@article{7452b6128d3d4c829e429bc9dfa79737,
title = "Simultaneous PML-IRIS after discontinuation of natalizumab in a patient with MS",
abstract = "Objective: Progressive multifocal leukoencephalopathy (PML) is a severe complication of natalizumab therapy in patients with multiple sclerosis (MS), which is often accompanied by an immune reconstitution inflammatory syndrome (IRIS) after removal of the drug. We describe a patient with MS who presented with simultaneous PML-IRIS 2 months after stopping natalizumab for other reasons. Case Report and Results: The patient had widespread PML and severe IRIS. He received corticosteroids and displayed a vigorous JC virus-specific cellular immune response. Elevated myoinositol and lipid/creatine peaks measured in PML lesions by proton magnetic resonance spectroscopy (1H-MRS) corresponded to episodes of contrast enhancement on MRI scans and persisted after the enhancement subsided. He demonstrated steady clinical improvement, but developed marked residual atrophy in areas affected by PML and inflammation, as well as seizures. Conclusions: New enhancing white matter lesions, occurring after discontinuation of natalizumab, can be the manifestation of PML-IRIS rather than an MS exacerbation. Elevated myoinositol and lipid/creatine peaks appear to be more sensitive markers of inflammation in PML lesions than contrast enhancement. 1H-MRS may become useful as a biomarker for PML-IRIS by helping clinicians determine the need for corticosteroid administration and anticipate continuing clinical recovery.",
author = "S. Gheuens and Smith, {D. R.} and X. Wang and Alsop, {D. C.} and Lenkinski, {R. E.} and Koralnik, {I. J.}",
note = "Funding Information: Dr. Gheuens is funded by NIH grant T32 AI07387-21 and is a fellow of the Clinical Investigator Training Program: Beth Israel Deaconess Medical Center–Harvard/MIT Health Sciences and Technology, in collaboration with Pfizer Inc. and Merck & Co. Dr. Smith has received consulting/advisory fees and speaking honoraria but not grant support or standing committee income from all of the manufacturers of FDA-approved products for multiple sclerosis treatment. Dr. Wang is supported in part by NIH grant R01 NS047029 . Dr. Alsop is an inventor on several patents related to perfusion MRI (US Patent Nos. 7,545,142, 7,369,888, 6,980,845, 6,717,405) , for which he has received royalties from GE Healthcare and Siemens Medical; receives research support from GE Healthcare and is also supported by grants from the NIH , CA115745, EB004582, MH80729, MH077073, DC008796, NS047029, CA101942, AG031720, AG028076, DK084463 , and the Congressionally Directed Military Research Program of the Department of Defense , SC090251 ; and serves as Associate Editor of Magnetic Resonance in Medicine . Dr. Lenkinski is supported in part by NIH grant R01 NS047029 and receives research support from GE Healthcare. Dr. Koralnik is funded by NIH grants R56 NS 041198, R01 NS 047029 and K24 NS 060950 ; has received a research grant from Biogen Idec and the National Multiple Sclerosis Society; served on scientific advisory boards for Hoffmann La Roche, GlaxoSmithKline and Merck Serono; received consulting fees from Bristol Myers Squibb, Ono Pharmaceuticals, Merck Serono, Hoffmann La Roche, GlaxoSmithKline, Perseid Therapeutics, Vertex Pharmaceutical, Johnson & Johnson; and is an editorial board member for the Journal of NeuroVirology and receives royalties from UpToDate for topics on the management of HIV and CNS mass lesions and on PML. Go to Neurology.org for full disclosures . ",
year = "2012",
month = may,
day = "1",
doi = "10.1212/WNL.0b013e318253d61e",
language = "English (US)",
volume = "78",
pages = "1390--1393",
journal = "Neurology",
issn = "0028-3878",
publisher = "Lippincott Williams and Wilkins",
number = "18",
}