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Fulminant Central Nervous System Nocardiosis in a Patient Treated With Alemtuzumab for Relapsing-Remitting Multiple Sclerosis

Horst Penkert, MD1; Claire Delbridge, MD2; Nina Wantia, MD3; Benedikt Wiestler, MD4; Thomas Korn, MD1,5
[+] Author Affiliations
1Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
2Division of Neuropathology, Institute of Pathology, Technische Universität München, Munich, Germany
3Institute of Microbiology, Immunology, and Hygiene, Technische Universität München, Munich, Germany
4Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
5Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
JAMA Neurol. 2016;73(6):757-759. doi:10.1001/jamaneurol.2016.0146.
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This case report describes a case of fulminant central nervous system nocardiosis at 5 months after initiation of alemtuzumab in a patient with multiple sclerosis.

A woman in her late 40s with relapsing-remitting multiple sclerosis (MS) was admitted because of reduced ambulation and personality change in the previous 3 weeks. Her diagnosis of MS was made in 2007, and she was initially treated with interferon beta-1a and switched to natalizumab because of ongoing disease activity. After 80 infusions, natalizumab was discontinued because of repeated relapses and seroconversion to positivity for JC virus. Her first cycle of alemtuzumab was given in February 2015 (Expanded Disability Status Scale score of 4.5), 18 weeks after the cessation of natalizumab treatment. Her medical history was remarkable for hypothyroidism, recurrent infections, and an anorectic disorder (body mass index [calculated as weight in kilograms divided by height in meters squared] on admission, 14).

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Sequential Magnetic Resonance Imaging Scans and Histologic Analysis of Intracerebral Biopsy

Coronal contrast enhanced T1-weighted images acquired 4 days before the patient’s admission to our multiple sclerosis center (A), on admission (B), and 8 weeks after first admission (C). Hematoxylin-eosin–stained brain biopsy specimens showing multiple abscess-like formations (D, original magnification ×100) localized in the vicinity of postcapillary venules (E, original magnification ×200).

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