natalizumab is one of the most effective treatment[s] in
       relapsing-remitting multiple xclerosis (RRMS). Its use may be
       complicated by the occurrence of progressive multifocal
       leukoencephalopathy (PML) due to JC virus (JCV) reactivation.
       CASE REPORT:
       A 28 year-old man affected by RRMS showed MRI findings
       compatible with PML (left thalamic lesion without contrast
       enhancement) during treatment with Natalizumab (just after [the
       24th course]), in absence of neurological signs or symptoms.
       Interferon beta-1a was the only previous therapy. Natalizumab
       was immediately interrupted and JCV-DNA was detected in
       cerebrospinal fluid (viral loads of 12 copies/mL). Three
       plasma-exchange were performed and mirtazapine administered.
       For the next two months patient remained asymptomatic and
       underwent a strict MRI follow up (one MRI every 2 weeks) with no
       changes. On October 2014 right-hand weakness and hypoesthesia
       suddenly occurred, followed by right leg paresis with gait
       impairment. A new MRI showed enlargement of the thalamic lesion,
       extending to upper white matter along the cortico-spinal tract
       up to the cortical prerolandic area and no contrast enhancement.
       Considering the probable late worsening of PML, anti-edema drugs
       were administered with partial recovery.
       Two weeks later a new MRI showed contrast enhancement of all
       the previous MS lesions and partially of the PML lesion, without
       a further dimension increase; moreover a new lesion of the left
       upper cerebellar peduncle appeared. [Since the findings were]
       consistent with PML-immune reconstruction inflammatory syndrome
       (IRIS), high dose intravenous steroids were administered.
       CONCLUSIONS:
       Pauci- or asymptomatic PML should be strictly clinically and
       radiologically followed up because of the possible rapid
       worsening even after a long period of stability. After some
       months from PML diagnosis, physicians should take into account
       that neurological worsening could be due to PML extension as
       well as to IRIS occurrence.
       ________
       Category - MS and CNS Inflammatory Disease: Clinical Science
       Session: P4: Poster Session IV: MS and CNS Inflammatory
       Diseases: Progressive Multifocal Leukoencephalopathy Risk (7:30
       AM-12:00 PM)
       Date/Time: Wednesday, April 22, 2015 - 7:30 am
       [/quote]
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