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Anti-CD20 Therapy – TB Reactivation Risk — SCE Neurology MCQ

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HardCNS InfectionsAnti-CD20 Therapy – TB Reactivation RiskSCE Neurology

A patient receiving natalizumab for multiple sclerosis develops subacute hemianopia and cognitive change. MRI shows enlarging non-enhancing juxtacortical T2 lesions with peripheral diffusion restriction; CSF JC-virus PCR is initially negative. What is the most appropriate immediate strategy?

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Correct answer: E — Withhold natalizumab and pursue urgent specialist PML reassessment

The clinical evolution and MRI pattern are highly suspicious for progressive multifocal leukoencephalopathy; an early negative CSF PCR does not exclude low-copy infection. Natalizumab should be withheld while an expert team repeats sensitive CSF testing and reviews serial imaging. Steroid treatment for relapse can worsen diagnostic delay, an immediate alternative DMT adds immunosuppression, and plasma exchange is a specialist decision after the diagnosis and immune-reconstitution plan are considered.

Reference: Association of British Neurologists 2024 guidance on multiple-sclerosis disease-modifying treatments (Published 2024; current ABN guidance): https://doi.org/10.1136/pn-2024-004228