Alopecia Barbae after Longterm Natalizumab Therapy

Background: Natalizumab is a standard disease-modifying medication for patients with multiple sclerosis.  It has been commercially available for over seven years. Most of the side effect information is focused on PML (progressive multifocal leukoencephalopathy). However, patients may present with other unusual side effects. We provide the first report  of  Alopecia Barbae  associated with longterm natalizumab therapy.

Objectives: To report unusual autoimmune disorder in patient with multiple sclerosis treated with natalizumab.

Methods: Case report and literature review.

Results: A 39 year old highly –functioning Indo-Canadian male presented to the MS Clinic with optic neuritis in early 2008. After confirmation of a diagnosis of relapsing remitting multiple sclerosis, the patient started   natalizumab in September 2008 at EDSS 2.0.  EDSS decreased to 0.0 by June 2009 and recently increased to 1.0 in September 2013. He had no prior therapies or underlying illnesses.  There have been no relapses on natalizumab.  His bi-annual MRI scans were stable until June 2013, with one new lesion evident at that time; the most recent MRI is again stable.  CD4/CD8 ratio’s were preformed at baseline and monthly throughout the course of therapy.  Of note, this ratio was abnormally low prior to treatment initiation, measuring 0.74 (normal 1.05 – 3.62).  Review by Immunology felt it was safe for the patient to start therapy.  In February 2013, the patient reported a small area of alopecia barbae on his right chin.  He received local steroid (triamcinolone) injections from Dermatology, who deemed it to be an autoimmune process.  Assessment in the MS Clinic in April 2013 showed the alopecia increasing in size.  By September, two more spots were evident.  It was decided to wean the patient off natalizumab.  He was given a 3-day PULSE steroid for prevention of rebound phenomenon as well as continued regular steroid injections from Dermatology for the alopecia.  His last dose of natalizumab was August 2013 and by late September the alopecia was significantly improved.  He was started on BG-12 in early October 2013.  The patient reported increased fatigue and leg numbness in mid-October and a second course of IV steroids was administered.  Assessment in late December revealed no new neurological events but two small alopecia spots had appeared since seen one month prior but were healing.  His CD4/CD8 tested in November was the lowest seen since starting testing in 2008, but more recent testing reveals ratio to be in the normal range. 

Conclusions: Literature review shows no cases of alopecia with natalizumab therapy.  The Medical Information Officer of Biogen reviewed resources and did not find anything suggesting a relation between natalizumab and facial alopecia.  It is interesting that a patient on natlizumab developed an unusual autoimmune disorder, which improved after discontinuation of natlizumab . It is possible that the low pretreatment CD4/8 ratio  predisposed the patient to such a response.