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Progressive multifocal leukoencephalopathy after interferon beta-1a monotherapy

Authors:
Helmar Lehmann at University of Cologne
Helmar Lehmann
Klaus Krüger at Independent Researcher
Klaus Krüger
  • Independent Researcher
Gereon R Fink
Gereon R Fink
Gereon R Fink
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Michael Schroeter at University of Cologne
Michael Schroeter
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Dear Sirs,We report a 46-year old woman who presented in 2009 with gait ataxia and dysarthria. Magnetic resonance (MR) imaging showed one isolated T2 hyperintense, slightly Gadolinium (Gd) enhancing lesion in the right cerebellar hemisphere. Oligoclonal bands in the cerebrospinal fluid (CSF) were positive, and the patient was diagnosed as clinically isolated syndrome. Over the next 2 years, symptoms partially remitted and repeated MRI scans confirmed regression of the cerebellar lesion. In August 2013 a relapse occurred, with gait ataxia and mild spastic paresis of the right arm. MRI scan at this time point demonstrated new periventricular and juxtacortical lesions (Fig. 1a, b). Subsequently immunomodulatory treatment with intramuscularly administered interferon beta-1a (Avonex®, 30 μg, weekly) was initiated.Fig. 1MR Imaging during interferon beta-1a treatment and development of PML: Axial T2-FLAIR (a, c, g) and Gd-enhanced T1-SE (e), coronal T2-FSE (d), and axial Double-Inversion Reco ...
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LETTER TO THE EDITORS
Progressive multifocal leukoencephalopathy after interferon
beta-1a monotherapy
Helmar C. Lehmann •Klaus Kru
¨ger •
Gereon R. Fink •Michael Schroeter
Received: 18 October 2014 / Revised: 11 December 2014 / Accepted: 13 December 2014
ÓSpringer-Verlag Berlin Heidelberg 2015
Dear Sirs,
We report a 46-year old woman who presented in 2009
with gait ataxia and dysarthria. Magnetic resonance (MR)
imaging showed one isolated T2 hyperintense, slightly
Gadolinium (Gd) enhancing lesion in the right cerebellar
hemisphere. Oligoclonal bands in the cerebrospinal fluid
(CSF) were positive, and the patient was diagnosed as
clinically isolated syndrome. Over the next 2 years,
symptoms partially remitted and repeated MRI scans con-
firmed regression of the cerebellar lesion. In August 2013 a
relapse occurred, with gait ataxia and mild spastic paresis
of the right arm. MRI scan at this time point demonstrated
new periventricular and juxtacortical lesions (Fig. 1a, b).
Subsequently immunomodulatory treatment with intra-
muscularly administered interferon beta-1a (Avonex
Ò
,
30 lg, weekly) was initiated.
In April 2014, the patient developed progressive left
hemiparesis. MRI scan showed progressive subcortical
lesions affecting U-fibers with spotty Gd-enhancement in
the right hemisphere and left frontal lobe suggestive of
PML (Fig. 1c–f) [10]. CSF was twice tested positive for
JC-virus by polymerase chain reaction.
Because of the unexpected occurrence of PML further
immunological workup was performed, revealing a serum
hypogammaglobulinemia (IgG 4.1 g/l, normal range
7–16 g/l; IgA 0.6 g/l; normal range 0.7–4.0 g/l), which was
in retrospect already present during a routine laboratory
test in 2009 (IgG 6.1 g/l). In addition mild lymphopenia
(1,190 per cubic millimeter) with reduced CD4 T cell count
(140 per cubic millimeter) was detected, compatible with
the diagnosis of a common variable immunodeficiency
syndrome (CVID). HIV infection and other causes of
secondary immunodeficiency were ruled out by appropriate
laboratory tests.
After establishing the diagnosis of PML, treatment with
interferon beta-1a was stopped immediately. Instead, the
patient was treated with mirtazapine (30 mg per day),
mefloquine (250 mg per day), filgrastim (30 Mio I.E. for 5
consecutive days) [11] and intravenous immunoglobulins
(1 g/kg bodyweight), because of the hypogammaglobulin-
emia. The following weeks these therapeutic measures lead
to rapid clinical stabilization and partial recovery of the
hemiparesis. Follow-up MRI scans 5 and 9 weeks after
treatment (Fig. 1g, e) showed a considerable reduction of
the right-hemispheric lesions without evidence for an
immune reconstitution syndrome.
This is to our knowledge the first report of a MS patient
who developed PML during monotherapy with interferon
beta-1a. All required criteria for the diagnosis of MS were
fulfilled [5], including typical clinical presentation of several
attacks affecting different functional systems, disseminated
MS-typical MRI lesions and presence of oligoclonal bands in
the CSF. Laboratory tests for, e.g. tick born diseases, herpes
H. C. Lehmann (&)G. R. Fink M. Schroeter
Department of Neurology, University Hospital of Cologne,
Kerpener Straße 62, 50937 Cologne, Germany
e-mail: helmar.lehmann@uk-koeln.de
G. R. Fink
e-mail: gereon.fink@uk-koeln.de
M. Schroeter
e-mail: michael.schroeter@uk-koeln.de
K. Kru
¨ger
Neurology Practice, Friedrich-Ebert-Platz 2B, 53773 Hennef,
Germany
e-mail: krueger@neurologie-hennef.de
G. R. Fink
Institute of Neuroscience and Medicine (INM-3), Research
Center Ju
¨lich, Ju
¨lich, Germany
123
J Neurol
DOI 10.1007/s00415-014-7620-4
viruses, syphilis, rheumatic disease, and thyroid disorders
were unremarkable and excluded MS mimics.
The clear temporal association suggests that interferon
beta-1a treatment may have provoked PML in our case.
However, similar to natalizumab-associated PML cases in
which risk factors are debated, we believe that the previ-
ously unrecognized and clinically inapparent immunodefi-
ciency syndrome may have been a critical predisposing
factor for PML. It explains why PML has never been
described before in other MS patients receiving interferon
beta monotherapy, despite extensive worldwide use of this
drug over the last 20 years.
Common variable immunodeficiency syndrome itself is
a sporadic primary immunodeficiency disorder with
increased susceptibility to infections [1,4]. Rarely, also
cases of PML have been reported in CVID [1,3,8,9].
Some CVID patients may present primarily with autoim-
mune disease, including encephalomyelitis, and are more
resistant to infections despite severe hypogammaglobulin-
emia [2,4,7].
Our case implies that interferon beta-1a may provoke
PML in MS patients who are not fully immunocompetent.
Thus, interferons should be carefully used in MS patients
with any history of immunodeficiency. Treatment de-
Fig. 1 MR Imaging during
interferon beta-1a treatment and
development of PML: Axial T2-
FLAIR (a,c,g) and Gd-
enhanced T1-SE (e), coronal
T2-FSE (d), and axial Double-
Inversion Recovery (DIR) with
WM and CSF suppression (b,f,
h). a,bInitial MRI in August
2013 showing periventricular
and juxtacortical lesions. c–
fMRI in April 2014, 7 months
after treatment initiation with
interferon beta-1a shows
multifocal progressive
hyperintense lesions with spots
of Gd-enhancement
(arrowhead) suggestive for
PML. g,hFollow-up scan
5 weeks after discontinuation of
interferon beta-1a and treatment
with IVIg shows lesions clearly
smaller and better demarcated
from surrounding white matter
J Neurol
123
escalation strategies in MS that include the use of inter-
ferons [6] should consider this potential risk.
Conflicts of interest HCL has received personal compensations
and/or grant support from Baxter, Celgene, CSL Behring, Fresenius,
Grifols, and Novartis. MS has received personal and/or institutional
compensations from Almirall, Baxter, Bayer HealthCare, Boehringer
Ingelheim, Biogen Idec, CSL Behring, Grifols, Merck Serono, Nov-
artis, Sanofi-Genzyme, and Teva.
Ethical standard This letter was written in accordance with the
ethical standards laid down in the Declaration of Helsinki and its later
amendments.
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... With more than 30 years of pharmacovigilance data, IFN-β use has been rarely associated with occurrence of additional serious AE. Despite the fact that IFN-β treatment is not commonly associated with significant immunodeficiency, one case of potential progressive multifocal leukoencephalopathy (PML) has been reported [18]. Laboratory findings in the patient determined long-standing common variable immunodeficiency syndrome (CVID with mild lymphopenia, low CD4 T-cell count and hypogammaglobulinemia) [18]. ...
... Despite the fact that IFN-β treatment is not commonly associated with significant immunodeficiency, one case of potential progressive multifocal leukoencephalopathy (PML) has been reported [18]. Laboratory findings in the patient determined long-standing common variable immunodeficiency syndrome (CVID with mild lymphopenia, low CD4 T-cell count and hypogammaglobulinemia) [18]. Although the PML can be attributed to the CVID, IFN-β may have the ability to provoke such complication [18]. ...
... Laboratory findings in the patient determined long-standing common variable immunodeficiency syndrome (CVID with mild lymphopenia, low CD4 T-cell count and hypogammaglobulinemia) [18]. Although the PML can be attributed to the CVID, IFN-β may have the ability to provoke such complication [18]. Another SAE associated with IFN-β use includes thrombotic microangiopathy (defined as hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura) which can lead to renal failure and cerebral ischemia [19]. ...
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... Given the atypical MRI findings, the diagnosis of PML was not realized until brain autopsy. Lehmann et al. reported a case of a patient whose hypogammaglobulinemia was recognized after diagnosis of PML, leading to a diagnosis of common variable immunodeficiency syndrome (CVID) [9]. In the case of our patient, no immunosuppressive condition has been formally diagnosed, but she was noted to have a mild lymphopenia during her admission, raising the possibility of an undiagnosed CVID. ...
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