Contributions
Abstract: P1287
Type: Poster
Abstract Category: Therapy - disease modifying - Others
Introduction: Natalizumab has been used to treat multiple sclerosis (MS) and has achieved relapse control, injury burden reduction, fewer new lesions on brain MRI, and fewer sequelae in patients with high disease activity who fail to respond to immunomodulation. Here, we describe a novel case of natalizumab-associated CNS tuberculosis.
Case report: A 54-year-old female was diagnosed with secondary progressive MS in February 2012, with a history of two previous relapses (2010 and 2011). Her clinical condition deteriorated over the last year with a global cerebellar syndrome, and cognitive impairment. Her EDSS score was 6.0. Natalizumab monthly therapy was initiated after considering clinical involvement, and elevated lesion burden on MRI. She did not have antibodies anti JCV, and a chest X-ray was normal. During follow-up, the patient showed stable disease with no clinical relapses, discrete improvement on cognition, and stable lesion burden on annual cranial MRI.
After 22 natalizumab infusions, the patient was taken to the emergency department after two seizures, and a subsequently low consciousness level. MRI showed a hypointense lesion on T2 and FLAIR in the left frontal region adjacent to the meninges, and gadolinium-enhancement on T1. CSF testing showed mild pleocytosis (four cells), protein of 46 mg/dL, and hypoglicorrhachia (CSF glucose, 59 mg/dL; serum glucose, 125 mg/dL). Syphilis and cryptococci tests and bacterioscopy were negative, as were CSF cultures for bacteria, fungus, and Mycobacterium tuberculosis negative. She had not been vaccinated with BCG. A biopsy of the meningeal lesion was performed after 3 weeks of initiation of oral empirical treatment for tuberculosis (isoniazid, rifampicin, pyrazinamide, and ethambutol). Meningeal biopsy confirmed caseous necrosis with granuloma formation, and she was diagnosed with tuberculosis pachymeningitis, although PCR was negative in this issue, and no bacillus was determined . The patient showed a good response to treatment with progressive neurological and MRI improvement, and no recurrence after one year of follow-up.
Conclusion: Besides natalizumab related progressive multifocal leukoencephalopathy, there are reported cases of neoplastic lesions and other infections related to its use. To the best of our knowledge, this is the first case of CNS tuberculosis associated with natalizumab treatment. Screening for pulmonary tuberculosis has been recommended, mainly in endemic areas.
Disclosure: Speaker in Board: Noovartis, Biogen, Merck-Serono, Genzyme, Pfizer, Teva and Boheringer;
Support for participation in conferences and scientific events: Novartis, Biogen, Merck-Serono, Genzyme, Teva , Bayer and Boheringer;
Participation in research : Novartis and Genzyme
Abstract: P1287
Type: Poster
Abstract Category: Therapy - disease modifying - Others
Introduction: Natalizumab has been used to treat multiple sclerosis (MS) and has achieved relapse control, injury burden reduction, fewer new lesions on brain MRI, and fewer sequelae in patients with high disease activity who fail to respond to immunomodulation. Here, we describe a novel case of natalizumab-associated CNS tuberculosis.
Case report: A 54-year-old female was diagnosed with secondary progressive MS in February 2012, with a history of two previous relapses (2010 and 2011). Her clinical condition deteriorated over the last year with a global cerebellar syndrome, and cognitive impairment. Her EDSS score was 6.0. Natalizumab monthly therapy was initiated after considering clinical involvement, and elevated lesion burden on MRI. She did not have antibodies anti JCV, and a chest X-ray was normal. During follow-up, the patient showed stable disease with no clinical relapses, discrete improvement on cognition, and stable lesion burden on annual cranial MRI.
After 22 natalizumab infusions, the patient was taken to the emergency department after two seizures, and a subsequently low consciousness level. MRI showed a hypointense lesion on T2 and FLAIR in the left frontal region adjacent to the meninges, and gadolinium-enhancement on T1. CSF testing showed mild pleocytosis (four cells), protein of 46 mg/dL, and hypoglicorrhachia (CSF glucose, 59 mg/dL; serum glucose, 125 mg/dL). Syphilis and cryptococci tests and bacterioscopy were negative, as were CSF cultures for bacteria, fungus, and Mycobacterium tuberculosis negative. She had not been vaccinated with BCG. A biopsy of the meningeal lesion was performed after 3 weeks of initiation of oral empirical treatment for tuberculosis (isoniazid, rifampicin, pyrazinamide, and ethambutol). Meningeal biopsy confirmed caseous necrosis with granuloma formation, and she was diagnosed with tuberculosis pachymeningitis, although PCR was negative in this issue, and no bacillus was determined . The patient showed a good response to treatment with progressive neurological and MRI improvement, and no recurrence after one year of follow-up.
Conclusion: Besides natalizumab related progressive multifocal leukoencephalopathy, there are reported cases of neoplastic lesions and other infections related to its use. To the best of our knowledge, this is the first case of CNS tuberculosis associated with natalizumab treatment. Screening for pulmonary tuberculosis has been recommended, mainly in endemic areas.
Disclosure: Speaker in Board: Noovartis, Biogen, Merck-Serono, Genzyme, Pfizer, Teva and Boheringer;
Support for participation in conferences and scientific events: Novartis, Biogen, Merck-Serono, Genzyme, Teva , Bayer and Boheringer;
Participation in research : Novartis and Genzyme