Progressive multifocal leukoencephalopathy in autoimmune diseases

Joint Bone Spine. 2012 Jul;79(4):351-5. doi: 10.1016/j.jbspin.2011.11.002. Epub 2012 Jan 26.


Progressive multifocal leukoencephalopathy (PML) is a subacute central nervous system infection due to reactivation of the JC virus. Most reported cases occurred in HIV-infected patients (80% of cases), patients with lymphoid malignancies (13%) and transplant recipients taking immunosuppressants (5%). Less often, PML has been described in patients with chronic inflammatory joint diseases associated with autoimmune disorders (lupus, rheumatoid arthritis [RA] and vasculitis) (2%). Magnetic resonance imaging of the brain shows suggestive changes and confirmation of the diagnosis is obtained by performing PCR tests to identify the JC virus in the cerebrospinal fluid or, when necessary, a brain biopsy. No treatments have been proven effective. Most patients experience progressive disease that is fatal within a few months or induces incapacitating neurological impairments. The risk of PML is 0.4/100,000 in patients with RA. In the few case-reports of PML in RA patients, the treatments used included methotrexate (five cases) combined with a biological agent such as infliximab (one case), rituximab (four cases), or leflunomide (two cases including one with concomitant rituximab). PML is an extremely rare but devastating complication. Rituximab therapy is associated with an increased prevalence of PML in RA patients (4/100,000), who should be informed of this risk. In patients with lupus, the risk of PML is higher than in RA (4/100,000) and 40% of cases of PML occur during low-dose glucocorticoid therapy without immunosuppressive therapy.

Publication types

  • Review

MeSH terms

  • Antibodies, Monoclonal / adverse effects
  • Antibodies, Monoclonal, Murine-Derived / adverse effects
  • Antirheumatic Agents / adverse effects
  • Arthritis, Rheumatoid / drug therapy
  • Arthritis, Rheumatoid / epidemiology*
  • Autoimmune Diseases
  • Comorbidity
  • Drug Therapy, Combination
  • Glucocorticoids / adverse effects
  • Humans
  • Infliximab
  • Isoxazoles / adverse effects
  • JC Virus / pathogenicity
  • JC Virus / physiology
  • Leflunomide
  • Leukoencephalopathy, Progressive Multifocal / epidemiology*
  • Leukoencephalopathy, Progressive Multifocal / etiology
  • Lupus Erythematosus, Systemic / drug therapy
  • Lupus Erythematosus, Systemic / epidemiology*
  • Rituximab
  • Virus Activation / drug effects


  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Murine-Derived
  • Antirheumatic Agents
  • Glucocorticoids
  • Isoxazoles
  • Rituximab
  • Infliximab
  • Leflunomide