Abstract Details

Title Facilitation of Progressive Multifocal Leukoencephalopathy Progression in Natalizumab-Treated Multiple Sclerosis Patients by Suppression of Viral Clearance wth Corticosteroids

Topic MS and Related Diseases

Presentation(s) P01 - (-)

Poster/Presentation
Number 180

Objective

Background BACKGROUND: IRIS that follows PML in natalizumab-treated multiple sclerosis (NTMS) is typically treated with IV corticosteroids upon its appearance by clinical or radiographic signs. The proper duration and dose of corticosteroids have not been investigated.

Design/Methods DESIGN/METHODS: Case reports.

Results RESULTS: Two NTMS patients with PML were treated with a previously described protocol of PLEX, granulocyte colony stimulating factor (G-CSF), and maraviroc. Upon developing clinical worsening or contrast enhancements on cranial MRI indicative of IRIS, both patients received intravenous methylprednisolone followed by prolonged oral prednisone taper (4-8 weeks). Within 2-4 weeks, the patients stabilized clinically and on MRI. Over the ensuing 4-8 weeks, they began to worsen clinically. Repeat brain MRI studies revealed increasing lesions without contrast enhancements. Suspecting poor viral clearance secondary to immunosuppression, corticosteroids were discontinued in both patients. One patient received a second course of G-CSF, which rekindled IRIS by MRI in 3 days. The other patient developed IRIS by MRI in 2 weeks without additional G-CSF. Recurring IRIS was allowed to evolve for about 1 week while monitoring clinically and by MRI for signs of intracranial hypertension. Shorter courses of lower dose IV methylprednisolone were followed by faster oral corticosteroids tapers, halting worsening. Persistent though diminishing IRIS on follow-up brain MRIs over the ensuing 6-8 weeks was not aggressively treated with corticosteroids as patients remained stable. Both patients have since stabilized radiographically and improved clinically.

Conclusions CONCLUSIONS: Early and aggressive use of corticosteroids prophylactically or after IRIS could result in facilitating progression of PML by suppressing viral clearance. In such cases, rekindling IRIS (with G-CSF or withdrawing corticosteroids) can increase viral clearance and stabilize patients clinically and radiographically.

Authors/Disclosures
Michael Ko, MD (CHPG Neuroscience and Spine - SAN Orchard) PRESENTER	No disclosure on file
Roumen D. Balabanov, MD (Northwestern University)	Dr. Balabanov has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Balabanov has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Balabanov has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. Dr. Balabanov has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen. The institution of Dr. Balabanov has received research support from NextCure. The institution of Dr. Balabanov has received research support from Biogen. The institution of Dr. Balabanov has received research support from NINDS.
Dusan Stefoski, MD, FAAN	No disclosure on file
Barbara Bumstead, NP	Ms. Bumstead has nothing to disclose.

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