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Natalizumab treatment in paediatric multiple sclerosis: a case of induction, de‐escalation and escalation
Author(s) -
Putzki Norman,
Stich Oliver,
Gartzen Kristina,
Kastrup Oliver,
Tettenborn Barbara,
Rauer Sebastian
Publication year - 2010
Publication title -
european journal of neurology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.881
H-Index - 124
eISSN - 1468-1331
pISSN - 1351-5101
DOI - 10.1111/j.1468-1331.2010.03178.x
Subject(s) - medicine , neurology , emergency department , natalizumab , multiple sclerosis , psychiatry
Data on the risk and benefit of the approved disease-modifying agents for the treatment of childhood MS are limited [1,2]. Natalizumab had substantial efficacy in adult MS [3], but it is rarely used in children. Here, we report the case of a 12-year-old girl with new-onset MS activity, who was treated de novo with natalizumab. De-escalation to IFN-beta resulted in recurrence of high disease activity. In June 2006, this previously healthy 12-year-old girl (39.8 kg) experienced subacute loss of vision on her right eye (0/6). Cerebrospinal fluid analyses were significant for mild mononuclear pleocytosis and oligoclonal bands. Brain magnetic resonance imaging (MRI) demonstrated seven T2-hyperintense lesions, five of them perpendicular to the long axis of the corpus callosum and within the corpus callosum and two of them showing gadolinium enhancement (Gd+). Optic neuritis as clinically isolated syndrome was diagnosed, and she was treated with two steroid pulses. MRI 6 weeks later demonstrated two new Gd+ lesions. Another 4 weeks later, three further Gd+ lesions were identified. Whilst the McDonald criteria for adult relapsing– remitting MS were met, this was not the case for paediatric consensus definitions [4]. The family refused IFN-beta. Because MRIs indicated potential signs of a more aggressive course of the disease, temporary treatment with natalizumab was initiated at a dose of 3.7 mg/kg every 4 weeks. Natalizumab was well tolerated. The girl did not experience any disease activity for 15 months. Safety concerns of longterm natalizumab led to de-escalation to IFN-beta 1a i.m. once weekly. The girl experienced one relapse after 5 months and two further relapses over the next 8 months (Fig. 1). MRI demonstrated six new T2 lesions, three of them Gd+. Natalizumab re-introduction at 200 mg i.v. resulted in full remission.