title: Treatment of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with intravenous immunoglobulin in a patient with multiple sclerosis treated with fingolimod after discontinuation of natalizumab.
abstract: We report a case of progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome in a multiple sclerosis (MS) patient 3.5 months after fingolimod commencement and 4.5 months after natalizumab (NTZ) cessation. Three cerebrospinal fluid analyses were required before a definitive diagnosis of progressive multifocal leukoencephalopathy was reached. Intravenous immunoglobulin (IVIG) was subsequently given as the sole MS treatment along with mirtazapine and mefloquine. There has been improvement and subsequent clinical stabilization. The notable features are the difficult timing of fingolimod commencement in the context of previous NTZ therapy, the role of repeated cerebrospinal fluid John Cunningham virus analyses in progressive multifocal leukoencephalopathy diagnosis, and the role of IVIG.
authors.affiliation: Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Z
authors.initials: Z
authors.lastname: Calic
authors.affiliation: Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia. Electronic address: Cecilia.Cappelen-Smith@swsahs.nsw.gov.au.
authors.forename: C
authors.initials: C
authors.lastname: Cappelen-Smith
authors.affiliation: Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
authors.forename: S J
authors.initials: SJ
authors.lastname: Hodgkinson
authors.affiliation: Department of Neurology and Neurophysiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
authors.forename: A
authors.initials: A
authors.lastname: McDougall
authors.affiliation: Department of Radiology, Liverpool Hospital, Liverpool BC, NSW, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Cuganesan
authors.affiliation: Department of Neurology, St Vincent's Hospital, Darlinghurst, NSW, Australia.
authors.forename: B J
authors.initials: BJ
authors.lastname: Brew
mesh_terms: D000328:Adult; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D005260:Female; D000068876:Fingolimod Hydrochloride / Q000627:therapeutic use*; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000150:complications / Q000188:drug therapy*; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D007155:Immunologic Factors / Q000627:therapeutic use*; D007968:Leukoencephalopathy, Progressive Multifocal / Q000150:complications / Q000188:drug therapy*; D009103:Multiple Sclerosis / Q000150:complications / Q000188:drug therapy*; D000069442:Natalizumab / Q000627:therapeutic use*; D019233:Retreatment; D016896:Treatment Outcome
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors; D000069442:Natalizumab; D000068876:Fingolimod Hydrochloride
keywords: Fingolimod; Intravenous immunoglobulin; Natalizumab; PML–IRIS