1
|
Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, treatment, and prognosis of the most common monophasic and relapsing acquired demyelinating disorders presenting in childhood. RECENT FINDINGS Our understanding of neuroimmune disorders of the central nervous system is rapidly expanding. Several clinical and paraclinical factors help to inform the diagnosis and ultimately the suspicion for a monophasic versus relapsing course, including the age of the patient (prepubertal versus postpubertal), presence or absence of clinical encephalopathy, identification of serum autoantibodies (eg, myelin oligodendrocyte glycoprotein [MOG] and aquaporin-4), presence of intrathecally unique oligoclonal bands, and location/extent of radiologic abnormalities. Collaborative international research efforts have facilitated understanding of the safety and efficacy of currently available immunotherapies in children with acquired demyelinating disorders, particularly multiple sclerosis. SUMMARY Although many of the demyelinating disorders presented in this article can affect children and adults across the age spectrum, the clinical and radiologic phenotypes, treatment considerations, and long-term prognoses are often distinct in children.
Collapse
|
2
|
Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2021; 35:152-169. [PMID: 34490814 DOI: 10.1177/19714009211042879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
Collapse
Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| |
Collapse
|
3
|
Qiu K, He Q, Chen X, Liu H, Deng S, Lu W. Pregnancy-Related Immune Changes and Demyelinating Diseases of the Central Nervous System. Front Neurol 2019; 10:1070. [PMID: 31649614 PMCID: PMC6794637 DOI: 10.3389/fneur.2019.01070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/23/2019] [Indexed: 12/31/2022] Open
Abstract
Demyelinating diseases of the central nervous system comprise a heterogeneous group of autoimmune disorders characterized by myelin loss with relative sparing of axons occurring on a background of inflammation. Some of the most common demyelinating diseases are multiple sclerosis, acute disseminated encephalomyelitis, and neuromyelitis optica spectrum disorders. Besides showing clinical, radiological, and histopathological features that complicate their diagnosis, demyelinating diseases often involve different immunological processes that produce distinct inflammatory patterns. Evidence of demyelination diseases derives mostly from animal studies of experimental autoimmune encephalomyelitis (EAE), a model that relies on direct antibody–antigen interactions induced by encephalitogenic T cells. Pregnancy is characterized by non-self-recognition, immunomodulatory changes and an altered Th1/Th2 balance, generally considered a Th2-type immunological state that protects the mother from infections. During pregnancy, the immune response of patients with autoimmune disease complicated with pregnancy is different. Immune tolerance in pregnancy may affect the course of some diseases, which may reach remission or be exacerbated. In this review, we summarize current knowledge on the immune status during pregnancy and discuss the relationship between pregnancy-related immune changes and demyelinating diseases of the central nervous system.
Collapse
Affiliation(s)
- Ke Qiu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiang He
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiqian Chen
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hui Liu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuwen Deng
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
4
|
Golub D, Williams F, Wong T, Iyengar N, Jolley H, Sabadiah S, Rhee D, Gold-von Simson G. A Longitudinally Extensive Spinal Cord Lesion Restricted to Gray Matter in an Adolescent Male. Front Neurol 2019; 10:270. [PMID: 30949125 PMCID: PMC6435483 DOI: 10.3389/fneur.2019.00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/28/2019] [Indexed: 01/19/2023] Open
Abstract
Longitudinally extensive spinal cord lesions (LECL) restricted to gray matter are poorly understood as are their neurodevelopmental repercussions in children. We herein report the critical case of a 13-year-old male presenting with progressive quadriparesis found to have cervical LECL restricted to the anterior horns. Challenged with a rare diagnostic dilemma, the clinical team systematically worked through potential vascular, genetic, infectious, rheumatologic, and paraneoplastic diagnoses before assigning a working diagnosis of acute inflammatory myelopathy. Nuanced consideration of and workup for both potential ischemic causes (arterial dissection, fibrocartilaginous embolism, vascular malformation) and specific inflammatory conditions including Transverse Myelitis, Neuromyelitis Optica Spectrum Disorders (NMOSD), Multiple Sclerosis (MS), Acute Disseminated Encephalomyelitis (ADEM), and Acute Flaccid Myelitis (AFM) is explained in the context of a comprehensive systematic review of the literature on previous reports of gray matter-restricted longitudinally extensive cord lesions in children. Treatment strategy was ultimately based on additional literature review of treatment-refractory acute inflammatory neurological syndromes in children. A combination of high-dose steroids and plasmapheresis was employed with significant improvement in functional outcome, suggesting a potential benefit of combination immune-modulatory treatment in these patients. This case furthermore highlights quality clinical reasoning with respect to the elusive nature of diagnosis, nuances in neuroimaging, and multifocal treatment strategies in pediatric LECL.
Collapse
Affiliation(s)
- Danielle Golub
- New York University School of Medicine, New York, NY, United States
| | - Faith Williams
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, United States
| | - Taylor Wong
- New York University School of Medicine, New York, NY, United States
| | - Nishanth Iyengar
- New York University School of Medicine, New York, NY, United States
| | - Hannah Jolley
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Sakinah Sabadiah
- Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - David Rhee
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Gabrielle Gold-von Simson
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States.,Health and Hospitals, Clinical Translational Science Institute, New York University, New York, NY, United States
| |
Collapse
|
5
|
Bisker Kassif O, Orbach R, Rimon A, Scolnik D, Glatstein M. Acute disseminated encephalomyelitis in children - clinical and MRI decision making in the emergency department. Am J Emerg Med 2019; 37:2004-2007. [PMID: 30846211 DOI: 10.1016/j.ajem.2019.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Acute disseminated encephalomyelitis (ADEM) is an uncommon, treatable, primarily pediatric, immune-mediated disease. Diagnosis of ADEM requires two essential elements: typical clinical presentation and magnetic resonance imaging (MRI) findings. The aim of this study was to evaluate how clinical findings in the initial emergency department (ED) presentation influenced the timing of MRI. METHODS A retrospective chart review was conducted of children diagnosed with ADEM, over a 12-year period, in a tertiary care pediatric center. Clinical presentation at ED admission was recorded and patients who underwent an MRI as part of their ED evaluation (early MRI) with those who had MRI performed during ward hospitalization (late MRI) were compared. RESULTS 30 patients were diagnosed with ADEM during the study period. Encephalopathy and polyfocal neurological signs were described in 80% and 50% of patients ED charts, respectively. Seven patients underwent early MRI and polyfocal neurological signs were more common in this group (p = 0.006). Fever was more common in the late MRI group (p = 0.02). Following diagnosis, all patients were treated with immune-modulation therapy, improved clinically, and were discharged. CONCLUSION 20% of ADEM patients were not encephalopathic at ED presentation. Polyfocal neurological signs and absence of fever at ED presentation were related to earlier MRI utilization and thus earlier diagnosis and treatment. Familiarity with the ADEM constellation of signs, and a high index of suspicion, may help the ED clinician in early diagnosis and treatment of this rare disease.
Collapse
Affiliation(s)
- Orly Bisker Kassif
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, University of Tel Aviv, Israel
| | - Rotem Orbach
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, University of Tel Aviv, Israel
| | - Ayelet Rimon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, University of Tel Aviv, Israel
| | - Dennis Scolnik
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Miguel Glatstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Dana-Dwek Children's Hospital, University of Tel Aviv, Israel; Division of Clinical Pharmacology and Toxicology, Tel Aviv Sourasky Medical Center, University of Tel Aviv, Israel.
| |
Collapse
|