JC virus reactivation during prolonged natalizumab monotherapy for multiple sclerosis

Abstract

Objective To determine the prevalence of JC virus (JCV) reactivation and JCV-specific cellular immune response during prolonged natalizumab treatment for multiple sclerosis (MS). Methods We enrolled 43 JCV-seropositive MS patients, including 32 on natalizumab monotherapy>18 months, 6 on interferon β-1a monotherapy>36 months and 5 untreated controls. We performed QPCR in cerebrospinal fluid (CSF), blood and urine for JCV DNA and we determined JCV-specific T cell responses using enzyme-linked immunosorbent spot (ELISpot) and intracellular cytokine staining (ICS) assays, ex vivo and after in vitro stimulation with JCV peptides. Results JCV DNA was detected in the CSF of 2/27 (7.4%) natalizumab-treated MS patients who had no symptoms or MRI lesions consistent with progressive multifocal leukoencephalopathy. JCV DNA was detected in blood of 12/43 (27.9%) and in urine of 11/43 (25.6%) subjects without difference between natalizumab-treated patients and controls. JC viral load was higher in CD34+ cells and in monocytes compared to other subpopulations. ICS was more sensitive than ELISpot, and JCV-specific T cell responses, mediated by both CD4+ and CD8+ T-lymphocytes, were detected more frequently after in vitro stimulation. JCV-specific CD4+ T-cells were detected ex vivo more frequently in MS patients with JCV DNA in CD34+ (p=0.05) and B cells (p=0.03). Interpretation Asymptomatic JCV reactivation may occur in CSF of natalizumab-treated MS patients. JCV DNA load is higher in circulating CD34+ cells and monocytes compared to other mononuclear cells, and JCV in blood might trigger a JCV-specific CD4+ T-cell response. JCV-specific cellular immune response is highly prevalent in all JCV-seropositive MS patients, regardless of treatment.

Monitoring the John Cunningham virus throughout natalizumab treatment in multiple sclerosis patients

“…Twenty-three percent of our patients had detectable JCV DNA levels in PBMCs and/or serum samples at least once during the treatment, which concurs with some previous results [9][10][11] but not with others [12]. Two patients developed PML at the moment of detection; therefore the presence of this virus could be associated with treatment with natalizumab.…”

“…The prevalence of the virus in urine samples at baseline (52%) was higher than that previously described amongst other MS patients: 26% or 25.6% . This could be explained by the greater sensitivity of our qPCR.…”

“…Previous studies have associated the CD4+ T‐cell‐mediated JCV‐specific response with the presence of JCV in PMBCs . Our results showed that the frequency of the DR7‐DQ2 haplotype was higher in patients with detectable JCV DNA levels in their PBMCs at some stage during natalizumab treatment than that observed in the patients with undetectable levels.…”

Monitoring the John Cunningham virus throughout natalizumab treatment in multiple sclerosis patients

“…Twenty-three percent of our patients had detectable JCV DNA levels in PBMCs and/or serum samples at least once during the treatment, which concurs with some previous results [9][10][11] but not with others [12]. Two patients developed PML at the moment of detection; therefore the presence of this virus could be associated with treatment with natalizumab.…”

“…The prevalence of the virus in urine samples at baseline (52%) was higher than that previously described amongst other MS patients: 26% or 25.6% . This could be explained by the greater sensitivity of our qPCR.…”

“…Previous studies have associated the CD4+ T‐cell‐mediated JCV‐specific response with the presence of JCV in PMBCs . Our results showed that the frequency of the DR7‐DQ2 haplotype was higher in patients with detectable JCV DNA levels in their PBMCs at some stage during natalizumab treatment than that observed in the patients with undetectable levels.…”

JC virus infection of meningeal and choroid plexus cells in patients with progressive multifocal leukoencephalopathy

“…Indeed, we found JCV DNA by PCR in the CSF of 2 of 27 (7.4%) natalizumab-treated MS patients who had no symptoms or MRI lesions consistent with PML. These individuals remained PML disease-free after discontinuation of natalizumab (Chalkias et al 2014). Others reported JCV DNA in CSF of 2 of 200 natalizumab-treated MS patients without evidence of PML (Sadiq et al 2010).…”

Frequent detection of IFN-gamma -producing memory effector and effector T cells in patients with progressive multifocal leukoencephalopathy

“…Firstly, direct and indirect evidence of ongoing JCV replication in the CNS of some patients on natalizumab has already been reported ( 16 , 35 , 51 , 52 ). JCV replication might initially be intermittent and low, subsequently intensifying progressively to cause substantial demyelination and lead to PML.…”

Monitoring the John Cunningham virus throughout natalizumab treatment in multiple sclerosis patients

“…Twenty-three percent of our patients had detectable JCV DNA levels in PBMCs and/or serum samples at least once during the treatment, which concurs with some previous results [9][10][11] but not with others [12]. Two patients developed PML at the moment of detection; therefore the presence of this virus could be associated with treatment with natalizumab.…”

“…The prevalence of the virus in urine samples at baseline (52%) was higher than that previously described amongst other MS patients: 26% or 25.6% . This could be explained by the greater sensitivity of our qPCR.…”

“…Previous studies have associated the CD4+ T‐cell‐mediated JCV‐specific response with the presence of JCV in PMBCs . Our results showed that the frequency of the DR7‐DQ2 haplotype was higher in patients with detectable JCV DNA levels in their PBMCs at some stage during natalizumab treatment than that observed in the patients with undetectable levels.…”

JC virus infection of meningeal and choroid plexus cells in patients with progressive multifocal leukoencephalopathy

“…Indeed, we found JCV DNA by PCR in the CSF of 2 of 27 (7.4%) natalizumab-treated MS patients who had no symptoms or MRI lesions consistent with PML. These individuals remained PML disease-free after discontinuation of natalizumab (Chalkias et al 2014). Others reported JCV DNA in CSF of 2 of 200 natalizumab-treated MS patients without evidence of PML (Sadiq et al 2010).…”

Frequent detection of IFN-gamma -producing memory effector and effector T cells in patients with progressive multifocal leukoencephalopathy

“…Firstly, direct and indirect evidence of ongoing JCV replication in the CNS of some patients on natalizumab has already been reported ( 16 , 35 , 51 , 52 ). JCV replication might initially be intermittent and low, subsequently intensifying progressively to cause substantial demyelination and lead to PML.…”

Monitoring the John Cunningham virus throughout natalizumab treatment in multiple sclerosis patients

“…Twenty-three percent of our patients had detectable JCV DNA levels in PBMCs and/or serum samples at least once during the treatment, which concurs with some previous results [9][10][11] but not with others [12]. Two patients developed PML at the moment of detection; therefore the presence of this virus could be associated with treatment with natalizumab.…”

“…The prevalence of the virus in urine samples at baseline (52%) was higher than that previously described amongst other MS patients: 26% or 25.6% . This could be explained by the greater sensitivity of our qPCR.…”

“…Previous studies have associated the CD4+ T‐cell‐mediated JCV‐specific response with the presence of JCV in PMBCs . Our results showed that the frequency of the DR7‐DQ2 haplotype was higher in patients with detectable JCV DNA levels in their PBMCs at some stage during natalizumab treatment than that observed in the patients with undetectable levels.…”

JC virus infection of meningeal and choroid plexus cells in patients with progressive multifocal leukoencephalopathy

“…Indeed, we found JCV DNA by PCR in the CSF of 2 of 27 (7.4%) natalizumab-treated MS patients who had no symptoms or MRI lesions consistent with PML. These individuals remained PML disease-free after discontinuation of natalizumab (Chalkias et al 2014). Others reported JCV DNA in CSF of 2 of 200 natalizumab-treated MS patients without evidence of PML (Sadiq et al 2010).…”

Frequent detection of IFN-gamma -producing memory effector and effector T cells in patients with progressive multifocal leukoencephalopathy

“…Firstly, direct and indirect evidence of ongoing JCV replication in the CNS of some patients on natalizumab has already been reported ( 16 , 35 , 51 , 52 ). JCV replication might initially be intermittent and low, subsequently intensifying progressively to cause substantial demyelination and lead to PML.…”