AIDS-related cancer seen in someone treated with fingolimod

Walker S, Brew B. Kaposi sarcoma in a fingolimod-treated patient with multiple sclerosis. J Clin Neurosci. 2016. pii: S0967-5868(16)00151-X. 

Kaposi sarcoma (KS) is a vascular tumour of endothelial cell origin, associated with human herpes virus 8. It develops in one of four clinical settings, one of which is immunosuppression. We present the case of a 46year-old man with relapsing-remitting multiple sclerosis who developed KS in the context of fingolimod use. To our knowledge, this is the second reported case of KS in a fingolimod-treated individual. This case highlights potential risks associated with immunosuppression with this medicine and ongoing need for vigilance in assessing for such complications.

Kaposi sarcoma (KS) is a systemic disease that can present with cutaneous lesions with or without internal involvement. Four subtypes have been described: Classic KS, affecting middle aged men of Mediterranean descent; African endemic KS; KS immunosuppressed patients; and AIDS-related KS. Fingolimod can induce immunosuppression and this has been associated with the development of PML, which can occur in immunosuppressed people. In this report there is another symptom of marked immunosuppression and this is Kaposi’s sarcoma which came to the public attention with the development of AIDS. If you notice skin lesions tell your physician 

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  • The problem with fingolimod is that you can't derisk the drug with regard to opportunistic infections (yes, Kaposi's sarcoma is caused by a herpes virus, HHV-8). Opportunistic infections occur and are not linked to absolute lymphocyte counts. This differs to DMF and other drugs. This is why if you are on fingolimod you need to be vigilant for any symptoms suggestive of infection. Obviously this includes new skin lesions.

  • @Gavin Giovannoni: "opportunistic infections occur and are not linked to absolute lymphocyte counts". At the same time, it seems that fingolimoders are mostly told by their doctors that as long as their absolute lymphocyte count is at a certain level (various levels are recommended), they are ok as regards risk of infections. Are you saying that opportunistic infections are totally independent of lymphocyte count? Although you consider Kapois's sarcoma a symptom of "MARKED" immunosuppression? If so, can you elaborate a little more or indicate relevant research? Thank you!

    • GILENYA binds to sphingosine-1 phosphate receptors 1,4 on certain lymphocytes (T cells)14
      This keeps these lymphocytes in the lymph nodes, where they are stored, not destroyed.14 They remain functional within the lymph nodes
      Blood lymphocyte counts are expected to decrease by 70% to 80% of baseline1
      The CBC does not measure a total body lymphocyte count. Only those circulating in the blood are measured, not those in the tissues-which is where ~98% of lymphocytes reside. Just ~2% of the total lymphocyte count is circulating in the bloodstream at any given time. This is why patients taking GILENYA may have low CBCs. Blood lymphocyte counts are decreased, but not total body count.14,20-22 (from Gilenya's manufacturer)

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