Case presentation – PML on Tysabri By Rachel Dorsey- Campbell BPharm(hons) MRPharmS MFRPSII NMP Senior Lead Pharmacist Neurosciences
Patient details • 54 yr old RH female • Diagnosed with RRMS 1984 • SH: – Lives with husband & son in 2 storey house – Not working – previous credit manager – Non smoker, occ EtOH • EDSS 6.0
MS history • RRMS diagnosed 1984 • Relapsing history • On Interferon for a number of years • Care transferred to CX 2004
Treatment • Relapses on Interferon • EDSS = 6 • Started Tysabri 2009 • 7 years 4 months (88 infusions) on Tysabri
2009 - 2016 • 6 monthly review • 6 monthly MRI – stable • JCV low positive • Patient “happy to continue” • Main problem spasticity – on amitryptiline, gabapentin, baclofen, Sativex, lamotrigine
JCV status Date JCV May 16 0.78 Oct 16 0.66 Apr 17 1.47
Jan – May 2017 • EDSS 6.0 • Jan 17 – Word finding difficulties – MRI : no new lesions , no evidence of PML • Mar 17 – MSN review - to continue • Apr & May 17 – Tysabri given • May – “balance bad, forgetting words”
June 2017 • 5 th June – admitted to Wexham – Speech difficulty, slurring, R side weakness. ?TIA – MRI – active lesions – Treated as MS relapse - IVMP • 14 th June – attended CX for Tysabri – Not given – for urgent LP • 23 rd June – JC virus DNA 1 million copies/ml • 25 th June – admitted – 5 month stay
On admission • PMH – nil sig • DH : – amitryptiline 50mg on – baclofen 10mg om, 20mg on – lamotrigine 150mg on + 50mg prn – simvastatin 40mg on – senna , ibuprofen & paracetamol prn
MRI 24 th June – PML reported
On examination: • Looked well • Orientated to time & place • Ataxia, R side weakness • Unable to stand unaided – swaying • Dysarthric • Nystagmus
Treatment plan • ?IVMP – could worsen PML • ?PLEX – could accelerate IRIS • ?GCSF – could worsen IRIS • ?mirtazepine (5HT) • ?maraviroc (ART) ?mefloquine Watch & Wait
JC DNA Date JC DNA results (copies /ml) 22-Jun-17 1,117,000 28-Jun-17 384,200 06-Jul-17 633,600 18-Jul-17 522,900 11-Aug-17 27,740 31-Aug-17 42,180 19-Sep-17 38,700 17-Nov-17 2,905
• @ 2 weeks - started mirtazepine • @ 1 month - worsening of symptoms – Increasing weakness – Worsening swallow – Nausea & dizziness • Repeat MRI – ?IRIS
• @ 7 weeks: – Dysarthria, episode of respiratory distress / choking - ICU outreach – 3/7 IVMP & oral prednisolone • @ 9 weeks: – Bed bound, locked in – PEG
• @ 10 weeks – early Sept – ICU admission & tracheostomy – 3 week ICU stay • @13 weeks – ward step down – Remains locked in – Communicates through eye movements – On prednisolone 60mg
• Dec 17 – discharged to rehab unit • Prednisolone weaning regime • Peg & Trachy in situ • Locked in – eye movements only • Update June 18 : remains in nursing care, some improvement, communicating, some movement of neck and arm.
Thank you
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