DIFFERENTIAL DIAGNOSIS OF EXACERBATIONS AND PSEUDO-EXACERBATIONS AGAINST THE BACKGROUND OF SARS-COV-2 BY THE EXAMPLE OF A CLINICAL CASE OF A PATIENT WITH MULTIPLE SCLEROSIS
Due to the COVID-19 pandemic, there is an increasing need for information on how SARS-CoV-2 affects individuals with multiple sclerosis (MS). The patients receiving disease-modifying therapy (DMT) for MS are more likely to require medical attention for infection than the general population. SARS-CoV-2 can cause the worsening of MS symptoms and be mistaken for a relapse, so physicians must carefully assess whether a patient is experiencing a relapse or pseudo-exacerbation. Thus, there is a necessity for science-based guidelines on how to lower the risk of infection, as well as an early differential diagnosis of relapse and pseudo-exacerbation, and effective care for MS patients with COVID-19.
Materials and methods of research: a patient with a history of MS treated with DMTs. The patient presented with worsening disease symptoms, likely exacerbation, and was diagnosed with COVID-19.
Results: a thorough analysis of existing literature was conducted, along with a quick examination of how DMT was used in MS patients with COVID-19. The patient we dealt with was receiving DMT and experienced a severe illness. Timely use of intravenous corticosteroids and antibiotics allowed taking under control the activity of the pathological process. Fortunately, the outcome was favorable.
Conclusions: this evaluation presents information about the clinical features, results, and functions of DMTs in MS patients infected with SARS-CoV-2. Healthcare professionals must carefully consider the possibility of relapse in MS patients with COVID-19, particularly during the pandemic, and should look out for pseudo-exacerbations. While many cases demonstrated a mild course of illness and successful recovery with DMTs, additional investigation is required to create guidelines supported by evidence.
Hollen C, Bernard B. Multiple Sclerosis Management During the COVID‑19 Pandemic. Current Neurology and Neuroscience Reports. 2022;22:537-543. https://doi.org/0.1007/s11910-022-01211-9.
Havla J, Hohlfeld R. Antibody Therapies for Progressive Multiple Sclerosis and for Promoting Repair. Neurotherapeutics. 2022;19(3):774-784. https://doi.org/10.1007/s13311-022-01214-x.
Stritt K, Lucca I, Roth B, Grilo N. Is EDSS Enough to Predict Risk of Upper Urinary Tract Damage in Patients with Multiple Sclerosis? Biomedicines. 2022;10(12). https://doi.org/10.3390/biomedicines10123001.
Meyer-Arndt L, Schmitz-Hübsch T, Bellmann-Strobl J, Brandt AU, Haynes JD, Gold SM, et al. Neural Processes of Psychological Stress and Relaxation Predict the Future Evolution of Quality of Life in Multiple Sclerosis. Front Neurol. 2021;12:753107. https://doi.org/10.3389/fneur.2021.753107.
Filippi M, Amato MP, Centonze D, Gallo P, Gasperini C, Inglese M, et al. Early use of high-efficacy disease‑modifying therapies makes the difference in people with multiple sclerosis: an expert opinion. J Neurol. 2022;269(10):5382-5394. https://doi.org/10.1007/s00415-022-11193-w.
Bsteh G, Riedl K, Krajnc N, Kornek B, Leutmezer F, Macher S, et al. Has the pandemic changed treatment strategy in multiple sclerosis? Mult Scler Relat Disord. 2022;63:103912. https://doi.org/10.1016/j.msard.2022.103912.
Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. https://doi.org/10.1164/rccm.201908-1581ST.
Bowen JD, Brink J, Brown TR, Lucassen EB, Smoot K, Wundes A, et al. COVID-19 in MS: Initial observations from the Pacific Northwest. Neurol Neuroimmunol Neuroinflamm. 2020;7(5). https://doi.org/10.1212/nxi.0000000000000783.
Willis MD, Robertson NP. Multiple sclerosis and the risk of infection: considerations in the threat of the novel coronavirus, COVID-19/SARS-CoV-2. J Neurol. 2020;267(5):1567-1569. https://doi.org/10.1007/s00415-020-09822-3.
Sormani MP. An Italian programme for COVID-19 infection in multiple sclerosis. Lancet Neurol. 2020;19(6):481-492. https://doi.org/10.1016/s1474-4422(20)30147-2.
Novi G, Mikulska M, Briano F, Toscanini F, Tazza F, Uccelli A, et al. COVID-19 in a MS patient treated with ocrelizumab: does immunosuppression have a protective role? Mult Scler Relat Disord. 2020;42:102120. https://doi.org/10.1016/j.msard.2020.102120.
Karandikar NJ, Crawford MP, Yan X, Ratts RB, Brenchley JM, Ambrozak DR, et al. Glatiramer acetate (Copaxone) therapy induces CD8(+) T cell responses in patients with multiple sclerosis. J Clin Invest. 2002;109(5):641-649. https://doi.org/10.1172/jci14380.
Longbrake EE, Cantoni C, Chahin S, Cignarella F, Cross AH, Piccio L. Dimethyl fumarate induces changes in B- and T-lymphocyte function independent of the effects on absolute lymphocyte count. Mult Scler. 2018;24(6):728-738. https://doi.org/10.1177/1352458517707069.
Gingele S, Jacobus TL, Konen FF, Hümmert MW, Sühs KW, Schwenkenbecher P, et al. Ocrelizumab Depletes CD20⁺ T Cells in Multiple Sclerosis Patients. Cells. 2018;8(1). https://doi.org/10.3390/cells8010012.
Giovannoni G, Hawkes C, Lechner-Scott J, Levy M, Waubant E, Gold J. The COVID-19 pandemic and the use of MS disease-modifying therapies. Mult Scler Relat Disord. 2020;39:102073. https://doi.org/10.1016/j.msard.2020.102073.
Brownlee W, Bourdette D, Broadley S, Killestein J, Ciccarelli O. Treating multiple sclerosis and neuromyelitis optica spectrum disorder during the COVID-19 pandemic. Neurology. 2020;94(22):949-952. https://doi.org/10.1212/wnl.0000000000009507.
Mills EA, Mao-Draayer Y. Aging and lymphocyte changes by immunomodulatory therapies impact PML risk in multiple sclerosis patients. Mult Scler. 2018;24(8):1014-1022. https://doi.org/10.1177/1352458518775550.
Aiello A, Farzaneh F, Candore G, Caruso C, Davinelli S, Gambino CM, et al. Immunosenescence and Its Hallmarks: How to Oppose Aging Strategically? A Review of Potential Options for Therapeutic Intervention. Front Immunol. 2019;10:2247. https://doi.org/10.3389/fimmu.2019.02247.
Longbrake EE, Naismith RT, Parks BJ, Wu GF, Cross AH. Dimethyl fumarate-associated lymphopenia: Risk factors and clinical significance. Mult Scler J Exp Transl Clin. 2015;1. https://doi.org/10.1177/2055217315596994.
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