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Minimal supportive treatment in natalizumab-related PML in a MS patient
  1. Patrice H Lalive1,2,
  2. Ruxandra Iancu Ferfoglia1,
  3. Claire Bridel1,
  4. Laurent Kaiser2,3,
  5. Renaud Du Pasquier4,5,
  6. Frederik Barkhof6,
  7. Sven Haller7
  1. 1Unit of Neuroimmunology and Multiple Sclerosis, Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospital and Faculty of Medicine of the University of Geneva, Geneva, Switzerland
  2. 2Division of Laboratory Medicine, Department of Genetic and Laboratory Medicine, Geneva University Hospital, Geneva, Switzerland
  3. 3Laboratory of Virology, Division of Infectious Diseases, University of Geneva Hospitals and University of Geneva Medical School, Geneva, Switzerland
  4. 4Division of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
  5. 5Division of Immunology and Allergy, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
  6. 6Department of Radiology & Nuclear Medicine and Image Analysis Centre (IAC), VU University Medical Centre, Amsterdam, The Netherlands
  7. 7Department of Imaging and Medical Informatics, University Hospitals of Geneva and Faculty of Medicine of the University of Geneva, Geneva, Switzerland
  1. Correspondence to Dr Sven Haller, Service neuro-diagnostique et neuro-interventionnel DISIM, University Hospitals of Geneva, rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland; sven.haller{at}hcuge.ch

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Introduction

Natalizumab (NTZ) is a recombinant humanised immunoglobulin G4 monoclonal antibody that selectively inhibits adhesion of α4-β1 receptor on the surface of lymphocytes and hinders circulating cells from leaving the vascular compartment of the brain.1 NTZ is associated with a risk of developing progressive multifocal leukoencephalopathy (PML), estimated at approximately 1/200 in JCV-positive patients after 24 months treatment duration.1 The overall survival rate is 71% in PML secondary to NTZ treatment, which is substantially better than the often-fatal course of PML in other immunosuppressed patients.2 This reflects the fact that immune reconstitution is more easily obtained in NTZ patient by treatment cessation.3 Immune reconstitution inflammatory syndrome (IRIS), characterised by contrast-enhancing MRI lesions with clinical deterioration, is observed in almost all PML patients after NTZ cessation.2 Plasma exchange (PLEX) is usually initiated after NTZ cessation to remove remaining circulating NTZ levels, which favours the immune reconstitution, whereas intravenous corticosteroids (CS) are given to suppress IRIS development.1 Nevertheless, the increased peripheral functional T-cell expansion following PLEX can be seen as an accelerator for IRIS, and the negative impact of CS on JCV-specific CD8 T cell response is also at risk of inhibiting the physiological immune response against the JC virus (JCV).

Report of a case

A patient was diagnosed with relapsing-remitting MS at the age of 46 years. Her JCV IgG serum status was positive 6 months after NTZ treatment initiation. After 22 infusions, she presented …

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