Asymptomatic progressive multifocal leukoencephalopathy: a case report and review of the literature

Abstract

BackgroundWe report the development of asymptomatic progressive multifocal leukoencephalopathy in a patient with multiple sclerosis on natalizumab therapy. Progressive multifocal leukoencephalopathy often presents with debilitating neurologic symptoms. Very few cases have documented a completely asymptomatic course of the disease.Case presentationA 26-year-old white woman with multiple sclerosis was treated with natalizumab. She was diagnosed as having progressive multifocal leukoencephalopathy based on characteristic magnetic resonance imaging lesions after 27 infusions of natalizumab. She had no neurologic deficits at the time of diagnosis and John Cunningham virus in cerebrospinal fluid was detected at 15 copies/ml. She was initially treated with mefloquine and mirtazapine and remained asymptomatic for 3 months. She later developed worsening magnetic resonance imaging lesions related to immune reconstitution inflammatory syndrome. At that time, she received intravenously administered immunoglobulin and high-dose intravenously administered methylprednisolone with radiologic improvement of the lesions.ConclusionsOur case report illustrates that early detection of asymptomatic progressive multifocal leukoencephalopathy and its subsequent treatment resulted in a benign clinical course. In consideration of the additional small number of cases of asymptomatic progressive multifocal leukoencephalopathy that have been reported, we conclude that routine magnetic resonance imaging surveillance is important for patients with multiple sclerosis who are at high risk for developing natalizumab-associated progressive multifocal leukoencephalopathy.

The Use of Antimalarial Drugs against Viral Infection

“…In many cases, MQ was combined with mirtazapine, an antidepressant that, acting on the 5-HT2A serotonin receptor, is able to inhibit JCPyV entry into glial cells, preventing the diffusion of the infection in oligodendrocytes. The outcomes of this treatment are controversial, leading to the resolution of the infection, with a claimed effect of MQ and mirtazapine treatment [86,87,[89][90][91][92][93][94][95][96][97][98][99][100][101][102][103][104][105], and to the resolution of the infection probably due to other factors [96,[106][107][108][109] or to the death of the patient, which was not always directly related to the unsuccessful therapy [87,96,[110][111][112][113][114][115][116]. In one case, the suspension of the therapy was necessary due to the side effects [117].…”

A case of progressive multifocal leukoencephalopathy in a post-kidney transplant patient with improvement after discontinuation of immunosuppressive drugs and combination therapy with mefloquine and mirtazapine

“…There was one case of a dialysis patient [15]. It should be noted that patients treated with natalizumab or ocrelizumab for multiple sclerosis have different symptoms and course at the onset of the disease and adjuvant treatment from other background diseases because of the medical behavior of monitoring JCV during the course of the disease [14,25,27,32,35,37,38,42,49,60]. The range of onset age was 19-85 years.…”

Risk of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patient Treated With Natalizumab: A Systematic Review

“…Three months after diagnosis she noticed mild dysmetria that progressed to tremor, repeated brain MRI shows enhancing lesion suggesting immune reconstitution inflammatory syndrome (IRIS). She was then given methylprednisolone for IRIS and started back on glatiramer acetate [13].…”