ClinicSpeak: cryptococcal infection on fingolimod

A slow but steady number of opportunistic infections on fingolimod. #ClinicSpeak #MSBlog #MSResearch

“Another case of cryptococcal infection on fingolimod with only a moderate lymphopaenia. Cryptococcosis is an indolent fungal infection and is not typically associated with prominent systemic symptoms and signs (temperature, etc.). There are now an increasing number of localised and systemic case reports appearing of this complication. So if you are on fingolimod please be vigilant of any suspicious skin lesions and any other symptoms to suggest an infection. The one to watch out for is meningitis. So please take any recent onset headache, visual blurring and unexplained vomiting seriously. Unlike other DMTs that cause lymphopaenia you can’t derisk fingolimod based on the lymphocyte count.”

Epub: Forrestel et al. Primary Cutaneous Cryptococcus in a Patient With Multiple Sclerosis Treated With Fingolimod.JAMA Neurol. 2016 Jan 11:1-2. doi: 10.1001/jamaneurol.2015.4259.

A 62-year-old woman with multiple sclerosis treated with fingolimod for 3 years presented to clinic with a tender nodule on the forehead that was diagnosed by a tissue culture as Cryptococcus neoformans. The patient was diagnosed with primary cutaneous cryptococcosis. She presented to the clinic with a tender nodule on her forehead, which had gradually grown over 3 weeks (Figure). She reported bumping her forehead on an air-conditioning unit several months prior. She denied fever, neck stiffness, and photophobia, and her neurological examination was at her baseline. She lived alone with a pet cat and spent minimal time outdoors. Her lymphocyte count was 650/mm3 with an absolute CD4 count of 56/mm3 and CD8 count of 121/mm3.

CoI: multiple

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • The problem is that the answer to MS cannot be lifelong immune suppression.
    We need more and more research about the disease cause, like Charcot2 for instance.
    (I've just contributed to crowdfunding)

  • On the subject of infections..Is it important for MSers to get warts (for example on hands) removed? As warts are caused by HPV virus and viruses can activate the immune system.
    And for those on a DMT, does this make it more or less important?
    Thank you.

  • I'm not sure about HPV. What I personally have discovered by accident is that fluconazole (diflucan) can really help with some MS symptoms (particularly fatigue). I took it for 2 weeks to treat athlete's foot and I noticed an improvement in my MS although the athlete's foot infection is not completely gone. I found that very surprising so I researched fluconazole & MS and the link below offered a plausible explanation as to why that may work in MS – candidiasis.. Who would have thought?

    • Cheers Newbie. I guess the answer to my question could be yes as warts are contagious – person to person. They can be picked up by touching towels and surfaces. Some webpages are saying warts are harmless.
      But for people who have MS I would of thought getting the wart removed would help the body fight infections better in other parts of the body.
      My local GP surgery have a wart clinic.

  • Hi! Yes, removing / avoiding any sort of immune system stimuli (viruses, bacteria, fungi) as much as possible seems to help. Are you EBV positive (I am)? If yes, have you tried any treatment for it?

    • Thanks again Newbie, I am EBV negative, JCV positive.
      I have had it frozen some months ago, it developed a black head and now it's returned to how it originally was. I've booked in to the wart clinic.
      When I was at middle school I had verruca's on my feet from the swimming pool.

By Prof G



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