Chickenpox and asymptomatic COVID-19 after first cycle of alemtuzumab for multiple sclerosis

Excerpt

A 28-year-old woman, kindergarten teacher, developed double vision on left gaze in May 2018. Neurological examination revealed right internuclear ophthalmoplegia. Brain and spinal cord MRI showed 15 T2 and FLAIR hyperintense periventricular, juxtacortical, and infratentorial lesions and 2 lesions in the cervical spinal cord; 2 brainstem lesions showed Gadolinium enhancement. Cerebrospinal fluid was positive for oligoclonal IgG bands, and she was diagnosed with relapsing remitting multiple sclerosis (RRMS). The patient fully recovered after pulse methylprednisolone treatment. In July 2018, she developed incomplete transverse myelitis with Th12 sensory level when she again received pulse methylprednisolone treatment. MRI performed in February 2019 showed 5 new supratentorial lesions. Because of the highly active RRMS and pregnancy planning, it was decided to start treatment with alemtuzumab. During the work-up before starting alemtuzumab, varicella zoster virus (VZV) IgG came back negative, and vaccination against VZV was recommended before starting treatment. However, it took three doses of live attenuated varicella virus (OKA strain) vaccine (Varilrix®) until a titer of VZV IgG was satisfactory for treatment start (0.87) (< 0.60 negative; 0.60—< 0.90 intermediate; ≥ 0.90 positive; enzyme linked fluorescent assay). From March 9 to 10, 2020, the patient received the first course of alemtuzumab. She developed a rash from day 2 through 5, which was symptomatically treated. The patient did not take any other concomitant treatments. Lymphocytes ranged from 0.32 in May 2020 to 0.88 × 10⁹ in October 2020. After an outbreak of chickenpox in the kindergarten, the patient developed small, itchy blisters on the arms and back on November 20, 2020 (Fig. 1). Therapy with acyclovir, 400 mg 5 times a day through 7 days, was initiated, and she completely recovered. At the same time, her husband was diagnosed with COVID-19, and she spent 14 more days in self isolation. She never developed any symptoms characteristic for COVID-19, and she returned to work. Oropharyngeal swab during her husband’s quarantine was not performed. In December 2020, serology for SARS-CoV-2 revealed the titer of antibody to spike protein titer of 102 U/ml (positive value ≥ 0.8 U/ml, Elecsys® anti-SARSCoV-2 S assay, Roche Diagnostics Int., Rotkreuz, Switzerland).In March 2021, VZV IgG titer was 3.89, and the patient received second cycle of alemtuzumab.

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