Highlights
- •A severe relapse under treatment with natalizumab is unexpected.
- •Rule out progressive multifocal leukoencephalopathy is required.
- •We hypothesize an association with development of antibodies to the drug.
- •Costimulation of peripheral T-cells could play a role.
Abstract
Multiple sclerosis (MS) patients treated with natalizumab have a significant reduction
in annualized relapse rate; in these patients, a relapse is uncommon but not unexpected.
In contrast, the appearance of a severe exacerbation is striking and requires the
differential diagnosis with progressive multifocal leukoencephalopathy. Here, we describe
a case of a 22-year-old woman with relapsing-remitting MS who developed an unexpected
response after the patient׳s fifth natalizumab infusion with an aggressive radiological
and clinical evolution. Changing the patient׳s treatment to fingolimod resulted in
the absence of new clinical relapses and the absence of active lesions on brain magnetic
resonance images (MRI) during the first 12 months of follow-up. We hypothesize that
the appearance of natalizumab antibodies in this patient triggered lymphocyte migration
to the central nervous system in a rebound phenomenon; this is similar to what occurs
during immune reconstitution inflammatory syndrome (IRIS) after removal of natalizumab.
Graphical abstract
Graphical Abstract
Keywords
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References
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Article info
Publication history
Published online: July 21, 2014
Accepted:
July 14,
2014
Received in revised form:
June 25,
2014
Received:
March 20,
2014
Identification
Copyright
© 2014 Elsevier B.V. Published by Elsevier Inc. All rights reserved.
