P 1168. Management of Highly Active MS in Children: Successful Early Escalation Therapy with Alemtuzumab

Background: Highly active multiple sclerosis (MS) accounts for ∼30% of childhood MS. The usual course of childhood onset cases is not yet very well known. Nevertheless, there are severe relapsing remitting courses reported, with marked disability before 18 years of age. Comparing with adults, childhood MS often shows more disease activity in the beginning stages. Patients with childhood MS have a higher relapse rate and show more disease activity on magnetic resonance imaging (MRI). These well-recognized hallmarks of pediatric MS indicate a more active inflammatory process. Therefore, early escalation is a reasonable option in highly active MS to avoid disability progression.

Methods: We present a girl who was 10 years when she first suffered from optic neuritis. After the first relapse, MS was diagnosed and treatment with glatiramer acetate was started. Due to local side effects, therapy was changed to interferon beta 1a after 6 weeks. Under this treatment, seven relapses occurred in the first year of the disease and it was also not well tolerated. This led to early escalation with natalizumab, causing nearly complete stabilization of disease activity. Due to a positive John Cunningham virus (JCV) antibody test, treatment was changed to fingolimod after 2 years on natalizumab. This was given for 8 months, when a first relapse occurred and MRI revealed contrast enhancing new lesions. In this situation, we decided to change treatment again and give alemtuzumab, a humanized CD52 antibody, which was well tolerated. We did not observe any side effects and no further relapses. Follow-up time is 3 years and 9 months. Until now, the patient has no neurological or cognitive deficits.

Conclusion: So far, little is known about the treatment of patients with highly active pediatric MS. Alemtuzumab can be an alternative treatment option, especially in JCV positive MS patients with a highly active disease course, who need a highly effective treatment. The drug can cause serious side effects such as autoimmune thrombocytopenia or thyroiditis. Fortunately until know, no progressive multifocal leucoencephalopathy was reported under alemtuzumab.