Thursday, 8 October 2015

imaging PML

Wattjes MP, Wijburg MT, Vennegoor A, Witte BI, de Vos M, Richert ND, Uitdehaag BM, Barkhof F, Killestein J; Dutch-Belgian Natalizumab-associated PML study group.MRI characteristics of early PML-IRIS after natalizumab treatment in patients with MS.
J Neurol Neurosurg Psychiatry. 2015 Sep 14. pii: jnnp-2015-311411

OBJECTIVE:The early detection of MRI findings suggestive of immune reconstitution inflammatory syndrome (IRIS) in natalizumab-associated progressive multifocal leukoencephalopathy (PML) is of crucial clinical relevance in terms of treatment decision-making and clinical outcome. The aim of this study was to investigate the earliest imaging characteristics of PML-IRIS manifestation in natalizumab-treated patients with multiple sclerosis and describe an imaging pattern that might aid in the early and specific diagnosis.
METHODS:This was a retrospective study assessing brain MRI of 26 patients with natalizumab-associated PML presenting with lesions suggestive of PML-IRIS during follow-up. MRI findings were evaluated considering the imaging findings such as mass effect, swelling, contrast enhancement, new perivascular T2 lesions and signs suggestive of meningeal inflammation.
RESULTS:Contrast enhancement was the most common imaging sign suggestive of PML-IRIS, seen in 92.3% of the patients (with patchy and/or punctuate pattern in 70.8% and 45.8% respectively), followed by new T2 lesions with a perivascular distribution pattern (34.6%). In those patients with contrast enhancement, the enhancement was present in the lesion periphery in 95.8% of the patients. Contrast-enhancing lesions with a perivascular distribution pattern outside of the PML lesion were observed in 33.3% of the patients. The most common overall pattern was contrast enhancement in the border of the PML lesion with either a patchy or punctuate appearance in 88.5% of all patients.
CONCLUSIONS:Contrast enhancement is the most common earliest sign of natalizumab-associated PML-IRIS with a frequent imaging pattern of contrast-enhancing lesions with either a patchy or punctuate appearance in the border of the PML lesion.

Maybe DrK will comment on this, but this study suggest ways to spot Immune Reconstitution Inflammatory Syndrome (IRIS) that can occur when you have subclinical PML/PML, a brain full of JV virus, and you have stopped natalizumab so the immune cells specific for the virus, enter the CNS and kill virally infected cells quicker than virally-infected cells can kill virally infected cells which are the oligodendrocytes leading to worse demyelination than your current MS and the resultant nerve loss that follows this and the consequent deterioration of the affected individual.


  1. It is therefore very important to an effective treatment against JCV, why this "damned" hinders the action of the most powerful DMTs ...

  2. I do not know if it's a silly question but as the JCV is to overcome the blood-brain barrier? Would he be in the brain all the time, from the first contact, the first infection with it, or JCV is "hidden" in "another place" and to undergo several mutations disrupts the BBB?

  3. I am not a doctor nor a researcher, but really I don't understand why we are not able to find a cure for PML. We know which virus is responsible and we know that if we are able to find a cure, we could probably derisking one of the best MS therapy sofar.

    1. There is work on a vaccine against JC virus that causes PML which shows promise but whether this would be effective for those who already have the virus (most people are already infected) is another matter. There is no effective anti-viral agent currently.

  4. I have MS. I don´t want have PML too. I prefer not treatment with immunosuppressive treatments including Tecfidera.

  5. I hope this report will encourage neurologists to return us higher risk Tysabri patients (JC +ve 4 plus years) back onto contrast enhancing MRIs every 6 months instead of just normal... #budgetcuts.


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