Kammeyer Joel A, Lehmann Nicole M
Division of Infectious Diseases, University of Toledo College of Medicine, Toledo, Ohio, USA.
Case Rep Neurol. 2022 Jun 24;14(2):286-290. doi: 10.1159/000524359. eCollection 2022 May-Aug.
Fingolimod is a disease-modifying treatment utilized in the treatment of relapsing-remitting multiple sclerosis. Fingolimod has been associated with an increased risk in herpes simplex and varicella infection in clinical trials. We report a case of cerebral venous thrombosis secondary to cryptococcus in a patient receiving fingolimod. A 61-year-old male with multiple sclerosis treated with fingolimod presented with a 2-week history of headache, chills, and night sweats. An MRI of the brain revealed a left transverse and sigmoid sinus thrombosis. Two blood cultures revealed ; a serum cryptococcal antigen was also positive. HIV testing was negative. A lumbar puncture was deferred as the patient was placed on heparin and, subsequently, warfarin for the cerebral venous thrombosis. The patient received antifungal therapy for 14 days with liposomal amphotericin B and flucytosine, followed by oral fluconazole for 8 weeks. He was subsequently readmitted 60 days later with bilateral papilledema; his anticoagulation was reversed, and a lumbar puncture revealed a negative cryptococcal antigen and an intracranial pressure of 20. A repeat MRI revealed worsening superior sagittal sinus thrombosis, thought to be the cause of the papilledema; his anticoagulation was reinitiated. He received a brief course of intravenous methylprednisolone, but as his multiple sclerosis was well-controlled, further therapy was deferred. His symptoms had resolved at a 3-month follow-up appointment. This is the first report of a multiple sclerosis patient treated with fingolimod to develop cerebral venous thrombosis secondary to cryptococcal fungemia. The risks of opportunistic infections should be considered in patients managed with fingolimod.
芬戈莫德是一种用于治疗复发缓解型多发性硬化症的疾病修正治疗药物。在临床试验中，芬戈莫德与单纯疱疹和水痘感染风险增加有关。我们报告一例接受芬戈莫德治疗的患者发生隐球菌性脑静脉血栓形成的病例。一名61岁接受芬戈莫德治疗的多发性硬化症男性患者，出现头痛、寒战和盗汗2周病史。脑部MRI显示左侧横窦和乙状窦血栓形成。两次血培养结果显示；血清隐球菌抗原也呈阳性。HIV检测为阴性。由于患者因脑静脉血栓形成接受肝素治疗，随后接受华法林治疗，故推迟了腰椎穿刺。患者接受脂质体两性霉素B和氟胞嘧啶抗真菌治疗14天，随后口服氟康唑8周。60天后他再次入院，出现双侧视乳头水肿；他的抗凝治疗被逆转，腰椎穿刺显示隐球菌抗原阴性，颅内压为20。重复MRI显示上矢状窦血栓形成恶化，被认为是视乳头水肿的原因；他重新开始抗凝治疗。他接受了一个短期的静脉注射甲泼尼龙疗程，但由于他的多发性硬化症得到了良好控制，进一步的治疗被推迟。在3个月的随访预约中，他的症状已经缓解。这是首例接受芬戈莫德治疗的多发性硬化症患者发生隐球菌性真菌血症继发脑静脉血栓形成的报告。使用芬戈莫德治疗的患者应考虑机会性感染的风险。
