Treatment of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with intravenous immunoglobulin in a patient with multiple sclerosis treated with fingolimod after discontinuation of natalizumab

Z Calic; C Cappelen-Smith; S J Hodgkinson; A McDougall; R Cuganesan; B J Brew

doi:10.1016/j.jocn.2014.08.016

Treatment of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with intravenous immunoglobulin in a patient with multiple sclerosis treated with fingolimod after discontinuation of natalizumab

J Clin Neurosci. 2015 Mar;22(3):598-600. doi: 10.1016/j.jocn.2014.08.016. Epub 2014 Dec 15.

Authors

Z Calic¹, C Cappelen-Smith², S J Hodgkinson¹, A McDougall¹, R Cuganesan³, B J Brew⁴

Affiliations

¹ Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
² Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia. Electronic address: Cecilia.Cappelen-Smith@swsahs.nsw.gov.au.
³ Department of Radiology, Liverpool Hospital, Liverpool BC, NSW, Australia.
⁴ Department of Neurology, St Vincent's Hospital, Darlinghurst, NSW, Australia.

PMID: 25523125
DOI: 10.1016/j.jocn.2014.08.016

Abstract

We report a case of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome in a multiple sclerosis (MS) patient 3.5 months after fingolimod commencement and 4.5 months after natalizumab (NTZ) cessation. Three cerebrospinal fluid analyses were required before a definitive diagnosis of progressive multifocal leukoencephalopathy was reached. Intravenous immunoglobulin (IVIG) was subsequently given as the sole MS treatment along with mirtazapine and mefloquine. There has been improvement and subsequent clinical stabilization. The notable features are the difficult timing of fingolimod commencement in the context of previous NTZ therapy, the role of repeated cerebrospinal fluid John Cunningham virus analyses in progressive multifocal leukoencephalopathy diagnosis, and the role of IVIG.

Keywords: Fingolimod; Intravenous immunoglobulin; Natalizumab; PML–IRIS.

Publication types

Case Reports

MeSH terms

Adult
Antibodies, Monoclonal, Humanized / therapeutic use
Female
Fingolimod Hydrochloride / therapeutic use*
Humans
Immune Reconstitution Inflammatory Syndrome / complications
Immune Reconstitution Inflammatory Syndrome / drug therapy*
Immunoglobulins, Intravenous / therapeutic use*
Immunologic Factors / therapeutic use*
Leukoencephalopathy, Progressive Multifocal / complications
Leukoencephalopathy, Progressive Multifocal / drug therapy*
Multiple Sclerosis / complications
Multiple Sclerosis / drug therapy*
Natalizumab / therapeutic use*
Retreatment
Treatment Outcome

Substances

Antibodies, Monoclonal, Humanized
Immunoglobulins, Intravenous
Immunologic Factors
Natalizumab
Fingolimod Hydrochloride