key: cord-0921152-r09venxb
authors: Borriello, Giovanna; Ianniello, Antonio
title: COVID-19 occurring during Natalizumab treatment: a case report in a patient with extended interval dosing approach
date: 2020-04-30
journal: Mult Scler Relat Disord
DOI: 10.1016/j.msard.2020.102165
sha: 05f51821fbd690cb484ef52e147871b04fd88c9d
doc_id: 921152
cord_uid: r09venxb

Abstract Background The novel Coronavirus SARS-CoV-2, which was identified after a recent outbreak in Wuhan, China, in December 2019, has generated a global pandemic impacting over 200 countries around the world. Recent reports suggest that ACE2, which is the target protein to invade the host, has a ubiquitous presence in human organs, including lung parenchyma, gastrointestinal tract, nasal mucosa, renal and urinary tract, airway epithelia, lymphoid tissues, reproductive organs, vascular endothelium and neurons. In this scenario, neurologists are particularly involved into considering even more specific therapeutic strategies according to the available data during the pandemic. In particular, MS patients are usually receiving disease-modifying therapies (DMTs) with immunosuppressant or immunomodulatory effects, which increase the risk of infections and morbidity, compared with the general population. Development of PML or other serious opportunistic infections during treatment with natalizumab forces to consider whether de-risking strategies are needed in this particular context and how to manage a high-efficacy treatment. Methods In this paper we report on a patient treated with natalizumab for relapsing MS who developed COVID-19 and recovered in a few days without complications. Results After recovery natalizumab has been administered in the window of the extended interval dosing (EID), without reporting any worsening or new symptoms. Discussion This case supports the opportunity to avoid discontinuing or delaying the retreatment over 8 weeks in patients recovered from a recent COVID-19.

pneumonia with different phenotypes, the most severe consisting in acute respiratory distress syndrome, typically followed by disseminated intravascular coagulation (DIC) and fatal multi organ failure (MOF) (1) . SARS-CoV-2 is thought able to invade CNS through the olfactory bulbs epithelium, which shows a higher expression of the protein hACE2, the receptor identified as the one used to gain entry into the host (1), or carried into the brain by the blood, with subsequent Although natalizumab potentially blocks viral immunosurveillance of the CNS, PML is a rare event:

approximately a total of 765,985 patient-years has been exposed globally in the post approval setting, with overall PML incidence of 4.08 per 1,000 (95% CI, 3.80-4.36 per 1,000 patients). EID has been suggested to reduce significantly PML risk compared to SID (4). At the time being, it is unknown if natalizumab could potentially be a risk factor for a severe PML-mimicking Neuro-COVID encephalopathy, whereas the risk of recurrence of disease activity when discontinuing natalizumab is deeply documented (5) . Arising data on SARS-CoV-2 neurotropism and about how the virus may be carried into the CNS will mitigate or clarify present concerns. 

A Novel Coronavirus from Patients with Pneumonia in China

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features

Extending the Interval of Natalizumab Dosing: Is Efficacy Preserved?

MS disease activity in RESTORE: a randomized 24-week natalizumab treatment interruption study