Progressive multifocal leukoencephalopathy
| Progressive multifocal leukoencephalopathy | |
|---|---|
| Specialty | Neurology  |
Progressive multifocal leukoencephalopathy (PML), also known as progressive multifocal leukoencephalitis, is a rare and usually fatal viral disease that is characterized by progressive damage (-pathy) or inflammation of the white matter (leuko-) of the brain (-encephalo-) at multiple locations (multifocal). It occurs almost exclusively in people with severe immune deficiency, e.g. transplant patients on immunosuppressive medications, patients receiving certain kinds of chemotherapy, people with multiple sclerosis infusing Natalizumab (Tysabri)[1] into their arms, psoriasis patients on long-term Efalizumab (Raptiva)[2] or AIDS patients.
It is caused by the JC virus.
Cause
The cause of PML is a type of polyomavirus called the JC virus (JCV), after the initials of the patient in whom it was first discovered. The virus is widespread, with 86% of the general population presenting antibodies, but it usually remains latent, causing disease only when the immune system has been severely weakened.
About 2-5% of AIDS patients develop PML. It is unclear why PML occurs more frequently in AIDS than in other immunosuppressive conditions; some research suggests that the effects of HIV on brain tissue, or on JCV itself, make JCV more likely to become active in the brain and increase its damaging inflammatory effects.[3]
Contributing causes
There are case reports of PML being caused by pharmacological agents, although there is some speculation this could be due in part to the existing impaired immune response or 'drug combination therapies' rather than individual drugs. These include efalizumab, rituximab,[4] infliximab,[5] natalizumab,[6] chemotherapy,[7] corticosteroids,[8] and various transplant drugs such as tacrolimus.[9]
Disease process
PML is a demyelinating disease, in which the myelin sheath covering the axons of nerve cells is gradually destroyed, impairing the transmission of nerve impulses. It affects the white matter, which is mostly composed of axons from the outermost parts of the brain (cortex). Symptoms include weakness or paralysis, vision loss, impaired speech, and cognitive deterioration. PML destroys oligodendrocytes and produces intranuclear inclusions. PML is similar to another demyelinating disease, multiple sclerosis, but since it destroys the cells that produce myelin (unlike MS, in which myelin itself is attacked but can be replaced), it progresses much more quickly. The median survival of patients with PML as a complication of AIDS is 6 months. In 10% of patients, survival exceeds 12 months. The longest reported survival is 11 years and 9 months from the onset of illness.
Diagnosis
PML is diagnosed by testing for JC virus DNA in cerebrospinal fluid or in a brain biopsy specimen. Characteristic evidence of the damage caused by PML in the brain can also be detected on MRI images.
Treatment
There is no known cure. In some cases, the disease slows or stops if the patient's immune system improves; some AIDS patients with PML have been able to survive for several years, with the advent of highly active antiretroviral therapy (HAART).
AIDS patients who start HAART after being diagnosed with PML tend to have a slightly longer survival time than patients who were already on HAART and then develop PML.[10] A rare complication of effective HAART is immune reconstitution inflammatory syndrome (IRIS), in which increased immune system activity actually increases the damage caused by the infection; though IRIS is often manageable with other types of drugs, it is extremely dangerous if it occurs in PML.[11]
Other antiviral agents that have been studied as possible treatments for PML include cidofovir[12] and interleukin-2, but this research is still preliminary.
Cytarabine (also known as ARA-C), a chemotherapy drug used to treat certain cancers, has been prescribed on an experimental basis for a small number of non-AIDS PML patients. It is reported to have stabilized the neurological condition of a minority of these patients.[13] One patient regained some cognitive function lost as a result of PML.[14]
See also
References
- ^ http://phx.corporate-ir.net/External.File?item=UGFyZW50SUQ9OTIyMXxDaGlsZElEPS0xfFR5cGU9Mw==&t=1
- ^ http://www.medpagetoday.com/MeetingCoverage/SDEF/12849
- ^ Berger JR (2003). "Progressive multifocal leukoencephalopathy in acquired immunodeficiency syndrome: explaining the high incidence and disproportionate frequency of the illness relative to other immunosuppressive conditions". J. Neurovirol. 9 Suppl 1: 38–41. doi:10.1080/713831410. PMID 12709870.
{{cite journal}}: Cite has empty unknown parameter:|unused_data=(help); Text "1B69BA326FFE69C3F0A8F227DF8201D0" ignored (help) - ^ "Off-Label Use of Rituxan Linked to Fatal Leukoencephalopathy".
- ^ Lavagna A, Bergallo M, Daperno M; et al. (2007). "Infliximab and the risk of latent viruses reactivation in active Crohn's disease". Inflamm. Bowel Dis. 13 (7): 896–902. doi:10.1002/ibd.20131. PMID 17345605.
{{cite journal}}: Explicit use of et al. in:|author=(help)CS1 maint: multiple names: authors list (link) - ^ "Potential risks of powerful MS drug are weighed - health - 2 March 2006 - New Scientist". Retrieved 2008-01-28.
- ^ Connolly RM, Doherty CP, Beddy P, O'Byrne K (2007). "Chemotherapy induced reversible posterior leukoencephalopathy syndrome". Lung Cancer. 56 (3): 459–63. doi:10.1016/j.lungcan.2007.01.012. PMID 17316891.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Viallard JF, Lazaro E, Ellie E; et al. (2007). "Improvement of progressive multifocal leukoencephalopathy after cidofovir therapy in a patient with a destructive polyarthritis". Infection. 35 (1): 33–6. doi:10.1007/s15010-006-5103-y. PMID 17297588.
{{cite journal}}: Explicit use of et al. in:|author=(help)CS1 maint: multiple names: authors list (link) - ^ Junna MR, Rabinstein AA (2007). "Tacrolimus induced leukoencephalopathy presenting with status epilepticus and prolonged coma". J. Neurol. Neurosurg. Psychiatr. 78 (12): 1410–1. doi:10.1136/jnnp.2007.121806. PMID 18024699.
- ^ Wyen, C., Hoffmann, C., Schmeisser, N., Wohrmann, A., Qurishi, N., Rockstroh, J., Esser, S., Rieke, A., Ross, B., Lorenzen, T., Schmitz, K., Stenzel, W., Salzberger, B. and Fatkenheuer, G. (2004) Progressive multifocal leukencephalopathy in patients on highly active antiretroviral therapy: survival and risk factors of death. Journal of Acquired Immune Deficiency Syndrome 37, 1263-1268. PMID 15385733
- ^ Vendrely A, Bienvenu B, Gasnault J, Thiebault JB, Salmon D, Gray F (2005). "Fulminant inflammatory leukoencephalopathy associated with HAART-induced immune restoration in AIDS-related progressive multifocal leukoencephalopathy". Acta Neuropathol. 109 (4): 449–55. doi:10.1007/s00401-005-0983-y. PMID 15739098.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Segarra-Newnham M, Vodolo KM (2001). "Use of cidofovir in progressive multifocal leukoencephalopathy". Ann Pharmacother. 35 (6): 741–4. doi:10.1345/aph.10338. PMID 11408993.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Aksamit AJ (2001). "Treatment of non-AIDS progressive multifocal leukoencephalopathy with cytosine arabinoside". J. Neurovirol. 7 (4): 386–90. doi:10.1080/13550280152537292. PMID 11517422.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Langer-Gould A, Atlas SW, Green AJ, Bollen AW, Pelletier D (2005). "Progressive multifocal leukoencephalopathy in a patient treated with natalizumab". N. Engl. J. Med. 353 (4): 375–81. doi:10.1056/NEJMoa051847. PMID 15947078.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link)