Use of Maraviroc in the prevention and Treatment of Immune Reconstitution Inflammatory Syndrome in Natalizumab-Associated Progressive Multifocal Leukoencephalopathy

Deepti Anbarasan,Jonathan Howard

doi:10.4172/jmso.1000116

Abstract

We discuss the case of a patient with Progressive Multifocal Leukoencephalopathy (PML), developed after treatment with Natalizumab for 42 months for relapsing remitting multiple sclerosis (RRMS). Imaging was consistent with wide-spread PML with features that portended a high risk of development of Immune Reconstitution Inflammatory Syndrome (IRIS). After completion of plasmapheresis, she was started on oral maraviroc, chemokine receptor 5 antagonists. Our patient did not develop radiological signs or symptoms of clinical IRIS and tolerated maraviroc without adverse side-effects. We propose that maraviroc merits further examination as an agent that may prevent IRIS in patients with natalizumab-associated PML.

Highlights

A 49-year-old, HIV negative woman with a history of relapsing remitting multiple sclerosis (RRMS) for twelve years, presented for a second opinion for complaints of three months of worsening ataxia and dysarthria
This case study illustrates the potential utility of maraviroc in the prevention of clinical symptoms of Immune Reconstitution Inflammatory Syndrome (IRIS), an entity that is considered to be an almost universal complication that occurs with or without plasmapheresis in patients with natalizumab–associated Progressive Multifocal Leukoencephalopathy (PML) (NTZPML) [1]
IRIS is a major cause of mortality and morbidity in patients with NTZ-PML and is characterized either by sudden clinical deterioration or by gadolinium enhancement and/or mass effect on brain magnetic resonance imaging (MRI) [2]

Summary

Introduction

A 49-year-old, HIV negative woman with a history of RRMS for twelve years, presented for a second opinion for complaints of three months of worsening ataxia and dysarthria. The patient remained free of clinical Immune Reconstitution Inflammatory Syndrome (IRIS), consecutive MRI brain imaging studies showed faint peripheral enhancement in some of the previously identified T2/FLAIR hyperintense lesions (Figure 1). This case study illustrates the potential utility of maraviroc in the prevention of clinical symptoms of IRIS, an entity that is considered to be an almost universal complication that occurs with or without plasmapheresis in patients with natalizumab–associated PML (NTZPML) [1].

Results

Conclusion