Case presentation PML on Tysabri By Rachel Dorsey- Campbell - - PowerPoint PPT Presentation

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Apr 24, 2023 166 likes •433 views

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 &

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Case presentation – PML on Tysabri

By Rachel Dorsey- Campbell

BPharm(hons) MRPharmS MFRPSII NMP

Senior Lead Pharmacist Neurosciences

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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

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MS history

RRMS diagnosed 1984
Relapsing history
On Interferon for a number of years
Care transferred to CX 2004

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Treatment

Relapses on Interferon
EDSS = 6
Started Tysabri 2009
7 years 4 months (88 infusions) on Tysabri

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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

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JCV status

Date JCV May 16 0.78 Oct 16 0.66 Apr 17 1.47

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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”

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June 2017

5th June – admitted to Wexham

– Speech difficulty, slurring, R side weakness. ?TIA – MRI – active lesions – Treated as MS relapse - IVMP

14th June – attended CX for Tysabri

– Not given – for urgent LP

23rd June – JC virus DNA 1 million copies/ml
25th June – admitted – 5 month stay

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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

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MRI 24th June – PML reported

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On examination:

Looked well
Orientated to time & place
Ataxia, R side weakness
Unable to stand unaided – swaying
Dysarthric
Nystagmus

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Treatment plan

?IVMP – could worsen PML
?PLEX – could accelerate IRIS
?GCSF – could worsen IRIS
?mirtazepine (5HT)
?maraviroc (ART) ?mefloquine

Watch & Wait

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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

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@ 2 weeks - started mirtazepine
@ 1 month - worsening of symptoms

– Increasing weakness – Worsening swallow – Nausea & dizziness

Repeat MRI – ?IRIS

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@ 7 weeks:

– Dysarthria, episode of respiratory distress / choking - ICU outreach – 3/7 IVMP & oral prednisolone

@ 9 weeks:

– Bed bound, locked in – PEG

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@ 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

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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.

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