Fatal iatrogenic cerebral β-amyloid-related arteritis in a woman treated with lecanemab for Alzheimer’s disease

Elena Solopova, Wilber Romero-Fernandez, Hannah Harmsen, Lissa Ventura-Antunes, Emmeline Wang, Alena Shostak, Jose Maldonado, Manus J. Donahue, Daniel Schultz, Thomas M. Coyne, Andreas Charidimou and Matthew Schrag ()
Additional contact information
Elena Solopova: Vanderbilt University Medical Center
Wilber Romero-Fernandez: Vanderbilt University Medical Center
Hannah Harmsen: Vanderbilt University Medical Center
Lissa Ventura-Antunes: Vanderbilt University Medical Center
Emmeline Wang: Vanderbilt University Medical Center
Alena Shostak: Vanderbilt University Medical Center
Jose Maldonado: Vanderbilt University
Manus J. Donahue: Vanderbilt University Medical Center
Daniel Schultz: Final Diagnosis: Private Autopsy Florida - Forensic Pathology Lab
Thomas M. Coyne: University of Florida
Andreas Charidimou: Boston University
Matthew Schrag: Vanderbilt University Medical Center

Nature Communications, 2023, vol. 14, issue 1, 1-8

Abstract: Abstract We report the case of a 79-year-old woman with Alzheimer’s disease who participated in a Phase III randomized controlled trial called CLARITY-AD testing the experimental drug lecanemab. She was randomized to the placebo group and subsequently enrolled in an open-label extension which guaranteed she received the active drug. After the third biweekly infusion, she suffered a seizure characterized by speech arrest and a generalized convulsion. Magnetic resonance imaging revealed she had multifocal swelling and a marked increase in the number of cerebral microhemorrhages. She was treated with an antiepileptic regimen and high-dose intravenous corticosteroids but continued to worsen and died after 5 days. Post-mortem MRI confirmed extensive microhemorrhages in the temporal, parietal and occipital lobes. The autopsy confirmed the presence of two copies of APOE4, a gene associated with a higher risk of Alzheimer’s disease, and neuropathological features of moderate severity Alzheimer’s disease and severe cerebral amyloid angiopathy with perivascular lymphocytic infiltrates, reactive macrophages and fibrinoid degeneration of vessel walls. There were deposits of β-amyloid in meningeal vessels and penetrating arterioles with numerous microaneurysms. We conclude that the patient likely died as a result of severe cerebral amyloid-related inflammation.

Date: 2023
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DOI: 10.1038/s41467-023-43933-5

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