Proceedings of the 25th BCTRIMS Annual Meeting

Case Presentation: A 27-year-old man, diagnosed with Multiple Sclerosis since 2019, with history of 2 relapses and stable on Fingolimod (first and only drug), was admitted in October 2023 with cognitive impairment (EDSS 2). MRI showed a tumefactive lesion in the right parieto-occipital region, with diffusion restriction and no contrast enhancement, raising the hypothesis of Progressive Multifocal Leukoencephalopathy (PML). Fingolimod was discontinued and JC virus levels were measured in the CSF (positive in blood). He received Methylprednisolone EV with significant clinical and radiological improvement. After 40 days without medication (considering the risk of PML) and waiting for anti-CD20, he presented with confusion, ataxia, and hemiparesis (EDSS 3), with MRI showing multiple new tumefactive lesions supra and infratentorially, again with diffusion restriction and no contrast enhancement, attributed to Fingolimod rebound. CSF JC virus was negative and patient underwent pulse teraphy, plasmapheresis, and received the first dose of Ocrelizumab, with slight improvement. 14 days after discharge, he returned to the emergency department, aphasic, paraparetic (wheelchair-bound), and confused (EDSS 8), with MMSE 9/30 and MRI showing contrast-enhancing lesions. He received another course of pulse therapy, along with additional Ocrelizumab and cycles of cyclophosphamide for 6 months. Patient returned after 3 months with EDSS 2, MMSE 27/30 and no new lesions on MRI.

Discussion: Initial MRI characteristics suggested PML, which limited therapy options. Furthermore, patient experienced a severe rebound with atypical imaging shortly after discontinuation of fingolimod, as well as clinical and radiological worsening after the first stage of treatment. This led us, after discussions with the family, to the addition of cyclophosphamide aiming to control the severe inflammation.

Final Comments: Despite the inherent risks and not being described in the literature, the combination of Ocrelizumab and Cyclophosphamide, in this context, seems to have contributed to a good outcome and control of the disease.