Correspondence
Progressive Multifocal Leukoencephalopathy, Natalizumab, and Multiple Sclerosis
N Engl J Med 2005; 353:1744-1746October 20, 2005
- Article
To the Editor:
According to the established definition of multiple sclerosis,1 the condition in the patient described by Kleinschmidt-DeMasters and Tyler (July 28 issue)2 should not have been diagnosed as multiple sclerosis. Apart from the unusual clinical findings, no oligoclonal bands were detected in two separate examinations of the cerebrospinal fluid, and repeated magnetic resonance imaging (MRI) scans obtained over the course of several years showed new and enlarging, but never enhancing, lesions. The most convincing argument against a diagnosis of multiple sclerosis is the neuropathology: no lesions that are characteristic for multiple sclerosis were detected. The patient described by Langer-Gould et al. in another article in the same issue3 may also raise concern about the diagnosis of at least “typical” multiple sclerosis. One to two oligoclonal bands in the cerebrospinal fluid would have to be considered negative,4 and repeated MRI scans would not show enhancing lesions. Therefore, it does not seem appropriate to conclude that patients with multiple sclerosis may be at risk for progressive multifocal leukoencephalopathy (PML) owing to treatment with natalizumab and interferon beta-1a. Is it possible to misdiagnose subclinical nonfatal cases of PML as multiple sclerosis in patients who are not obviously immunosuppressed? Further investigations of JC virus infections should extend our knowledge of this scenario.
Thomas Berger, M.D., M.Sc.
Florian Deisenhammer, M.D., M.Sc.
Innsbruck Medical University, A-6020 Innsbruck, Austria
thomas.berger@uibk. ac. at Dr. Berger reports having received unrestricted research-grant support, lecture fees, and consulting fees from Berlex, Biogen-Idec, Sanofi-Aventis, Schering, and Serono; and Dr. Deisenhammer, unrestricted research-grant support, lecture fees, and consulting fees from Biogen-Idec, Schering, and Serono.
4 References1
Noseworthy JH ,Lucchinetti C ,Rodriguez M ,Weinshenker BG . Multiple sclerosis. N Engl J Med 2000;343:938-952
Full Text | Web of Science | Medline2
Kleinschmidt-DeMasters BK ,Tyler KL . Progressive multifocal leukoencephalopathy complicating treatment with natalizumab and interferon beta-1a for multiple sclerosis. N Engl J Med 2005;353:369-374
Full Text | Web of Science | Medline3
Langer-Gould A ,Atlas SW ,Green AJ ,Bollen AW ,Pelletier D . Progressive multifocal leukoencephalopathy in a patient treated with natalizumab. N Engl J Med 2005;353:375-381
Full Text | Web of Science | Medline4
Freedman MS ,Thompson EJ ,Deisenhammer F , et al. Recommended standard of cerebrospinal fluid analysis in the diagnosis of multiple sclerosis: a consensus statement. Arch Neurol 2005;62:865-870
CrossRef | Web of Science | Medline
To the Editor:
Kleinschmidt-DeMasters and Tyler described a patient with multiple sclerosis and PML that developed after she received natalizumab treatment. However, some of the findings in this patient are uncommon in multiple sclerosis. The absence of contrast enhancement in the MRI studies that were performed — almost a rule in patients with PML — is uncommon in multiple sclerosis.1 The lack of intrathecal synthesis of IgG is unusual in multiple sclerosis, although it is frequent in PML.2 Moreover, an autopsy study found no multiple sclerosis plaques but only PML lesions. Therefore, the pathological findings did not support a diagnosis of multiple sclerosis, which raises some questions. Can initial PML mimic multiple sclerosis? Was PML the only disease in this patient? To our knowledge, PML with a relapsing–remitting course has not been described. To clarify whether PML may have a relapsing–remitting course, it is necessary to study the cerebrospinal fluid in patients with relapsing neurologic disorders to rule out this disease. This seems particularly important for patients with suspected multiple sclerosis with atypical findings, such as early mental symptoms or an absence of oligoclonal bands. If it is demonstrated that PML can have an initial relapsing–remitting course, the risks of natalizumab treatment3 should be reevaluated.
3 ReferencesJosé C. Álvarez-Cermeño, M.D.
Jaime Masjuan, M.D.
Luisa M. Villar, Ph.D.
Hospital Ramón y Cajal, 28034 Madrid, Spain
jalvarez.hrc@salud. madrid. org 1
Barkhof F ,Scheltens P ,Frequin ST , et al. Relapsing-remitting multiple sclerosis: sequential enhanced MR imaging vs clinical findings in determining disease activity. AJR Am J Roentgenol 1992;159:1041-1047
Web of Science | Medline2
Villar LM ,Masjuan J ,Sadaba MC , et al. Early differential diagnosis of multiple sclerosis using a new oligoclonal band test. Arch Neurol 2005;62:574-577
CrossRef | Web of Science | Medline3
Drazen JM . Patients at risk. N Engl J Med 2005;353:417-417
Full Text | Web of Science | Medline
Author/Editor Response
We appreciate the comments of Drs. Berger and Deisenhammer and Dr. Álvarez-Cermeño and colleagues. Our involvement with this case began only post mortem; we were not involved in this patient's initial clinical evaluation, diagnosis, and treatment. The clinical and laboratory data presented were supplied by the patient's treating physician and supplemented by the Biogen company representative. Unfortunately, in some instances only the original MRI reports, not the actual scans, were available for independent review.
A variety of diagnostic criteria for multiple sclerosis have been proposed, including the widely accepted criteria of McDonald et al.1 These criteria do allow for the diagnosis of multiple sclerosis to be made solely on clinical grounds in a patient with two or more attacks and objective clinical evidence of two or more lesions. Criteria specific to MRI can provide supportive evidence of the dissemination of lesions over time; this criterion can be satisfied by the appearance of new T2-weighted lesions on appropriately spaced sequential scans. Oligoclonal bands on evaluation of the cerebrospinal fluid and enhancing lesions as shown on MRI are found in the majority of patients with definite multiple sclerosis; however, their presence is not absolutely required for diagnosis, nor does their absence completely rule out a diagnosis of multiple sclerosis.
We cannot resolve whether the absence of multiple sclerosis lesions at autopsy reflects obliteration of a limited number of multiple sclerosis plaques by the widespread and extremely destructive PML lesions, sampling error, or the presence of an alternative disease process. With regard to this last possibility, we believe it is unlikely that a chronic indolent or relapsing–remitting form of PML was the sole disease that this patient had or that it was responsible for this patient's symptoms early in her clinical course.
Our report, in combination with the others published in the same issue of the Journal, 2,3 clearly indicates that natalizumab is associated with an increased risk of PML in patients without other recognized risk factors for this disease. The common denominator in all three reported cases, regardless of the underlying disease, was treatment with natalizumab.2,3
We hope that ongoing studies will clarify the pathogenesis of this disorder, including the viral factors and specific host factors responsible, and also the mechanisms by which natalizumab facilitates induction of PML.
3 ReferencesB.K. Kleinschmidt-DeMasters, M.D.
Kenneth L. Tyler, M.D.
University of Colorado Health Sciences Center, Denver, CO 802621
McDonald WI ,Compston A ,Edan G , et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the Diagnosis of Multiple Sclerosis. Ann Neurol 2001;50:121-127
CrossRef | Web of Science | Medline2
Van Assche G ,Van Ranst M ,Sciot R , et al. Progressive multifocal leukoencephalopathy after natalizumab therapy for Crohn's disease. N Engl J Med 2005;353:362-368
Full Text | Web of Science | Medline3
Langer-Gould A ,Atlas SW ,Green AJ ,Bollen AW ,Pelletier D . Progressive multifocal leukoencephalopathy in a patient treated with natalizumab. N Engl J Med 2005;353:375-381
Full Text | Web of Science | Medline
Author/Editor Response
The clinical history of our patient does not support the notion that subclinical cases of PML are masquerading as multiple sclerosis. To clarify, our patient had typical relapsing–remitting multiple sclerosis with clinical episodes of neurologic dysfunction for more than 20 years. He repeatedly had enhancing lesions in his brain and spinal cord during the 10 years before he was randomly assigned to the natalizumab trial, as well as a typical periventricular enhancing lesion concomitant with the first PML lesion. Finally, PML rarely affects the spinal cord.
We agree that the case in Colorado that was reported by Kleinschmidt-DeMasters and Tyler is troubling. The clinical criteria for multiple sclerosis were recently revised to improve their sensitivity, with unknown effects on specificity. The revised criteria rely heavily on the presence or absence of lesions on T2-weighted imaging, which frequently occur in patients with migraine,1 such as this patient. The natalizumab trial included patients with normal neurologic examinations (such as this patient), despite the fact that the risk of permanent disability in such patients is very low.2 These problems with the diagnostic criteria for multiple sclerosis and the entry criteria for clinical trials need to be addressed.
Annette Langer-Gould, M.D.
Scott W. Atlas, M.D.
Stanford University, Stanford, CA 94305-5405
annette1@stanford.edu Daniel Pelletier, M.D.
University of California, San Francisco, San Francisco, CA 94143Since publication of the article, Dr. Langer-Gould reports having received consulting fees from Genentech.
2 References1
Kruit MC ,van Buchem MA ,Hofman PA , et al. Migraine as a risk factor for subclinical brain lesions. JAMA 2004;291:427-434
CrossRef | Web of Science | Medline2
Achiron A ,Barak Y ,Rotstein Z . Longitudinal disability curves for predicting the course of relapsing-remitting multiple sclerosis. Mult Scler 2003;9:486-491
CrossRef | Web of Science | Medline
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