Cytomegalovirus Reactivation During Alemtuzumab Treatment for Multiple Sclerosis: A Case Report

OBJECTIVE: Provide useful insight into management of viral infections in multiple sclerosis (MS) patients treated with alemtuzumab.BACKGROUND: The immunosuppressive antibody alemtuzumab, used in B-cell chronic lymphocytic leukemia (B-CLL) and multiple sclerosis therapy, induces a long-standing lymphopenia, particularly of T CD4+ subset. Cytomegalovirus (CMV) reactivation occurs in 15-25[percnt] B-CLL patients receiving alemtuzumab. The window of reactivation occurs mainly between weeks 3 and 6 after treatment, soon after the nadir of T cell count. This reactivation should be dealt promptly to prevent CMV disease, which could be fatal if untreated. There are no guidelines regarding the monitoring of CMV-DNA in MS patients treated with alemtuzumab.DESIGN/METHODS: We treated a 29 year old woman with highly active MS (three relapses in six months after ending natalizumab 24 courses) with alemtuzumab 12 mg/day for 5 consecutive days. According to guidelines, oral prophylaxis for herpes infection was administered starting on the first day with acyclovir 200 mg twice a day. CMV DNA was tested with the PCR technology before treatment and weekly thereafter.RESULTS: CMV DNA before treatment was negative. After a week the viral load (expressed as number of copies per ml) was 9800/ml and after two weeks 21900/ml. Patient reported gastralgia and emesis. The patient was hospitalized, acyclovir was discontinued and patient was treated with ganciclovir 250 mg twice a day i.v. for 5 days, after which viral load went down to zero. Patient became asymptomatic already after the first day of treatment.CONCLUSIONS: Considering the rapid CMV reactivation, we recommend that a PCR CMV test should be carried out weekly after alemtuzumab course even in asymptomatic patients. Ganciclovir should be initiated in PCR CMV positive patients, and continued till the negativity of CMV viral load. This strategy would prevent a potentially serious disease in patients at risk. Disclosure: Dr. De Mercanti has nothing to disclose. Dr. Durelli has nothing to disclose. Dr. Iudicello has nothing to disclose. Dr. Artusi has nothing to disclose. Dr. Barbero has nothing to disclose. Dr. Guerrasio has nothing to disclose. Dr. Clerico has received personal compensation for activities with Merck Serono as an advisory board member.