Contributions
Abstract: EP1755
Type: ePoster
Abstract Category: Therapy - disease modifying - 29 Risk management for disease modifying treatments
We report the case of a 21 years old female, affected by multiple sclerosis since June 2016 with a very high clinical and neuroradiological disease activity in the very first months after onset. She was initially treated with natalizumab discontinued due to an allergic reaction. In February 2017 she was then switched to alemtuzumab-ALEM, administered without any adverse event during the five days of infusion. Two days after she complained for fever, vomiting and headache with progressive worsening. She arrived at our E.R. three days later with high fever (39.5 °C) and severe headache. We performed blood tests finding marked leukocytosis (17600 - 97.1% neutrophils and 0% lymphocytes) and CRP increase (158 mg/L). Due to severe headache we performed spinal tap with normal CSF biochemistry and negative bacterioscopic examination. Blood cultures were also performed and empirical antimicrobic therapy was promptly started with a regimen including ampicilline (2 g 6 times daily) and acyclovir (10mg/kg tid). Within the first 24 hours blood cultures revealed the presence of a Gram positive bacterium characterized as Listeria monocytogenes the day after. We added Gentamycine 5mg/kg with clinical improvement in 2 days and blood tests normalization in 7 days. This case underlines the importance of a strict clinical monitoring for infections in ALEM patients, especially in the first two months after drug administration. In the presence of fever with respiratory or gastrointestinal symptoms CMV is the most frequently involved pathogen. However Listeria represent another infective agent that should be taken into account, even in the very first days after ALEM infusion despite long incubation period, because of a pre-existing colonization of the gastrointestinal tract. An element that, besides routinary laboratory tests, may help the diagnostic process is the collection of a careful history, including food habits, being Listeria mainly acquired from some dietary products. ALEM eligible patients should be therefore recommended to avoid, since at least one month before treatment is scheduled, products such as not pastorized milk and cheese, raw meat and fish. Furthermore they should be instructed to consume in a few days any prepacked and ready to eat food, even if kept in the fridge, and to observe common hygienic rules (such as washing carefully fruit and vegetables before consumption, and hands before eating or preparing meals).
Disclosure:
Lucia Moiola: I received compensation for consulting services, travel grants and / or speaking activities from Biogen-Idec, Merck-Serono, Sanofi-Genzyme, Teva
Simone Guerrieri: nothing to disclose
Marco Pisa: nothing to disclose
Vittorio Martinelli: I received compensation for consulting services, travel grants and / or speaking activities from Novartis, Teva, Sanofi-Genzyme, Merck, Biogen, Bayer
Giancarlo Comi: I received compensation for consulting services, travel grants and / or speaking activities from Novartis, Teva, Sanofi-Genzyme, Merck, Biogen, Roche, Almirall, Celgene, Forward Pharma
Abstract: EP1755
Type: ePoster
Abstract Category: Therapy - disease modifying - 29 Risk management for disease modifying treatments
We report the case of a 21 years old female, affected by multiple sclerosis since June 2016 with a very high clinical and neuroradiological disease activity in the very first months after onset. She was initially treated with natalizumab discontinued due to an allergic reaction. In February 2017 she was then switched to alemtuzumab-ALEM, administered without any adverse event during the five days of infusion. Two days after she complained for fever, vomiting and headache with progressive worsening. She arrived at our E.R. three days later with high fever (39.5 °C) and severe headache. We performed blood tests finding marked leukocytosis (17600 - 97.1% neutrophils and 0% lymphocytes) and CRP increase (158 mg/L). Due to severe headache we performed spinal tap with normal CSF biochemistry and negative bacterioscopic examination. Blood cultures were also performed and empirical antimicrobic therapy was promptly started with a regimen including ampicilline (2 g 6 times daily) and acyclovir (10mg/kg tid). Within the first 24 hours blood cultures revealed the presence of a Gram positive bacterium characterized as Listeria monocytogenes the day after. We added Gentamycine 5mg/kg with clinical improvement in 2 days and blood tests normalization in 7 days. This case underlines the importance of a strict clinical monitoring for infections in ALEM patients, especially in the first two months after drug administration. In the presence of fever with respiratory or gastrointestinal symptoms CMV is the most frequently involved pathogen. However Listeria represent another infective agent that should be taken into account, even in the very first days after ALEM infusion despite long incubation period, because of a pre-existing colonization of the gastrointestinal tract. An element that, besides routinary laboratory tests, may help the diagnostic process is the collection of a careful history, including food habits, being Listeria mainly acquired from some dietary products. ALEM eligible patients should be therefore recommended to avoid, since at least one month before treatment is scheduled, products such as not pastorized milk and cheese, raw meat and fish. Furthermore they should be instructed to consume in a few days any prepacked and ready to eat food, even if kept in the fridge, and to observe common hygienic rules (such as washing carefully fruit and vegetables before consumption, and hands before eating or preparing meals).
Disclosure:
Lucia Moiola: I received compensation for consulting services, travel grants and / or speaking activities from Biogen-Idec, Merck-Serono, Sanofi-Genzyme, Teva
Simone Guerrieri: nothing to disclose
Marco Pisa: nothing to disclose
Vittorio Martinelli: I received compensation for consulting services, travel grants and / or speaking activities from Novartis, Teva, Sanofi-Genzyme, Merck, Biogen, Bayer
Giancarlo Comi: I received compensation for consulting services, travel grants and / or speaking activities from Novartis, Teva, Sanofi-Genzyme, Merck, Biogen, Roche, Almirall, Celgene, Forward Pharma