Hemianopia and visual loss due to progressive multifocal leukoencephalopathy in natalizumab-treated multiple sclerosis

Tina Rike Herold,¹ Veronika Jakl,³ Anno Graser,⁴ Kirsten Eibl-Lindner<sup>1,2

1</sup>Department of Ophthalmology, ²Department of Ophthalmology, Campus Innenstadt, ³Department of Neurology, ⁴Department of Clinical Radiology, Campus Grosshadern, University of Munich, Ludwig-Maximilians University, Munich, Germany

Abstract: This case describes typical ophthalmic findings as a key feature for diagnosis of progressive multifocal leukoencephalopathy (PML) and its possible differential diagnosis. A 58-year-old female patient with relapsing-remitting multiple sclerosis on immunotherapy with natalizumab developed visual disturbance, reading problems, and visual field defects due to PML. PML is a reactivation of latent infection with the John Cunningham virus, which is a type of polyomavirus acquired in childhood or adolescence and is quite common in the general population. PML so far has been mostly associated with other immunodeficiency disorders, such as acquired immunodeficiency syndrome, but is also gaining importance in association with the increasing use and duration of treatment with natalizumab in patients suffering from multiple sclerosis. Natalizumab is a highly specific α4-integrin antagonist approved for treatment of patients with active relapsing-remitting multiple sclerosis.

Keywords: progressive multifocal leukoencephalopathy, natalizumab, multiple sclerosis, hemianopia