Patients With MS, Reactivation of Varicella-Zoster Should Follow Proper Vaccination

Individuals with multiple sclerosis (MS) should follow proper vaccination guidelines from the CDC before starting disease-modifying therapies (DMTs) and report initial signs and symptoms of zoster reactivation while they are on the medication, results of a study published in Cureus showed.

The case follows a 66-year-old woman who was treated for MS with a delayed-release oral DMF and had reactivation of the varicella-zoster virus.

She was diagnosed with MS about 2 decades ago and began taking interferon beta-1b for approximately 4 years before switching to interferon beta-1a, because of tolerance issues.

After developing pancytopenia, she discontinued interferon beta-1a and started taking a delayed-release dimethyl fumarate (DMF) 240 mg capsules twice a day for 6 years, until the zoster rash reappeared.

She had not received the zoster vaccine.

After the patient reported fatigue with no other new symptoms, laboratory results showed lymphopenia with an ALC of 590 cells/µl, which is grade 2 lymphopenia, but she had a normal white blood cell (WBC) count.

She was found to have indeterminate anti-JC virus antibody titers of 0.21. She continued on the DMF, because it was effective and was also prescribed long-acting methylphenidate for fatigue.

She visited the clinic again with new symptoms of unilateral continuous dull headache mixed with burning and a rash on the left side of her face, but no neurological deficit was found.

Her ALC/µl and T cell count were low, with a mildly low WBC count. Additionally, her CD4+ and CD8+ T cell counts were very low.

The ALC was, notably, higher this time by approximately 13.6% compared with the 3 months prior.

The immunoglobulin M antibody to the varicella-zoster virus was positive, with no immunoglobulin G value, so DMF and methylphenidate were discontinued and oral valacyclovir at 1 gram 3 times a day was started. Additionally, oral prednisone of 60 mg a day for the initial few days with gradual tapering was started. Local lidocaine ointment with a non-steroidal anti-inflammatory drug was also started for the burning pain.

Herpes zoster ophthalmicus retinal necrosis and vasculitis were ruled out. The follow up had a good clinical response, and the rash cleared up. The DMF was restarted after 3 weeks, with plans to monitor the ALC and its subsets once a month.

Investigators concluded that lymphopenia occurs with DMTs and possesses risks for infection in individuals with MS. They suggest that it may be helpful to follow lymphocyte subsets along with ALC for the treatment of MS with DMF, hopefully preventing infections, such as varicella-zoster reactivation.

However, they noted that controlled trials have showed no serious infection from the 500-to-800 cells/µl lymphopenia range but concluded that this is not necessarily true in real-world clinics.

Reference

Daripa B, Lucchese S. Varicella-zoster reactivation in a non-immunized elderly multiple sclerosis patient while on delayed-release dimethyl fumarate with grade 2 lymphopenia and profoundly low CD4+ and CD8+ cell counts: a case report. Cureus. 2022;14(2):e22679. doi:10.7759/cureus.22679