Double Filtration Plasmapheresis Treatment of Refractory Multiple Sclerosis Relapsed on Fingolimod: A Case Report

Double filtration plasmapheresis (DFPP) is an emerging semi-selective apheretic method for treating immuno-mediated neurological diseases. Here we report the first case of steroid-refractory relapsed multiple sclerosis (MS) on Fingolimod (FTY), treated effectively by this technique, in a 37-year-old woman. This condition is thought to be caused by soluble inflammatory species, but its demyelinating pattern is unknown; moreover, despite megadoses of intravenous 6-methyl prednisolone, it induces severe neurological deterioration, but dramatically responded to DFPP in our patient. The clinical improvement was driven by a strong DFPP-induced anti-inflammatory effect, with significant reduction of C3/C4 components, total gamma globulin concentrations (IgG), and gamma-fibrinogen (FGG), resulting in a brain pseudoatrophy phenomenon. Our findings are: first, the steroid-refractory relapsed MS on FTY, however serious, can be treated with DFPP; second, given the good clinical improvement due to the DFPP-induced neuroinflammatory components removal, this clinical condition can be associated with a Lucchinetti pattern II of demyelination.