Mild progressive multifocal leukoencephalopathy after switching from natalizumab to ocrelizumab

Objective To describe the disease course of carryover progressive multifocal leukoencephalopathy (PML) after switching from natalizumab to ocrelizumab in 2 patients with relapsing-remitting MS. Methods Two case reports with 1 year of follow-up and retrospective longitudinal measurements of serum neurofilament light (NfL) levels and B-cells. Results PML was diagnosed 78 days (case 1) and 97 days (case 2) after discontinuation of natalizumab. Both patients developed mild immune reconstitution inflammatory syndrome (IRIS) despite B-cell depletion caused by ocrelizumab. NfL levels increased in both patients during PML-IRIS. PML-IRIS lesions stabilized after treatment with mefloquine and mirtazapine, followed by methylprednisolone, and both patients continued therapy with ocrelizumab when B-cells started to repopulate. Conclusions The clinical course of carryover PML was mild in both patients, suggesting that B-cell depletion possibly did not aggravate PML-IRIS in these 2 patients.

Automated summary

Two patients with relapsing-remitting MS developed carryover PML after switching from natalizumab to ocrelizumab. Despite mild immune reconstitution inflammatory syndrome (IRIS) and increasing NfL levels, PML-IRIS lesions stabilized after treatment and both patients continued therapy with ocrelizumab.