Basiliximab/belatacept/mycophenolate-mofetil

Basiliximab/belatacept/mycophenolate-mofetil Reactions 1680, p65 - 2 Dec 2017 Basiliximab/belatacept/mycophenolate- mofetil Progressive multifocal leukoencephalopathy and the associated complications: case report An elderly man in his late 60s [exact age at the time of reaction onset not stated] developed progressive multifocal leukoencephalopathy (PML) and the associated complications including right hemiplegia, cortical blindness, coma and respiratory failure during treatment with basiliximab, belatacept and mycophenolate mofetil [not all routes, dosages and outcomes stated]. Eventually, he died of the PML and respiratory failure. The man, who had a history of immunoglobulin A nephropathy, had undergone deceased-donor kidney transplant in October 2013, at the age of 67-years. His immunosuppressive regimen included basiliximab induction with a maintenance therapy which included belatacept injection and mycophenolate mofetil. He received IV basiliximab 10 mg/kg on day 1 and 5, week 2, 4, 8 and 12. Beyond the third month, basiliximab was administered at a dose of 5 mg/kg/month. During the post-transplantation period, he had experienced multiple complications of viral reactivation for which he was concurrently treated with valganciclovir. He developed nephropathy of unspecified aetiology, due to which the dose of mycophenolate mofetil was reduced to 500mg twice daily. In June 2015, at 20 months post-transplantation, he was admitted due to left upper-limb weakness and visual disturbances. A month prior to the admission, he had the symptoms of mood disorders and confusion. He further developed symptoms of progressive right-sided hemiparesis with temporospatial disorientation. An MRI showed left frontoparietal sub-cortical white-matter lesions, without gadolinium enhancement, which suggested no vascular disease occurrence. These lesions were consistent with demyelination, suggestive of PML. Cerebrospinal (CSF) fluid analysis revealed a presence of John Cunningham virus (JCV) deoxyribonucleic acid, which confirmed the diagnosis of PML (JCV viral load of 7.15 × 10 copies/mL) that was considered to be related with basiliximab, belatacept and mycophenolate mofetil. The man’s mycophenolate mofetil therapy was discontinued. He had received the last injection of belatacept was administered two days prior to the admission. Due to the 2-week half life of belatacept, two plasma exchanges were performed for belatacept elimination. He received treatment with IV perfusion of polyclonal Igs [sic] for mild hypogammaglobulinaemia of unspecified aetiology. Thereafter, he developed complete right hemiplegia, cortical blindness and experienced no understanding towards the simple orders. His PML worsened and the he became bedridden. The JCV viral load in CSF increased to 1.67 × 10 copies/mL) on day 22. On day 33, his brain lesions deteriorated. He further received treatment with interleukin-7. However, his clinical neurological status worsened, with onset of coma on day 41. The JC virus viral load in CSF remained stable (1.45 × 10 copies/mL). After 69 days of the PML diagnosis, he died due to PML and respiratory failure. Author comment: "Progressive multifocal leukoencephalopathy (PML) is a deadly demyelinating disease due to central nervous system replication of the human polyomavirus JC virus (JCV) in immunosuppressed patients." Dekeyser M, et al. Refractory T-cell anergy and rapidly fatal progressive multifocal leukoencephalopathy after prolonged CTLA4 therapy. Open Forum Infectious Diseases 4: No. 2, 16 May 2017. Available from: URL: http:// doi.org/10.1093/ofid/ofx100 - France 803284771 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Reactions Weekly Springer Journals

Basiliximab/belatacept/mycophenolate-mofetil

Reactions Weekly , Volume 1680 (1) – Dec 2, 2017
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Publisher
Springer International Publishing
Copyright
Copyright © 2017 by Springer International Publishing AG, part of Springer Nature
Subject
Medicine & Public Health; Drug Safety and Pharmacovigilance; Pharmacology/Toxicology
ISSN
0114-9954
eISSN
1179-2051
D.O.I.
10.1007/s40278-017-38996-0
Publisher site
See Article on Publisher Site

Abstract

Reactions 1680, p65 - 2 Dec 2017 Basiliximab/belatacept/mycophenolate- mofetil Progressive multifocal leukoencephalopathy and the associated complications: case report An elderly man in his late 60s [exact age at the time of reaction onset not stated] developed progressive multifocal leukoencephalopathy (PML) and the associated complications including right hemiplegia, cortical blindness, coma and respiratory failure during treatment with basiliximab, belatacept and mycophenolate mofetil [not all routes, dosages and outcomes stated]. Eventually, he died of the PML and respiratory failure. The man, who had a history of immunoglobulin A nephropathy, had undergone deceased-donor kidney transplant in October 2013, at the age of 67-years. His immunosuppressive regimen included basiliximab induction with a maintenance therapy which included belatacept injection and mycophenolate mofetil. He received IV basiliximab 10 mg/kg on day 1 and 5, week 2, 4, 8 and 12. Beyond the third month, basiliximab was administered at a dose of 5 mg/kg/month. During the post-transplantation period, he had experienced multiple complications of viral reactivation for which he was concurrently treated with valganciclovir. He developed nephropathy of unspecified aetiology, due to which the dose of mycophenolate mofetil was reduced to 500mg twice daily. In June 2015, at 20 months post-transplantation, he was admitted due to left upper-limb weakness and visual disturbances. A month prior to the admission, he had the symptoms of mood disorders and confusion. He further developed symptoms of progressive right-sided hemiparesis with temporospatial disorientation. An MRI showed left frontoparietal sub-cortical white-matter lesions, without gadolinium enhancement, which suggested no vascular disease occurrence. These lesions were consistent with demyelination, suggestive of PML. Cerebrospinal (CSF) fluid analysis revealed a presence of John Cunningham virus (JCV) deoxyribonucleic acid, which confirmed the diagnosis of PML (JCV viral load of 7.15 × 10 copies/mL) that was considered to be related with basiliximab, belatacept and mycophenolate mofetil. The man’s mycophenolate mofetil therapy was discontinued. He had received the last injection of belatacept was administered two days prior to the admission. Due to the 2-week half life of belatacept, two plasma exchanges were performed for belatacept elimination. He received treatment with IV perfusion of polyclonal Igs [sic] for mild hypogammaglobulinaemia of unspecified aetiology. Thereafter, he developed complete right hemiplegia, cortical blindness and experienced no understanding towards the simple orders. His PML worsened and the he became bedridden. The JCV viral load in CSF increased to 1.67 × 10 copies/mL) on day 22. On day 33, his brain lesions deteriorated. He further received treatment with interleukin-7. However, his clinical neurological status worsened, with onset of coma on day 41. The JC virus viral load in CSF remained stable (1.45 × 10 copies/mL). After 69 days of the PML diagnosis, he died due to PML and respiratory failure. Author comment: "Progressive multifocal leukoencephalopathy (PML) is a deadly demyelinating disease due to central nervous system replication of the human polyomavirus JC virus (JCV) in immunosuppressed patients." Dekeyser M, et al. Refractory T-cell anergy and rapidly fatal progressive multifocal leukoencephalopathy after prolonged CTLA4 therapy. Open Forum Infectious Diseases 4: No. 2, 16 May 2017. Available from: URL: http:// doi.org/10.1093/ofid/ofx100 - France 803284771 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680

Journal

Reactions WeeklySpringer Journals

Published: Dec 2, 2017

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