title: Case report of a patient with progressive multifocal leukoencephalopathy under treatment with dimethyl fumarate.
abstract: BACKGROUND
  Progressive multifocal leukoencephalopathy is a severe demyelinating disease caused by the polyoma JC virus in patients with reduced immunocompetence. A few cases of progressive multifocal leukoencephalopathy have been reported in patients treated with fumaric acid esters.
  
  
  METHODS
  A 53-year-old Caucasian woman reported to our clinic with a first focal epileptic seizure and mild cognitive impairment. Since 1.5 years, she was treated with fumaderm for her psoriasis. During that time, her lymphocyte counts ranged between 450 and 700/μl. Cerebral magnet resonance imaging showed multifocal subcortical T2 hyperintense lesions with partial gadolinium enhancement. She did not have antibodies against human immunodeficiency virus 1 and 2 and cerebrospinal fluid-polymerase chain reaction for viral infections including a sensitive JC-virus polymerase chain reaction were negative. The diagnosis of progressive multifocal leukoencephalopathy was established by histological analysis and detection of JC-virus desoxyribonucleic acid in brain biopsy specimens. Dimethyl fumarate was stopped and Mirtazapin and Mefloquin were initiated. Neurological examination and imaging remained stable.
  
  
  CONCLUSIONS
  Progressive multifocal leukoencephalopathy can occur in patients with lymphocyte counts between 450 and 700/μl, produce only faint symptoms and is not excluded by negative JC-virus-polymerase chain reaction in cerebrospinal fluid. The incidence of progressive multifocal leukoencephalopathy may thus be underestimated and a more careful surveillance of patients would be necessary.
authors.affiliation: University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany. nele.dammeier@uni-tuebingen.de.
authors.forename: Nele
authors.initials: N
authors.lastname: Dammeier
authors.affiliation: University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany. victoria.schubert@med.uni-tuebingen.de.
authors.forename: Victoria
authors.initials: V
authors.lastname: Schubert
authors.affiliation: University Tübingen, Diagnostic and interventional Neuroradiology, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany. till-karsten.hauser@med.uni-tuebingen.de.
authors.forename: Till-Karsten
authors.initials: TK
authors.lastname: Hauser
authors.affiliation: Institute for pathology und neuropathology, section neuropathology, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany. antje.bornemann@med.uni-tuebingen.de.
authors.forename: Antje
authors.initials: A
authors.lastname: Bornemann
authors.affiliation: University Tübingen, Center of Neurology and Hertie Institute for Clinical Brain Research, Hoppe-Seyler Strasse 3, 72076, Tübingen, Germany. felix.bischof@uni-tuebingen.de.
authors.forename: Felix
authors.initials: F
authors.lastname: Bischof
mesh_terms: D001921:Brain / Q000473:pathology; D000069462:Dimethyl Fumarate / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D007577:JC Virus / Q000302:isolation & purification; D007968:Leukoencephalopathy, Progressive Multifocal / Q000175:diagnosis*; D008875:Middle Aged; D016133:Polymerase Chain Reaction
chemical_list: D000069462:Dimethyl Fumarate