Progressive Multifocal Leukoencephalopathy in a Patient With Progressive Multiple Sclerosis Treated With Ocrelizumab Monotherapy

• DOI: 10.1001/jamaneurol.2021.0627
• Publication Date: 2021-03-16T19:59:19Z
• Authors: Arpan Patel; James Sul; Marc L. Gordon; Jared Steinklein; Shayna Sanguinetti; Bidyut Pramanik; Dushyant Purohit; Vahram Haroutunian; Alex Williamson; Igor Koralnik; Asaff Harel
• Keywords: Ocrelizumab; JC Virus

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection caused by the JC virus that has no proven effective treatment. Although rare cases of PML have occurred with other anti-CD20 therapies, there had been prior associated ocrelizumab.To report first ever case occurring ocrelizumab monotherapy in a patient progressive multiple sclerosis without immunomodulation.This was reported from academic medical center. The while receiving monotherapy.Ocrelizumab monotherapy.A 78-year-old man treated for 2 years presented weeks visual disturbance and confusion. Examination demonstrated right homonymous hemianopia, magnetic resonance imaging revealed enlarging nonenhancing left parietal lesion mass effect. Cerebrospinal fluid 1000 copies/mL virus, confirming diagnosis PML. Blood work on grade lymphopenia, absolute lymphocyte count 710/μL, CD4 294/μL (reference range, 325-1251/μL), CD8 85/μL 90-775/μL), CD19 1/μL, preserved CD4/CD8 ratio (3.45), negative HIV serology. Retrospective intermittent 1 lymphopenia preceded (absolute 800-1200/μL). patient's symptoms progressed over to involve bilateral loss, right-sided facial droop, dysphasia. Ocrelizumab discontinued off-label pembrolizumab treatment initiated. nevertheless declined rapidly ultimately died. confirmed at autopsy.In this report, occurrence likely result immunomodulatory function as well age-related immunosenescence. This emphasizes importance thorough discussion risks benefits ocrelizumab, especially patients higher risk infections such elderly patients.