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Voortman M, Drent M, Stern BJ. Neurosarcoidosis and Neurologic Complications of Sarcoidosis Treatment. Clin Chest Med 2024; 45:91-103. [PMID: 38245373 DOI: 10.1016/j.ccm.2023.08.005] [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: 01/22/2024]
Abstract
Sarcoidosis is an immune-mediated multisystem granulomatous disorder. Neurosarcoidosis (NS) accounts for 5% to 35% of cases. The diagnostic evaluation of NS can be a clinical challenge. Gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard to evaluate central nervous system NS. In almost all cases treatment is warranted. Although glucocorticoids remain the first-line therapy in patients with sarcoidosis, in NS timely initiation of second- or third-line treatment is strongly recommended. Of these, tumor necrosis factor-alpha inhibitors are the most promising. However, the treatment itself may be responsible for/associated with developing neurologic symptoms mimicking NS. Thus, it is important to consider the possibility of drug-induced neurologic symptoms in sarcoidosis.
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Affiliation(s)
- Mareye Voortman
- Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands.
| | - Marjolein Drent
- Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; Department of Respiratory Medicine, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands; ILD Care Foundation Research Team, Heideoordlaan 8, Ede 6711NR, The Netherlands
| | - Barney J Stern
- Department of Neurology, School of Medicine, Johns Hopkins University, 601 North Caroline Street, Neurology Room 5066B, Baltimore, MD 21287, USA
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Shrestha K, Kleinschmidt-DeMasters BK, Ormond DR. Diagnostic challenges of neurosarcoidosis in non-endemic areas. Front Neurol 2024; 14:1220635. [PMID: 38274870 PMCID: PMC10809150 DOI: 10.3389/fneur.2023.1220635] [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: 05/10/2023] [Accepted: 10/06/2023] [Indexed: 01/27/2024] Open
Abstract
Background Neurosarcoidosis (NS) is a challenging diagnosis, particularly when cases occur in low-prevalence, non-endemic geographic regions. In the United States, the highest incidence is in the Midwest and Northeast, compared to our Southwest location. While it is well known that NS may clinically and neuroradiographically mimic meningeal carcinomatosis, autoimmune or infectious pachymeningitis, neurosyphilis, or tuberculosis, diagnosis may be particularly challenging if systemic signs of sarcoidosis are lacking or unconfirmed or if dural-based masses are present. We reviewed our Colorado experience with NS cases, focusing our study on cases where NS represented the first histological confirmation of disease. Methods A search of departmental databases was conducted with the search term "neurosarcoidosis" to identify cases 1-2008 to 12-2019, inclusive of the given case numbers. Patients were only included if their clinical and neuroimaging features were unusual and only when a biopsy of the central nervous system (CNS) represented the first confirmed diagnosis of sarcoidosis. Results A total of 17 cases were identified, of which the biopsy of the CNS was used for the initial confirmation of the disease in 9 of them. The most unusual findings were two patients with dural-based masses, one of which had pure NS as the cause of meningioma-like lesions and the second of which had coexistent meningioma and intimately admixed non-necrotizing granulomas of NS. Conclusion NS with unusual features, especially in non-endemic areas, continues to yield diagnostic challenges for neurologists, neuroradiologists, and pathologists.
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Affiliation(s)
- Keshari Shrestha
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - B. K. Kleinschmidt-DeMasters
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, United States
| | - D. Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
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Moltoni G, Romano A, Blandino A, Palizzi S, Romano A, D'Arrigo B, Guarnera A, Dellepiane F, Frezza V, Gagliardo O, Tari Capone F, Grossi A, Trasimeni G, Bozzao A. Extra-axial cranial nerve enhancement: a pattern-based approach. LA RADIOLOGIA MEDICA 2024; 129:118-132. [PMID: 37882918 PMCID: PMC10808254 DOI: 10.1007/s11547-023-01734-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023]
Abstract
Cranial nerve enhancement is a common and challenging MRI finding that requires a meticulous and systematic evaluation to identify the correct diagnosis. Literature mainly describes the various pathologies with the associated clinic-radiological characteristics, while the radiologist often needs a reverse approach that starts from the radiological findings to reach the diagnosis. Therefore, our aim is to provide a new and practical pattern-based approach to cranial nerve enhancement, which starts from the radiological findings and follows pattern-driven pipelines to navigate through multiple differential diagnoses, guiding the radiologist to reach the proper diagnosis. Firstly, we reviewed the literature and identified four patterns to categorize the main pathologies presenting with cranial nerve enhancement: unilateral linear pattern, bilateral linear pattern, unilateral thickened pattern, and bilateral thickened pattern. For each pattern, we describe the underlying pathogenic origin, and the main radiological features are displayed through high-quality MRI images and illustrative panels. A suggested MRI protocol for studying cranial nerve enhancement is also provided. In conclusion, our approach for cranial nerve enhancement aims to be an easy tool immediately applicable to clinical practice for converting challenging findings into specific pathological patterns.
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Affiliation(s)
- Giulia Moltoni
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy.
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy.
| | - Andrea Romano
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Antonella Blandino
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Serena Palizzi
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Allegra Romano
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | | | - Alessia Guarnera
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Francesco Dellepiane
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Valentina Frezza
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Olga Gagliardo
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Francesca Tari Capone
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Andrea Grossi
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Guido Trasimeni
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
| | - Alessandro Bozzao
- NESMOS, Department of Neuroradiology, S.Andrea Hospital, University Sapienza, Via di Grottarossa, 00135, Rome, Italy
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Bekkour I, Courtin E, Dulau-Metras C, Duffau P, Kremer L, Mathey G. Defining the course of neurosarcoidosis according to presentation at onset and disease modifying treatment: a cohort study of 84 patients. Ther Adv Neurol Disord 2023; 16:17562864231205954. [PMID: 38143513 PMCID: PMC10748905 DOI: 10.1177/17562864231205954] [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] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 12/26/2023] Open
Abstract
Background Neurosarcoidosis is a rare manifestation of sarcoidosis with heterogeneous presentations. Patient management is challenging due to the current lack of knowledge about the long-term disease course. Objective To identify specific disease courses of neurosarcoidosis according to the clinical and paraclinical presentations at onset. Methods We conducted an observational multicenter cohort study by retrospectively collecting data from the medical records of 84 patients diagnosed with definite, probable, or possible neurosarcoidosis in three tertiary referral centers in France (Nancy, Strasbourg, and Bordeaux). We collected demographic characteristics, clinical and paraclinical data at the beginning of patient management, and during follow-up under the different treatment lines. Two expert neurologists determined disease course profiles. Results The mean follow-up was 6.6 years. Almost every patient (96.4%) received steroids at some point of their follow-up. Tumor Necrosis Factor-alpha blockers were given in 10.7% as first-line treatment and in 33.3% during follow-up. Every patient presented with a relapsing disease, often monophasic (75%) and sometimes polyphasic with the recurrence of identical manifestations (11.9%). Patients developing new neurological symptoms during follow-up were a minority (13.1%). No patients exhibited a progressive course. Patients with isolated cranial nerves injury or aseptic meningitis always exhibited a monophasic course, and 62.5-75% of them had a full recovery after first-line treatments. This proportion was 15.6% in other forms of the disease. Those with peripheral presentations were more likely to present a polyphasic course than patients with other forms of neurosarcoidosis. Spinal cord presentations were monophasic, but resulted in sequelae and exhibited poor response to first-line treatments despite frequent use of TNF-alpha blockers. Conclusion Identification of these disease course profiles, based on the initial clinical and paraclinical presentation, could guide the clinician to select the optimal therapeutic approach and follow-up modalities for their patients with neurosarcoidosis.
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Affiliation(s)
- Inès Bekkour
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Edouard Courtin
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | | | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Bordeaux, France
- CNRS, ImmunoConcEpT, UMR 5164, University of Bordeaux, Bordeaux, France
| | - Laurent Kremer
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- INSERM U1119, Strasbourg, France
| | - Guillaume Mathey
- Service de Neurologie, Hopital Central, CHRU de Nancy, 1 Avenue du Maréchal de Lattre de Tassigny, Nancy 54000, France
- Department of Neurology, Nancy University Hospital, Nancy, France
- CIC-Epidémiologie Clinique, Nancy University Hospital, INSERM, Université de Lorraine, Nancy, France
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Kleinschmidt-DeMasters BK. Unusual features of neurosarcoidosis: A 18-year retrospective. Ann Diagn Pathol 2023; 67:152201. [PMID: 37607450 DOI: 10.1016/j.anndiagpath.2023.152201] [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: 07/18/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Neurosarcoidosis (NS) is a challenging diagnosis for clinicians and pathologists. NS most often presents with leptomeningeal involvement where it mimics infectious or neoplastic meningitis, and in up to half of cases, systemic signs of sarcoidosis are lacking. Rare presentations include dural-based mass(es) (mimicking meningioma), hypothalamic/sellar-based lesions (mimicking pituitary adenoma), or as myelopathy (mimicking tumor or neurodegenerative condition). For pathologists, the morphological effects of prior therapy are not well documented. NS as an unsuspected cause of demise today is even less well known. METHODS Search of departmental databases and personal files, 2004-2022, for NS cases, with focus on the subset with features of interest to pathologists. RESULTS 22 cases were identified (8 M: 14F, 13-66 years), in 11 of which the CNS specimen represented first diagnosis of sarcoidosis. 20 were surgical and 2 were autopsy cases. Focus of the study revolved around 2 surgical cases with NS granulomas intimately admixed with tumor (1 meningoma, 1 gonadotroph pituitary adenoma/pituitary neuroendocrine tumor (PitNET). One surgical and one autopsy case each had decrease in lymphocytes and well-formed granulomas, with increased fibrosis and hemosiderin in post-treatment tissues. We speculate, but cannot prove, that this may be due to prior steroid therapy. Both autopsy cases were women (38, 43-years), both with cauda equina syndrome/ progressive weakness as first presentation, and extensive spinal cord/nerve root sarcoidosis at demise. First diagnosis of NS/sarcoidosis was at autopsy in the 38-year-old. CONCLUSIONS Unusual features for pathologists are that NS can co-exist within benign tumors, prior therapy alters histological features, and even in the modern era, may be first diagnosed at autopsy.
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Affiliation(s)
- B K Kleinschmidt-DeMasters
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
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Silva L, Correia J, Santos E. [Diagnosis and Treatment of Neuro-Behçet: A Clinical Update]. ACTA MEDICA PORT 2023; 36:588-594. [PMID: 37345389 DOI: 10.20344/amp.19734] [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: 02/06/2023] [Accepted: 05/03/2023] [Indexed: 06/23/2023]
Abstract
Behçet's disease is a relapsing multisystemic inflammatory syndrome characterized by recurrent oral and/or genital ulcers, uveitis, arthritis, skin lesions, and gastrointestinal and neurological involvement. Neuro-Behçet corresponds to nervous system involvement and is one of the most severe complications of Behçet disease. It occurs in 3% to 30% of cases and is categorized into parenchymal (most common) or non-parenchymal disease. The most common manifestation of parenchymal neuro-Behçet is meningoencephalitis with involvement of the brainstem, where patients present with cranial neuropathies, encephalopathy, sensory-motor syndromes, epilepsy, or myelitis. The main non-parenchymal manifestation is cerebral venous thrombosis. Neuro-Behçet has a predominantly subacute course, with remission within weeks, or clinical progression in one third of the cases. The diagnosis is essentially clinical and diagnostic tests help to corroborate the suspicion, distinguish from differential diagnoses, and exclude complications. Brain magnetic resonance imaging allows the identification of acute lesions (hypointense or isointense on T2-weighted and hypointense on T1-weighted sequences) contrast-enhanced, and chronic lesions characterized by non-contrast enhanced small lesions and brainstem atrophy. If non-parenchymal involvement is suspected, cerebral veno-magnetic resonance imaging /computed tomography should be performed. Cerebrospinal fluid shows elevated proteinorachia and pleocytosis in parenchymal and no changes in non-parenchymal neuro-Behçet (except increased opening pressure). Outbursts of parenchymal disease should be treated with high dose intravenous corticosteroid therapy, with subsequent switch to oral corticoids, followed by biologic therapy, usually an anti-TNF. The treatment of cerebral venous thrombosis is controversial and may consist of a combination of corticosteroids and anticoagulation.
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Affiliation(s)
- Lénia Silva
- Serviço de Neurologia. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - João Correia
- Serviço de Medicina Interna. Centro Hospitalar Universitário de Santo António. Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ernestina Santos
- Serviço de Neurologia. Centro Hospitalar Universitário de Santo António. Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
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Ungprasert P, Sukpornchairak P, Moss BP, Ribeiro Neto ML, Culver DA. Neurosarcoidosis: an update on diagnosis and therapy. Expert Rev Neurother 2022; 22:695-705. [PMID: 35914766 DOI: 10.1080/14737175.2022.2108705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Clinically overt granulomatous involvement of the nervous system (i.e., neurosarcoidosis) can be seen in up to 10% of patients with sarcoidosis. Establishing a diagnosis of neurosarcoidosis is often challenging due to the heterogeneity of clinical presentations that are sometimes non-specific, and inaccessibility of tissue confirmation. Recommended treatments are based on expert opinions that are derived from clinical experience and limited data from retrospective studies, as data from randomized controlled studies are limited. AREA COVERED In this article, we comprehensively review all available literature on epidemiology, clinical presentations, diagnosis, treatment, and outcomes of neurosarcoidosis. We also offer our opinions on diagnostic approach and treatment strategy. EXPERT OPINION Given the invasive nature and the limited sensitivity of biopsy of the nervous system, diagnosis of neurosarcoidosis is usually made when ancillary tests (such as magnetic resonance imaging and cerebrospinal fluid analysis) are compatible, and alternative diagnoses are reasonably excluded in patients with established extraneural sarcoidosis. Several factors must be taken into consideration to formulate the initial treatment strategy, including the extent of the disease, severity, functional impairment, comorbidities and patient's preference. In addition, treatment regimen of neurosarcoidosis should be formulated with an emphasis on long-term strategy.
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Affiliation(s)
- Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Persen Sukpornchairak
- Department of Neurology, Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brandon P Moss
- Cleveland Clinic, Neurologic Institute, Cleveland, OH, USA
| | - Manuel L Ribeiro Neto
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Уханова ЮА, Иловайская ИА, Терпигорев СА. [Panhypopituitarism as the first manifestation of sarcoidosis: case report]. PROBLEMY ENDOKRINOLOGII 2022; 68:46-51. [PMID: 36104964 PMCID: PMC9762432 DOI: 10.14341/probl13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 01/09/2023]
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology characterized by the formation of noncaseating granulomas in various organs and tissues and the activation of T-cells at the site of granulomatous inflammation with the release of various chemokines and cytokines [1]. The incidence on average ranges from 10 to 20 per 100,000 population [2]. Most often in patients with sarcoidosis, lesions of the lungs and intrathoracic lymph nodes are detected. Significantly less often (in about 5-20% of patients) damage to the nervous system is noted [6,7,9]. In 9-18% of patients with neurosarcoidosis, involvement of the pituitary gland, pituitary infundibulum and hypothalamus is found, which is manifested by a variety of clinical symptoms [8,10]. We observed a patient with sarcoidosis whose disease debuted with clinical symptoms of hypogonadism, followed by the development of signs of secondary hypothyroidism, adrenal insufficiency, and diabetes insipidus, which was initially regarded as panhypopituitarism against the background of a hypothalamic lesion of unknown origin. Later, additional examination revealed signs of intrathoracic lymphadenopathy and focal changes in the lung parenchyma on CT, as well as skin lesions. Despite the biochemical compensation of hypopituitarism, the clinical efficacy of hormonal therapy with cabergoline, testosterone, hydrocortisone and levothyroxine sodium was insufficient, and the patient's condition improved after the addition of immunosuppressive and anti-inflammatory therapy with methotrexate and methylprednisolone.
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Affiliation(s)
- Ю. А. Уханова
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - И. А. Иловайская
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - С. А. Терпигорев
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
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Buelens T, Scifo L, Valyi Z, Willermain F. Sarcoidosis revealed by simultaneous optic nerve and eyelid involvement: A case report. Am J Ophthalmol Case Rep 2022; 26:101451. [PMID: 35252626 PMCID: PMC8889372 DOI: 10.1016/j.ajoc.2022.101451] [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: 09/10/2021] [Revised: 02/11/2022] [Accepted: 02/20/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Ocular disease can be the initial manifestation in patients with sarcoidosis. It is most often associated with uveitis, but eyelid or optic nerve disease can also be presenting features. Although uncommon and easy to overlook in a patient presenting with visual loss, paying attention to the presence of eyelid granulomas in our patient proved to be very helpful in our diagnostic work up for optic neuropathy. Observations A young otherwise healthy patient was addressed with a 3 month history of bilateral painless visual loss. At presentation, best-corrected visual acuity was counting fingers in both eyes. Anterior segment slit-lamp examination was completely normal in both eyes. Eye fundus examination revealed subtle optic disc swelling in the left eye. Interestingly, flesh-colored nodular eyelid lesions were found bilaterally. Basic work-up for optic neuropathy showed elevated levels of serum lysozyme and serum angiotensin converting enzyme. More importantly, a biopsy specimen of an eyelid nodule demonstrated multiple non-necrotizing granulomas, a hallmark sign of sarcoidosis. Despite a delay in treatment of several months after onset of symptoms, response to systemic corticosteroids was prompt and important with visual acuity improving to 20/20 in both eyes as well as complete resorption of all eyelid lesions. Conclusion and importance In the diagnostic work-up for optic neuropathy, the answer can sometimes be hiding where it's least expected: the possible presence of eyelid lesions should not be overlooked as they may orient us towards sarcoidosis as an underlying etiology.
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Moss BP, Miller DM, Culver DA. Clinical perspective on clinical outcome assessments in neurosarcoidosis. Mult Scler Relat Disord 2021; 57:103403. [PMID: 34875486 DOI: 10.1016/j.msard.2021.103403] [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: 09/28/2021] [Revised: 10/26/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND There are no validated clinical outcome assessments (COAs) used in neurosarcoidosis. OBJECTIVE We surveyed clinicians who treat patients with neurosarcoidosis to determine: 1) current approaches to assessment of neurologic impairment, and 2) clinicians' needs regarding future COA development. METHODS Physician contacts from the Foundation for Sarcoidosis Research and Neurosarcoidosis Consortium Group were sent an online survey. RESULTS For 43/143 responders, COAs were used in a minority of settings. Apart from time for administration, the biggest barriers to implementation were lack of validated, disease-specific measures. CONCLUSIONS Lack of validated, disease-specific measures is a barrier to monitoring neurological impairment in neurosarcoidosis.
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Affiliation(s)
- Brandon P Moss
- Sarcoidosis Center, Cleveland Clinic, Cleveland, OH 44195, United States; Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH 44195, United States.
| | - Deborah M Miller
- Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Daniel A Culver
- Sarcoidosis Center, Cleveland Clinic, Cleveland, OH 44195, United States; Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, United States
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Hilker C, Tizek L, Rüth M, Schielein M, Biedermann T, Zink A. Leveraging internet search data to assess prevalence, interest, and unmet needs of sarcoidosis in Germany. Sci Rep 2021; 11:20841. [PMID: 34675234 PMCID: PMC8531327 DOI: 10.1038/s41598-021-00131-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 09/30/2021] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis is a multisystemic disease of connective tissue with granuloma formation of unknown etiology and unclear prevalence. Internet search data has been shown to correlate with disease incidences and the population’s interest as well as seasonal variations. Accordingly, aim of this study was to leverage internet search data on sarcoidosis-related keywords to identify unmet needs, geographical and seasonal factors influencing sarcoidosis and estimating its prevalence. In this retrospective longitudinal study, Google Ads Keyword Planner was used to determine the internet search volume of terms related to sarcoidosis across Germany as a whole and in 17 major German cities between July 2015 and June 2019. Identified keywords were qualitatively categorized, converted into number of searches per 100,000 inhabitants and analyzed including regional and seasonal differences. With 3,068,200 queries and 425 different sarcoidosis-related search terms in the studied time period, the search volume was very high for a rare disease. Most searches (67.9%) related to general disease information with “sarcoidosis”, "Löfgren's syndrome", "sarcoidosis lung", "Morbus Boeck" and "neurosarcoidosis" as the top five keywords. Searches per 100,000 inhabitants were comparable in all 17 cities but higher than in Germany as a whole. Overall, the search volume increased from 2015 to 2019 and peaked annually in European springtime with annual lows in European autumn and winter months. The overall high search volume suggests an unmet need for sarcoidosis-related information and a diagnostic gap. Seasonal fluctuations indicate environmental as well as climatic factors that may influence sarcoidosis.
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Affiliation(s)
- Charlotte Hilker
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Linda Tizek
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany.,Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Melvin Rüth
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Maximilian Schielein
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany.,Unit of Dermatology and Venerology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tilo Biedermann
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany
| | - Alexander Zink
- Department of Dermatology and Allergy, Technical University of Munich, School of Medicine, Biedersteiner str. 29, 80802, Munich, Germany. .,Unit of Dermatology and Venerology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. .,Division of Dermatology and Venereology, Department of Medicine Solna, Karolinska Institutet, K2 Medicin, Solna, K2, 171 77, Stockholm, Sweden.
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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13
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Abstract
Sarcoidosis is a multisystem disease of unknown cause with heterogenous clinical manifestations and variable course. Spontaneous remissions occur in some patients while others have progressive disease impacting survival, organ function, and quality of life. Four high-risk sarcoidosis phenotypes associated with chronic inflammation have recently been identified as high-priority areas for research. These include treatment-refractory pulmonary disease, cardiac sarcoidosis, neurosarcoidosis and multiorgan sarcoidosis. Significant gaps currently exist in understanding of these high-risk manifestations of sarcoidosis, including their natural history, diagnostic criteria, biomarkers, and the treatment strategy such as the ideal agent, optimal dose and treatment duration. The use of registries with well-phenotyped patients is a critical first step to study high-risk sarcoidosis manifestations systematically. We review the diagnostic and treatment approach to high-risk sarcoidosis manifestations. Appropriately identifying these disease sub-groups will help enroll well-phenotyped patients in sarcoidosis registries and clinical trials, a necessary step to narrow existing gaps in understanding of this enigmatic disease.
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14
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Belperio JA, Shaikh F, Abtin F, Fishbein MC, Saggar R, Tsui E, Lynch JP. Extrapulmonary sarcoidosis with a focus on cardiac, nervous system, and ocular involvement. EClinicalMedicine 2021; 37:100966. [PMID: 34258571 PMCID: PMC8254127 DOI: 10.1016/j.eclinm.2021.100966] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 02/07/2023] Open
Abstract
Sarcoidosis is a poorly understood granulomatous disease that involves the lungs and/or intrathoracic lymph nodes in more than 90% of cases. Although pulmonary sarcoidosis is the leading cause of mortality in this disease, this review focuses on three sites of extrapulmonary involvement (heart, nervous system, and eyes), since involvement of any of these sites can be catastrophic, leading to death, debilitation, or blindness. Patients with cardiac, ocular and neurosarcoidosis necessitate a multidisciplinary approach with careful and long-term follow-up. Prompt diagnosis with imaging and/or biopsy and treatment is required to avoid irreversible damage. Corticosteroids are the mainstay of therapy and are often associated with rapid and durable remissions. Immunosuppressive or biologic agents are reserved for patients failing or experiencing side effects from steroids. Managing sarcoidosis requires vigilance, judgement, and awareness of the vagaries of this fascinating disease.
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Affiliation(s)
- John A. Belperio
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Faisal Shaikh
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Fereidoun Abtin
- Department of Radiology, Thoracic and Interventional Section, David Geffen School of Medicine at UCLA, United States
| | - Michael C. Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, United States
| | - Rajan Saggar
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Edmund Tsui
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, United States
| | - Joseph P. Lynch
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
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15
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Sève P, Pacheco Y, Durupt F, Jamilloux Y, Gerfaud-Valentin M, Isaac S, Boussel L, Calender A, Androdias G, Valeyre D, El Jammal T. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells 2021; 10:cells10040766. [PMID: 33807303 PMCID: PMC8066110 DOI: 10.3390/cells10040766] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, 69007 Lyon, France
- Correspondence:
| | - Yves Pacheco
- Faculty of Medicine, University Claude Bernard Lyon 1, F-69007 Lyon, France;
| | - François Durupt
- Department of Dermatology, Lyon University Hospital, 69004 Lyon, France;
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Sylvie Isaac
- Department of Pathology, Lyon University Hospital, 69310 Pierre Bénite, France;
| | - Loïc Boussel
- Department of Radiology, Lyon University Hospital, 69004 Lyon, France
| | - Alain Calender
- Department of Genetics, Lyon University Hospital, 69500 Bron, France;
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Dominique Valeyre
- Department of Pneumology, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, 93008 Bobigny, France;
| | - Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
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16
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Raibagkar P, Ramineni A. Autoimmune Neurologic Emergencies. Neurol Clin 2021; 39:589-614. [PMID: 33896534 DOI: 10.1016/j.ncl.2021.01.006] [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: 11/17/2022]
Abstract
Over the past decade, understanding of autoimmune neurologic disorders has exponentially increased. Many patients present as a neurologic emergency and require timely evaluation with rapid management and intensive care. However, the diagnosis is often either missed or delayed, which may lead to a significant burden of disabling morbidity and even mortality. A high level of suspicion in the at-risk population should be maintained to facilitate more rapid diagnosis and prompt treatment. At present, there is no all-encompassing algorithm specifically applicable to the management of fulminant autoimmune neurologic disorders. This article discusses manifestations and management of various autoimmune neurologic emergencies.
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Affiliation(s)
- Pooja Raibagkar
- Concord Hospital Neurology Associates, 246 Pleasant Street, Concord, NH 03301, USA.
| | - Anil Ramineni
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, 41 Mall Road, Burlington, MA 01803, USA
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17
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Abstract
Hypothalamo-pituitary sarcoidosis is a rare manifestation of sarcoidosis, usually presenting alongside other symptoms of neurosarcoidosis. We describe the case of a 58-year-old man from Ghana who presented with progressive gait disturbance, cognitive dysfunction, hypothermia and bradycardia. He was found to have pituitary stalk thickening on imaging, and lymph node biopsy identified non-caseating granulomatous disease. Serology revealed gonadotropin deficiency, hypothyroidism and central adrenal insufficiency. Treatment with immunomodulatory therapy resulted in resolution of findings on imaging and improved cognition, though pituitary function never recovered. Treatment for his sarcoidosis unfortunately resulted in recurrent infections and avascular necrosis. Work-up, management and ongoing care required multidisciplinary cooperation between the admitting internal medicine team, infectious diseases, respirology, rheumatology, endocrinology and neurology.
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Affiliation(s)
- Elina Liu
- Department of Internal Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Axel Rohr
- Department of Neuroradiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammed AlMehthel
- Department of Endocrinology, The University of British Columbia, Vancouver, British Columbia, Canada
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18
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Togashi S, Maruya J, Abe H, Nishimaki K, Ouchi H, Hara K, Tokairin T, Nishiyama K, Shimizu H. Endoscopic Management for Recurrent Hydrocephalus Associated with Neurosarcoidosis. World Neurosurg 2020; 144:121-124. [PMID: 32890842 DOI: 10.1016/j.wneu.2020.08.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recurrent hydrocephalus may occur as a complication of neurosarcoidosis with chronic inflammation. We present a case that required a combination of multistage endoscopic diversion of the cerebrospinal fluid pathway and shunt surgery. CASE DESCRIPTION A 34-year-old man presented with progressive nausea and vomiting. Magnetic resonance imaging revealed hydrocephalus with leptomeningeal enhancement along the base of the fourth ventricle and the bilateral foramina of Luschka. Concurrent endoscopic third ventriculostomy and biopsy were performed. The diagnosis was neurosarcoidosis. Immediately after the procedure, the endoscopic third ventriculostomy stoma was occluded, and a right ventriculoperitoneal shunt was urgently performed. However, left unilateral hydrocephalus developed during the late phase of immunosuppressive therapy for neurosarcoidosis. Endoscopic septostomy with repositioning of the ventricular catheter was indicated. Intraoperative findings included a white pasty tissue with nodules that covered the ventricular wall close to the foramen of Monro and sealed the side holes of the catheter. Chemotherapy with a tumor necrosis factor-α inhibitor was initiated after the surgical procedure. The patient had an uneventful course without recurrence of hydrocephalus for >6 months. CONCLUSIONS Endoscopic diversion of the cerebrospinal fluid pathway should be actively considered for treating hydrocephalus without a shunt and performing biopsy simultaneously. Even if a subsequent shunt is needed, complex hydrocephalus can be avoided with a combination of endoscopic techniques.
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Affiliation(s)
- Shuntaro Togashi
- Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan; Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan.
| | - Jun Maruya
- Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan
| | - Hideaki Abe
- Department of Neurosurgery, Akita Red Cross Hospital, Akita, Japan
| | | | - Haruka Ouchi
- Department of Neurology, Akita Red Cross Hospital, Akita, Japan
| | - Kenju Hara
- Department of Neurology, Akita Red Cross Hospital, Akita, Japan
| | - Takuo Tokairin
- Department of Pathology, Akita Red Cross Hospital, Akita, Japan
| | | | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan
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19
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Voortman M, Stern BJ, Saketkoo LA, Drent M. The Burden of Neurosarcoidosis: Essential Approaches to Early Diagnosis and Treatment. Semin Respir Crit Care Med 2020; 41:641-651. [PMID: 32777849 DOI: 10.1055/s-0040-1710576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neurosarcoidosis (NS) is an often severe, destructive manifestation with a likely under-reported prevalence of 5 to 15% of sarcoidosis cases, and in its active phase demands timely treatment intervention. Clinical signs and symptoms of NS are variable and wide-ranging, depending on anatomical involvement. Cranial nerve dysfunction, cerebrospinal parenchymal disease, aseptic meningitis, and leptomeningeal disease are the most commonly recognized manifestations. However, non-organ-specific potentially neurologically driven symptoms, such as fatigue, cognitive dysfunction, and small fiber neuropathy, appear frequently.Heterogeneous clinical presentations and absence of any single conclusive test or biomarker render NS, and sarcoidosis itself, a challenging definitive diagnosis. Clinical suspicion of NS warrants a thorough systemic and neurologic evaluation hopefully resulting in supportive extraneural physical exam and/or tissue findings. Treatment targets the severity of the manifestation, with careful discernment of whether NS reflects active potentially reversible inflammatory granulomatous disease versus inactive postinflammatory damage whereby functional impairment is unlikely to be pharmacologically responsive. Non-organ-specific symptoms are poorly understood, challenging in deciphering reversibility and often identified too late to respond to conventional immunosuppressive/pharmacological treatment. Physical therapy, coping strategies, and stress reduction may benefit patients with all disease activity levels of NS.This publication provides an approach to screening, diagnosis, disease activity discernment, and pharmacological as well as nonpharmacological treatment interventions to reduce disability and protect health-related quality of life in NS.
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Affiliation(s)
- Mareye Voortman
- Division of Heart and Lungs, Department of Pulmonology, University Medical Centre Utrecht, The Netherlands.,ILD Care Foundation Research Team, Ede, The Netherlands
| | - Barney J Stern
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, Louisiana.,Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, University Medical Center, New Orleans, Louisiana.,Louisiana State University and Tulane University Schools of Medicine, New Orleans, Louisiana
| | - Marjolein Drent
- ILD Care Foundation Research Team, Ede, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands.,Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
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20
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Shaikh F, Abtin FG, Lau R, Saggar R, Belperio JA, Lynch JP. Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display. Semin Respir Crit Care Med 2020; 41:758-784. [PMID: 32777856 DOI: 10.1055/s-0040-1712534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sarcoidosis is a multisystemic granulomatous disorder that can affect virtually any organ. However, pulmonary and thoracic lymph node involvement predominates; abnormalities on chest radiographs are present in 80 to 90% of patients with sarcoidosis. High-resolution computed tomographic (HRCT) scans are superior to chest X-rays in assessing extent of disease, and some CT features may discriminate an active inflammatory component (which may be amenable to therapy) from fibrosis (for which therapy is not indicated). Typical findings on HRCT include micronodules, perilymphatic and bronchocentric distribution, perihilar opacities, and varying degrees of fibrosis. Less common findings on CT include mass-like or alveolar opacities, miliary opacities, mosaic attenuation, honeycomb cysts, and cavitation. With progressive disease, fibrosis, architectural distortion, upper lobe volume loss with hilar retraction, coarse linear bands, cysts, and bullae may be observed. We discuss the salient CT findings in patients with sarcoidosis (with a major focus on pulmonary features) and present classical radiographic and histopathological images of a few extrapulmonary sites.
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Affiliation(s)
- Faisal Shaikh
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Fereidoun G Abtin
- Department of Radiology, Thoracic and Interventional Section, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ryan Lau
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Rajan Saggar
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
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21
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Chung EJ, Lee SY, Lee JH, Park YA, Chun BK, Huh SY. Cervical myelitis in a patient with pulmonary sarcoidosis. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.190112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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22
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Voortman M, Beekman E, Drent M, Hoitsma E, De Vries J. Determination of the smallest detectable change (SDC) and the minimal important difference (MID) for the Small Fiber Neuropathy Screening List (SFNSL) in sarcoidosis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2020; 35:333-341. [PMID: 32476921 PMCID: PMC7170121 DOI: 10.36141/svdld.v35i4.7260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
Background: Previous studies found that 40-60% of the sarcoidosis patients suffer from small fiber neuropathy (SFN), substantially affecting quality of life. SFN is difficult to diagnose, as a gold standard is still lacking. The need for an easily administered screening instrument to identify sarcoidosis-associated SFN symptoms led to the development of the SFN Screening List (SFNSL). The usefulness of any questionnaire in clinical management and research trials depends on its interpretability. Obtaining a clinically relevant change score on a questionnaire requires that the smallest detectable change (SDC) and minimal important difference (MID) are known. Objectives: The aim of this study was to determine the SDC and MID for the SFNSL in patients with sarcoidosis. Methods: Patients with neurosarcoidosis and/or sarcoidosis-associated SFN symptoms (N=138) included in the online Dutch Neurosarcoidosis Registry participated in a prospective, longitudinal study. Anchor-based and distribution-based methods were used to estimate the MID and SDC, respectively. Results: The SFNSL was completed both at baseline and at 6-months’ follow-up by 89/138 patients. A marginal ROC curve (0.6) indicated cut-off values of 3.5 points, with 73% sensitivity and 49% specificity for change. The SDC was 11.8 points. Conclusions: The MID on the SFNSL is 3.5 points for a clinically relevant change over a 6-month period. The MID can be used in the follow-up and management of SFN-associated symptoms in patients with sarcoidosis, though with some caution as the SDC was found to be higher. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 333-341)
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Affiliation(s)
- Mareye Voortman
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, The Netherlands.,ild care foundation research team, Ede, The Netherlands
| | - Emmylou Beekman
- Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Zuyd University of Applied Sciences, Heerlen, The Netherlands.,Physiotherapy-multidisciplinary centre, ParaMedisch Centrum Zuid, Sittard, The Netherlands.,Department of Family Medicine, CAPHRI School for Public Health and Primary care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marjolein Drent
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands.,ild care foundation research team, Ede, The Netherlands
| | - Elske Hoitsma
- Department of Neurology, Alrijne Hospital, Leiden, The Netherlands
| | - Jolanda De Vries
- ild care foundation research team, Ede, The Netherlands.,Department of Medical Psychology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
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23
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Borhani-Haghighi A, Kardeh B, Banerjee S, Yadollahikhales G, Safari A, Sahraian MA, Shapiro L. Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment. Mult Scler Relat Disord 2019; 39:101906. [PMID: 31887565 DOI: 10.1016/j.msard.2019.101906] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 02/08/2023]
Abstract
Neuro-Behcet's disease (NBD) is defined as a combination of neurologic symptoms and/or signs in a patient with Behcet's disease (BD). Relevant syndromes include brainstem syndrome, multiple-sclerosis like presentations, movement disorders, meningoencephalitic syndrome, myelopathic syndrome, cerebral venous sinus thrombosis (CVST), and intracranial hypertension. Central nervous involvement falls into parenchymal and non-parenchymal subtypes. The parenchymal type is more prevalent and presents as brainstem, hemispheric, spinal, and meningoencephalitic manifestations. Non-parenchymal type includes CVST and arterial involvement. Perivascular infiltration of polymorphonuclear and mononuclear cells is seen in most histo-pathologic reports. In parenchymal NBD, cerebrospinal fluid (CSF) generally exhibits pleocytosis, increased protein and normal glucose. In NBD and CVST, CSF pressure is increased but content is usually normal. The typical acute NBD lesions in brain magnetic resonance imaging (MRI) are mesodiencephalic lesions. The pattern of extension from thalamus to midbrain provides a cascade sign. Brain MRI in chronic NBD usually shows brain or brainstem atrophy and/or black holes. The spinal MRI in the acute or subacute myelopathies reveals noncontiguous multifocal lesions mostly in cervical and thoracic lesions. In chronic patients, cord atrophy can also be seen. Brain MRI (particularly susceptibility-weighted images), MR venography (MRV) and computerized tomographic venography (CTV) can be used to diagnose CVST. Parenchymal NBD attacks can be treated with glucocorticoids alone or in combination with azathioprine. For patients with relapsing-remitting or progressive courses, shifting to more potent immunosuppressive drugs such as mycophenolate, methotrexate, cyclophosphamide, or targeted therapy is warranted. For NBD and CVST, immunosuppressive drugs with or without anticoagulation are suggested.
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Affiliation(s)
| | - Bahareh Kardeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shubhasree Banerjee
- Division of Rheumatology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anahid Safari
- Stem Cells Technology Research Center, Shiraz University of Medical Sciences Shiraz, Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical sciences, Tehran, Iran
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24
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Abstract
Sarcoidosis is an inflammatory disorder of unknown cause that is characterized by granuloma formation in affected organs, most often in the lungs. Patients frequently suffer from cough, shortness of breath, chest pain and pronounced fatigue and are at risk of developing lung fibrosis or irreversible damage to other organs. The disease develops in genetically predisposed individuals with exposure to an as-yet unknown antigen. Genetic factors affect not only the risk of developing sarcoidosis but also the disease course, which is highly variable and difficult to predict. The typical T cell accumulation, local T cell immune response and granuloma formation in the lungs indicate that the inflammatory response in sarcoidosis is induced by specific antigens, possibly including self-antigens, which is consistent with an autoimmune involvement. Diagnosis can be challenging for clinicians because of the potential for almost any organ to be affected. As the aetiology of sarcoidosis is unknown, no specific treatment and no pathognomic markers exist. Thus, improved biomarkers to determine disease activity and to identify patients at risk of developing fibrosis are needed. Corticosteroids still constitute the first-line treatment, but new treatment strategies, including those targeting quality-of-life issues, are being evaluated and should yield appropriate, personalized and more effective treatments.
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25
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Caruana LB, Redwine GD, Rohde RE, Russian CJ. A prospective study of patients diagnosed with sarcoidosis: factors - environmental exposure, health assessment, and genetic outlooks. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2019; 36:228-242. [PMID: 32476958 DOI: 10.36141/svdld.v36i3.7112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/01/2019] [Indexed: 12/19/2022]
Abstract
This original research is a directional study that determined the habits of individuals using four analyses to find statistical significance in the data collected from the surveys of 801 qualified of 1,340 individuals who agreed to participate. Results from the self-reported diagnosis of individuals affected by sarcoidosis produced seven statistically significant indicators of future research needed. The demographics revealed a significantly greater number of women and African-Americans participants than other minorities in the United States and suggested a sense of urgency to find a cure. Most important are the seven statistically significant findings that also gave credence to the researchers' four subdiagnostic classifications. They are acute sarcoidosis (AS) and chronic sarcoidosis with limited dissemination (CSLD), while more severe cases include those with chronic sarcoidosis with full dissemination including cutaneous involvement (CSFDIC) and chronic sarcoidosis with neurosarcoidosis (CSN). The most severe sarcoidosis cases (CSN) were on the "most likely" side of every statistically significant category except drinking alcohol, and the "least likely" to participate in physical activities. Conversely, the least severe case of sarcoidosis (AS) was the opposite. The complete list of statistically significant areas was related to alcohol use, tobacco use, ciprofloxacin use, environmental exposure to metals (copper, iron), infectious diseases (candidiasis), genetics, and physical exercise. Statistically, the most crucial study needed; emerged from the Rh blood grouping of the participants.
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Affiliation(s)
| | | | - Rodney E Rohde
- Texas State University Clinical Laboratory Science Program
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26
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Voortman M, De Vries J, Hendriks CMR, Elfferich MDP, Wijnen PAHM, Drent M. Everyday cognitive failure in patients suffering from neurosarcoidosis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2019; 36:2-10. [PMID: 32476930 DOI: 10.36141/svdld.v36i1.7412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/14/2018] [Indexed: 11/02/2022]
Abstract
Background Cognitive failure is associated with memory and concentration problems. Previously, a prevalence of one third was found in a general sarcoidosis population. The aim of this study was to assess if neurosarcoidosis patients are at higher risk for developing everyday cognitive failure using the Cognitive Failure Questionnaire (CFQ) and to determine what factors were associated with cognitive failure. Methods A cross-sectional web-based survey was conducted from April to May 2017 in a national sample of neurosarcoidosis patients. The survey asked about complaints and included 3 questionnaires (Fatigue Assessment Scale [FAS], Small Fiber Neuropathy Screening List [SFNSL] and CFQ. Data were compared to a general sarcoidosis population. Results Of the 152 patients who completed the survey, 131 had neurosarcoidosis. The mean CFQ score was significantly higher in the neurosarcoidosis (45.6±20.7) compared to the general sarcoidosis population (36.2±15.9; p< 0.0001). High CFQ scores (≥43) were found in 55.7% and 33.9%, respectively (p<0.0001). The FAS score (OR 21.4) and SFNSL score (OR 4.3) were the strongest positive predictors of a high CFQ score. Conclusion Cognitive failure is a significant problem in neurosarcoidosis. More than half of the patients reported cognitive deficits, compared to one third of a general sarcoidosis population. Fatigue and small fiber neuropathy play a role in cognitive failure.
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Affiliation(s)
- Mareye Voortman
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, The Netherlands.,ild care foundation research team, Ede, The Netherlands
| | - Jolanda De Vries
- ild care foundation research team, Ede, The Netherlands.,Department of Medical Psychology, Elisabeth-TweeSteden Hospital Tilburg, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Celine M R Hendriks
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.,ild care foundation research team, Ede, The Netherlands
| | | | - Petal A H M Wijnen
- ild care foundation research team, Ede, The Netherlands.,Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marjolein Drent
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.,ild care foundation research team, Ede, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands
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Current management of sarcoidosis I: pulmonary, cardiac, and neurologic manifestations. Curr Opin Rheumatol 2019; 30:243-248. [PMID: 29389828 DOI: 10.1097/bor.0000000000000489] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Sarcoidosis is a systemic disease characterized by noncaseating granulomatous inflammation of multiple organ systems. Pulmonary, cardiac, and neurologic involvements have the worst prognosis. Current recommendations for the therapeutic management and follow-up of sarcoidosis involving these critical organs will be reviewed. RECENT FINDINGS In those sarcoidosis patients requiring immunosuppressive therapy, corticosteroids are used first at varying doses depending on the presenting manifestation. Patients with symptomatic pulmonary, cardiac, or neurologic involvement will be maintained on corticosteroids for at least a year. Many require a second immunosuppressive agent with methotrexate used most commonly. Anti-tumor necrosis factor agents, especially infliximab, are effective and recommendations for their use have been proposed. SUMMARY Evidence-based treatment guidelines do not exist for most sarcoidosis clinical manifestations. Therefore, clinical care of these patients must rely on expert opinion. Patients are best served by a multidisciplinary approach to their care. Future research to identify environmental triggers, genetic associations, biomarkers for treatment response, and where to position new steroid-sparing immunosuppressive agents is warranted.
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Kalmárová K, Kurča E, Sivák Š, Michalik J, Plank L, Vyšehradský R, Zeleňák K, Šutovský J, Nosáľ V. A case of relapsing isolated neurosarcoidosis in an 18-year-old male patient successfully treated by corticosteroids. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2019; 36:79-85. [PMID: 32476939 DOI: 10.36141/svdld.v36i1.7168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/30/2018] [Indexed: 11/02/2022]
Abstract
Sarcoidosis is a granulomatous multisystemic disease of unknown cause most often affecting the lungs, lymph nodes of the pulmonary hilus, eyes, skin, and other structures including central (CNS) or peripheral nervous system (PNS). Isolated neurosarcoidosis is extremely rare. The diagnosis of isolated neurosarcoidosis is challenging because of its rarity, variety of manifestations, and the lack of systemic signs. We report relapsing and remitting isolated intracranial neurosarcoidosis in an 18-year-old male patient who undervent complex diagnostics including cerebral and meninges biopsy. Patient was succesfully treated with corticosteroids.
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Affiliation(s)
- Klaudia Kalmárová
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Štefan Sivák
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jozef Michalik
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Lukáš Plank
- Department of Pathological Anatomy, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Robert Vyšehradský
- Clinic of Pneumology and Phthisiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Juraj Šutovský
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Vladimír Nosáľ
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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Zella S, Kneiphof J, Haghikia A, Gold R, Woitalla D, Thöne J. Successful therapy with rituximab in three patients with probable neurosarcoidosis. Ther Adv Neurol Disord 2018; 11:1756286418805732. [PMID: 30386436 PMCID: PMC6204624 DOI: 10.1177/1756286418805732] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 09/07/2018] [Indexed: 12/25/2022] Open
Abstract
Background Neurosarcoidosis occurs in about 5-15% of patients with sarcoidosis. Therapy with corticosteroids is generally accepted as the first-line medication, followed by various immunomodulating and cytotoxic agents or combined therapy. However, some patients show an unsatisfactory outcome or have adverse events and require novel treatment strategies. Methods We describe three patients with systemic sarcoidosis and central nervous system involvement who received CD20-targeted B-cell depletion with rituximab. Results Treatment with rituximab was well tolerated and followed by marked remission in patients nonresponsive to other immunosuppressive agents. Conclusion Rituximab may be used for patients with neurosarcoidosis who are nonresponsive to established treatment regimes.
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Affiliation(s)
- Samis Zella
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Gudrunstr. 56, D-44791 Bochum, Germany Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Heidbergweg 22-24, D-45257 Essen, Germany
| | - Janina Kneiphof
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Dirk Woitalla
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Essen, Germany
| | - Jan Thöne
- Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Essen, Germany
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Abstract
Sarcoidosis is a systemic granulomatous lung disease of unknown origin affecting people of any age, mainly young adults. The disease is extremely heterogeneous with an unpredictable clinical course. Different phenotypes have been identified: an acute syndrome can be distinguished from subacute and chronic variants. About 20% of patients are chronically progressive and may develop lung fibrosis. Sarcoidosis usually involves the lungs and thoracic lymph nodes, although the skin, eyes, bones, liver, spleen, heart, upper respiratory tract and nervous system can also be affected. No reliable indicators of clinical outcome are available, and there is no single serological biomarker with demonstrated unequivocal diagnostic and prognostic value. Diagnosis requires histological confirmation although a presumptive diagnosis may be acceptable in special conditions. This review examines the diagnostic approach to sarcoidosis involving a multidisciplinary team of specialists in which the internist has the task of identifying all pulmonary and extrapulmonary localizations of the disease and of managing complications and comorbidities.
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Affiliation(s)
- Elena Bargagli
- Respiratory Medicine, Department of Clinical and Experimental Medicine, Department of Clinical and Experimental Biomedical Sciences, University Hospital Careggi (AOUC), Largo Brambilla 1, 50134, Florence, Italy.
| | - Antje Prasse
- Medizinische Hochschule Hannover, Abteilung für Pneumologie Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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