Extensive rebound MS activity following dimethyl fumarate discontinuation in a 63 year old – A case report

Laura Ghezzi , Victoria A. Levasseur , Dana C. Perantie , Gregory F. Wu , Anne H. Cross
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Abstract

Background

Dimethyl fumarate (DMF) is an oral disease modifying therapy (DMT) approved for the treatment of relapsing-remitting multiple sclerosis (RRMS). DMF is effective at reducing relapses, and decreasing disease activity. Reports of rebound activity following DMF discontinuation are rare.

Case report

We report the case of a 63-year old woman with RRMS, showing an extensive radiological and clinical rebound after DMF discontinuation. She started DMF in 2014 at which time her EDSS was 1.5. She was clinically stable until 2019, when she noted the onset of progressive left leg weakness but without signs of radiological activity on brain MRI. In 2020, she experienced further worsening and MRI showed one new brain lesion. She was treated with oral steroids with partial recovery. She self-discontinued DMF in February 2021. Approximately 5 months after discontinuation she developed severe left side weakness and her brain MRI showed 34 enhancing lesions. She was treated with another course of oral steroids with clinical benefit and her DMT was switched to oral cladibrine.

Conclusions

This case is unusual because MS disease rebound is uncommon after DMF discontinuation and because disease activity of this magnitude with over 30 gadolinium enhancing lesions is rare in people with MS over the age of 60. Our case stresses that a reactivation of MS activity including a large number of enhancing lesions can occur in older individuals, despite a presumably senescent immune system. Monitoring for disease activity before and after discontinuing a DMT is important, regardless of the patient's age.

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一名63岁老人停药富马酸二甲酯后广泛反弹MS活性——一例报告
背景富马酸二甲酯(DMF)是一种口服疾病改良疗法(DMT),被批准用于治疗复发-缓解型多发性硬化症(RRMS)。DMF在减少复发和减少疾病活动方面是有效的。DMF停用后出现反弹活动的报告很少。病例报告我们报告了一例63岁女性RRMS,在DMF停药后出现广泛的放射学和临床反弹。她于2014年创办DMF,当时她的EDSS为1.5。她在2019年之前一直处于临床稳定状态,当时她注意到左腿开始出现渐进性无力,但在脑部MRI上没有放射性活动的迹象。2020年,她的病情进一步恶化,核磁共振显示有一处新的脑部病变。她接受了口服类固醇治疗,部分康复。她于2021年2月自行停用DMF。停药约5个月后,她出现严重的左侧无力,脑部MRI显示34处增强性病变。她接受了另一个疗程的口服类固醇治疗,具有临床益处,她的DMT改为口服cladibrine。结论这种情况是不寻常的,因为DMF停药后多发性硬化症的反弹是不常见的,而且在60岁以上的多发性痴呆症患者中,这种程度的疾病活动和超过30个钆增强病变是罕见的。我们的病例强调,尽管免疫系统可能衰老,但老年人可能会出现MS活性的重新激活,包括大量增强性病变。无论患者年龄大小,在停止DMT前后监测疾病活动都很重要。
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