Progression of HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis after Pregnancy: A Case Series and Review of the Literature
Abstract
:1. Introduction
2. Patients and Methods
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Pt No | Marital Status | Race or Ethnicity a | Length of Breastfeeding | Received Blood Transfusion, Year | Family Members HTLV-1 Positive | Family Members with Paralytic Disease | Probable Way of Acquisition |
---|---|---|---|---|---|---|---|
1 | Married | Mestizo | 6 months to 1 year | 1981 b | Husband, daughter | - | Sexual or transfusion? |
2 | Single | Andean/Quechua | >1 year | No | Sister, 2 daughters | Sister, daughter | Breastfeeding? |
3 | Partner | Mestizo | <6 months | 2000, 2005, 2006 c | Father d, husband, son | Husband, son | Sexual or breastfeeding? |
4 | Single | Mestizo | 6 months to 1 year | No | - | - | UK |
5 | Married | Andean/Quechua | >2 years | No | Husband | - | Sexual? |
6 | Partner | Andean/Quechua | >1 year | No | - | - | UK |
7 | Partner | Mestizo | >2 years | No | Father d, mother, 2 sisters | Mother, sister | Breastfeeding? |
8 | Widowed | Andean/Quechua | >2 years | No | Sister, 3 children | Sister | Breastfeeding? |
9 | Partner | Andean/Quechua | 6 months to 1 year | No | Mother | - | Breastfeeding? |
10 | Single | Mestizo | >2 years | No | Child | - | UK |
11 | Married | Andean/Quechua | 1 to 2 years | No | - | - | UK |
12 | Married | Andean/Quechua | 1 to 2 years | 1981 b | Daughter | - | Transfusion? |
13 | Married | Andean/Quechua | 1 to 2 years | No | Sister, niece, daughter | - | Breastfeeding? |
14 e | Married | Andean/Quechua | > 1 year | No | - | - | UK |
15 | Partner | Mestizo | > 1 year | 1995 | Daughter | - | Transfusion (confirmed) |
Appendix B
Pt No | Year of Onset | Dx Delay (Years) | Delivery | Time from Delivery to Symptoms | Symptoms from Medical Chart | In-Person Interview | Type of Delivery and Postpartum Complication | Delivery Order | Worsening after Successive Deliveries | PVL (Copies per 104 PBMC) (Year) | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Age | Year | Self-Reported Symptoms a | Activity Modifications | |||||||||
1 b | 1991 | 0 | 38 | 1991 | 4 months | Difficulty walking c, | - | - | UK | Last (3) | NA | (Lost to follow up) |
2 | 1995 | 1 | 36 | 1995 | <1 week | Difficulty walking c | Weakness, numbness | Stop working, doing chores, and taking kids to school | Vaginal, postpartum depression | Last (3) | NA | 7526 (2006); 5060 (2012) |
3 | 1995 | 1 | 33 | 1995 | 2 months | Difficulty walking c, | Weakness R > L, constipation, mixed incontinence | Stop working | Vaginal | Last (5) | NA | 5057 (2012) |
4 | 2002 | 0 | 39 | 2002 | <1 month | Difficulty walking c, | Weakness L > R, electric currents, constipation, urge incontinence | Stop going out alone, still working | Vaginal | First (1) | NA | 1653 (2004), 4434 (2012) |
5 | 1982 | 12 | 26 | 1982 | <1 week | Difficulty walking c, | Weakness, stumbling, incontinence, constipation | Stop working, doing chores, still cook | Vaginal | Last (3) | NA | 9271 (2012) |
6 b | 2007 | 0 | 25 | 2007 | 1.5 month | Difficulty walking c,d | - | - | Hyperemesis gravidarum | Last (2) | NA | 2608 (2007) |
7 | 1999 | 13 | 21 | 1999 | <1 week | Difficulty walking c | Weakness, numbness, stumbling, knee pain | Stop going out alone | C-section for fetal distress | First (1) | NA | 3176 (2012) |
8 | 1962 | 42 | 20 | 1962 | 1 month | Difficulty walking c | Stumbling, numbness | Stop working, doing chores | Vaginal | First (7) | Yes f | 2779 (2006), 4384 (2012) |
9 | 1999 | 6 | 28 | 1999 | 2 months | Difficulty walking c | Stumbling, lumbar pain | Normal activities | C-section, cardiac malformation in NB | First (2) | Yes | 3035 (2006), 3849 (2012) |
10 | 1996 | 10 | 29 | 1996 | 1 week | Difficulty walking c | Weakness, cramps, spasms | Stop working, doing chores | Vaginal | First (2) | Yes | 8150 (2012) |
11 | 1978 | 24 | 35 | 1983 | 2 months | Difficulty walking c | Worsened weakness, spasms, stumbling d, paresthesia | Stop working, doing chores | Vaginal, maternal malaria | Last (2) | NA | 8667 (2012) |
12 | 1990 | 5 | 36 | 1993 | 1 week | Difficulty walking c | Worsened weakness, numbness, stumbling d | Stop working, doing chores | C-section, twins | Last (4) | NA | 2267 (2012) |
13 | 1999 | 13 | 24 | 2009 | 2 weeks | Difficulty walking c | Worsened weakness and stumbling d | Stop walking with heels, long distance, could not carry her NB in her arms | C-section, preeclampsia | First (1) | NA | 9981 (2012) |
14 b | 1985 | 7 | 39 | 1994 | 1 week | Could not walk anymore (wheelchair) e | - | Stop working, doing chores | C-section | Last (4) | NA | 7473 (2007) |
15 | 1999 | 2 | 34 | 2007 | 1 week | Difficulty walking c | Worsened weakness, numbness, stumbling d | Stop working | Vaginal, premature NB | Third (4) | Yes g | 3481 (2006), 8200 (2012) |
Appendix C
Characteristics (N = 15) | Sub-Categories | n (%) | Mean (SD) | Median (Range) |
---|---|---|---|---|
Quechua ethnicity | 9 (60) | |||
History of breastfeeding | <6 months | 1 (7) | ||
≥6 months–<1 year | 3 (20) | |||
≥1 year | 11 (73) | |||
History of blood transfusion before 1998 | 3 (20) | |||
Women with HTLV-1 infected children | 8 (53) | |||
Women with HTLV-1 infected family members | 11 (73) | |||
Delay to diagnosis | 6 (0–42 | |||
Age at delivery (years) | Women with onset (n = 10) | 29.5 (6.8) | 28.5 (20–39) | |
Women with worsening (n = 5) | 33.2 (7.8) | 35 (24–39) | ||
Time from delivery to symptoms (weeks) | Women with onset (n = 10) | 3 (0.5–16) | ||
Women with worsening (n = 5) | 1 (1–8) | |||
Symptoms within 1 month of delivery | 10 (67) | |||
Symptoms within 4 months of delivery | 15 (100) | |||
In-person interviews (n = 12) | ||||
Self-reported symptoms at onset | Weakness | 11 (92) | ||
Stumbling | 8 (67) | |||
Numbness | 5 (42) | |||
Sphincter dysfunction | 3 (25) | |||
Other symptoms a | 5 (42) | |||
Interference with daily activity | 12 (100) | |||
Stop working due to symptoms | 9 (75) | |||
Neurologic exam (2012) | ||||
Pyramidal symptoms b | 12 (100) | |||
Urinary complaints c | 12 (100) | |||
Bowel continence (constipation) | 10 (83) | |||
Duration of disease (years) | 16.5 (10–50) | |||
Time to wheelchair (years) | 26 (13–36) | |||
Permanent use of wheelchair use | 5 (42) | |||
Fast disease progression | 1 (8) | |||
Treatment with myorelaxant | 10 (83) | |||
Treatment with myorelaxant, antiretroviral, prednisone | 3 (25) | |||
Kurtzke EDSS d score | 6 (4.5–8) |
References
- Verdonck, K.; Gonzalez, E.; Van Dooren, S.; Vandamme, A.M.; Vanham, G.; Gotuzzo, E. Human T-lymphotropic virus 1: Recent knowledge about an ancient infection. Lancet Infect. Dis. 2007, 7, 266–281. [Google Scholar] [CrossRef] [PubMed]
- Gessain, A.; Mahieux, R. Tropical spastic paraparesis and HTLV-1 associated myelopathy: Clinical, epidemiological, virological and therapeutic aspects. Rev. Neurol. 2012, 168, 257–269. [Google Scholar] [CrossRef]
- Araujo, A.Q.; Leite, A.C.; Lima, M.A.; Silva, M.T. HTLV-1 and neurological conditions: When to suspect and when to order a diagnostic test for HTLV-1 infection? Arq. Neuropsiquiatr. 2009, 67, 132–138. [Google Scholar] [CrossRef]
- Gotuzzo, E.; Cabrera, J.; Deza, L.; Verdonck, K.; Vandamme, A.M.; Cairampoma, R.; Vizcarra, D.; Cabada, M.; Narvarte, G.; Casas, C.D.L. Clinical characteristics of patients in Peru with human T cell lymphotropic virus type 1-associated tropical spastic paraparesis. Clin. Infect. Dis. 2004, 39, 939–944. [Google Scholar] [CrossRef] [PubMed]
- Olindo, S.; Cabre, P.; Lézin, A.; Merle, H.; Saint-Vil, M.; Signate, A.; Bonnan, M.; Chalon, A.; Magnani, L.; Cesaire, R.; et al. Natural history of human T-lymphotropic virus 1-associated myelopathy: A 14-year follow-up study. Arch. Neurol. 2006, 63, 1560–1566. [Google Scholar] [CrossRef] [PubMed]
- Casseb, J. Is human T cell lymphotropic type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) syndrome a neglected disease? PLoS Negl. Trop. Dis. 2009, 3, e487. [Google Scholar] [CrossRef]
- Bangham, C.R.; Osame, M. Cellular immune response to HTLV-1. Oncogene 2005, 24, 6035–6046. [Google Scholar] [CrossRef]
- Lepoutre, V.; Jain, P.; Quann, K.; Wigdahl, B.; Khan, Z.K. Role of resident CNS cell populations in HTLV-1-associated neuroinflammatory disease. Front. Biosci. 2009, 14, 1152–1168. [Google Scholar] [CrossRef]
- Saito, S.; Nakashima, A.; Shima, T.; Ito, M. Th1/Th2/Th17 and regulatory T-cell paradigm in pregnancy. Am. J. Reprod. Immunol. 2010, 63, 601–610. [Google Scholar] [CrossRef]
- WHO Diagnostic Guidelines for TSP/HAM. Report of WHO Scientific Group on HTLV-1 Infection and Associated Diseases (Kagoshima, Japan 10–15 December 1988). Weekly Epidemiological Record. March 1989. Available online: http://www.who.int/wer/en/ (accessed on 2 June 2013).
- De Castro-Costa, C.M.; Araújo, A.Q.C.; Barreto, M.M.; Takayanagui, O.M.; Sohler, M.P.; Da Silva, E.L.M.; De Paula, S.M.B.; Ishak, R.; Ribas, J.G.R.; Rovirosa, L.C.; et al. Proposal for diagnostic criteria of tropical spastic paraparesis/HTLV-I-associated myelopathy (TSP/HAM). AIDS Res. Hum. Retroviruses 2006, 22, 931–935. [Google Scholar] [CrossRef]
- Adaui, V.; Verdonck, K.; Best, I.; González, E.; Tipismana, M.; Arévalo, J.; Vanham, G.; Campos, M.; Zimic, M.; Gotuzzo, E. SYBR green-based quantitation of human T-lymphotropic virus type 1 proviral load in Peruvian patients with neurological disease and asymptomatic carriers: Influence of clinical status, sex, and familial relatedness. J. Neurovirol. 2006, 12, 456–465. [Google Scholar] [CrossRef]
- Kurtzke, J.F. Rating neurologic impairment in multiple sclerosis: An expanded disability status scale (EDSS). Neurology 1983, 33, 1444–1452. [Google Scholar] [CrossRef]
- Mizokami, T.; Okamura, K.; Sato, K.; Kuroda, T.; Itoyama, Y.; Fujishima, M. Postpartum exacerbation of HTLV-I associated myelopathy/tropical spastic paraparesis followed by an episode of painless thyroiditis. Intern. Med. 1994, 33, 703–705. [Google Scholar] [CrossRef]
- Zihlmann, K.F.; de Alvarenga, A.T.; Casseb, J. Living Invisible: HTLV-1-infected persons and the lack of care in public health. PLoS Negl. Trop. Dis. 2012, 6, e1705. [Google Scholar] [CrossRef] [PubMed]
- Bohiltea, R.E.; Turcan, N.; Berceanu, C.; Munteanu, O.; Georgescu, T.A.; Ducu, I.; Neacsu, A.; Furtunescu, F. Implications of human T-lymphotropic virus in pregnancy: A case report and a review of the diagnostic criteria and management proposal. Exp. Ther. Med. 2021, 21, 82. [Google Scholar] [CrossRef] [PubMed]
- Araujo, A.Q.; Silva, M.T. The HTLV-1 neurological complex. Lancet Neurol. 2006, 5, 1068–1076. [Google Scholar] [CrossRef] [PubMed]
- Toldi, G.; Saito, S.; Shima, T.; Halmos, A.; Veresh, Z.; Vásárhelyi, B.; Rigó, J.; Molvarec, A. The frequency of peripheral blood CD4+ CD25high FoxP3+ and CD4+ CD25- FoxP3+ regulatory T cells in normal pregnancy and pre-eclampsia. Am. J. Reprod. Immunol. 2012, 68, 175–180. [Google Scholar] [CrossRef] [PubMed]
- Steinborn, A.; Schmitt, E.; Kisielewicz, A.; Rechenberg, S.; Seissler, N.; Mahnke, K.; Schaier, M.; Zeier, M.; Sohn, C. Pregnancy-associated diseases are characterized by the composition of the systemic regulatory T cell (Treg) pool with distinct subsets of Tregs. Clin. Exp. Immunol. 2012, 167, 84–98. [Google Scholar] [CrossRef] [PubMed]
- Bangham, C.R. Human T-lymphotropic virus type 1 (HTLV-1): Persistence and immune control. Int. J. Hematol. 2003, 78, 297–303. [Google Scholar] [CrossRef]
- Tattermusch, S.; Bangham, C.R. HTLV-1 infection: What determines the risk of inflammatory disease? Trends Microbiol. 2012, 20, 494–500. [Google Scholar] [CrossRef]
- Asquith, B.; Mosley, A.J.; Barfield, A.; Marshall, S.E.; Heaps, A.; Goon, P.; Hanon, E.; Tanaka, Y.; Taylor, G.P.; Bangham, C.R.M. A functional CD8+ cell assay reveals individual variation in CD8+ cell antiviral efficacy and explains differences in human T-lymphotropic virus type 1 proviral load. J. Gen. Virol. 2005, 86 Pt 5, 1515–1523. [Google Scholar] [CrossRef] [PubMed]
- Bangham, C.R. CTL quality and the control of human retroviral infections. Eur. J. Immunol. 2009, 39, 1700–1712. [Google Scholar] [CrossRef] [PubMed]
- Saito, M. Immunogenetics and the Pathological Mechanisms of Human T-cell Leukemia Virus Type 1 (HTLV-1) Associated Myelopathy/tropical Spastic Paraparesis (HAM/TSP). Interdiscip. Perspect. Infect Dis. 2010, 2010, 478461. [Google Scholar] [CrossRef]
- Jeffery, K.J.M.; Usuku, K.; Hall, S.E.; Matsumoto, W.; Taylor, G.P.; Procter, J.; Bunce, M.; Ogg, G.S.; Welsh, K.I.; Weber, J.N.; et al. HLA alleles determine human T-lymphotropic virus-I (HTLV-I) proviral load and the risk of HTLV-I-associated myelopathy. Proc. Natl. Acad. Sci. USA 1999, 96, 3848–3853. [Google Scholar] [CrossRef] [PubMed]
- Vine, A.M.; Heaps, A.G.; Kaftantzi, L.; Mosley, A.; Asquith, B.; Witkover, A.; Thompson, G.; Saito, M.; Goon, P.K.C.; Carr, L.; et al. The role of CTLs in persistent viral infection: Cytolytic gene expression in CD8+ lymphocytes distinguishes between individuals with a high or low proviral load of human T cell lymphotropic virus type 1. J. Immunol. 2004, 173, 5121–5129. [Google Scholar] [CrossRef]
- Satou, Y.; Utsunomiya, A.; Tanabe, J.; Nakagawa, M.; Nosaka, K.; Matsuoka, M. HTLV-1 modulates the frequency and phenotype of FoxP3+CD4+ T cells in virus-infected individuals. Retrovirology 2012, 9, 46. [Google Scholar] [CrossRef]
- Ramirez, E.; Cartier, L.; Rodriguez, L.; Alberti, C.; Valenzuela, M.A. In vivo fluctuation of Tax, Foxp3, CTLA-4, and GITR mRNA expression in CD4(+)CD25(+) T cells of patients with human T-lymphotropic virus type 1-associated myelopathy. Braz. J. Med. Biol. Res. 2010, 43, 1109–1115. [Google Scholar] [CrossRef]
- Oh, U.; Grant, C.; Griffith, C.; Fugo, K.; Takenouchi, N.; Jacobson, S. Reduced Foxp3 protein expression is associated with inflammatory disease during human t lymphotropic virus type 1 infection. J. Infect. Dis. 2006, 193, 1557–1566. [Google Scholar] [CrossRef]
- Birk, K.; Rudick, R. Pregnancy and multiple sclerosis. Arch. Neurol. 1986, 43, 719–726. [Google Scholar] [CrossRef]
- De Man, Y.A.; Bakker-Jonges, L.E.; Dufour-Van Den Goorbergh, C.M.; Tillemans, S.P.R.; Hooijkaas, H.; Hazes, J.M.W.; Dolhain, R.J.E.M. Women with rheumatoid arthritis negative for anti-cyclic citrullinated peptide and rheumatoid factor are more likely to improve during pregnancy, whereas in autoantibody-positive women autoantibody levels are not influenced by pregnancy. Ann. Rheum. Dis. 2010, 69, 420–423. [Google Scholar] [CrossRef]
- Kaaja, R.J.; Greer, I.A. Manifestations of chronic disease during pregnancy. JAMA 2005, 294, 2751–2757. [Google Scholar] [CrossRef]
- Confavreux, C.; Hutchinson, M.; Hours, M.M.; Cortinovis-Tourniaire, P.; Moreau, T.; Pregnancy in Multiple Sclerosis Group. Rate of pregnancy-related relapse in multiple sclerosis. N. Engl. J. Med. 1998, 339, 285–291. [Google Scholar] [CrossRef] [PubMed]
- Hughes, M.D. Multiple sclerosis and pregnancy. Neurol. Clin. 2004, 22, 757–769. [Google Scholar] [CrossRef] [PubMed]
- Araujo, A.; Bangham, C.R.M.; Casseb, J.; Gotuzzo, E.; Jacobson, S.; Martin, F.; Penalva de Oliveira, A.; Puccioni-Sohler, M.; Taylor, G.P.; Yamano, Y. Management of HAM/TSP: Systematic Review and Consensus-based Recommendations. Neurol. Clin. Pract. 2021, 11, 49–56. [Google Scholar] [CrossRef] [PubMed]
- Yamauchi, J.; Tanabe, K.; Sato, T.; Nakagawa, M.; Matsuura, E.; Tsuboi, Y.; Tamaki, K.; Sakima, H.; Ishihara, S.; Ohta, Y.; et al. Efficacy of Corticosteroid Therapy for HTLV-1-Associated Myelopathy: A Randomized Controlled Trial (HAMLET-P). Viruses 2022, 14, 136. [Google Scholar] [CrossRef]
- Ando, Y.; Matsumoto, Y.; Kakimoto, K.; Tangigawa, T. Pregnancy complicated by HTLV-I associated myelopathy: Two cases. Arch. Gynecol. Obstet. 2003, 268, 61–64. [Google Scholar] [CrossRef]
- Ville, Y.; Delaporte, E.; Peeters, M.; Leruez, M.; Glowaczower, E.; Fernandez, H. Human T-cell lymphotropic virus type I infection and pregnancy: A case-control study and 12-month follow-up of 135 women and their infants. Am. J. Obstet. Gynecol. 1991, 65 Pt 1, 1438–1443. [Google Scholar] [CrossRef]
- Mori, H.; Shibata, E.; Kuwazuru, T.; Uchimura, T.; Kondo, E.; Iwanaka, Y.; Yoshino, K. Pregnancy complicated by HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP): A case report. Clin. Case Rep. 2021, 9, e04511. [Google Scholar] [CrossRef]
- Komatsu, N.; Iwanaga, M.; Hasegawa, Y.; Miura, S.; Fuchi, N.; Moriuchi, H.; Yanagihara, K.; Miura, K. Frequency of HTLV-1 seroconversion between pregnancies in Nagasaki, Japan, 2011–2018. Front. Microbiol. 2022, 13, 1036955. [Google Scholar] [CrossRef]
- Gotuzzo, E.; Moody, J.; Verdonck, K.; Cabada, M.M.; González, E.; Van Dooren, S.; Vandamme, A.-M.; Terashima, A.; Vermund, S.-H. Frequent HTLV-1 infection in the offspring of Peruvian women with HTLV-1 associated myelopahty/tropical spastic paraparesis or strongyloidiasis. Rev. Panam. Salud Publica 2007, 22, 223–230. [Google Scholar] [CrossRef]
- Hino, S. Establishment of the milk-borne transmission as a key factor for the peculiar endemicity of human T-lymphotropic virus type 1 (HTLV-1): The ATL Prevention Program Nagasaki. Proc. Jpn. Acad. Ser. B Phys. Biol. Sci. 2011, 87, 152–166. [Google Scholar] [CrossRef] [PubMed]
- Wiktor, S.Z.; Pate, E.J.; Rosenberg, P.S.; Barnett, M.; Palmer, P.; Medeiros, D.; Maloney, E.M.; A Blattner, W. Mother-to-child transmission of human T-cell lymphotropic virus type I associated with prolonged breast-feeding. J. Hum. Virol. 1997, 1, 37–44. [Google Scholar] [PubMed]
- Catalan-Soares, B.C.; Almeida, R.T.; Carneiro-Proietti, A.B. Prevalence of HIV-1/2, HTLV-I/II, hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema pallidum and Trypanosoma cruzi among prison inmates at Manhuaҁu, Minas Gerais State, Brazil. Rev. Soc. Bras. Med. Trop. 2000, 33, 27–30. [Google Scholar] [CrossRef]
- Li, H.; Biggar, R.J.; Miley, W.J.; Maloney, E.M.; Cranston, B.; Hanchard, B.; Hisada, M. Provirus load in breast milk and risk of mother-to-child transmission of human T lymphotropic virus type I. J. Infect. Dis. 2004, 190, 1275–1278. [Google Scholar] [CrossRef] [PubMed]
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Jacquerioz, F.A.; La Rosa, M.; González-Lagos, E.; Alvarez, C.; Tipismana, M.; Luhmann, K.; Gotuzzo, E. Progression of HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis after Pregnancy: A Case Series and Review of the Literature. Pathogens 2024, 13, 731. https://doi.org/10.3390/pathogens13090731
Jacquerioz FA, La Rosa M, González-Lagos E, Alvarez C, Tipismana M, Luhmann K, Gotuzzo E. Progression of HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis after Pregnancy: A Case Series and Review of the Literature. Pathogens. 2024; 13(9):731. https://doi.org/10.3390/pathogens13090731
Chicago/Turabian StyleJacquerioz, Frederique A., Mauricio La Rosa, Elsa González-Lagos, Carolina Alvarez, Martin Tipismana, Karen Luhmann, and Eduardo Gotuzzo. 2024. "Progression of HTLV-1 Associated Myelopathy/Tropical Spastic Paraparesis after Pregnancy: A Case Series and Review of the Literature" Pathogens 13, no. 9: 731. https://doi.org/10.3390/pathogens13090731