jason chiang, md, phd & clayton wiley, md, phd university of pittsburgh medical center...
TRANSCRIPT
![Page 1: Jason Chiang, MD, PhD & Clayton Wiley, MD, PhD University of Pittsburgh Medical Center Department of Pathology Division of Neuropathology](https://reader035.vdocuments.us/reader035/viewer/2022062408/56649e6a5503460f94b674b3/html5/thumbnails/1.jpg)
Jason Chiang, MD, PhD & Clayton Wiley, MD, PhDUniversity of Pittsburgh Medical CenterDepartment of Pathology Division of Neuropathology
![Page 2: Jason Chiang, MD, PhD & Clayton Wiley, MD, PhD University of Pittsburgh Medical Center Department of Pathology Division of Neuropathology](https://reader035.vdocuments.us/reader035/viewer/2022062408/56649e6a5503460f94b674b3/html5/thumbnails/2.jpg)
• 67 years old male with multiple sclerosis (MS) for 39 years• Treated with Tysabri (Natalizumab) during the past 5 years
• What is MS?
• What is Tysabri?
Case History
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• New onset of arm dysmetria, slurred speech and choking• Describe MRI findings
Case History
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Radiologic Findings - MRI T1 + Contrast
R R
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Radiologic Findings - MRI FLAIR/T2
R R
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![Page 6: Jason Chiang, MD, PhD & Clayton Wiley, MD, PhD University of Pittsburgh Medical Center Department of Pathology Division of Neuropathology](https://reader035.vdocuments.us/reader035/viewer/2022062408/56649e6a5503460f94b674b3/html5/thumbnails/6.jpg)
• CSF analysis:– Normal differential count and glucose level– Elevated protein level, elevated IgG index and oligoclonal bands
• Tysabri discontinued, plasmapheresis, IV dexamethasone
• Why are they stopping the Tysabri?
• Died 25 days after MRI
Further Studies and Clinical Course
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Gross Neuropathology Findings
RR
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Peri-ventricular Area Cerebellum
2x
20x
Microscopic Findings
H&E
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Microscopic Findings
LFB/CV
Peri-ventricular Area Cerebellum
2x
20x
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Neurofilament stain
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Peri-ventricular Area Cerebellum
20x
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Further Studies
Peri-ventricular Area
CD68
CD3
Cerebellum
10x
11
CD8
CD4CD68
CD3
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JC Virus in situ Hybridization
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4x 40x
Cerebellum
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Timeline
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Death10/5/2012
MRI6/5/2012
MRI9/10/2012
PML
Symptoms
TysabriTysabriTysabriTysabriTysabri PlasmapheresesSteroid
IRIS
MS
MS39 years
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• Progressive multifocal leukoencephalopathy (PML)– Bilateral cerebellar white matter– Dentate nuclei– Middle cerebellar peduncles
• Superimposed immune reconstitution inflammatory syndrome (IRIS)
• Quiescent multiple sclerosis (MS) plaques– Multiple areas of cerebral peri-ventricular white matter– Gray and white matter of spinal cord
Final Diagnosis
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