Diagnosis and Treatment of Progressive Multifocal Leukoencephalopathy Associated with Multiple Sclerosis Therapies

Abstract

Progressive multifocal leukoencephalopathy (PML) is a rare, but serious, complication encountered in patients treated with a select number of disease-modifying therapies (DMTs) utilized in treating multiple sclerosis (MS). PML results from a viral infection in the brain for which the only demonstrated effective therapy is restoring the perturbed immune system-typically achieved in the patient with MS by removing the offending therapeutic agent or, in the case of HIV-associated PML, treatment with highly active antiretroviral therapies. Other therapies for PML remain either ineffective or experimental. Significant work to understand the virus and host interaction has been undertaken, but lack of an animal model for the disorder has significantly hindered progress, especially with respect to development of treatments. Strategies to limit risk of PML with natalizumab, a drug that carries a uniquely high risk for the development of the disorder, have been developed. Identifying factors such as positive JC virus antibody status that increase PML risk, at least in theory, should decrease the incidence rate of the disease. Whether other risk factors for PML can be identified and validated or unique strategies should be employed in association with other DMTs that predispose to PML and whether this has a salutary effect on outcome remains to be demonstrated. Identifying PML early, then promptly eliminating drug in the case of natalizumab-associated PML has demonstrated better outcomes, but the complication of PML continues to carry significant morbidity and mortality. While the scientific community has yet to identify targeted therapy with proven efficacy against JCV or PML there are several candidates being studied.

Keywords: Immune suppression; JC virus; Multiple sclerosis; Natalizumab; Progressive multifocal leukoencephalopathy; Viral infections.

Fig. 1

JC Virus (JCV)–progressive multifocal leukoencephalopathy life cycle

Fig. 2

Progressive multifocal leukoencephalopathy pathology. Black arrow highlights enlarged bizarre astrocyte; red arrow illustrates oligodendrocyte with intranuclear viral inclusion. Photo credit to MacLean Nasrallah, MD, PhD, Department of Pathology and Laboratory Medicine, University of Pennsylvania

Fig. 3

Progressive multifocal leukoencephalopathy (PML) radiographically. (a) Typical lesion of PML as a T2 hyperintensity involving large portion of 1 hemisphere. (b) T2 fluid-attenuated inversion recovery image demonstrating hyperintensity in the bilateral cerebellum consistent with PML