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Neuroimaging findings in rheumatologic disorders. J Neurol Sci 2021; 427:117531. [PMID: 34130065 DOI: 10.1016/j.jns.2021.117531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/12/2021] [Accepted: 06/02/2021] [Indexed: 01/06/2023]
Abstract
Patients with rheumatological diseases may present with neurological manifestations of peripheral and/or central nervous system (CNS). Symptoms may be related to underlying rheumatological disease or CNS effects of immune-modulating drugs. Early diagnosis and therapy may help prevent serious complications. Magnetic resonance imaging (MRI), given its excellent soft tissue details, is the preferred imaging modality when evaluating patients with rheumatological disease and suspected CNS involvement. We present a review of the neuroimaging manifestations of various rheumatic diseases with emphasis on the imaging findings on MRI.
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2
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Abstract
The risk of JC polyomavirus encephalopathy varies among biologic classes and among agents within the same class. Of currently used biologics, the highest risk is seen with natalizumab followed by rituximab. Multiple other agents have also been implicated. Drug-specific causality is difficult to establish because many patients receive multiple immunomodulatory medications concomitantly or sequentially, and have other immunocompromising factors related to their underlying disease. As use of biologic therapies continues to expand, further research is needed into pathogenesis, treatment, and prevention of JC polyomavirus encephalopathy such that risk for its development is better understood and mitigated, if not eliminated altogether.
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Atzeni F, Talotta R, Masala IF, Gerardi MC, Casale R, Sarzi-Puttini P. Central nervous system involvement in rheumatoid arthritis patients and the potential implications of using biological agents. Best Pract Res Clin Rheumatol 2019; 32:500-510. [PMID: 31174819 DOI: 10.1016/j.berh.2019.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Central nervous system (CNS) involvement is quite unusual in patients with rheumatoid arthritis (RA), although cerebral vasculitis, rheumatoid nodules and meningitis have all been reported, and patients with RA may also have CNS comorbidities such as stroke and neuro-degenerative and demyelinating syndromes. It has been found that biological drugs, especially anti-tumour necrosis factor-alpha (anti-TNF-α) drugs, slightly increase the risk of developing demyelinating diseases, and they are consequently discouraged in patients with multiple sclerosis and related disorders. Furthermore, the risk of opportunistic CNS infections is increased in immunosuppressed patients. To review the current literature concerning CNS involvement in patients with RA (including RA-related forms and comorbidities) and the incidence of new-onset CNS diseases in patients with RA undergoing biological treatment (anti-TNF or non-anti-TNF drugs), the Medline database was searched using the key words 'rheumatoid arthritis', 'central nervous system', 'anti-TNF', 'abatacept', 'tocilizumab', 'rituximab' and 'anakinra'. Abstracts not in English were excluded. We selected 76 articles published between 1989 and 2017, which were divided into four groups on the basis of whether CNS involvement was RA-related or not and according to the type of biological agent used (TNF inhibitors or other agents). The RA-related diseases included aseptic meningitis, vasculitis and cerebral rheumatoid nodules, which benefit from immunosuppressive treatments. CNS comorbidities included stroke, seizures, dementia and neuropsychiatric disorders, which have been frequently described in biological agent-naïve patients with RA, and other rarely reported neurological diseases, such as extra-pyramidal syndromes and demyelinating disorders. CNS comorbidities are relatively frequent among patients with RA and may be related to systemic inflammation or concomitant medications. The use of anti-TNF drugs is associated with the risk of developing demyelinating diseases, and CNS infections have been described in patients treated with anti-TNF and non-anti-TNF agents. Non-anti-TNF drugs may be preferred in the case of demyelinating diseases, cerebral vasculitis or neurolupus. Patients with RA may suffer from CNS involvement as a manifestation of RA or as a comorbidity. The treatment of such medical conditions should be guided on the basis of their etiopathogenesis: steroids and immunosuppressants are useful in the case of RA-related CNS diseases but are often detrimental in other situations. Similarly, the choice of biological agents in patients with RA with CNS complications should be guided by a correct diagnosis in order to prevent further complications.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, University of Messina, Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Rossella Talotta
- Post-graduate School of Pharmacology and Clinical Toxicology, University of Milan, Piazza Ospedale Maggiore 3, 20152, Milano, Italy.
| | - Ignazio Francesco Masala
- Orthopedic and Trauma Unit, Santissima Trinità Hospital, Via Is Mirrionis 92, 09121, Cagliari, Italy.
| | - Maria Chiara Gerardi
- Rheumatology Unit, Spedali Civili di Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Roberto Casale
- Habilita Hospitals & Research Rehabilitation Unit, Bergamo, Zingonia, Italy.
| | - Piercarlo Sarzi-Puttini
- Department of Rheumatology, University Hospital ASST-Fatebenefratelli-Sacco, Via GB Grassi 74, 20157, Milano, Italy.
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4
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McCaughan G, Massey J, Sutton I, Curnow J. Acquired haemophilia A complicating alemtuzumab therapy for multiple sclerosis. BMJ Case Rep 2017; 2017:bcr-2017-223016. [PMID: 29212866 DOI: 10.1136/bcr-2017-223016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Alemtuzumab is a highly efficacious therapy used in the treatment of multiple sclerosis (MS), but uncoupling of T and B cell repopulation during immune reconstitution associates with an increasing range of secondary B cell-mediated autoimmune complications. A 34-year-old woman developed Graves' disease 11 months following an initial course of alemtuzumab treatment for MS. Nine months following the second treatment with alemtuzumab, the patient presented with spontaneous intramuscular and subcutaneous haemorrhage due to development of an inhibitory autoantibody to coagulation factor VIII. Acquired haemophilia A (AHA) is an extremely rare complication in patients treated with alemtuzumab. Treatment with rituximab may induce a rapid remission of AHA; however, the patient's high John Cunningham virus (JCV) antibody index and alemtuzumab-induced T cell lymphopenia may lead to an increased risk of progressive multifocal leucoencephalopathy, a potential complication which was unacceptable to the patient.
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Affiliation(s)
- Georgia McCaughan
- Haematology Department, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, Sydney, Australia
| | - Jennifer Massey
- Neurology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,UNSW Medical School, Sydney, New South Wales, Australia
| | - Ian Sutton
- Neurology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Haematology Department, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Sydney, New South Wales, Australia
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Rodio DM, Anzivino E, Mischitelli M, Bellizzi A, Scrivo R, Scribano D, Conte G, Prezioso C, Trancassini M, Valesini G, Palamara AT, Pietropaolo V. Increased Prevalence of Human Polyomavirus JC Viruria in Chronic Inflammatory Rheumatic Diseases Patients in Treatment with Anti-TNF α: A 18 Month Follow-Up Study. Front Microbiol 2016; 7:672. [PMID: 27242700 PMCID: PMC4861734 DOI: 10.3389/fmicb.2016.00672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/22/2016] [Indexed: 12/04/2022] Open
Abstract
Chronic inflammatory rheumatic diseases (CIRDs) are immune-mediated pathologies involving joints. To date, TNFα-blocking agents administration is the most promising therapy, although these treatments are associated with an increased Polyomavirus JC (JCPyV) reactivation, the etiological agent of the Progressive Multifocal Leukoencephalopathy (PML). The aim of this study was the recruitment and the analysis of a CIRDs cohort in order to investigate a possible correlation between JCPyV presence and the influence of anti-TNF-α agents on viral loads. Blood and urine samples were collected from 34 CIRDs subjects prior the first anti-TNF-α infusion (T0) and after 3 (T3), 6 (T6), 12 (T12), and 18 (T18) months. Results showed persistent JC viruria significantly higher than JC viremia throughout the 18 month follow-up study (p = 0.002). In JCPyV positive samples, the non-coding control region (NCCR) was analyzed. Results evidenced archetypal structures (type II-S) in all isolates with the exception of a sequence isolated from a plasma sample, that corresponds to the type II-R found in PML subjects. Finally, the viral protein 1 (VP1) genotyping was performed and results showed the prevalence of the European genotypes 1A, 1B, and 4. Since only few studies have been carried out to understand whether there is a PML risk in CIRDs population infected by JCPyV, this study contributes to enrich literature insight on JCPyV biology in this cluster. Further investigations are necessary in order to recognize the real impact of biologics on JCPyV life cycle and to identify possible and specific viral variants related to increased virulence in CIRDs patients.
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Affiliation(s)
- Donatella Maria Rodio
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Elena Anzivino
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Monica Mischitelli
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Anna Bellizzi
- Department of Public Health and Infectious Diseases, Institute Pasteur, Cenci-Bolognetti Foundation, "Sapienza" University of Rome Rome, Italy
| | - Rossana Scrivo
- Department of Internal Medicine and Medical Disciplines, Rheumatology, "Sapienza" University of Rome Rome, Italy
| | - Daniela Scribano
- Department of Experimental and Clinical Sciences, "G. D'Annunzio" University of Chieti Chieti, Italy
| | - Gianlorenzo Conte
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Carla Prezioso
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Maria Trancassini
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome Rome, Italy
| | - Guido Valesini
- Department of Internal Medicine and Medical Disciplines, Rheumatology, "Sapienza" University of Rome Rome, Italy
| | - Anna Teresa Palamara
- Department of Public Health and Infectious Diseases, Institute Pasteur, Cenci-Bolognetti Foundation, "Sapienza" University of RomeRome, Italy; San Raffaele Pisana Scientific Institute for Research, Hospitalization and Health CareRome, Italy
| | - Valeria Pietropaolo
- Department of Public Health and Infectious Diseases, "Sapienza" University of RomeRome, Italy; Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, College of Science and Technology, Temple UniversityPhiladelphia, PA, USA
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Domínguez-Mozo MI, Toledano-Martínez E, Rodríguez-Rodríguez L, García-Montojo M, Alvarez-Lafuente R, Fernández-Gutiérrez B. JC virus reactivation in patients with autoimmune rheumatic diseases treated with rituximab. Scand J Rheumatol 2016; 45:507-511. [DOI: 10.3109/03009742.2015.1135980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- MI Domínguez-Mozo
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
| | - E Toledano-Martínez
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
| | - L Rodríguez-Rodríguez
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
| | - M García-Montojo
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
| | - R Alvarez-Lafuente
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
| | - B Fernández-Gutiérrez
- Departments of Neurology and Rheumatology, Health Research Institute, San Carlos Clinical Hospital (IDISSC), Madrid, Spain
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Joaquim AF, Appenzeller S. Neuropsychiatric manifestations in rheumatoid arthritis. Autoimmun Rev 2015; 14:1116-22. [PMID: 26238502 DOI: 10.1016/j.autrev.2015.07.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/27/2015] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic disease characterized by persistent synovitis, systemic inflammation, and the presence of autoantibodies. Neuropsychiatric manifestations are quite common in RA, including depression, cognitive dysfunction, behavior changes, spinal cord compression and peripheral nerve involvement. Potential causes include systemic inflammatory process, neural compression due to bone and joint destruction, side effects of medications and copying difficulties due to the chronicity of the disease. A high level of suspicious is required for an adequate diagnosis and treatment. In this review, we will discuss topographically the main neuropsychiatric manifestations described in RA patients, in an attempt to help in the management of these complex and multifaceted disease.
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Affiliation(s)
- Andrei F Joaquim
- Department of Neurology, State University of Campinas (UNICAMP), 13083-970 Campinas SP, Brazil.
| | - Simone Appenzeller
- Department of Medicine, State University of Campinas (UNICAMP), 13083-970 Campinas SP, Brazil
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