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İsmayılov R, Talibov T, Gündüz T, Kürtüncü M. Parenchymal Neuro-Behçet's disease or Comorbid Behçet's disease with multiple sclerosis: A discriminative analysis of a complex clinical entity. Mult Scler Relat Disord 2024; 87:105684. [PMID: 38788360 DOI: 10.1016/j.msard.2024.105684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/11/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Patients with Behçet's disease (BD) may rarely manifest with cerebral white matter lesions resembling multiple sclerosis (MS). This may result in misdiagnosis due to diagnostic difficulties between parenchymal neuro-BD (pNBD) and MS. This study aims to elucidate the distinguishing features of patients with comorbid BD and MS (BD+MS) in comparison to those with pNBD and MS alone by focusing on clinical and laboratory features. We also aimed to identify the distinctive characteristics of BD+MS patients by comparing them to patients with pNBD and MS. METHODS The methodology of this study involved a retrospective analysis of patient records followed in the Department of Neurology at the Istanbul Faculty of Medicine, Istanbul University. The study population included patients diagnosed with pNBD, MS, and a comorbid condition of BD and MS (BD+MS). We assessed clinical, radiological, and laboratory data, including disease onset, annual relapse rates, Expanded Disability Status Scale (EDSS) progression, and cerebrospinal fluid examination. Several parameters were examined between the pNBD, MS, and BD+MS patient groups to find similarities and differences between subgroups. RESULTS Our study included 1,764 patients: 172 with pNBD, 1,574 with MS, and 18 with BD+MS. A predominance of females was noted in the BD+MS (72%, p < 0.001) and MS (69 %, p < 0.001) groups compared to pNBD (30 %). The median age at the onset of neurological symptoms was 35.5 (IQR: 16.8) years for BD+MS, 34.6 (13.6) years for pNBD, and 27.6 (13.3) years for MS (BD+MS vs. MS; p = 0.3, pNBD vs. MS, p = 0.7). Additionally, the number of attacks was notably different, with BD+MS patients experiencing a median of 3.5 (2.0) attacks compared to 3.0 (3.0) for MS patients and only 1.0 (1.0) for pNBD patients, suggesting a more active disease course in the MS and BD+MS groups compared to pNBD (p < 0.001). The median annualized relapse rate for BD+MS was 0.3 (0.2), which was lower than the rate of 0.4 (0.4) in MS (p = 0.048) and equivalent to the rate of 0.2 (0.3) in pNBD (p = 0.2). The time to the first relapse was similar to those with BD+MS and MS, but considerably shorter than in individuals with pNBD (p < 0.0001). The cerebrospinal fluid (CSF) analysis showed no significant differences in neutrophil and lymphocyte counts between BD+MS and MS patients but elevated levels in pNBD patients (p < 0.05). CSF protein levels were consistent across all groups (p = 0.1 and p = 0.7). Oligoclonal bands were detected in all patients with BD+MS, in the majority of MS patients (83.6 %), and a small percentage of pNBD patients (19.7 %), showing a notable distinction between the BD+MS and pNBD groups (p < 0.001). CONCLUSION Our study underscores the need for a skeptical approach in diagnosing and treating patients with BD who exhibit symptomatic MS-like MRI lesions. Our findings suggest that BD+MS is a distinct clinical entity, warranting specific diagnostic and treatment approaches. Our findings highlight that BD patients with MS-like lesions meeting MS diagnostic criteria should be managed as patients with comorbid MS and BD rather than pNBD.
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Affiliation(s)
- Rashad İsmayılov
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Tural Talibov
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Turkey.
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2
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Comer JD, Capizzano AA. Uncommon and Miscellaneous Inflammatory Disorders of the Brain and Spine. Magn Reson Imaging Clin N Am 2024; 32:277-287. [PMID: 38555141 DOI: 10.1016/j.mric.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Inflammatory disorders of the brain and spine have a highly variable MRI appearance, often demonstrating significant overlap in imaging features. The resulting diagnostic dilemma is particularly challenging when considering the more uncommon neuroinflammatory entities. Diligent examination of the salient clinical presentation and signal alteration on imaging examination is necessary when considering neuroinflammation as a diagnostic possibility and may aid in raising suspicion for a particular neuroinflammatory entity. This article reviews a selection of uncommon and miscellaneous inflammatory disorders of the brain and spine to raise awareness of the clinical and imaging features that may assist in this challenging diagnostic task.
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Affiliation(s)
- John D Comer
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA.
| | - Aristides A Capizzano
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, B2-A209 UH, Ann Arbor, MI 48109, USA
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3
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Kidd DP. Neurological involvement by Behçet's syndrome: clinical features, diagnosis, treatment and outcome. Pract Neurol 2023; 23:386-400. [PMID: 37775123 DOI: 10.1136/pn-2023-003875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 10/01/2023]
Abstract
Neurological involvement in Behçet's syndrome arises predominately through an inflammatory meningoencephalitis characterised by perivenular inflammation due to activation of Th-17 immunological pathways. The brainstem is involved in 50% of cases, the diencephalon and other areas of the brain in 30%, and the spinal cord in 10%. Movement disorders and epilepsy may occur. Psychiatric syndromes may arise with brain and brainstem involvement, and cognitive disorders relate to the brain disease, to circulating inflammatory factors, and to fatigue and despondency. Eighty per cent of cases begin with a relapsing disease course, of whom 70% have only one attack, and 30% have a progressive disease course either from onset or following an initially relapsing course. Venous thrombosis leading to intracranial hypertension and cerebral venous infarction is less common and caused by inflammation in affected veins and a circulating prothrombotic state. Arterial involvement is rare and relates to an arteritis affecting large-sized and medium-sized vessels within the brain leading to infarction, subarachnoid and parenchymal haemorrhage, aneurysm formation and arterial dissection. There is a newly recognised disorder of cerebral cortical hypoperfusion. Cranial neuropathy, peripheral neuropathy and myositis are rare. There has been significant progress in understanding the pathophysiology and treatment of the systemic disease, leading to improved outcomes, but there has been no randomised trial of treatment in the neurological disorder.
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Ion IM, Villessot M, Goulabchand R, Cagnazzo F, Thouvenot E. Tumefactive lesion revealing neuro-Behçet disease. Rheumatology (Oxford) 2022; 61:e352-e353. [PMID: 35333305 DOI: 10.1093/rheumatology/keac194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ioana Maria Ion
- Department of Neurology, Nîmes University Hospital, Nîmes, France
| | | | - Radjiv Goulabchand
- Department of Internal Medicine, Nîmes University Hospital, Nîmes, France
| | | | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, Nîmes, France.,Institut de Génomique Fonctionnelle, UMR5203, INSERM 1191, Université de Montpellier, Montpellier, France
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5
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Emekli AS, Ersözlü E, Emekli MA, Gündüz T, Kürtüncü M. Lesion distribution pattern of parenchymal Neuro-Behçet's disease using probability mapping. Mult Scler Relat Disord 2021; 58:103457. [PMID: 34929453 DOI: 10.1016/j.msard.2021.103457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/10/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Behçet's disease (BD) is an inflammatory disorder with multisystemic involvement. The most disabling aspect of BD is Neuro-Behçet's disease (NBD). In NBD, parenchymal lesions tend to occur in the mesodiencephalic region and brainstem, as reported in large series of NBD. Our study aimed to generate probability maps of parenchymal lesions to compare patient subgroups with different clinical and laboratory features. METHOD We included 66 non-standardized acute relapse MRIs of 55 patients with parenchymal NBD (p-NBD). We used T2-weighted axial images to digitalize the lesions using the CAD software. Boundaries of lesions were determined as polygons and converted into high-definition raster datasets. Then, digitalized lesion maps were transferred into the ICBM-152 brain template to perform spatial analyses. Finally, we created subtraction maps to compare the patient subgroups. RESULTS We used a total of 66 MRIs of 55 patients to generate the probability maps. The most frequently affected parenchymal structures were the rostral pons, mesencephalon, and diencephalic region. Interestingly, the brainstem was more commonly affected in females than males (p<0.01). In the late-onset disease, lesions were localized in the corticospinal tracts and caudal brainstem (p<0.01). Progressive disease and severe disability at the end of the follow-up period were associated with corticospinal tract lesions during relapses (p<0.01). Patients with positive pathergy tests were more likely to present right hemisphere involvement (p<0.01). Additionally, cyclosporine-induced lesions tend to be in atypical locations such as hemispheric white matter. CONCLUSIONS In the published studies, lesions in NBD were localized according to coarse anatomical regions. Our study uses visual maps to offer accurate lesion localizations using non-standardized brain MRIs, allowing comparisons across different NBD subgroups. By using this technique, we investigated the relationship of the clinical and laboratory features with the lesion locations. We found that the late age of onset was associated with a poor prognosis. Additionally, corticospinal lesions may predict severe and progressive disease course, requiring aggressive treatment. Interestingly, females had more brainstem lesions and lesion lateralization might be influenced by the pathergy test status.
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Affiliation(s)
- Ahmed Serkan Emekli
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ersin Ersözlü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat Kürtüncü
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Okamoto N, Ogawa N, Kitamura A, Yamakawa I, Kim H, Urushitani M. [A case of neuro-Behçet's disease triggered by herpes zoster-associated uveitis]. Rinsho Shinkeigaku 2021; 61:640-645. [PMID: 34433748 DOI: 10.5692/clinicalneurol.cn-001625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 69-year-old man was admitted for persistent fever, arthralgia, and visual impairment. Physical examination demonstrated bilateral uveitis and recurrent aphthous stomatitis. The PCR analysis of the aqueous humor of the anterior chamber was positive for the Varicella-zoster virus (VZV). Although no neurological defect was evident, the cerebrospinal fluid contained elevated monocytes but was negative for VZV-PCR. Brain MRI revealed Gd-enhanced lesions in the subcortical white matter, basal ganglia, and cerebellum. With his positive HLAB51, he was diagnosed with neuro-Behcet's disease (NBD) and was successfully treated with high-dose prednisolone. Although the pathogenesis of Behcet's disease is still unknown, the involvement of viral infection is reported. The present case implies that NBD could be triggered by herpes zoster virus associate-uveitis; the accumulation of such cases would help clarify the pathogenesis of Behcet's disease.
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Affiliation(s)
- Naoki Okamoto
- Department of Neurology, Shiga University of Medical Science
| | - Nobuhiro Ogawa
- Department of Neurology, Shiga University of Medical Science
| | | | - Isamu Yamakawa
- Department of Neurology, Shiga University of Medical Science
| | - Hyoh Kim
- Department of Neurology, Shiga University of Medical Science
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Maghrebi O, Hanachi M, Bahrini K, Kchaou M, Jeridi C, Belal S, Ben Sassi S, Barbouche MR, Souiai O, Belghith M. Differential Gene Expression Patterns in Blood and Cerebrospinal Fluid of Multiple Sclerosis and Neuro-Behçet Disease. Front Genet 2021; 12:638236. [PMID: 33719347 PMCID: PMC7954360 DOI: 10.3389/fgene.2021.638236] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/05/2021] [Indexed: 11/13/2022] Open
Abstract
Inflammatory demyelinating disorders of the central nervous system are debilitating conditions of the young adult, here we focus on multiple sclerosis (MS) and neuro-Behçet disease (NBD). MS is an autoimmune disorder of the central nervous system. NBD, a neurological manifestation of an idiopathic chronic relapsing multisystem inflammatory disease, the behçet disease. The diagnosis of MS and NBD relies on clinical symptoms, magnetic resonance imaging and laboratory tests. At first onset, clinical and imaging similarities between the two disorders may occur, making differential diagnosis challenging and delaying appropriate management. Aiming to identify additional discriminating biomarker patterns, we measured and compared gene expression of a broad panel of selected genes in blood and cerebrospinal fluid (CSF) cells of patients suffering from NBD, MS and non inflammatory neurological disorders (NIND). To reach this aim, bivariate and multivariate analysis were applied. The Principal Analysis Component (PCA) highlighted distinct profiles between NBD, MS, and controls. Transcription factors foxp3 in the blood along with IL-4, IL-10, and IL-17 expressions were the parameters that are the main contributor to the segregation between MS and NBD clustering. Moreover, parameters related to cellular activation and inflammatory cytokines within the CSF clearly differentiate between the two inflammatory diseases and the controls. We proceeded to ROC analysis in order to identify the most distinctive parameters between both inflammatory neurological disorders. The latter analysis suggested that IL-17, CD73 in the blood as well as IL-1β and IL-10 in the CSF were the most discriminating parameters between MS and NBD. We conclude that combined multi-dimensional analysis in blood and CSF suggests distinct mechanisms governing the pathophysiology of these two neuro-inflammatory disorders.
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Affiliation(s)
- Olfa Maghrebi
- Laboratory of Transmission, Control and Immunobiology of Infections, Institut Pasteur de Tunis, Tunis, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Tunis El Manar University, Tunis, Tunisia
| | - Mariem Hanachi
- Laboratory of Bioinformatics, Biomathematics and Biostatistics-LR16IPT09, Institut Pasteur de Tunis, Tunis, Tunisia.,Faculty of Science of Bizerte, University of Carthage, Jarzouna, Tunisia
| | - Khadija Bahrini
- Laboratory of Transmission, Control and Immunobiology of Infections, Institut Pasteur de Tunis, Tunis, Tunisia.,Tunis El Manar University, Tunis, Tunisia
| | - Mariem Kchaou
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Charles Nicolle Hospital, Tunis, Tunisia
| | - Cyrine Jeridi
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Department of Neurology, Mongi Ben Hmida National Institute of Neurology, Tunis, Tunisia
| | - Samir Belal
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Department of Neurology, Mongi Ben Hmida National Institute of Neurology, Tunis, Tunisia
| | - Samia Ben Sassi
- Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia.,Department of Neurology, Mongi Ben Hmida National Institute of Neurology, Tunis, Tunisia
| | - Mohamed-Ridha Barbouche
- Laboratory of Transmission, Control and Immunobiology of Infections, Institut Pasteur de Tunis, Tunis, Tunisia.,Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Oussama Souiai
- Tunis El Manar University, Tunis, Tunisia.,Laboratory of Bioinformatics, Biomathematics and Biostatistics-LR16IPT09, Institut Pasteur de Tunis, Tunis, Tunisia
| | - Meriam Belghith
- Laboratory of Transmission, Control and Immunobiology of Infections, Institut Pasteur de Tunis, Tunis, Tunisia.,Tunis El Manar University, Tunis, Tunisia
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Kone-Paut I, Barete S, Bodaghi B, Deiva K, Desbois AC, Galeotti C, Gaudric J, Kaplanski G, Mahr A, Noel N, Piram M, Tran TA, Wechsler B, Saadoun D. French recommendations for the management of Behçet's disease. Orphanet J Rare Dis 2021; 16:352. [PMID: 33622338 PMCID: PMC7903591 DOI: 10.1186/s13023-020-01620-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Behçet's disease (BD) is a systemic variable vessel vasculitis that involves the skin, mucosa, joints, eyes, arteries, veins, nervous system and gastrointestinal system, presenting with remissions and exacerbations. It is a multifactorial disease, and several triggering factors including oral cavity infections and viruses may induce inflammatory attacks in genetically susceptible individuals. BD vasculitis involves different vessel types and sizes of the vascular tree with mixed-cellular perivascular infiltrates and is often complicated by recurrent thrombosis, particularly in the venous compartment. Several new therapeutic modalities with different mechanisms of action have been studied in patients with BD. A substantial amount of new data have been published on the management of BD, especially with biologics, over the last years. These important therapeutic advances in BD have led us to propose French recommendations for the management of Behçet's disease [Protocole National de Diagnostic et de Soins de la maladie de Behçet (PNDS)]. These recommendations are divided into two parts: (1) the diagnostic process and initial assessment; (2) the therapeutic management. Thirty key points summarize the essence of the recommendations. We highlighted the main differential diagnosis of BD according to the type of clinical involvement; the role of genetics is also discussed, and we indicate the clinical presentations that must lead to the search for a genetic cause.
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Affiliation(s)
- Isabelle Kone-Paut
- Pediatric Rheumatology and CEREMAIA, Bicêtre Hospital APHP, University of Paris Sud Saclay, Le Kremlin-Bicêtre, France.
| | - Stéphane Barete
- Unit of Dermatology, DMU3ID, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), INSERM-UMRS 959, Sorbonne Universités, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, CRMR OPHTARA, IHU FOReSIGHT, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France
| | - Kumaran Deiva
- Department of Pediatric Neurology, National Referral Center for Rare Inflammatory Brain and Spinal Diseases, Assistance Publique-Hopitaux de Paris, University Hospitals of Paris-Saclay, Bicêtre Hospital, Paris, France
- Inserm UMR1184, Immunology of Viral Infections and Autoimmune Diseases, University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Anne-Claire Desbois
- UPMC Université Paris 06, Inserm UMR S 959, Immunology Immunopathology Immunotherapy (I3), Sorbonne Universités, 75005, Paris, France
- Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, AP-HP, 75651, Paris, France
- AP-HP groupe hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, centre national de référence maladies autoinflammatoires et amylose inflammatoire, centre national de références maladies autoimmunes systémiques rares, 75013, Paris, France
| | - Caroline Galeotti
- Pediatric Rheumatology and CEREMAIA, Bicêtre Hospital APHP, University of Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpétrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Gilles Kaplanski
- Internal Medicine and Clinical Immunology Department, Hôpital de la Conception, Aix-Marseille Université, Marseille, France
| | - Alfred Mahr
- Clinic for Rheumatology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Nicolas Noel
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne et Immunologie Clinique, CHU Bicêtre, Le Kremlin Bicêtre, France
- INSERM, UMR 1184, Immunologie des Maladies Virales et Autoimmunes, Université Paris Saclay, Le Kremlin Bicêtre, France
- CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Fontenay aux Roses, France
| | - Maryam Piram
- Pediatric Rheumatology and CEREMAIA, Bicêtre Hospital APHP, University of Paris Sud Saclay, Le Kremlin-Bicêtre, France
- Pediatric Dermatology, CHU Sainte Justine Research Centre, CHU Sainte Justine, University of Montreal, Montreal, Canada
| | - Tu-Anh Tran
- Department of Pediatrics, Nîmes University Hospital, INSERM U1183, Montpellier-Nîmes University, Nîmes, France
| | - Bertrand Wechsler
- UPMC Université Paris 06, Inserm UMR S 959, Immunology Immunopathology Immunotherapy (I3), Sorbonne Universités, 75005, Paris, France
- Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, AP-HP, 75651, Paris, France
- AP-HP groupe hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, centre national de référence maladies autoinflammatoires et amylose inflammatoire, centre national de références maladies autoimmunes systémiques rares, 75013, Paris, France
| | - David Saadoun
- UPMC Université Paris 06, Inserm UMR S 959, Immunology Immunopathology Immunotherapy (I3), Sorbonne Universités, 75005, Paris, France.
- Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, AP-HP, 75651, Paris, France.
- AP-HP groupe hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, centre national de référence maladies autoinflammatoires et amylose inflammatoire, centre national de références maladies autoimmunes systémiques rares, 75013, Paris, France.
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Gündüz T, Kürtüncü M, Matur Z, Tüzün E, Limon U, Tanyıldız B, İzgi B, Erdoğan N, Öge AE, Gürvit H, Bilgiç B, Akman-Demir G. Laboratory and clinical correlates of brain atrophy in Neuro-Behçet's disease. J Neurol Sci 2020; 414:116831. [PMID: 32380297 DOI: 10.1016/j.jns.2020.116831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Tuncay Gündüz
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey.
| | - Murat Kürtüncü
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Zeliha Matur
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Utku Limon
- Department of Ophthalmology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Burak Tanyıldız
- Department of Ophthalmology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Belgin İzgi
- Department of Ophthalmology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | | | - Ali Emre Öge
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Hakan Gürvit
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Başar Bilgiç
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
| | - Gülşen Akman-Demir
- Department of Neurology, İstanbul Faculty of Medicine, İstanbul University, İstanbul, Turkey
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Law LY, Riminton DS, Nguyen M, Barnett MH, Reddel SW, Hardy TA. The spectrum of immune-mediated and inflammatory lesions of the brainstem: Clues to diagnosis. Neurology 2020; 93:390-405. [PMID: 31451586 DOI: 10.1212/wnl.0000000000008015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/29/2019] [Indexed: 11/15/2022] Open
Abstract
The presentation of a patient with brainstem symptoms and signs invokes a number of common and less common differential diagnoses, and accurate diagnosis can be challenging. We review the major immune-mediated and inflammatory syndromes that can affect the brainstem including multiple sclerosis, neuromyelitis optica spectrum disorder, neuro-Behçet disease, chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, neurosarcoidosis, Susac syndrome, and the histiocytic disorders. We focus on clinical features and MRI clues that help to distinguish among the different brainstem conditions. Accurate diagnosis is important to guide appropriate treatment and limit neurologic disability.
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Affiliation(s)
- Lai Yin Law
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia
| | - D Sean Riminton
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia
| | - MaiAnh Nguyen
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia
| | - Michael H Barnett
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia
| | - Stephen W Reddel
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia
| | - Todd A Hardy
- From the Neuroimmunology Clinic, Concord Hospital (L.Y.L., D.S.R., M.N., S.W.R., T.A.H.), Brain and Mind Centre (M.H.B., S.W.R., T.A.H.), and Department of Neurology, Royal Prince Alfred Hospital (M.H.B.), University of Sydney, NSW, Australia.
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11
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Piven VD, Krasnov VS, Lashok PA, Neofidoff NA, Bubnova EV, Totolyan NA. Behcet's disease with neurologic manifestations. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:67-73. [DOI: 10.17116/jnevro201911910167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Omari A, Hanafi Y, Abaloune Y, Reda K, Aoubaaz A. Occlusion artérielle rétinienne associée à une méningo-encéphalite dans la maladie de Behcet : à propos d’un cas. J Fr Ophtalmol 2018; 41:e201-e204. [DOI: 10.1016/j.jfo.2017.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/08/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
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13
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Cerebrospinal fluid IL-10 as an early stage discriminative marker between multiple sclerosis and neuro-Behçet disease. Cytokine 2018; 108:160-167. [PMID: 29625335 DOI: 10.1016/j.cyto.2018.03.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/17/2022]
Abstract
Multiple Sclerosis (MS) and Neuro-Behçet's Disease (NBD) are two recurrent disorders affecting the central nervous system (CNS) by causing inflammation and irreversible damage. Inaugural clinical symptoms for both diseases might be very similar and definitive diagnosis could be delayed. The present study aimed to find out possible differences at early stages in the transcription factors/cytokines expression profiles in blood and cerebrospinal fluid (CSF) of MS and NBD patients which could be useful discriminative markers. Cytokines and transcription factors related to Th1, Th2, Th17 and T regulatory populations were studied by quantitative RT-PCR simultaneously in PBMCs and CSF, from 40 patients presenting a first episode of clinical features related to CNS inflammation and 22 controls with non inflammatory neurological diseases enrolled mainly for severe headache. The follow up of 12 months did allow a definitive diagnosis of remitting relapsing MS (RRMS) in 21 patients and of NBD in the other 19 among those with CNS inflammation compared to controls. In initial blood samples, T-bet was significantly increased in NBD patients only while IFN-γ was elevated in patients who evolved into RRMS or NBD. IL-17a, GATA-3 and IL-4 were significantly lower in RRMS patients than in the NBD group. In initial CSF samples, ROR-γt, IL-17a and IFN-γ were significantly elevated in patients compared to controls. The most striking finding was the significant increase of CSF IL-10 that we did observe in NBD patients only. Thus, we propose CSF IL-10 as a predictive marker to help clinicians discriminating between these two neurological disorders.
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14
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Adult leukoencephalopathies with prominent infratentorial involvement can be caused by Erdheim-Chester disease. J Neurol 2017; 265:273-284. [PMID: 29204962 DOI: 10.1007/s00415-017-8692-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/20/2017] [Accepted: 11/23/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Leukoencephalopathies with prominent involvement of cerebellum and brainstem, henceforward called prominent infratentorial leukoencephalopathies (PILs), encompass a variety of inherited and acquired white matter diseases. Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis likely under-diagnosed as cause of adult PIL. METHODS We reviewed the clinical and laboratory information of ten consecutive sporadic adult patients with PIL of unknown origin, who were investigated for ECD. RESULTS There were seven males and three females; mean age at clinical onset was 49.6 years (range 38-59); cerebellar ataxia with or without other neurological symptoms was the only or the main clinical manifestation; diabetes insipidus was present in three individuals. Eight patients had white matter focal supratentorial abnormalities, in addition to the infratentorial white matter changes. Six out of eight patients had spinal cord lesions. Thoraco-abdominal CT showed periaortic sheathing in two patients, whole-body FDG-PET revealed increased glucose uptake in the long bones of the legs in five patients, brain FDG-PET showed overt infratentorial hypermetabolism in one patient. In eight patients, ECD was confirmed by bone scintigraphy, pathological data, or both. Two ECD patients treated with vemurafenib showed a marked improvement of neurological symptoms and brain MRI abnormalities at 1 year follow-up. CONCLUSIONS Symptoms of PIL can be the only clinical manifestation of ECD. Adult patients with PIL of unknown origin should undergo investigations aimed at unveiling ECD, including bone scintigraphy and whole-body FDG-PET. The early diagnosis allows starting disease-modifying therapies of an otherwise life-threatening disease.
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15
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A rare case of neuro-Behçet's disease presenting with limbic encephalitis. Turk J Phys Med Rehabil 2017; 63:351-354. [PMID: 31453479 DOI: 10.5606/tftrd.2017.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/30/2016] [Indexed: 11/21/2022] Open
Abstract
Behçet's syndrome is a recurrent systemic inflammation with an unknown etiology. The onset of the condition often occurs in the second decade of life and it is more common in males than in females. One of the most feared organ involvements associated with BS is neurological involvement, which often affects the brain stem, although hemispheric involvement may be primary in a limited number of patients. Parenchymal neurological involvement in BS affects the prognosis unfavorably, as it may result in severe sequelae or mortality. Early diagnosis and treatment is important to prevent sequelae. Herein, we report the first case of neuro-Behçet's disease presenting with limbic encephalitis who received early stage immunotherapy.
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16
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Dutra LA, de Souza AWS, Grinberg-Dias G, Barsottini OGP, Appenzeller S. Central nervous system vasculitis in adults: An update. Autoimmun Rev 2017; 16:123-131. [PMID: 28087351 DOI: 10.1016/j.autrev.2016.12.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 11/27/2022]
Abstract
Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.
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Affiliation(s)
- Lívia Almeida Dutra
- General Neurology Division, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Simone Appenzeller
- Rheumatology Division, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil.
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17
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Jade J, Chung K, Arendse M, Hussain Z, White D. Neuro-Behçet's disease presenting with tumour-like lesions and responding to rituximab. J Clin Neurosci 2016; 32:139-41. [PMID: 27320374 DOI: 10.1016/j.jocn.2016.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/14/2016] [Indexed: 11/29/2022]
Abstract
We describe a patient with neuro-Behçets disease (NBD) that presented with symptoms of raised intracranial pressure including papilloedema. MRI revealed tumour-like lesions which, on biopsy, confirmed an active vasculitis. Treatment was commenced with prednisone and cyclophosphamide which proved unsuccessful with enlargement of the cerebral mass lesions. Infliximab and mycophenolate were trialled also without benefit. The patient required ventriculoperitoneal shunts to relieve the symptoms of hydrocephalus. Rituximab was then commenced with significant symptomatic and imaging improvement. The case is unique, in our experience, in the need for shunting to relieve the symptoms of hydrocephalus related to vasculitis.
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Affiliation(s)
- J Jade
- Waikato DHB, Hamilton 3204, New Zealand
| | - K Chung
- Sydney Adventist Hospital Clinic, Wahroonga, NSW 2076, Australia
| | - M Arendse
- Waikato DHB, Hamilton 3204, New Zealand
| | - Z Hussain
- Waikato DHB, Hamilton 3204, New Zealand
| | - D White
- Waikato DHB, Hamilton 3204, New Zealand; Waikato Clinical School, Waikato Hospital, University of Auckland, Pembroke Street, Private Bag 3200, Hamilton 3240, New Zealand.
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18
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Rovira A, Auger C. Spinal Cord in Multiple Sclerosis: Magnetic Resonance Imaging Features and Differential Diagnosis. Semin Ultrasound CT MR 2016; 37:396-410. [PMID: 27616313 DOI: 10.1053/j.sult.2016.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multiple sclerosis (MS) is an idiopathic inflammatory disorder of the central nervous system that affects not only the brain but also the spinal cord. In the diagnostic and monitoring process of MS, spinal cord magnetic resonance imaging (MRI) is not performed as commonly as brain MRI, mainly because of certain technical difficulties and the increase in total acquisition time. Nonetheless, spinal cord MRI findings are important to establish a prompt accurate diagnosis of MS, impart prognostic information, and provide valuable data for monitoring the disease course in certain cases. In this article, we discuss the technical aspects of spinal cord MRI, the typical MRI features of the spinal cord in MS, the clinical indications for this examination, and the differential diagnosis with other disorders that may produce similar clinical or MRI findings.
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Affiliation(s)
- Alex Rovira
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Cristina Auger
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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19
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Abstract
OPINION STATEMENT Management of neuro-Behçet's disease can be divided into two stages: treatment of acute attacks and prevention of relapses. Treatment of acute attacks is accomplished by high-dose intravenous corticosteroids followed by maintenance treatment with oral steroids for 6-12 months depending on the type and severity of the neurological involvement. Relapses can be prevented by using immunosuppressants. Oral immunosuppressants such as azathioprine and mycophenolate are the most widely utilized agents for this purpose. Patients who are refractory or who cannot tolerate these medications can be managed by cyclophosphamide, interferon alpha, or anti-TNF-α monoclonal antibodies such as infliximab, etanercept, and adalimumab. Recent reports showed that newer agents such as tocilizumab, canakinumab, and anakinra, which exert their biological activity through IL-1 and IL-6 pathways, are also promising treatment alternatives for progressive or relapsing patients.
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Affiliation(s)
- Murat Kürtüncü
- Istanbul Faculty of Medicine, Department of Neurology, Istanbul University, Istanbul, Turkey
| | - Erdem Tüzün
- Institute of Experimental Medicine and Research, Department of Neuroscience, Istanbul University, Istanbul, Turkey
| | - Gulsen Akman-Demir
- School of Medicine, Department of Neurology, Istanbul Bilim (Science) University, Istanbul, Turkey.
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20
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Rovira Á, Auger C, Rovira A. Other noninfectious inflammatory disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 135:425-446. [PMID: 27432677 DOI: 10.1016/b978-0-444-53485-9.00021-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Idiopathic inflammatory-demyelinating diseases (IIDDs) represent a broad spectrum of central nervous system (CNS) disorders, including monophasic, multiphasic, and progressive disorders that range from highly localized forms to multifocal or diffuse variants. In addition to the classic multiple sclerosis (MS) phenotypes, several MS variants have been described, which can be differentiated on the basis of severity, clinical course, and lesion distribution. Other forms of IIDD are now recognized as distinct entities and not MS variants, such as acute disseminated encephalomyelitis, and neuromyelitis optica spectrum disorders. The CNS can also be affected by a variety of inflammatory diseases. These include primary angiitis of the CNS (PACNS), a rare disorder specifically targeting the CNS vasculature, and various systemic conditions which, among other organs and systems, can also affect the CNS, such as systemic vasculitis and sarcoidosis. The diagnosis of PACNS is difficult, as this condition may be confused with reversible cerebral vasoconstriction syndrome (RCVS), a term comprising a group of conditions characterized by prolonged but reversible vasoconstriction of the cerebral arteries. Magnetic resonance imaging of the brain and spine is the radiologic technique of choice for diagnosing these disorders, and, together with the clinical and laboratory findings, enables a prompt and accurate diagnosis.
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Affiliation(s)
- Álex Rovira
- MR Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Cristina Auger
- MR Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Rovira
- Corporació Sanitària Parc Taulí, CD-UDIAT, Sabadell, Spain
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21
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Gür Özmen S, Hanağasi H, Gürvit H, Emre M, Akman Demir G. Neuro-Behçet's Disease with Chorea. Noro Psikiyatr Ars 2015; 52:200-201. [PMID: 28360705 DOI: 10.5152/npa.2015.7316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 04/11/2014] [Indexed: 11/22/2022] Open
Abstract
Behçet's disease (BD) was described as a three-symptom complex comprising uveitis, oral aphthae, and genital ulcerations. It is a multisystemic, recurrent, inflammatory disorder and it is of unknown cause. Neuro-Behçet (NB) is present in 5%-7% of BD. Movement disorders have rarely been reported in NB. Here, we report a case of chronic parenchymal NB presenting with chorea.
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Affiliation(s)
- Selen Gür Özmen
- Department of Neuroscience, Institute for Experimental and Medical Research (DETAE), Istanbul University, İstanbul, Turkey; Clinic of Neurology, Iğdır State Hospital, Iğdır, Turkey
| | - Haşmet Hanağasi
- Department of Neurology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Hakan Gürvit
- Department of Neurology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Murat Emre
- Department of Neurology, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
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22
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Uygunoglu U, Benbir G, Saip S, Kaynak H, Siva A. A Polysomnographic and Clinical Study of Sleep Disorders in Patients with Behçet and Neuro-Behçet Syndrome. Eur Neurol 2014; 71:115-9. [DOI: 10.1159/000355277] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 08/25/2013] [Indexed: 11/19/2022]
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23
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Andrade-Rodado FM, Hurtado-García R, Alvarez Cienfuegos A, Mola Caballero S, Barreras Mateos JC, Custardoy Olavarrieta J. Acute meningitis in Behcet's disease. REUMATOLOGIA CLINICA 2014; 10:59-61. [PMID: 23660120 DOI: 10.1016/j.reuma.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/09/2013] [Accepted: 01/11/2013] [Indexed: 06/02/2023]
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24
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Abstract
Behçet syndrome (BS) is an idiopathic chronic relapsing multisystem vascular-inflammatory disease of unknown origin. As the disease affects many organs and systems and shows a wide range of clinical manifestations and presentations, it is prefereable to call Behçet's a syndrome (BS) rather than a disease. Nervous system involvement, known as "neuro-BS" (NBS), is seen in about 5-10% of all cases. Clinical and imaging evidence suggests that primary neurologic involvement in BS may be subclassified into two major forms: the first, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system disease with focal or multifocal parenchymal involvement, mostly presenting with a subacute brainstem syndrome and hemiparesis (intra-axial NBS); the other, which has few symptoms and a better neurologic prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension (extra-axial NBS), occurring in 10-20% of the cases. These two types are rarely seen in the same individual, and their pathogenesis is likely to be different. Isolated behavioral syndromes and peripheral nervous system involvement are rare, whereas a vascular type headache is relatively common and independent from neurologic involvement. Neurologic complications secondary to systemic involvement of BS, as well as neurologic complications related to BS treatments are considered as secondary neurologic involvement of the syndrome. The core histopathologic phenomenon seems to be a vasculitic involvement in some cases, and low-grade chronic nonspecific inflammation in others. As the neurologic involvement in this syndrome is so heterogeneous, it is difficult to predict its course and prognosis, and its response to treatment. Currently, treatment options for NBS are limited to attack therapies with high-dose intravenous methylprednisolone followed by a prolonged oral taper, symptomatic management, and generally the use of azathioprine, cyclophosphamide, interferon-α and anti-TNF agents for long-term preventive treatment, although there no evidence for their efficacy.
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Affiliation(s)
- Sabahattin Saip
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey
| | - Gulsen Akman-Demir
- Department of Neurology, School of Medicine, Istanbul Bilim University, Istanbul, Turkey
| | - Aksel Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey.
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25
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Diagnosis and management of Neuro-Behçet's disease: international consensus recommendations. J Neurol 2013; 261:1662-76. [PMID: 24366648 PMCID: PMC4155170 DOI: 10.1007/s00415-013-7209-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/04/2013] [Indexed: 11/16/2022]
Abstract
Neuro-Behçet’s disease (NBD) is one of the more serious manifestations of Behçet’s disease (BD), which is a relapsing inflammatory multisystem disease with an interesting epidemiology. Though NBD is relatively uncommon, being potentially treatable, neurologists need to consider it in the differential diagnosis of inflammatory, infective, or demyelinating CNS disorders. Evidence-based information on key issues of NBD diagnosis and management is scarce, and planning for such studies is challenging. We therefore initiated this project to develop expert consensus recommendations that might be helpful to neurologists and other clinicians, created through an extensive literature review and wide consultations with an international advisory panel, followed by a Delphi exercise. We agreed on consensus criteria for the diagnosis of NBD with two levels of certainty in addition to recommendations on when to consider NBD in a neurological patient, and on the use of various paraclinical tests. The management recommendations included treatment of the parenchymal NBD and cerebral venous thrombosis, the use of disease modifying therapies, prognostic factors, outcome measures, and headache in BD. Future studies are needed to validate the proposed criteria and provide evidence-based treatments.
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26
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Noel N, Drier A, Wechsler B, Piette JC, De Paz R, Dormont D, Cacoub P, Saadoun D. [Neurological manifestations of Behçet's disease]. Rev Med Interne 2013; 35:112-20. [PMID: 24290030 DOI: 10.1016/j.revmed.2013.10.332] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/12/2013] [Indexed: 11/17/2022]
Abstract
Neurological manifestations of Behçet's disease (BD) occur in 5.3 to more than 50% of patients. They are divided into two major forms: "parenchymal" lesions, which include mainly meningoencephalitis as opposed to "extra-parenchymal" lesions (i.e. cerebral venous thrombosis and arterial aneurysms). Myelitis or peripheral neuropathy is exceptional. The neuro-Behçet syndrome (NBS) should be considered in the setting of neurological manifestations, particularly headache and pyramidal signs, in a young man diagnosed with BD. However, its recognition may be difficult when neurological manifestations are the presenting features of BD (one third of cases), and requires a thorough knowledge of clinical manifestations and morphological lesions. Thus, parenchymal NB lesions classically exhibit inflammatory characteristics on MRI and are located at the meso-diencephalic junction and in the brainstem, rarely with a supratentorial extension. Meningitis is not systematically associated, and may be absent in about 30% of cases. The pathogenesis of these lesions is incompletely understood, but inflammatory infiltrates include mainly neutrophils and activated T cells (mainly Th17). Differential diagnoses include infectious diseases (herpes, listeria, tuberculosis), and inflammatory diseases (i.e. multiple sclerosis and sarcoidosis). A prompt recognition of NBS should lead to initiate adequate therapies in order to limit the risk of sequelae, relapses or death.
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Affiliation(s)
- N Noel
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - A Drier
- Service de neuroradiologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - B Wechsler
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - J-C Piette
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - R De Paz
- Service de neurologie, groupe hospitalier Pitié-Salpétrière, AP-HP, 75013 Paris, France
| | - D Dormont
- Service de neuroradiologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - P Cacoub
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France
| | - D Saadoun
- Service de médecine interne 2, centre de référence des maladies autoimmunes rares, DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Faculté de médecine, université Pierre-et-Marie-Curie, Paris 6, 75013 Paris, France.
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Abstract
Systemic autoimmune disorders affect multiple organ systems. Brain involvement commonly causes seizures, which may be the presenting symptom. Systemic lupus erythematosus, Sjorgren's syndrome, Wegener's granulomatosis, sarcoidsosis, celiac disease, Crohn's disease, Behcet's, and Hashimoto's encephalopathy are reviewed. Mechanisms underlying CNS pathology in systemic autoimmune disorders-and specifically factors predisposing these patients-are discussed, including vascular disease (e.g., prothrombotic state, anticardiolipin antibody, emboli, vasculitis), antineuronal antibodies, immune complexes, cytokines, metabolic disorders, infection, and therapy. Diagnostic and therapeutic strategies must be individualized for both the disorder and the patient. Systemic autoimmune disorders affect multiple organ systems and frequently involve the central and peripheral nervous systems. Seizures are among the most common neurological manifestation and occasionally can be the presenting symptom. There are many causes of seizures in systemic autoimmune disorders (Table 1), and the first clinical challenge is to determine not only the cause but also the significance of seizures. In some cases, they are clues to metabolic or infectious disorders or medication toxicity; in other cases, seizures herald a life-threatening progression of the underlying illness.
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28
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Pipitone N, Versari A, Hunder GG, Salvarani C. Role of imaging in the diagnosis of large and medium-sized vessel vasculitis. Rheum Dis Clin North Am 2013; 39:593-608. [PMID: 23719077 DOI: 10.1016/j.rdc.2013.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In large-vessel vasculitis, imaging studies are useful to document temporal artery involvement and crucial to show large-vessel involvement. Color Doppler sonography, magnetic resonance, and computed tomography show early vasculitic lesions. Angiography delineates later vascular complications well. Color Doppler sonography, magnetic resonance angiography, and computed tomography angiography can also be used to show vascular luminal changes. Positron emission tomography is very sensitive in detecting large-vessel inflammation. Imaging procedures can also be used to monitor the course of large-vessel vasculitis. In medium-vessel vasculitis, imaging studies can be used to show both vascular changes and internal organ changes.
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Affiliation(s)
- Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia 42123, Italy
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29
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de Boysson H, Pagnoux C, Zuber M. Vasculiti del sistema nervoso centrale. Neurologia 2013. [DOI: 10.1016/s1634-7072(12)63926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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30
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Mora P, Menozzi C, Orsoni JG, Rubino P, Ruffini L, Carta A. Neuro-Behçet's disease in childhood: a focus on the neuro-ophthalmological features. Orphanet J Rare Dis 2013; 8:18. [PMID: 23360593 PMCID: PMC3567996 DOI: 10.1186/1750-1172-8-18] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/23/2013] [Indexed: 02/01/2023] Open
Abstract
Neuro-Behçet's disease (NBD) involves the central nervous system; peripheral nervous system involvement is not often reported. NBD is quite common in adult patients and occurs rarely during childhood and adolescence. Young patients may share symptoms and signs of NBD with other neuro-ophthalmological disorders (e.g. idiopathic intracranial hypertension); thus, making the differential diagnosis difficult. Neuroimaging is mandatory and necessary for a correct NBD diagnosis but in children radiological examinations are often difficult to perform without sedation. From 1971 to 2011, 130 patients aged ≤16 years have been reported with NBD, according to retrospective surveys, case series, and case reports. The origin of the reported cases met the well-known geographical distribution of Behçet's disease (BD); the mean age at presentation of neurological findings was 11.8 years, with male gender prevalence (ratio, 2.9:1). We considered in detail the neuro-ophthalmological features of the 53 cases whose neuroimaging alterations were described with an assigned radiological pattern of the disease (parenchymal: 14 cases, non-parechymal: 35 cases, and mixed: 4 cases). In 19/53 patients (36%), neuro-ophthalmological symptoms anticipated any pathognomonic sign for a BD diagnosis, or only occasional aphtae were recalled by the patients. Family history was positive in 17% of subjects. Headache was reported in 75% of the patients; in those presenting with cerebral vascular involvement, headache was combined to other symptoms of intracranial hypertension. Papilledema was the most frequently reported ophthalmological finding, followed by posterior uveitis. Treatment consisted of systemic steroids in 93% of patients, often combined with other immunosuppressive drugs (especially colchicine and azathioprine). Clinical recovery or improvement was documented in the large majority of patients. Nine subjects had definitive alterations, and one died. Based on our review and personal experience, a delayed diagnosis, and the consequently delayed immunosuppressive treatment, may favour permanent sequelae, in particular, optic atrophy.
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Affiliation(s)
- Paolo Mora
- Institute of Ophthalmology - Department of Biological, Biotechnological, and Translational Sciences, University of Parma, via Gramsci 14, 43126, Parma, Italy.
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Tokgoz OS, Akpinar Z, Guney F, Seyithanoğlu A. A Neuro-Behçet's Case Operated with the Intracranial Mass Misdiagnosis. J Korean Neurosurg Soc 2013; 52:488-90. [PMID: 23323172 PMCID: PMC3539086 DOI: 10.3340/jkns.2012.52.5.488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/06/2012] [Accepted: 10/31/2012] [Indexed: 11/27/2022] Open
Abstract
Behçet's disease (BD) is an inflammatory systemic disorder with oral and genital ulcers, as well as ophthalmologic and cutaneous symptoms. Neurological manifestations in BD represent between 2.2% to 50% of the cases. The 25-year-old male patient, diagnosed with BD three years earlier, was admitted to our clinic with complaints of recurrent headaches. Tumor-like-parenchimal involvement was detected on a cranial magnetic resonance imaging. The lesion was removed surgically and then he suffered from right hemiparesis and epilepsy. Pathological examination of the lesion noted a demyelinating non-tumoural etiology. A neuro-Behğet's case with parenchymal involvement has been examined in light of the literature, in terms of a tumor and a demyelinating disease differential diagnosis.
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Affiliation(s)
- Osman Serhat Tokgoz
- Department of Neurology, Meram Medical Faculty, Konya University, Konya, Turkey
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Farahangiz S, Sarhadi S, Safari A, Borhani-Haghighi A. Magnetic resonance imaging findings and outcome of neuro-Behçet's disease: the predictive factors. Int J Rheum Dis 2012; 15:e142-9. [DOI: 10.1111/1756-185x.12013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Anahid Safari
- Research Center for Traditional Medicine and History of Medicine; Shiraz; Iran
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Gündüz T, Emir Ö, Kürtüncü M, Mutlu M, Tumaç A, Akca S, Coban O, Bahar S, Öktem-Tanör Ö, Tüzün E, Eraksoy M, Gürvit H, Akman-Demir G. Cognitive impairment in neuro-Behcet's disease and multiple sclerosis: a comparative study. Int J Neurosci 2012; 122:650-6. [PMID: 22720779 DOI: 10.3109/00207454.2012.704454] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Both multiple sclerosis (MS) and neuro-Behcet's disease (NBD) can cause a cognitive dysfunction mainly involving the executive functions. We conducted this study to clarify the probable differential cognitive/behavioral profiles of MS and NBD. Twenty consecutive cases with parenchymal NBD (13 male, seven female), and 20 cases with MS (five male, 15 female) were evaluated. Both groups had a thorough neurological examination; an evaluation for Expanded Disability Status Scale (EDSS), Multiple Sclerosis Functional Composite (MSFC), and Beck's Depression Scale; and a detailed neuropsychological evaluation masked to the diagnosis. Among the two groups, male/female ratio differed significantly while other demographic and clinical features were not different. In California Verbal Learning Test, both short- and long-term delayed recall and cued recognition were worse in neuro-Behcet's cases. They had impaired semantic clustering and increased false positives. Stroop Test was also more impaired in neuro-Behcet's cases. They needed significantly more trials to complete the first category of the Wisconsin Card Sorting Test and had a poorer total Frontal Behavioral Inventory Score. Our results suggest that neuro-Behcet's patients have a more severe "frontal"-executive dysfunction than MS patients.
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Affiliation(s)
- Tuncay Gündüz
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Alkan A, Goktan A, Karincaoglu Y, Kamisli S, Dogan M, Oztanir N, Turan N, Kocakoc E. Brain perfusion MRI findings in patients with Behcet's disease. ScientificWorldJournal 2012; 2012:261502. [PMID: 22654579 PMCID: PMC3361152 DOI: 10.1100/2012/261502] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 12/08/2011] [Indexed: 11/17/2022] Open
Abstract
Objective. To search brain perfusion MRI (pMRI) changes in Behcet's disease (BD) with or without neurological involvement. Materials and Method. The pMRI were performed in 34 patients with BD and 16 healthy controls. Based on neurologic examination and post-contrast MRI, 12 patients were classified as Neuro-Behcet (group 1, NBD) and 22 patients as BD without neurological involvement (group 2). Mean transit time (MTT), time to peak (TTP), relative cerebral blood volume (rCBV), and relative cerebral blood flow (rCBF) were obtained and compared to those of healthy control group (group 3). Results. There was a significant difference in the MTT and rCBF within the pons and parietal cortex in groups 1 and 2. rCBV increased in cerebral pedicle in group 1 compared with groups 2 and 3. In the temporal lobe white matter, prolonged MTT and decreased rCBF were found in groups 1 and 2. In the corpus striatum, internal capsule, and periventricular white matter, rCBF increased in group 1 compared with group 3 and decreased in groups 1 and 2. Conclusion. Brain pMRI is a very sensitive method to detect brain involvement in patients with BD and aids the clinical diagnosis of NBD, especially in patients with negative MRI findings.
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Affiliation(s)
- Alpay Alkan
- Department of Radiology, School of Medicine, Bezmialem Vakif University, İstanbul, Turkey. alpay
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von Geldern G, McPharlin T, Becker K. Immune mediated diseases and immune modulation in the neurocritical care unit. Neurotherapeutics 2012; 9:99-123. [PMID: 22161307 PMCID: PMC3271148 DOI: 10.1007/s13311-011-0096-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This chapter will review the spectrum of immune-mediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.
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Affiliation(s)
- Gloria von Geldern
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Thomas McPharlin
- University of Washington School of Pharmacy, Seattle, WA 98104 USA
| | - Kyra Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA 98104 USA
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Abstract
PURPOSE OF REVIEW To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD). RECENT FINDINGS Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME). SUMMARY Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.
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Affiliation(s)
- Cem Evereklioglu
- Department of Ophthalmology, Erciyes University Medical Faculty, Kayseri, Turkey
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Neuro-Behçet avec atteinte du corps calleux. Rev Neurol (Paris) 2011; 167:533-6. [DOI: 10.1016/j.neurol.2010.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 08/20/2010] [Accepted: 10/26/2010] [Indexed: 11/17/2022]
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Albayram S, Saip S, Hasiloglu ZI, Teke M, Ceyhan E, Tutuncu M, Selcuk H, Kina A, Siva A. Evaluation of parenchymal neuro-behçet disease by using susceptibility-weighted imaging. AJNR Am J Neuroradiol 2011; 32:1050-5. [PMID: 21511865 DOI: 10.3174/ajnr.a2477] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE Neurologic involvement in Behçet disease, also known as NBD, is one of the most devastating manifestations of the disease. The precise pathologic mechanism of parenchymal NBD lesions has not been established. We evaluated lesion characteristics and probable venous hemorrhage in parenchymal NBD by using SWI, and we compared the imaging results with conventional MR imaging sequences. MATERIALS AND METHODS We performed cranial MR imaging by using a 1.5T scanner in 23 patients with a definitive diagnosis of parenchymal NBD. We compared the proportion of lesion detection and the performance of hemorrhagic detection with the T2 FSE, T2*GE, and SWI magnitude, and SWI mIP by using the χ(2) test. RESULTS The proportion of lesion detection with both SWI magnitude and SWI MinMIP was significantly larger than that with T2*GE. The proportions of lesion detection among all other pairs of methods were not significantly different according to the corresponding P value (χ(2) = 17.4929, df = 3, P = .0006). Proportions of hypointense hemorrhagic lesions with T2 FSE and T2*GE were not significantly different, and likewise for the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP. In contrast, the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP were significantly larger than that with T2 FSE and T2*GE (χ(2) = 108.5396, df = 3, P < .0001). CONCLUSIONS Most of the lesions in parenchymal NBD were found to be hemorrhagic with SWI, supporting the proposed venous theory in pathology. In addition, compared with T2 FSE and T2*GE sequences, SWI was more successful in the determination of widespread involvement of the disease, particularly in nonchronic cases.
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Affiliation(s)
- S Albayram
- Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, Turkey
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MRI findings of neuro-Behcet’s disease. Clin Rheumatol 2010; 30:765-70. [DOI: 10.1007/s10067-010-1650-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 10/25/2010] [Accepted: 11/29/2010] [Indexed: 11/27/2022]
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Guzmán-De-Villoria JA, Ferreiro-Argüelles C, Fernández-García P. Differential diagnosis of T2 hyperintense brainstem lesions: Part 2. Diffuse lesions. Semin Ultrasound CT MR 2010; 31:260-74. [PMID: 20483393 DOI: 10.1053/j.sult.2010.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diffuse brainstem lesions are poorly defined, often large abnormalities and include tumors (gliomas and lymphomas) vasculitis (Behçet's disease), traumatic brainstem injury, degenerative disorders (Wallerian degeneration), infections, processes secondary to systemic conditions (central pontine myelinolysis, hypertensive or hepatic encephalopathy), and ischemic pathology (leukoaraiosis). Magnetic resonance imaging is the most appropriate imaging modality to use in evaluating lesions of this type, but often findings are nonspecific. Therefore, radiologists need to bear in mind such additional information as patient age and clinical features in making a differential diagnosis.
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Affiliation(s)
- Juan A Guzmán-De-Villoria
- Department of Radiology/Neuroradiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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42
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Conca W, Kamel SA, Venne D, Corr P. Transient involvement of the cerebral cortex in a flare of Behçet's syndrome. Rheumatol Int 2010; 32:791-4. [PMID: 20054691 DOI: 10.1007/s00296-009-1362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 12/29/2009] [Indexed: 11/30/2022]
Abstract
We describe a flare of Behçet's syndrome in a 42-year-old man who presented with florid mucocutaneous manifestations, headache and vomiting, but without meningeal or neurologic signs. A single, non-enhancing cortical lesion was found in the frontal lobe by computed tomography and magnetic resonance (MR) imaging studies. Diffusion-weighted analysis and MR spectroscopy were consistent with focal inflammation. The patient improved with colchicine, and after 5 months, a repeat MR scan demonstrated resolution of the inflammatory changes suggesting that involvement of the cerebral cortex may be a self-limiting phenomenon, distinct from other more frequent and destructive parenchymal manifestations of neuro-Behçet's disease.
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Affiliation(s)
- Walter Conca
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates.
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Du-Boutin L, Wechsler B. Neuro-Behçet. Neurologia 2010. [DOI: 10.1016/s1634-7072(10)70503-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Houman M, Salem R, Ben Salem T. Les manifestations neurologiques de la maladie de Behçet. Rev Med Interne 2009; 30 Suppl 4:S238-42. [DOI: 10.1016/j.revmed.2009.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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45
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Cavaco S, Da Silva AM, Pinto P, Coutinho E, Santos E, Bettencourt A, Pinto C, Gonçalves A, Silva S, Gomes F, Carvalho L, Pereira C, Martins B, Correia J, Vasconcelos C. Cognitive Functioning in Behçet's Disease. Ann N Y Acad Sci 2009; 1173:217-26. [DOI: 10.1111/j.1749-6632.2009.04670.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Neurological manifestations of Behçet's disease (neuro-Behçet's disease) present in 5-30% of cases. They are classified into parenchymal and nonparenchymal categories. Poor prognostic factors include multifocal involvement, spinal presentations, more than two attacks per year, progressive course and increased cerebrospinal fluid cell count and protein content at the time of neurologic manifestations. For patients with parenchymal neuro-Behçet's disease without any poor prognostic factor, azathioprine or methotrexate and corticosteroids are recommended as the first-line treatment. For high-risk patients, intravenous cyclophosphamide and corticosteroids are recommended. If these regimens failed, TNF-alpha-blocking drugs, such as infliximab or etanercept, should be added. Alternating IFN-alpha and then chlorambucil or experimental treatments are the last resorts for most refractory patients. Treatment of venous sinus thrombosis is achieved by using anticoagulation and short-term corticosteroids with or without immunosuppressants.
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Affiliation(s)
- Afshin Borhani Haghighi
- Associate Professor of Neurology, Nemazee Hospital, Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran.
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47
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Thalidomide: an emerging drug in oral mucosal lesions. Clin J Gastroenterol 2009; 2:149-155. [DOI: 10.1007/s12328-009-0089-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 04/21/2009] [Indexed: 10/20/2022]
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48
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Greer DM, Friday RP, Romero J, Auluck PK. Case records of the Massachusetts General Hospital. Case 17-2009. A 30-year-old man with progressive neurologic deficits. N Engl J Med 2009; 360:2341-51. [PMID: 19474432 DOI: 10.1056/nejmcpc0810842] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David M Greer
- Department of Neurology, Massachusetts General Hospital, USA
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Occurrence of ankylosing spondylitis and multiple sclerosis-like syndrome in a HLA-B27 positive patient. Neurol Sci 2009; 30:329-32. [PMID: 19444380 DOI: 10.1007/s10072-009-0092-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 04/21/2009] [Indexed: 10/20/2022]
Abstract
Occurrence of multiple sclerosis (MS) in patients with ankylosing spondylitis (AS) has been reported in isolated cases. We describe a white 33-year-old male with a definite familial HLAB27 positive AS and MS-like syndrome. The patient developed acute onset of gait difficulty, postural unsteadiness, dysarthria and right side weakness that resolved within 1 month; after 6 months he presented right-sided face sensory loss, disappeared after 2 weeks. Brain and cervical MRI was performed twice and showed disseminated lesions in space (multiple foci of increased signal intensity in the periventricular white matter, in the corpus callosum, in the hypothalamus, in the brainstem and in the cervical spinal cord) and in time (a new enhancing lesion >3 months after the onset of the clinical event). Visual evoked potentials were markedly altered. Cerebrospinal fluid examination was negative for intrathecal production of oligoclonal bands. Differential diagnosis was considered and other pathologies were excluded.
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Tohmé A, Koussa S, Haddad-Zébouni S, El-Rassi B, Ghayad E. Étude de 22 observations de neuroBehçet dans une série de 170 maladies de Behçet. Presse Med 2009; 38:701-9. [DOI: 10.1016/j.lpm.2008.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 03/17/2008] [Accepted: 04/09/2008] [Indexed: 12/14/2022] Open
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