CMV meningitis associated with dimethyl fumarate therapy-induced lymphopenia in a multiple sclerosis patient

Abstract

A 55-year-old Caucasian man with relapsing-remitting multiple sclerosis (RRMS) presented to hospital with headache, neck pain, nausea and chills. Symptoms started 3 hours prior to his presentation. Clinical examination showed meningism. MS was diagnosed in 2018 and was currently treated with dimethyl fumarate (DMF) (480 mg/day) for the last 9 months (4/20-1/21). Recommended white blood cell controls had not been realized in the last 6 months by the outpatient physicians. Previous MS therapy was 300 mg ocrelizumab in March 2018, after one infusion this therapy was stopped on patients' request. His medical history included type 2 diabetes mellitus (HbA1c 6.4%; normal value: 4.8-6.0), hypertension and coronary artery disease.Upon admission, blood count showed a normal white cell count (9480/µl) but marked lymphopenia (240/µl). C-reactive protein was 18.40 mg/l (normal value < 5 mg/l), procalcitonin was 4.68 ng/ml (normal value 0.5 ng/ml). U-Status showed a urinary tract infection (UTI), blood

Clinical use of dimethyl fumarate in multiple sclerosis treatment: an update to include China, using a modified Delphi method

“… 70 , 71 However, the degree of lymphopenia induced by DMF has not been associated with increased incidence of serious infections, 44 , 65 , 72 despite some case reports and database review findings of opportunistic infections. 69 , 73 – 80 Degree of lymphopenia has also been proposed by some to predict better responses to DMF, as a proxy measure for a less overactive immune response and pro-tolerogenic profile, 44 , 70 , 71 , 81 , 82 but most of the data have come from relatively small studies. The data are equivocal, as some studies (e.g.…”