We report the case of a young woman with multiple sclerosis who discontinued natalizumab twice and experienced a severe relapse following each natalizumab withdrawal. The first relapse was successfully treated by intravenous methylprednisolone (IVMP). In contrast the second relapse was unresponsive to IVMP. Subsequent treatment by plasma exchanges (PLEX) was followed by a dramatic neurological worsening. This case suggests that PLEX after natalizumab discontinuation may increase relapse severity.
PolmanCHO’ConnorPWHavrdovaE. A randomized, placebo-controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med2006; 354: 899–910.
2.
MillerDHKhanOASheremataWA. A controlled trial of natalizumab for relapsing multiple sclerosis. N Engl J Med2003; 348: 15–23.
3.
StuveOCravensPDFrohmanEM. Immunologic, clinical, and radiologic status 14 months after cessation of natalizumab therapy. Neurology2009; 72: 396–401.
4.
KillesteinJVennegoorAStrijbisEM. Natalizumab drug holiday in multiple sclerosis: poorly tolerated. Ann Neurol2010; 68: 392–395.
5.
BergerJRCentonzeDComiG. Considerations on discontinuing natalizumab for the treatment of multiple sclerosis. Ann Neurol2010; 68: 409–411.
6.
MiravalleAJensenRKinkelRP. Immune reconstitution inflammatory syndrome in patients with multiple sclerosis following cessation of natalizumab therapy. Arch Neurol2010; in press.
7.
CliffordDBDe LucaASimpsonDMArendtGGiovannoniGNathA. Natalizumab-associated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: lessons from 28 cases. Lancet Neurol2010; 9: 438–446.
8.
KhatriBOManSGiovannoniG. Effect of plasma exchange in accelerating natalizumab clearance and restoring leukocyte function. Neurology2009; 72: 402–409.
9.
LenhardTBillerAMuellerWMetzISchonbergerJWildemannB. Immune reconstitution inflammatory syndrome after withdrawal of natalizumab?Neurology2010; 75: 831–833.
