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Marlikowska A, Szcześniak D, Kosowska N, Wieczorek T, Rymaszewska JE, Augustyniak-Bartosik H, Krajewska M, Rymaszewska J. The clinical complexity among patients with systemic, chronic diseases. J Psychosom Res 2024; 181:111670. [PMID: 38636301 DOI: 10.1016/j.jpsychores.2024.111670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 03/15/2024] [Accepted: 04/13/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES This study aimed to assess the clinical complexity of patients with chronic systemic diseases (systemic lupus erythematosus [SLE] and ANCA-associated vasculitis [AAV]) using the INTERMED Self-Assessment questionnaire (IMSA) to determine the most important factors responsible for this phenomenon in these patients. METHODS This was a cross-sectional, observational study. Questionnaires were used to evaluate biopsychosocial complexity (IMSA), quality of life (Short Form Survey [SF-36]), mental state (General Health Questionnaire - 28 [GHQ-28] and Hospital Anxiety and Depression Scale [HADS]), and acceptance of illness (Acceptance of Illness Scale [AIS]). RESULTS The final analysis included 81 patients. There was a moderate correlation between clinical complexity (total IMSA score) and quality of life related to mental health (SF-36) and mental state (GHQ-28) in patients with SLE. However, in patients with AAV, clinical complexity had a strong relationship with physical health-related quality of life and a moderate relationship with mental health-related quality of life. Stepwise regression analysis showed that low mental health-related quality of life is a predictor of higher complexity in SLE. The predictors of high clinical complexity in AAV were low physical and mental health-related quality of life and aggravated depressive symptoms (HADS). Other principal factors of clinical complexity were employment status, place of residence, social functioning, and illness duration. CONCLUSION This study confirmed the importance of holistic attitudes and complex healthcare among patients with chronic diseases.
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Affiliation(s)
| | - Dorota Szcześniak
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Natalia Kosowska
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-529 Wroclaw, Poland
| | - Tomasz Wieczorek
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Julia E Rymaszewska
- Department of Dermatology and Allergology, Wroclaw Medical University, 50-529 Wroclaw, Poland
| | - Hanna Augustyniak-Bartosik
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-529 Wroclaw, Poland.
| | - Magdalena Krajewska
- Department and Clinic of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-529 Wroclaw, Poland.
| | - Joanna Rymaszewska
- Department of Clinical Neuroscience, Wroclaw University of Science and Technology, 50-372 Wroclaw, Poland.
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Sherri A, Mortada MM, Makowska J, Lewandowska-Polak A. Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment. Rheumatol Int 2024; 44:211-222. [PMID: 37777632 PMCID: PMC10796583 DOI: 10.1007/s00296-023-05461-9] [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] [Received: 07/26/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023]
Abstract
Vasculitis of the central nervous system can be a localized process, such as primary angiitis of the central nervous system (PACNS), or systemic vasculitis, such as ANCA-associated vasculitis (AAV). Since both conditions share neurological manifestations, the following review will discuss the neurological aspects of both. This review aims to provide a comprehensive comparison of the pathogenesis, clinical manifestation and assessment, diagnostic workup, and treatment protocol for both PACNS and AAV with central nervous system involvement. To provide a comprehensive comparison and update, a literature review was conducted using PubMed and Ovid databases (Embase and Medline). Then, the references were retrieved, screened, and selected according to the inclusion and exclusion criteria. PACNS and AAV share similarities in clinical presentation and neurological symptoms, especially in terms of headache, focal deficits, and cognitive impairment. Additionally, both conditions may exhibit similarities in laboratory and radiological findings, making brain biopsy the gold standard for differentiation between the two conditions. Moreover, the treatment protocols for PACNS and AAV are nearly identical. Comparing PACNS and AAV with CNS involvement highlights the similarities in clinical presentation, radiological findings, and treatment protocols between the two conditions. Further research should focus on establishing a practical diagnostic protocol.
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Affiliation(s)
- Alaa Sherri
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland.
| | | | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
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Seifert RM, Rauch M, Klingebiel R, Boese LM, Greeve I, Rudwaleit M, Schäbitz WR. Case report: Cerebral amyloid angiopathy-related inflammation in a patient with granulomatosis with polyangiitis. Front Neurol 2023; 14:1277843. [PMID: 38020617 PMCID: PMC10666051 DOI: 10.3389/fneur.2023.1277843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Cerebral amyloid angiopathy-related inflammation (CAA-ri) defines a subacute autoimmune encephalopathy, which is presumably caused by increased CSF concentrations of anti-Aβ autoantibodies. This autoinflammatory reaction is temporally and regionally associated with microglial activation, inflammation and radiological presence of vasogenic edema. Clinical characteristics include progressive demential development as well as headache and epileptic seizures. In the absence of histopathologic confirmation, the criteria defined by Auriel et al. allow diagnosis of probable resp. possible CAA-ri. CAA-ri shows responsiveness to immunosuppressive therapies and a possible coexistence with other autoinflammatory diseases. Methods We present a case report and literature review on the diagnosis of CAA-ri in a patient with known granulomatosis with polyangiitis (GPA). Results Initially, the presented patient showed neuropsychiatric abnormalities and latent arm paresis. Due to slight increase in CSF cell count, an initial antiviral therapy was started. MR tomography showed a pronounced frontotemporal edema as well as cerebral microhemorrhages, leading to the diagnosis of CAA-ri. Subsequent high-dose steroid treatment followed by six intravenous cyclophosphamide pulses resulted in decreased CSF cell count and regression of cerebral MRI findings. Conclusion The symptoms observed in the patient are consistent with previous case reports on CAA-ri. Due to previously known GPA, we considered a cerebral manifestation of this disease as a differential diagnosis. However, absence of pachymeningitis as well as granulomatous infiltrations on imaging made cerebral GPA less likely. An increased risk for Aβ-associated pathologies in systemic rheumatic diseases is discussed variously.
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Affiliation(s)
- Rebecca M. Seifert
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Michael Rauch
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Lennart-Maximilian Boese
- Institut für diagnostische und interventionelle Neuroradiologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Isabell Greeve
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Martin Rudwaleit
- Universitätsklinik für Innere Medizin und Rheumatologie, Klinikum Bielefeld Rosenhöhe, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Universitätsklinik für Neurologie, Evangelisches Klinikum Bethel, Bielefeld, Germany
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Suksai P, Wasuanankun S, Lekhavat V, Sirimongkolchaiyakul O, Tangcheewinsirikul S. Atypical Neurological Manifestation in Childhood Microscopic Polyangiitis: A Case Report and Review of Literature. Front Pediatr 2022; 10:855338. [PMID: 35359892 PMCID: PMC8963201 DOI: 10.3389/fped.2022.855338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
UNLABELLED Microscopic polyangiitis (MPA), a systemic necrotizing vasculitis of small vessels, is primarily associated with necrotizing and crescentic glomerulonephritis and pulmonary capillaritis. Neurological involvement, particularly of the central nervous system (CNS) is scarcely observed. The diversity of CNS symptoms could puzzle the diagnosis causing delays in treatment and potentially having a considerable effect on patient's quality of life or even death. The aim of this case report is to highlight the unusual manifestation of MPA in order to raise awareness of this orphaned disease among pediatricians or even pediatric rheumatologists and neurologists. CASE REPORT Herein we report the case of a 13-year-old Thai girl diagnosed with MPA presented with rapidly progressive glomerulonephritis (RPGN). Renal biopsy was performed demonstrated crescentic glomerulonephritis with negative immunofluorescence and positive titer of myeloperoxidase (MPO) antibody. Pulse methylprednisolone (MP) and cyclophosphamide (CYC) as well as plasmapheresis were initiated. Despite treatment with prednisolone (45 mg/day) and monthly CYC for two doses, she experienced a brief generalized tonic-clonic seizure during the follow-up period. The potential differential diagnosis of new-onset neurological manifestation contains infection owing to the immunocompromised status of the patient and CNS vasculitis as a result of the disease itself. Lumbar puncture was performed, and cerebrospinal fluid analysis demonstrated pleocytosis with negative infectious panel. Contrast magnetic resonance imaging studies of the brain showed multifocal patchy T2/FLAIR-hyperintense lesions in the cerebral as well as cerebellum regions, and irregular narrowing along the V4 segment of the right vertebral artery was demonstrated in magnetic resonance angiography. In the presence of CNS vasculitis, pulse MP and CYC were provided. The symptom of nervous system has progressively improved. CONCLUSION In our case, MPA revealed RPGN with neurological manifestation. Despite the fact that it is scarcely reported, CNS vasculitis is one of the organ-threatening symptoms. To improve patient morbidity and mortality, multidisciplinary care teams with prompt diagnosis and treatment are highly recommended.
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Affiliation(s)
- Preawkalaya Suksai
- Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradriraj University, Bangkok, Thailand
| | - Suphawe Wasuanankun
- Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradriraj University, Bangkok, Thailand
| | - Vitit Lekhavat
- Department of Radiology, Faculty of Medicine Vajira Hospital, Navamindradriraj University, Bangkok, Thailand
| | - Ornatcha Sirimongkolchaiyakul
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradriraj University, Bangkok, Thailand
| | - Sirikarn Tangcheewinsirikul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradriraj University, Bangkok, Thailand
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[Towards a better recognition of cognitive disorders in internal medicine?]. Rev Med Interne 2021; 42:299-301. [PMID: 33867196 DOI: 10.1016/j.revmed.2021.03.331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/23/2021] [Indexed: 01/09/2023]
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Amnesia in a Patient with Rheumatoid Arthritis: A Case of Granulomatosis with Polyangiitis. Case Rep Rheumatol 2020; 2020:8844951. [PMID: 33178476 PMCID: PMC7644318 DOI: 10.1155/2020/8844951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/20/2020] [Indexed: 11/17/2022] Open
Abstract
A 56-year-old male with a history of seropositive rheumatoid arthritis complained of polyarthritis and forgetfulness. The initial CT scan of the head without contrast was negative for acute pathologies. However, as he continued to decline despite being on oral prednisone, an MRI of the head was ordered and revealed a subtle small region of acute infarction in the left mammillary body. He was diagnosed with granulomatosis with polyangiitis in light of his positive C-ANCA antibodies, PR3 antibody, and a kidney biopsy, which showed focal necrotizing pauci-immune crescentic glomerulonephritis. Despite undergoing steroid pulse therapy, the patient developed diffuse alveolar damage which finally responded to rituximab infusion.
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No Difference in Cognitive Dysfunction Among Patients with ANCA-Associated Vasculitis, Rheumatoid Arthritis or Chronic Kidney Disease. J Int Neuropsychol Soc 2019; 25:595-602. [PMID: 31030697 DOI: 10.1017/s1355617719000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To characterize cognitive function in patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) in comparison with other chronic conditions, and to investigate its association with disease activity, and other psychological factors. METHODS Cross-sectional study including patients with AAV, rheumatoid arthritis (RA) (n = 30), and chronic kidney disease (CKD) (n = 29). Patients underwent a standardized neuropsychological battery (NEUROPSI). Sleep quality, fatigue, depression, and anxiety levels were assessed. RESULTS A total of 60 patients with AAV were included, median age of 54 years, and disease duration of 5.6 years. Prevalence of cognitive dysfunction (CD) in AAV patients was similar to RA and CKD (35%, 40%, and 39.3%, respectively, p = .88). When AAV patients with (n = 21) and without (n = 39) CD were compared, significantly more patients with CD had high disease activity (67% vs. 31%, p = .009). Abnormal performance was more frequent in the executive functions in the three groups (45% AAV, 51.7% RA, and 50% CKD), followed by language (25%, 13.8%, and 25%, respectively). Verbal and visual attentional tests were more frequently impaired in patients from the CKD group (p = .021), and psychomotor functions were more frequently affected in AAV patients (p < .05). Hospital Anxiety and Depression Scale (HADS) total score (especially anxiety) was higher in patients with memory impairment than in those with normal memory function (M = 6.79, SD = 4.53 vs. M = 4.5, SD = 3.6, p < .01). Neither Sleep Quality Index nor fatigue scale scores differed between those cognitively impaired and not impaired. CONCLUSIONS No statistically significant differences were found in the frequency of CD among the three clinical populations. (JINS, 2019, 25, 595-602).
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Miłkowska-Dymanowska J, Laskowska P, Rzuczkowski M, Białas AJ, Piotrowski WJ, Górski P. Untypical Manifestations of Granulomatosis with Polyangiitis—A Review of the Literature. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00083-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zheng Y, Zhang Y, Cai M, Lai N, Chen Z, Ding M. Central Nervous System Involvement in ANCA-Associated Vasculitis: What Neurologists Need to Know. Front Neurol 2019; 9:1166. [PMID: 30687221 PMCID: PMC6335277 DOI: 10.3389/fneur.2018.01166] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective: To provide a comprehensive review of the central nervous system (CNS) involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), including the pathogenesis, clinical manifestations, ancillary investigations, differential diagnosis, and treatment. Particular emphasis is placed on the clinical spectrum and diagnostic testing of AAV. Recent Findings: AAV is a pauci-immune small-vessel vasculitis characterized by neutrophil-mediated vasculitis and granulomatousis. Hypertrophic pachymeninges is the most frequent CNS presentation. Cerebrovascular events, hypophysitis, posterior reversible encephalopathy syndrome (PRES) or isolated mass lesions may occur as well. Spinal cord is rarely involved. In addition, ear, nose and throat (ENT), kidney and lung involvement often accompany or precede the CNS manifestations. Positive ANCA testing is highly suggestive of the diagnosis, with each ANCA serotype representing different groups of AAV patients. Pathological evidence is the gold standard but not necessary. Once diagnosed, prompt initiation of induction therapy, including steroid and other immunosuppressants, can greatly mitigate the disease progression. Conclusions and Relevance: Early recognition of AAV as the underlying cause for various CNS disorders is important for neurologists. Ancillary investigations especially the ANCA testing can provide useful information for diagnosis. Future studies are needed to better delineate the clinical spectrum of CNS involvement in AAV and the utility of ANCA serotype to classify those patients. Evidence Review: We searched Pubmed for relevant case reports, case series, original research and reviews in English published between Sep 1st, 2001 and Sep 1st, 2018. The following search terms were used alone or in various combinations: “ANCA,” “proteinase 3/PR3-ANCA,” “myeloperoxidase/MPO-ANCA,” “ANCA-associated vasculitis,” “Wegener's granulomatosis,” “microscopic polyangiitis,” “Central nervous system,” “brain” and “spinal cord”. All articles identified were full-text papers.
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Affiliation(s)
- Yang Zheng
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yinxi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mengting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Nanxi Lai
- Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhong Chen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Chimelli L. The role of biopsies and autopsies in the diagnosis of cognitive impairment, with emphasis on small vessel diseases: A critical appraisal enriched by personal experience. Dement Neuropsychol 2018; 11:356-363. [PMID: 29354215 PMCID: PMC5769993 DOI: 10.1590/1980-57642016dn11-040004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acquired and hereditary microangiopathies cause cerebral small vessel diseases (CSVD) that impair cognition. The most frequent is primary angiitis of the CNS (PACNS), whose diagnosis remains challenging, requiring a multidisciplinary approach. Secondary vasculitis, CADASIL, miscellaneous microangiopathies and lymphomas, also cause cognitive impairment. Despite the fact that the need for biopsy has decreased in the era of new neuroimaging methods, biopsies that include small leptomeningeal and parenchymal arterial vessels still remain the gold standard to diagnose PACNS and other CSVD, and to exclude mimics such as infections and malignancies. New approaches for pathological consequences relevant to vascular cognitive impairment such as silent brain lesions, microinfarcts, microbleeds and subtle loss of microstructural integrity, may be detected in autopsies. This article addresses the role of biopsies and autopsies for the diagnosis of cognitive impairment related to small vessel diseases or other inflammatory/ischemic processes, and presents a critical appraisal based on personal experience.
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Affiliation(s)
- Leila Chimelli
- Instituto Estadual do Cérebro Paulo Niemeyer - Laboratory of Neuropathology and Universidade Federal do Rio de Janeiro - Pathology Department, Rio de Janeiro, RJ - Brazil
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Graf J. Central Nervous System Disease in Antineutrophil Cytoplasmic Antibodies–Associated Vasculitis. Rheum Dis Clin North Am 2017; 43:573-578. [DOI: 10.1016/j.rdc.2017.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Atzeni F, Pipitone N, Iaccarino L, Masala IF, Weiss R, Alciati A, Doria A, Chapmanand J, Sarzi-Puttini P. Rheumatic diseases and autoimmune vascular dementia. Autoimmun Rev 2017; 16:1265-1269. [PMID: 29037904 DOI: 10.1016/j.autrev.2017.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/02/2017] [Indexed: 11/17/2022]
Abstract
Vascular dementia (VD) comes second after Alzheimer's disease (AD) as a cause of impaired cognition. VD is not a specific nosological entity, but rather a syndrome encompassing a number of diseases caused by impaired supply of blood to the brain. Systemic autoimmune disorders such as systemic lupus erythematosus, rheumatoid arthritis, vasculitis and antiphospholipid syndrome (APS) can be associated with dementia. VD is often related to the presence of traditional cardiovascular risk factors, but it may also be associated with a host of disorders affecting the brain blood vessels, neuronal cells, or both. It is important to entertain in the differential diagnosis of VD, to recognize and to cure them accurately in order to preserve life's quality of our patients.
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Affiliation(s)
| | - Nicolò Pipitone
- Rheumatology Department, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | | | | | - Ronen Weiss
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Alessandra Alciati
- Department of Clinical Neurosciences, Villa San Benedetto Menni, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy
| | - Andrea Doria
- Division of Rheumatology, University of Padoa, Italy
| | - Joab Chapmanand
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Robert and Martha Harden Chair in Mental and Neurological Diseases, Sackler Faculty of Medicine, Tel Aviv University, Israel
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Zafar SF, Goodman JC, Ubogu EE. A man with small vessel vasculitis presenting with brachial diplegia, multiple cranial mononeuropathies and severe orthostatic hypotension in diabetes mellitus: a case report. J Med Case Rep 2013; 7:229. [PMID: 24083508 PMCID: PMC4015480 DOI: 10.1186/1752-1947-7-229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 08/12/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION We report a rare case of fulminant vasculitic mononeuropathy resulting in brachial diplegia, with suspected brainstem and autonomic nervous system involvement in a patient with diabetes mellitus. CASE PRESENTATION A 58-year-old Hispanic Caucasian man with diabetes mellitus presented with a 1-year history of progressive bilateral upper extremity weakness, orthostatic intolerance and progressive memory decline. Diagnostic evaluation including laboratory tests for progressive encephalopathies, systemic inflammatory and non-inflammatory neuropathies, cerebrospinal fluid analyses, electrodiagnostic studies, and nerve biopsy were performed. Clinical examination revealed moderate cognitive deficits on the Montreal Cognitive Assessment scale, bilateral facial weakness and weakness of bilateral shoulder girdle and intrinsic hand muscles. Cerebrospinal fluid analyses revealed elevated protein and an elevated immunoglobulin G synthesis rate, suggesting an immune-mediated process. Further laboratory work up was non-diagnostic. Electrodiagnostic studies demonstrated chronic asymmetric axonal mononeuropathies with ongoing denervation. A superficial radial nerve biopsy showed a chronic vasculitic neuropathy. Glucocorticosteroid treatment, symptomatic pharmacologic and supportive non-pharmacologic therapies resulted in improved clinical outcomes despite challenges with glycemic control. CONCLUSIONS This case report emphasizes the importance of a thorough evaluation of atypical or uncommon neuromuscular presentations in diabetic patients without etiological presumptions. This is necessary in order to promptly establish a diagnosis, initiate appropriate therapies and prevent irreversible nerve injury.
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Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB 302, Houston, TX 77030, USA.
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Abstract
The location of both autoimmune processes and other causes of brain inflammation is important in determining the impact of inflammation on brain function. This chapter focuses on autoimmune and infectious diseases leading to inflammatory brain disease resulting in cognitive defects with a special focus on systemic lupus erythematosus (SLE). Collectively called neuropsychiatric SLE (NPSLE), NPSLE occurs in 20-95% of pediatric patients with SLE (pSLE). The incidence of cognitive dysfunction is difficult to ascertain in pediatric patients as few studies have been performed. Using formal neurocognitive testing of unselected pediatric SLE patients, the rate of cognitive abnormalities was approximately 50% and impairment was associated with longer disease duration in one study. A second small study showed global depression on performance and academic scores while a larger study using a neuropsychiatric inventory showed a 55% rate of dysfunction. These diverging findings may result from the lack of a standardized cognitive assessment battery. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) group of pediatric rheumatologists proposed a 2 hour 40 minutes battery for assessment of cognitive testing of SLE patients from age 9 to 18 years. Further assessments using this battery should provide a better neurocognitive profile of pSLE.
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Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) include Wegener's granulomatosis, microscopic polyangiitis, and Churg-Strauss syndrome. Given their rarity, protean clinical manifestations, imperfect diagnostic tests, and wide differential diagnosis, they pose a diagnostic challenge even to experienced clinicians. This article describes diagnostic approaches for patients suspected of having one of the ANCA-associated vasculitides. The clinical findings at presentation, the role of laboratory and imaging tests, and the importance of tissue diagnosis are presented. In each section, issues relevant to the differential diagnosis of AAV are discussed.
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Affiliation(s)
- Angelo L Gaffo
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL 35233, USA.
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Rossi CM, Di Comite G. The clinical spectrum of the neurological involvement in vasculitides. J Neurol Sci 2009; 285:13-21. [PMID: 19497586 DOI: 10.1016/j.jns.2009.05.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 05/11/2009] [Accepted: 05/15/2009] [Indexed: 11/15/2022]
Abstract
Both the central nervous system (CNS) and the peripheral nervous system (PNS) are major target organs in primary vasculitides. They may either be affected in the setting of systemic vasculitis, potentially involving any other organ, or they may be the sole site of the inflammatory process. In both cases, the clinical pattern of PNS involvement is essentially uniform, presenting as sensory axonal polyneuropathy or mononeuritis multiplex. The damage is related to the ischemic occlusion of the vasanervorum due to small-vessel vasculitis. On the contrary, the range of manifestations of CNS vasculitis is much wider and several pathogenetic mechanisms are implicated, including angiitis of the hemispheres and spinal cord, thrombosis of dural sinuses, stenosis and aneurysms of medium and large arteries, granulomatous meningeal involvement and direct cytokine damage presenting with encephalopathy. Besides, even extracranial noninflammatory vascular disease may induce CNS symptoms, as is the case of carotid stenosis, vena cava syndrome and renovascular hypertension. In this paper we will review the broad spectrum of clinical manifestations of CNS and PNS neuropathy as they occur in primary systemic and non systemic vasculitides.
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Challenges in the management of microscopic polyangiitis: past, present and future. Curr Opin Rheumatol 2008; 20:3-9. [DOI: 10.1097/bor.0b013e3282f370d1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Ito Y, Suzuki K, Yamazaki T, Yoshizawa T, Ohkoshi N, Matsumura A. ANCA-associated vasculitis (AAV) causing bilateral cerebral infarction and subsequent intracerebral hemorrhage without renal and respiratory dysfunction. J Neurol Sci 2006; 240:99-101. [PMID: 16274697 DOI: 10.1016/j.jns.2005.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 07/15/2005] [Accepted: 07/18/2005] [Indexed: 11/29/2022]
Abstract
A 56-year-old man complained of headache and the analgesia of the four extremities. Laboratory data presented signs of inflammation, but no other abnormality such as renal or respiratory dysfunction. Two months after the appearance of the primary symptoms, he developed cerebral infarction of the bilateral corona radiata. The patient did not have any of the risk factors for cerebrovascular disease. He was diagnosed with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) because the systemic examinations revealed only that he tested positive for anti-neutrophil cytoplasmic autoantibody (ANCA). Moreover, the biopsy of the sural nerve displayed microscopic polyangitis (MPA). Despite undergoing steroid pulse therapy, the patient died from the fatal cerebral hemorrhage. The clinical course of AAV is rapid progressive. In cases of atypical cerebrovascular disease, the possibility of ANCA should be investigated.
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Affiliation(s)
- Yoshiro Ito
- Department of Neurosurgery, Kensei General Hospital, and Department of Neurology, Institute of Clinical Medicine, University of Tsukuba, Japan
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Seror R, Mahr A, Ramanoelina J, Pagnoux C, Cohen P, Guillevin L. Central nervous system involvement in Wegener granulomatosis. Medicine (Baltimore) 2006; 85:53-65. [PMID: 16523054 DOI: 10.1097/01.md.0000200166.90373.41] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Wegener granulomatosis (WG) is an antineutrophil cytoplasmic antibody (ANCA)-associated granulomatous vasculitis of small and medium-sized vessels. This vasculitis involves mainly the upper and lower respiratory tracts and kidneys, although WG may affect any organ. Central nervous system (CNS) involvement is an uncommon manifestation of WG, reported in 7%-11% of patients. Three major mechanisms have been incriminated as causing CNS disease in WG: contiguous invasion of granuloma from extracranial sites, remote intracranial granuloma, and CNS vasculitis. Herein we describe 6 patients with WG-related CNS involvement, 2 of whom had chronic hypertrophic pachymeningitis, 3 with pituitary involvement, and 1 with cerebral vasculitis. CNS involvement was present at disease onset in 2 patients and occurred 5-18 years after WG diagnosis in the remaining 4. Based on these observations and a review of the literature, we discuss the pathogenic mechanisms, clinical features, imaging findings, treatment, and outcome of meningeal, pituitary, and vascular involvement, with an emphasis on differential diagnoses, prognosis, and therapeutic management of WG-related CNS involvement.
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Affiliation(s)
- Raphaèle Seror
- From Department of Internal Medicine, Hôpital Cochin, Université René-Descartes Paris 5, Assistance Publique-Hôpitaux de Paris, Paris, France
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Hellmich B, Gross WL. Difficult to diagnose manifestations of vasculitis: Does an interdisciplinary approach help? Best Pract Res Clin Rheumatol 2005; 19:243-61. [PMID: 15857794 DOI: 10.1016/j.berh.2004.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the early stages of disease, primary systemic vasculitides often present with non-specific symptoms that make early diagnosis a challenge. The variety of clinical manifestations found in systemic vasculitis is huge, and some manifestations are frequently not clinically overt at first presentation. A logical implication of the often non-specific and sometimes subclinical presentation of vasculitis is that a systematic diagnostic work-up is necessary. This requires a multidisciplinary approach involving the expert opinion of specialists from many disciplines, such as neurology, radiology, respiratory medicine, pathology and microbiology. There are no generally accepted diagnostic criteria for primary systemic vasculitides, and the application of classification criteria as diagnostic criteria is not feasible and may even be misleading. The demonstration of vasculitis on biopsy is still the gold standard for the diagnosis of vasculitis. In cases where biopsies cannot be obtained, surrogate parameters of vasculitis (e.g. glomerular hematuria or mononeuritis multiplex), along with serology and imaging, can support a clinical diagnosis of vasculitis. This review discusses the approach to the diagnosis of central nervous system and pulmonary manifestations of primary systemic vasculitis. These two examples of difficult to diagnose manifestations of vasculitis illustrate the necessity of an interdisciplinary approach to the diagnostic work-up.
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Affiliation(s)
- Bernhard Hellmich
- Department of Rheumatology, Poliklinik für Rheumatologie, Universitätsklinfikum Schleswig-Holstein, Campus Lübeck and Rheumaklinik Bad Bramstedt, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Incalzi RA, Arena V, Capelli A, Gambassi G. Isolated PACNS-like presentation of a systemic vasculitis complicating a myelodysplastic syndrome. J Intern Med 2004; 255:674-9. [PMID: 15147531 DOI: 10.1111/j.1365-2796.2004.01310.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Myelodysplastic syndromes (MDS) are a series of haematological malignancies ranging from chronic refractory anaemia to leukaemia. There is increasing recognition of immunological abnormalities in patients with MDS, including few reports of cutaneous vasculitis; in no instance, a cerebral localization has been ascertained. Here, the case of a patient with MDS who presented exclusively with neurological signs that were considered indicative of a primary, isolated central nervous system vasculitis (PACNS) is reported. Although histological findings on brain tissue confirmed a small-vessel vasculitis, this had to be considered in the context of a systemic vasculitis. In fact, at autopsy, an involvement of skin, myocardium, lungs, liver, kidney and bone marrow was also found. An autoimmune vasculitis should be included in the differential diagnosis of acute-onset, isolated, cerebral symptoms complicating the course of MDS.
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Affiliation(s)
- R A Incalzi
- Dipartimento di Scienze Gerontologiche, Geriatriche e Fisiatriche, Centro di Medicina dell'Invecchiamento, Università Cattolica del Sacro Cuore, Rome, Italy
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