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. 2014:2014:307872.
doi: 10.1155/2014/307872. Epub 2014 Nov 23.

PML-IRIS during Fingolimod Diagnosed after Natalizumab Discontinuation

J Killestein  1 , A Vennegoor  1 , A E L van Golde  2 , R L J H Bourez  3 , M L B Wijlens  2 , M P Wattjes  4
Affiliations

PML-IRIS during Fingolimod Diagnosed after Natalizumab Discontinuation

J Killestein et al. Case Rep Neurol Med. 2014.

Abstract

Background. Natalizumab treatment is frequently discontinued and replaced by alternative medication in multiple sclerosis (MS) patients having a high risk of progressive multifocal leukoencephalopathy (PML). Case Presentation. We report a PML case that was missed on magnetic resonance imaging (MRI) at the time Natalizumab treatment was discontinued. The patient subsequently developed a PML-immune reconstitution inflammatory syndrome after the initiation of Fingolimod treatment, suggesting that immune reconstitution may occur even during Fingolimod induced lymphopenia. Conclusion. This report highlights the need for strict drug surveillance using MRI of Natalizumab-associated MS patients at the time of drug discontinuation and beyond. This is important with respect to pharmacovigilance purposes not only for Natalizumab, but also for alternative drugs used after Natalizumab discontinuation.

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Figures

Figure 1
Figure 1
Axial T2-weighted (top row) and contrast-enhanced T1-weighted images (bottom row) obtained during Natalizumab treatment (3 December 2012), at the time of Natalizumab discontinuation (22 April 2013), at the time of PML-IRIS occurrence (16 September 2013), and after PML-IRIS treatment (21 October 2013). A small lesion suggestive of PML was already visible at the time of Natalizumab discontinuation (arrow). During Fingolimod treatment, this lesion progressed and changed to a PML-IRIS manifestation with slight mass effect and contrast enhancement (arrows) leading to posttreatment sequelae (arrow).
See this image and copyright information in PMC

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