Case Reports

. 2020 Dec 15;8(1):e929.

doi: 10.1212/NXI.0000000000000929. Print 2021 Jan.

Treating MS after surviving PML: Discrete strategies for rescue, remission, and recovery patient 1: From the National Multiple Sclerosis Society Case Conference Proceedings

Nidhiben Anadani¹, Megan Hyland¹, Roberto Alejandro Cruz¹, Robert Lisak¹, Kathleen Costello¹, Eugene O Major¹, Yasir Jassam¹, Ethan Meltzer¹, Thomas C Varkey¹, Matthew S Parsons¹, Andrew D Goodman¹, Jennifer S Graves¹, Scott Newsome¹, Scott S Zamvil¹, Elliot M Frohman², Teresa C Frohman²

Affiliations

¹ From the University of Rochester (N.A.), NY. N. Anadani is now with Department of Neurology, University of Oklahoma Health Science Center; Department of Neurology (M.H., A.D.G.), University of Rochester, NY; Department of Neurology (R.A.C., E.M., T.C.V.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.L.), Wayne State University, Detroit, MI; The National Multiple Sclerosis Society (K.C.), New York, NY; Laboratory of Molecular Medicine and Neuroscience (E.O.M.), Neurological Institute of Neurological Disorder and Stroke (Y.J.), Bethesda, MD. Y. Jassam is now with Department of Neurology, The University of Kansas Health System; Colangelo College of Business (T.C.V.), Grand Canyon University, Phoenix, AZ; Division of Microbiology and Immunology (M.S.P.), Yerkes National Primate Research Center, and Department of Pathology and Laboratory Medicine (M.S.P.), Emory University, Atlanta, GA; Department of Neurosciences (J.S.G.), University of California at San Diego; Department of Neurology (S.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco; and Department of Neurology, Neurosurgery, and Ophthalmology (E.M.F., T.C.F.), Dell Medical School at the University of Texas at Austin.
² From the University of Rochester (N.A.), NY. N. Anadani is now with Department of Neurology, University of Oklahoma Health Science Center; Department of Neurology (M.H., A.D.G.), University of Rochester, NY; Department of Neurology (R.A.C., E.M., T.C.V.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.L.), Wayne State University, Detroit, MI; The National Multiple Sclerosis Society (K.C.), New York, NY; Laboratory of Molecular Medicine and Neuroscience (E.O.M.), Neurological Institute of Neurological Disorder and Stroke (Y.J.), Bethesda, MD. Y. Jassam is now with Department of Neurology, The University of Kansas Health System; Colangelo College of Business (T.C.V.), Grand Canyon University, Phoenix, AZ; Division of Microbiology and Immunology (M.S.P.), Yerkes National Primate Research Center, and Department of Pathology and Laboratory Medicine (M.S.P.), Emory University, Atlanta, GA; Department of Neurosciences (J.S.G.), University of California at San Diego; Department of Neurology (S.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco; and Department of Neurology, Neurosurgery, and Ophthalmology (E.M.F., T.C.F.), Dell Medical School at the University of Texas at Austin. Elliot.frohman@austin.utexas.edu.

PMID: 33411672
PMCID: PMC7803340
DOI: 10.1212/NXI.0000000000000929

Case Reports

Treating MS after surviving PML: Discrete strategies for rescue, remission, and recovery patient 1: From the National Multiple Sclerosis Society Case Conference Proceedings

Nidhiben Anadani et al. Neurol Neuroimmunol Neuroinflamm. 2020.

. 2020 Dec 15;8(1):e929.

doi: 10.1212/NXI.0000000000000929. Print 2021 Jan.

Authors

Affiliations

¹ From the University of Rochester (N.A.), NY. N. Anadani is now with Department of Neurology, University of Oklahoma Health Science Center; Department of Neurology (M.H., A.D.G.), University of Rochester, NY; Department of Neurology (R.A.C., E.M., T.C.V.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.L.), Wayne State University, Detroit, MI; The National Multiple Sclerosis Society (K.C.), New York, NY; Laboratory of Molecular Medicine and Neuroscience (E.O.M.), Neurological Institute of Neurological Disorder and Stroke (Y.J.), Bethesda, MD. Y. Jassam is now with Department of Neurology, The University of Kansas Health System; Colangelo College of Business (T.C.V.), Grand Canyon University, Phoenix, AZ; Division of Microbiology and Immunology (M.S.P.), Yerkes National Primate Research Center, and Department of Pathology and Laboratory Medicine (M.S.P.), Emory University, Atlanta, GA; Department of Neurosciences (J.S.G.), University of California at San Diego; Department of Neurology (S.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco; and Department of Neurology, Neurosurgery, and Ophthalmology (E.M.F., T.C.F.), Dell Medical School at the University of Texas at Austin.
² From the University of Rochester (N.A.), NY. N. Anadani is now with Department of Neurology, University of Oklahoma Health Science Center; Department of Neurology (M.H., A.D.G.), University of Rochester, NY; Department of Neurology (R.A.C., E.M., T.C.V.), Dell Medical School at the University of Texas at Austin; Department of Neurology (R.L.), Wayne State University, Detroit, MI; The National Multiple Sclerosis Society (K.C.), New York, NY; Laboratory of Molecular Medicine and Neuroscience (E.O.M.), Neurological Institute of Neurological Disorder and Stroke (Y.J.), Bethesda, MD. Y. Jassam is now with Department of Neurology, The University of Kansas Health System; Colangelo College of Business (T.C.V.), Grand Canyon University, Phoenix, AZ; Division of Microbiology and Immunology (M.S.P.), Yerkes National Primate Research Center, and Department of Pathology and Laboratory Medicine (M.S.P.), Emory University, Atlanta, GA; Department of Neurosciences (J.S.G.), University of California at San Diego; Department of Neurology (S.N.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology and Program in Immunology (S.S.Z.), University of California San Francisco; and Department of Neurology, Neurosurgery, and Ophthalmology (E.M.F., T.C.F.), Dell Medical School at the University of Texas at Austin. Elliot.frohman@austin.utexas.edu.

PMID: 33411672
PMCID: PMC7803340
DOI: 10.1212/NXI.0000000000000929

No abstract available

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Figures

**Figure 1. Chronological heat map**
In this figure, we detail the condition of the patient over time. The longitudinal axis (left to right) depicts the condition of disease, where the smaller amplitude and lighter color indicates greater stability of MS. Alternately, the expanded amplitude of the colored heat map (above and below the horizontal linear axis over time) designates increased disease activity (whether on a clinical or paraclinical basis) or complications of the treatment of disease (e.g., PML). Four other fields of information are added either above or below the heat map and include information about treatments, diagnoses, commentaries adding contextual perspectives, and results from specific test assessments from each most relevant period of clinical decision-making. Each field is consistently color coded throughout as defined in the figure legend. IRIS = immune reconstitution inflammatory syndrome; IVIG = IV immunoglobulin; JCV Ab = John Cunningham Polyomavirus antibody; LFT = liver function test; PML = progressive multifocal leukoencephalopathy.

**Figure 2. Evolution of the left thalamic lesion**
In (A), an axial T2 fluid-attenuated inversion recovery (FLAIR) image demonstrates a new hyperintense lesion localized to the left thalamus (red arrows), with periventricular and juxtacortical lesions typical of MS. In (B), an axial T1 postcontrast scan shows hypointensity of the left thalamic lesion without contrast enhancement. In (C–G), we present axial FLAIR images performed serially at 3, 7, 11, 16, and 20 weeks, respectively, after the inception of the right upper extremity tremor. Over this period, the lesion has slightly increased in size, and in (F), the lesion takes on a ring configuration with central hypointensity (red arrows). This lesion failed to exhibit any evidence of contrast enhancement over the period of surveillance imaging.

**Figure 3. Interval neuroradiographic progression**
In (A), we present axial fluid-attenuated inversion recovery images revealing disseminated lesions characteristic for inflammatory demyelination in the periventribular zones, in the centrum semiovale, in the corona radiata, and in the cortex and juxtacortical zones, in addition to the previously identified left thalamic lesion, here exhibiting a ring configuration with central hypointensity (red arrow). In (B), we present axial T1 postcontrast images showing various nodular enhancing lesions in left dorsolateral pons and bilateral frontal lobes and patchy punctate enhancements in left frontal and parietal white matter (red arrows).

See this image and copyright information in PMC

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Treating MS after surviving PML: Discrete strategies for rescue, remission, and recovery patient 1: From the National Multiple Sclerosis Society Case Conference Proceedings

Affiliations

Treating MS after surviving PML: Discrete strategies for rescue, remission, and recovery patient 1: From the National Multiple Sclerosis Society Case Conference Proceedings

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