Alemtuzumab
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Eosinophilic central nervous system vasculitis: case report An approximately 45-year-old woman developed eosinophilic central nervous system (CNS) vasculitis during treatment with alemtuzumab for relapsing-remitting multiple sclerosis [route, dosage and duration of treatment to reaction onset not stated]. The woman was diagnosed with relapsing-remitting multiple sclerosis at the age of 36 years in 2005. Initially, she was treated with several medications including steroids, glatiramer acetate and dimethyl-fumarate, but she experienced multiple relapses. Thus, from March 2015, further treatment was started with alemtuzumab. She received the first 5 days course of alemtuzumab along with viral prophylaxis. The MRI in December 2015, showed a new lesion, but no clinical relapse was considered. However, in January 2016, she presented with a right-sided spasm. The woman was treated with gabapentin. Three weeks later, she reported partial seizures comprising dysgeusia, speech arrest and left head version. Subsequently, she was hospitalised and treated with levetiracetam. The brain MRI indicated multiple foci of poorly defined high T2 signal involving the left insular and perisylvian cortex, bilateral temporal poles and the left inferior parietal lobe suggestive of progressive multifocal leukoencephalopathy. Subsequent MRI scans revealed evolving abnormalities of the left temporal and parietal lesion. The CSF testing was negative for the JC virus and other viral infections. A CSF flow cytometry demonstrated small numbers of reactive lymphocytes with a CD4:CD8 ratio of 1:1. Flow cytometry of blood showed a reduced count of CD4+, CD8+ and T-cell, Her condition worsened with progressive disinhibition, euphoria and dysphasia. She required antiepileptics in escalated doses. Thereafter, a brain biopsy was performed that revealed demyelination within the white matter and cortical gliosis, astrocytosis and micro-vacuolation associated with neuronal loss. Within the cortex and leptomeninges, a predominantly perivascular inflammatory cell infiltrate was observed, comprising lymphocytes, macrophages, eosinophils and plasma cells. There was no evidence of any infection. Thus, from these investigations, a diagnosis of eosinophilic CNS vasculitis was made. She was treated with prednisolone, along with plasma exchange therapy. Thereafter, she was commenced on cyclophosphamide. Due to lymphopenia, a granulocyte-colony stimulating factor was added to the treatment. After 6 weeks, she was discharged for rehabilitation. At this point, she exhibited right-sided weakness, left hemianopia and dysphasia. After 5 months of cyclophosphamide initiation, she exhibited full recovery of vision and power, along with an almost complete resolution of dysphasia. Leach OA, et al. Alemtuzumab-related eosinophilic central nervous system vasculitis. Multiple Sclerosis Journal 26: 1602-1606, No. 12, 2020. Available from: URL: http:// 803516023 doi.org/10.1177/1352458519898113
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