title: Massive exacerbation of multiple sclerosis after withdrawal and early restart of treatment with natalizumab.
abstract: We present a 46-year-old woman with a relapse of multiple sclerosis (MS) that began 3 months after withdrawal from long-term treatment with natalizumab. Shortly after restart of a single dose of natalizumab she developed a fulminant MS rebound with stupor and tetraparesis. Cerebral MRI showed massive progression in the number of lesions and tumefactive lesions with ring gadolinium-enhancement. Stereotactic brain biopsy revealed acute demyelination and B-cell dominated inflammation. The patient improved during therapeutic plasma exchange. We speculate that early restart of natalizumab in the case of a relapse may worsen disease evolution possibly by modifying regulatory immune effector processes during an inflammatory rebound phase. A restart of natalizumab in MS patients suffering from a recent relapse or with signs of active inflammation should be considered with caution.
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany. Electronic address: lena.beume@uniklinik-freiburg.de.
authors.forename: Lena-Alexandra
authors.initials: LA
authors.lastname: Beume
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
authors.forename: Rick
authors.initials: R
authors.lastname: Dersch
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
authors.forename: Hannah
authors.initials: H
authors.lastname: Fuhrer
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Stich
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Rauer
authors.affiliation: Department of Neurology, University Hospital Freiburg, Breisacherstrasse 64, 79106 Freiburg, Germany.
authors.forename: Wolf D
authors.initials: WD
authors.lastname: Niesen
mesh_terms: D001402:B-Lymphocytes / Q000276:immunology / Q000473:pathology; D003711:Demyelinating Diseases / Q000209:etiology / Q000473:pathology; D005260:Female; D006801:Humans; D007249:Inflammation / Q000473:pathology; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D020529:Multiple Sclerosis, Relapsing-Remitting / Q000150:complications* / Q000188:drug therapy*; D000069442:Natalizumab / Q000627:therapeutic use*; D010243:Paralysis / Q000209:etiology; D010951:Plasma Exchange; D012008:Recurrence; D013238:Stereotaxic Techniques; D053608:Stupor / Q000209:etiology; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy* / Q000503:physiopathology* / Q000523:psychology
chemical_list: D000069442:Natalizumab
keywords: IRIS; Multiple sclerosis; Natalizumab; Plasmapheresis; Rebound; Regulatory T-cells; Restart