Cutaneous cryptococcosis in a patient taking fingolimod for multiple sclerosis: Here come the opportunistic infections?

Abstract

Background:

Fingolimod is an oral disease-modifying therapy for relapsing forms of multiple sclerosis, which acts by sequestering lymphocytes within lymph nodes.

Objective:

To describe a case of extrapulmonary cryptococcosis in a patient taking fingolimod.

Methods:

Case report.

Results:

A 47-year-old man developed a non-healing skin lesion approximately 16 months after starting treatment with fingolimod. Biopsy revealed cryptococcosis. Fingolimod was discontinued and the lesion resolved with antifungal therapy.

Conclusion:

Despite few reported opportunistic infections in the pivotal clinical trials and first few years post-marketing, there has been a recent increase in reported AIDS-defining illnesses in patients taking fingolimod. Neurologists should be alert for opportunistic infections in their patients using this medication.

Keywords

Cryptococcosis fingolimod cutaneous multiple sclerosis AIDS skin

Get full access to this article

View all access options for this article.

References

Kowarik

Pellkofer

Cepok

. Differential effects of fingolimod (FTY720) on immune cells in the CSF and blood of patients with MS. Neurology 2011; 76(14): 1214–1221.

Mehling

Brinkmann

Antel

. FTY720 therapy exerts differential effects on T cell subsets in multiple sclerosis. Neurology 2008; 71(16): 1261–1267.

Cohen

Barkhof

Comi

. Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med 2010; 362(5): 402–415.

Calabresi

Radue

E-W

Goodin

. Safety and efficacy of fingolimod in patients with relapsing-remitting multiple sclerosis (FREEDOMS II): A double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2014; 13(6): 545–556.

Francis

Kappos

O’Connor

. Temporal profile of lymphocyte counts and relationship with infections with fingolimod therapy. Mult Scler 2014; 20(4): 471–480.

Huang

Disseminated cryptococcosis in a patient with multiple sclerosis treated with fingolimod. Neurology 2015; 85: 1001–1003.

Forrestel

Modi

Longworth

. Primary cutaneous cryptococcus in a patient with multiple sclerosis treated with fingolimod. JAMA Neurol 2016; 73: 355–356.

Tully

Barkley

Silber

Kaposi sarcoma in a patient with relapsing-remitting multiple sclerosis receiving fingolimod. Neurology 2015; 84(19): 1999–2001.

Artemiadis

Nikolaou

Kolokythopoulos

. Visceral leishmaniasis infection in a fingolimod-treated multiple sclerosis patient. Mult Scler 2015; 21(6): 795–796.

10.

Novartis. Long-term efficacy of Gilenya® reinforced by new “no evidence of disease activity” (NEDA-4) analysis in MS patients over seven years, vol. 1. Novartis International, 2015, pp. 9–14, http://multimediacapsule.thomsonone.com/novartis/ectrims-neda-4-press-release-

11.

Mirza

Phelan

Rimland

. The changing epidemiology of cryptococcosis: An update from population-based active surveillance in 2 large metropolitan areas, 1992–2000. Clin Infect Dis 2003; 36(6): 789–794.