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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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Hamid M, Adan K, Satte A, Bourazza A. Chorea in Neuro-Behçet's Disease. Cureus 2021; 13:e19039. [PMID: 34853756 PMCID: PMC8608035 DOI: 10.7759/cureus.19039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 12/05/2022] Open
Abstract
Behçet’s disease (BD) was described as a multisystemic recurrent inflammatory disorder of unknown cause comprising uveitis, skin lesions, recurrent genital, and oral ulcers. Involvement of the central nervous system in BD is about 10-25%. Chorea is defined as a hyperkinetic movement disorder, which can be caused by different etiologies. It was rarely mentioned in the literature as a manifestation of neuro-Behçet’s disease (NB). Radiological lesions are predominant in basal ganglia and periventricular white matter. The evolution of chorea in NB is variable in literature studies. We present a rare case of parenchymal NB with chorea.
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Affiliation(s)
- Mohamed Hamid
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Kadira Adan
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Amal Satte
- Department of Neurophysiology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
| | - Ahmed Bourazza
- Department of Neurology, Mohamed V Military Teaching Hospital, Mohamed V University, Rabat, MAR
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Movement disorders in systemic autoimmune diseases: Clinical spectrum, ancillary investigations, pathophysiological considerations. Parkinsonism Relat Disord 2021; 88:116-128. [PMID: 34092506 DOI: 10.1016/j.parkreldis.2021.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 02/08/2023]
Abstract
With the advances in neuroimmunology especially due to the discovery of new neuronal antibodies, the recognition of treatable antibody-related movement disorders has recently received much attention. In contrast, the identification and characterisation of movement disorders associated with systemic autoimmune diseases remains a substantially unexplored area. Beyond the classic few associations such as chorea and antiphospholipid syndrome, or ataxia and coeliac disease, movement disorders have been reported in association with several systemic autoimmune diseases, however a clear image of clinical phenotypes, investigations, and treatment outcomes in these conditions has never been drawn. In this review, we analyse data from approximately 300 cases and summarise the epidemiological, clinical and diagnostic features of movement disorders associated with systemic autoimmune diseases, and the available knowledge about treatment and outcomes. We highlight that movement disorders in systemic autoimmune conditions are frequently the only or among a few presenting manifestations and are mostly treatable disorders responding to immunotherapy or dietary modifications. We point out the pertinent combination of clinical features and investigations which can suggest the underlying autoimmune nature of these movement disorders, and thus address the most appropriate treatment.
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Rubio‐Hernandez M, Rodriguez‐Leyva I, Alvarado‐Gutierrez A, Gallegos Ríos C, Abud Mendoza C, Abad‐Guangorena E. Parkinsonism and Rapidly Progressive Dementia Secondary to Neuro‐
B
ehçet. Mov Disord Clin Pract 2020; 7:S74-S76. [DOI: 10.1002/mdc3.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Moises Rubio‐Hernandez
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Ildefonso Rodriguez‐Leyva
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Alma Alvarado‐Gutierrez
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Carlos Gallegos Ríos
- Neurology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Carlos Abud Mendoza
- Rheumatology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
| | - Edgar Abad‐Guangorena
- Dermatology Service, Hospital Central “Dr. Ignacio Morones Prieto,” Facultad de Medicina Universidad Autonoma de San Luis Potosí San Luis Potosí Mexico
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Watanabe E, Tanaka A, Sugawara H, Nishina K, Yabe H, Gono T, Terai C. Unclassified Vasculitis with Episcleritis, Thrombophlebitis, Deep Vein Thrombosis, Pulmonary Vasculitis, and Intracranial Vasculitis: An Autopsy Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:886-895. [PMID: 31230060 PMCID: PMC6604764 DOI: 10.12659/ajcr.915527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 04/18/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Systemic vasculitides constitute heterogenous conditions affecting many organs and systems through blood vessel inflammation. Although there are some classifications for vasculitis, several vasculitides are "unclassified" because they cannot be clearly assigned to one of the known entities. CASE REPORT We report an autopsy case of a 67-year-old Japanese man who presented with fever, ocular pain, erythema, chest pain, and headache. The disease caused episcleritis, thrombophlebitis, extensive deep vein thrombosis, multiple pulmonary nodules and masses, hypertrophic pachymeningitis, and hyper-intensity areas in brain parenchyma on magnetic resonance images. Histopathology of the pulmonary nodule confirmed vasculitis affecting medium-to-small veins and arteries without necrotizing vasculitis or granulomatous inflammation. We diagnosed the patient with unclassified vasculitis based on the clinicopathological characteristics. Steroids in combination with immunosuppressants were used, but the disease was refractory and relapsing. The disease activity was eventually controlled with rituximab, but the patient died of bronchopneumonia. On autopsy, lung and brain findings indicated healed vascular inflammation. CONCLUSIONS This is the first case report of unclassified vasculitis, which is characterized as medium-to-small-sized arteritis and phlebitis, causing episcleritis, thrombophlebitis, deep vein thrombosis, pulmonary vasculitis, and intracranial vasculitis. The clinical conditions share some similarities with granulomatosis with polyangiitis and Behçet's disease; however, they meet no classification criteria of any specific vasculitis. More cases need to be analyzed to confirm our findings.
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Affiliation(s)
- Eri Watanabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Akira Tanaka
- Department of Pathology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Hitoshi Sugawara
- Department of General Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Kumiko Nishina
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
- Department of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroki Yabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Takahisa Gono
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
| | - Chihiro Terai
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Saitama City, Saitama, Japan
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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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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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Menezes R, Pantelyat A, Izbudak I, Birnbaum J. Movement and Other Neurodegenerative Syndromes in Patients with Systemic Rheumatic Diseases: A Case Series of 8 Patients and Review of the Literature. Medicine (Baltimore) 2015; 94:e0971. [PMID: 26252269 PMCID: PMC4616569 DOI: 10.1097/md.0000000000000971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Patients with rheumatic diseases can present with movement and other neurodegenerative disorders. It may be underappreciated that movement and other neurodegenerative disorders can encompass a wide variety of disease entities. Such disorders are strikingly heterogeneous and lead to a wider spectrum of clinical injury than seen in Parkinson's disease. Therefore, we sought to stringently phenotype movement and other neurodegenerative disorders presenting in a case series of rheumatic disease patients. We integrated our findings with a review of the literature to understand mechanisms which may account for such a ubiquitous pattern of clinical injury.Seven rheumatic disease patients (5 Sjögren's syndrome patients, 2 undifferentiated connective tissue disease patients) were referred and could be misdiagnosed as having Parkinson's disease. However, all of these patients were ultimately diagnosed as having other movement or neurodegenerative disorders. Findings inconsistent with and more expansive than Parkinson's disease included cerebellar degeneration, dystonia with an alien-limb phenomenon, and nonfluent aphasias.A notable finding was that individual patients could be affected by cooccurring movement and other neurodegenerative disorders, each of which could be exceptionally rare (ie, prevalence of ∼1:1000), and therefore with the collective probability that such disorders were merely coincidental and causally unrelated being as low as ∼1-per-billion. Whereas our review of the literature revealed that ubiquitous patterns of clinical injury were frequently associated with magnetic resonance imaging (MRI) findings suggestive of a widespread vasculopathy, our patients did not have such neuroimaging findings. Instead, our patients could have syndromes which phenotypically resembled paraneoplastic and other inflammatory disorders which are known to be associated with antineuronal antibodies. We similarly identified immune-mediated and inflammatory markers of injury in a psoriatic arthritis patient who developed an amyotrophic lateral sclerosis (ALS)-plus syndrome after tumor necrosis factor (TNF)-inhibitor therapy.We have described a diverse spectrum of movement and other neurodegenerative disorders in our rheumatic disease patients. The widespread pattern of clinical injury, the propensity of our patients to present with co-occurring movement disorders, and the lack of MRI neuroimaging findings suggestive of a vasculopathy collectively suggest unique patterns of immune-mediated injury.
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Affiliation(s)
- Rikitha Menezes
- From the Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (RM); Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (AP); Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (II); and Division of Rheumatology and Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (JB)
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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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Neuro-Behçet's Disease Presented with Progressive Disinhibition. Dement Neurocogn Disord 2012. [DOI: 10.12779/dnd.2012.11.1.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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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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