Spectrum Library

Introduction: Vaccination in patients with multiple sclerosis (MS) is generally considered to be safe. Riskbenefit analysis favors vaccination in MS patients, even though several reports of acute disseminated encephalomyelitis (ADEM), post-vaccination encephalitis, Guillain- Barr? syndrome or MS exacerbations following vaccination appear in literature. Quadrivalent HPV vaccination (Gardasil) is a relatively new vaccine, designed to prevent infection with HPV types 6, 11, 16 and 18 that has proven efficacy in the prevention of cervical, vulval and vaginal dysplasia, genital warts and cervical cancer. Recently, it has been proposed that HPV vaccination should be applied to young men in order to facilitate the eradication of HPV and protect boys from infection and thus preventing the transmission of HPV associated diseases which it is believed to cause about 70 per cent of cervical cancers. Patients and Methods: We report five cases, age ranging from 15 to 28 years old who presented with a central nervous system (CNS) demyelinating syndrome following HPV immunization with Gardasil. Four patients were diagnosed with a clinically isolated syndrome (CIS) and one patient had experienced several episodes of neurological dysfunction, but had never been assessed by a neurologist. They underwent a thorough clinical, radiological and laboratory evaluation. MRI scan of brain and cervical spinal cord revealed multiple demyelinating lesions. Lumbar puncture was performed and oligoclonal bands were present in all patients’ CSF, while serum immunological screen was normal. Discussion: Our five cases are added to those reported by Sutton et al, 2009, who presented with multifocal or atypical demyelinating syndromes within 21 days of immunization with the quadrivalent HPV vaccine. Considering the fact that the vaccination is addressed to young females one should keep in mind the immunostimulatory properties of the HPV virus-like particles (VLP’s) which comprise the vaccine. These particles are considered to be potent immunogens that could induce a CNS inflammatory response leading to demyelination and axonal damage. Even though vaccination is generally considered safe in patients with multiple sclerosis, close monitoring of any emerging side effects is necessary as well as the reassurance that the benefits of vaccination in terms of preventing cervical cancer, other genital cancers and genital warts, far outweigh possible side effects.

Read More: A report of five cases of CNS demyelination after quadrivalent human papilloma virus vaccination: could there be any relationship?