Possible cerebral toxoplasmosis in a fingolimod-treated MS patient

Objective: To describe a suspect cerebral toxoplasmosis in a fingolimod-treated MS patient Background: A 40-year-old female with relapsing-remitting multiple sclerosis (RR-MS) was treated with fingolimod for 29 months and interrupted this treatment for pneumonia onset. Two months later, due to the occurrence of a relapse, she received high doses steroids for 10 consecutively days. One month later she was admitted to our hospital for apathy and right gaze deviation onset. After admission she rapidly developed mild coma. Design/Methods: She was admitted to intensive unite care and she underwent to cranial CT scan, head MRI, spinal tap and hematological analyses both routinely tests as well as Polymerase Chain Reaction (PCR) test for viruses: CMV, HSV, VZV, JCV, EBV. Results: Cranial CT scan revealed two large hypodense areas in right cerebellar peduncle and right internal capsule. Cerebellar lesions showed modest contrast enhancement, as a spotty right frontal subcortical-area. MRI confirmed findings of non-univoque interpretation, with aspects typical of a cerebral delimited infection. CSF analysis was normal. Viral (CMV, HSV, VZV, JCV, EBV) genome amplification with PCR resulted negative. Immunofenotypization revealed marked reduction of CD4+ and CD8+ lymphoytes. Considering the radiological aspect of some lesions in the withe matter, the immunodepressive ground and following the infectivologic evaluation which raised the suspicion of cerebral toxoplasmosis, patient received treatment with atovaquone and pirimetamine. This lead to an immediate improvement of the clinical conditions, The case was reported to the Agenzia Italiana del Farmaco (AIFA) and to fingolimod’s manufacturer. Conclusions: This is a single case of possible toxoplasmosis in a patient coming from a long course of fingolimod. We recomend to consider the possibility of an opportunistic infection in patient with fingolimod e atypical, numerous and spread encephalic lesion, specially if a depressive ground is evident. Study Supported by: Not applicable Disclosure: Dr. Clerico has received personal compensation for activities with EMD Serono and Biogen as an advisory board member. Dr. De Mercanti has nothing to disclose. Dr. Artusi has nothing to disclose. Dr. Barbero has nothing to disclose. Dr. Iudicello has nothing to disclose. Dr. Durelli has received personal compensation for activities with Sanofi Genzyme.