0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Images in Neurology |

Leflunomide-Associated Progressive Multifocal Leukoencephalopathy

Megan Rahmlow, MD; Elizabeth A. Shuster, MD; Jacob Dominik, MD; H. Gordon Deen Jr, MD; Dennis W. Dickson, MD; Allen J. Aksamit Jr, MD; Hector A. Robles, MD; William D. Freeman, MD
Arch Neurol. 2008;65(11):1538-1539. doi:10.1001/archneur.65.11.1538.
Text Size: A A A
Published online

Extract

A 68-year-old man had a subacute progressive decline in speech and right-sided weakness after his rheumatoid arthritis regimen was changed from azathioprine to leflunomide. His primary care physician diagnosed a stroke. Three months later, in our neurology clinic, the patient sought treatment for transcortical motor aphasia and mild right hemiparesis, and magnetic resonance imaging (MRI) was performed (Figure 1). Results showed bilateral subcortical, asymmetrical hyperintensities, without notable mass effect, in the frontal lobes, greater on the left than the right, and in the left parietal lobe. Gadolinium images (not shown) revealed no abnormal enhancement. Cerebrospinal fluid analysis revealed 3 white blood cells, no red blood cells, a glucose level within the reference range, an elevated protein level (48 mg/dL), and no organisms. Results of a polymerase chain reaction analysis for John Cunningham (JC) virus were negative. Analysis of a brain biopsy specimen confirmed the presence of progressive multifocal leukoencephalopathy (PML)1,2 (Figure 2). The patient's condition improved with discontinuation of leflunomide and treatment with cytosine arabinoside (2 mg/kg intravenously each day for 5 days).

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview

Figures

Place holder to copy figure label and caption
Figure 1.

Fluid-attenuated inversion recovery (A) and T2-weighted (B) images show bilateral, asymmetrical subcortical white matter hyperintensities in the frontal and left parietal lobes, without mass effect. The gadolinium-enhanced sequence (not shown) demonstrated no abnormal enhancement.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Analysis of a left frontal brain biopsy specimen revealed multiple areas of demyelination on the Luxol fast blue stain (A) with many lipid-laden macrophages that were immunoreactive for major histocompatibility antigen (HLA-DR) (B). There was relative preservation of axons in these foci with the Bielschowsky silver stain (C). Viral inclusions within oligodendrocyte nuclei were detected with immunohistochemical analysis for papovavirus using an antibody to SV40 (D; inset shows high magnification of an infected oligodendrocyte), which confirmed the diagnosis of progressive multifocal leukoencephalopathy (all images ×200, except inset to D, ×1000).

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

471 Views
30 Citations
×

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
brightcove.createExperiences();