Herpes simplex virus encephalitis temporally associated with dimethyl fumarate-induced lymphopenia in a multiple sclerosis patient

Multiple Sclerosis and Related Disorders
Paola PeriniPaolo Gallo

Abstract

Dimethyl fumarate (DMF) is approved as first line therapy for relapsing-remitting multiple sclerosis (RRMS). In some (3%) patients, DMF induces a marked lymphopenia. Herpes simplex encephalitis (HSE) may occur in lymphopenic subjects under treatment with immune-suppressive drugs. We report a case of a 39-year-old female patient with RRMS that developed HSE temporally associated with a marked and sudden drop in lymphocyte count, from 1200/µl to 600/µl, in the peripheral blood. HSE DNA was demonstrated in the cerebrospinal fluid. HSE had the features that characterize HSE occurring in immunosuppressed subjects, i.e. less prominent CSF pleocytosis, bilateral and mainly cortical involvement and less extensive tissue necrosis. Antiviral therapy determined a progressive, although incomplete, improvement. Three months later the patient presented only a mild short-term memory deficit and sporadic episodes of inappropriate emotionality. Lymphocyte count returned to normal values (1120/µl) after DMF discontinuation. Our case of HSE in a lymphopenic DMF-treated RRMS patient, points out the necessity of further studies on DMF-related lymphopenia, especially whether it implies an impaired immunity against viruses.

Citations

Feb 14, 2020·Clinical Microbiology Reviews·Jocelyne Piret, Guy Boivin
Jun 15, 2019·Expert Review of Neurotherapeutics·Xavier AyrignacPierre Duquette
Jul 10, 2020·Nature Reviews. Neurology·Catharina KorsukewitzHeinz Wiendl
Jun 18, 2020·Viruses·Rachael E TarlintonSubhash Verma
Nov 25, 2020·Journal of Neurology, Neurosurgery, and Psychiatry·Martijn T WijburgMike P Wattjes
Oct 23, 2020·Pharmacology & Therapeutics·Cinzia Dello RussoMunir Pirmohamed
May 20, 2021·Current Neurology and Neuroscience Reports·Tyler Ellis Smith, Ilya Kister

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