High copy numbers of VZV, EBV and CMV were detected from serum collected on admission and the 28th day (Day 1: VZV 68900 copies/ml, EBV 65400 copies/ml, CMV 650 copies/ml, Day 28: VZV 78450 copies/ml, EBV 52950 copies/ml, CMV 2350 copies/ml), and VZV and EBV were detected from CSF samples (Day 2: VZV 4750 copies/ml, EBV 9200 copies/ml, Day 18: VZV 3650 copies/ml, EBV 5300 copies/ml). == Figure1. costimulatory signal is necessary for complete activation of T cells.13Currently, abatacept is used for the treatment of rheumatoid arthritis in cases of an inadequate response to tumour necrosis factor- (TNF-) antagonist therapy.4Only a small number of opportunistic infections have been observed in association with abatacept, including mycobacterial tuberculosis, aspergillosis, blastomycosis and systemic candidiasis.4In addition, there have been no previous reports showing neurological complications. Herein, we report a serious case of acute encephalomyelitis associated with the reactivation of varicella zoster virus (VZV), Epstein-Barr virus (EBV) and cytomegalovirus (CMV) following abatacept treatment. == Case presentation == A 61-year-old woman developed a disturbance in her consciousness and was referred to our hospital 2 weeks after the onset of gait disturbance. Her medical history included rheumatoid arthritis, which had been treated with methotrexate and prednisolone, as well as TNF- antagonist for 6 years. Four months prior to admission, she was switched from the TNF- antagonist to abatacept (500 mg every 30 days intravenously). At the time of admission to our hospital, she was in a somnolent mental state and showed paraplegia with bilateral pyramidal signs. She had no skin rash. Laboratory tests revealed lymphopenia: the white blood cell count was 7900/l and the lymphocyte cell count was 474/l (below the normal range of 15004000/l). Her serum C Acetate gossypol reactive protein level was 5.7 mg/dl (a normal level is <0.20 mg/dl). She had an elevated titre of antinuclear antibodies (1:80). However, Acetate gossypol the Acetate gossypol other serum antibodies such as anti-CCP, anti-SSA, anti-SSB, anti-dsDNA, anti-Sm and anti-RNP were negative. A cerebrospinal fluid (CSF) study showed pleocytosis (73/l, all mononuclear cells), elevated protein level (382 mg/dl), normal glucose level (102 mg/dl), elevated myelin basic protein level (588 pg/dl) and no oligoclonal IgG bands. A culture of a CSF sample was negative for bacteria, tuberculosis and fungi. PCR analysis showed no herpes simplex virus (HSV). MRI performed at admission indicated multifocal parenchymal lesions in the brainstem, supratentorial areas and cervical spinal cord (figure 1AE). Based on these findings, we diagnosed her with acute disseminated encephalomyelitis (ADEM), and Rabbit Polyclonal to STON1 methylprednisolone (1000 mg/day for 3 days) was administered for 3 days following intravenous dexamethasone (12 mg/day). During follow-up, her mental status normalised, and brain MRI on the 13th day demonstrated marked improvement (figure 1FI). On the 17th day, she showed acute loss of vision in the left eye, and CMV retinitis was revealed. Although ganciclovir and immunoglobulins were administered, CMV retinitis did not improve. She showed newly developed pneumonia and CMV antigenemia was revealed by a C7-HRP test and elevated serum (1,3)–D-glucan. Although a follow-up brain MRI on the 20th day revealed no recurring exacerbation, the patient died of sepsis aggravated by a fungal coinfection on the 34th day. Retrospectively, PCR analysis to test for HSV-1, HSV-2, VZV, CMV, EBV, human herpes virus 6 (HHV-6) and HHV-7 was performed. High copy numbers of VZV, EBV and CMV were detected from serum collected on admission and the 28th day (Day 1: VZV 68 900 copies/ml, EBV 65 400 copies/ml, CMV 650 copies/ml, Day 28: VZV 78 450 copies/ml, EBV 52 950 copies/ml, CMV 2350 copies/ml), and VZV and EBV were detected from CSF samples (Day 2: VZV 4750 copies/ml, EBV 9200 copies/ml, Day 18: VZV 3650 copies/ml, EBV 5300 copies/ml). == Figure 1. == Brain and cervical spinal cord MR images on admission (AE) and the 13th day (FI). The T2-weighted image shows multiple hyperintensities in the cervical spinal cord (A), and.