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Published on: February 28, 2021
Rituximab treatment did not aggravate ongoing progressive multifocal leukoencephalopathy in a patient with multiple
F Asztely1, E Gilland1, M P Wattjes2
1Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
Abstract:
A multiple sclerosis (MS) patient developed progressive multifocal leukoencephalopathy (PML) after 43 months of natalizumab treatment. New clinical and magnetic resonance imaging (MRI) findings were initially misinterpreted as breakthrough MS disease activity and natalizumab treatment was replaced by rituximab treatment. The patient had a single infusion of rituximab 1000 mg before a definite PML diagnosis was confirmed. Despite undetectable levels of B-cells, JC virus DNA became undetectable in the cerebrospinal fluid by quantitative polymerase chain reaction. The patient partially recovered without any clinical or MRI signs of new MS activity. These findings suggest that B-cell depletion in a non-immune compromised individual did not prevent the patient from clearing the JC virus infection.
Insights
A multiple sclerosis patient developed progressive multifocal leukoencephalopathy despite B-cell depletion. This case suggests B-cell depletion may not prevent JC virus clearance in non-immunocompromised individuals.
Area of Science:
- Neuroimmunology
- Viral pathogenesis
Background:
- Multiple sclerosis (MS) is an autoimmune disease.
- Natalizumab is a disease-modifying therapy for MS.
- Progressive multifocal leukoencephalopathy (PML) is a rare, serious brain infection associated with natalizumab.
Observation:
- A patient on natalizumab developed PML.
- Initial symptoms were misdiagnosed as MS activity.
- Treatment was switched to rituximab before PML confirmation.
Findings:
- The patient achieved undetectable JC virus DNA in cerebrospinal fluid despite B-cell depletion.
- Partial recovery was observed without new MS activity.
- B-cell depletion did not impede JC virus clearance.
Implications:
- This case challenges the necessity of B-cell depletion for JC virus clearance in PML.
- It highlights the importance of accurate diagnosis in MS patients on immunotherapy.
- Further research is needed to understand the role of B-cells in PML pathogenesis and resolution.
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