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Mahmood S, Sallowm Y, Affan M, Schultz L, Cerghet M, Ali A. Radiological features of patients with headache as a presenting symptom of neurosarcoidosis. Headache 2024. [PMID: 38780214 DOI: 10.1111/head.14738] [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: 08/06/2022] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To describe the radiological features of patients with headache as a presenting symptom of neurosarcoidosis. BACKGROUND Neurologic complications occur in approximately 5%-10% of patients with sarcoidosis, and approximately 50% of these patients have neurologic deficits at the time sarcoidosis is first diagnosed. A wide spectrum of central and peripheral nervous system clinical manifestations may be observed, including cranial nerve palsies, sensory and/or motor deficits, and headache. Magnetic resonance imaging (MRI) results in patients with neurosarcoidosis may include abnormal contrast enhancement, structural masses, and demyelinating lesions. METHODS This single-center retrospective cohort study assessed patients who were diagnosed with neurosarcoidosis in an urban tertiary care center between 1995 and 2016. We included patients who had MRI results at the time of diagnosis. Patients were divided into two groups based on the presence or absence of headache as a presenting symptom. The MRI result of meningeal contrast enhancement was reviewed. RESULTS Of the 110 patients analyzed, 30 (27.3%) had an initial presenting symptom of headache while 80 (72.7%) did not. Patients with headache had a higher proportion of meningeal contrast enhancement on MRI (66.7% [20/30] vs. 25.0% [20/80]; p < 0.001) and leptomeningeal involvement (53.3% [16/30] vs. 7.5% [6/80], p < 0.001) compared to patients with no headache. However, those with headache had a lower proportion of spinal cord localization (13.8% [4/29] vs. 34.2% [26/76], p = 0.038) and intraparenchymal central nervous system involvement (16.7% [5/30] vs. 51.3% [41/80], p = 0.001) compared to patients with no headache. CONCLUSION Patients with neurosarcoidosis who presented with headache as an initial symptom had a higher proportion of meningeal contrast enhancement seen by MRI than patients who presented with other neurological symptoms. This suggests a clinico-radiologic link between headache and meningeal disruption in patients with neurosarcoidosis.
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Affiliation(s)
- Selina Mahmood
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yamin Sallowm
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Muhammad Affan
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lonni Schultz
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mirela Cerghet
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Ashhar Ali
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
- College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
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Winter Y, Groppa S, Uphaus T, Ellwardt E, Fuest S, Meuth S, Bittner S, Hayani E. Cerebral vasculitis as a clinical manifestation of neurosarcoidosis: A scoping review. Autoimmun Rev 2024; 23:103528. [PMID: 38492907 DOI: 10.1016/j.autrev.2024.103528] [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: 02/27/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 03/18/2024]
Abstract
The occurrence of cerebral vasculitis in individuals with neurosarcoidosis (NS) is considered to be rare. Although the number of relevant publications has increased in recent years, evidence is mostly limited to case reports. To obtain a better understanding of this rare and severe manifestation of disease, we carried out a scoping review on cerebral vasculitis in patients diagnosed with NS. The results of the review indicate that the diagnosis of cerebral vasculitis in patients with NS is made especially in patients with systemic sarcoidosis. However, recurrent strokes in patients with NS remains the main indicator of cerebral vasculitis. A tissue biopsy is considered the gold standard to confirm the diagnosis despite occasional false-negative results. Glucocorticoids and steroid-sparing agents are the most successful current treatments. Favorable outcomes were observed with strategies targeting TNFα and B cells. The goal of this review is to summarize the current literature and treatment options for cerebral vasculitis in patients with NS.
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Affiliation(s)
- Yaroslav Winter
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Neurology, Philipps-University Marburg, Baldingerstr, 35043 Marburg, Germany.
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Erik Ellwardt
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Neurology, Helios-HSK Wiesbaden, Wiesbaden, Germany
| | - Sven Fuest
- Department of Neurology, Hephata Klinik, Schwalmstadt, Germany
| | - Sven Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany; Department of Neurology, University of Düsseldorf, Düsseldorf, Germany
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eyad Hayani
- Department of Neurology, Focus Program Translational Neuroscience (FTN), Rhine Main Neuroscience Network (rmn(2)), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Saade A, Denwood HM, Tannoury T, Tannoury C. Surgical management of intramedullary cervical spinal sarcoidosis complicated by transient unilateral weakness: A case report. Surg Neurol Int 2024; 15:76. [PMID: 38628516 PMCID: PMC11021060 DOI: 10.25259/sni_41_2024] [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: 01/16/2024] [Accepted: 01/30/2024] [Indexed: 04/19/2024] Open
Abstract
Background Sarcoidosis, a multisystem inflammatory non-caseating granulomatous disease, can present with neurologic lesions in up to 10% of patients. Case Description A 57-year-old male presented with three months of worsening upper extremity radicular pain associated with dysmetria, hyperreflexia, bilateral Hoffman's, and positive Babinski signs. The contrast magnetic resonance imaging (MRI) showed a diffuse T2 signal hyperintensity and T1-enhancing 2.5 cm lesion extending sagittally between C4 and C6. The cerebrospinal fluid analysis showed a high protein level and lymphocytic pleocytosis. A cardiac positron emission tomography scan was consistent with the diagnosis of cardiac sarcoidosis. With the diagnosis of multisystemic/probable neurosarcoidosis, the patient was unsuccessfully treated with intravenous methylprednisolone, followed by infliximab. Due to severe cord compression/myelopathy, a C3-C6 laminectomy and C3-C7 posterior spinal fusion were performed. Postoperatively, the patient developed a transient right-sided hemiparesis. Over nine postoperative months, the patient had four relapses of transient repeated episodes of paresis, although follow-up cervical MRI scans revealed adequate cord decompression with a stable intramedullary hyperintense lesion. Conclusion Patients with neurosarcoidosis respond unpredictably to surgical decompression and require prolonged medical care, which is often unsuccessful.
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Affiliation(s)
- Aziz Saade
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California, United States
| | - Hayley M. Denwood
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
| | - Tony Tannoury
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
| | - Chadi Tannoury
- Department of Orthopedic Surgery, Boston Medical Center, One Boston Medical Center Place, Boston, Massachusetts, United States
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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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Borciuch C, El-Jammal T, Kodjikian L, Boussel L, Romain-Scelle N, Nourredine M, Gerfaud-Valentin M, Sève P. Value of Chest X-Ray and Chest Computed Tomography for Systemic Sarcoidosis Diagnosis in Undifferentiated Uveitis. Ocul Immunol Inflamm 2024; 32:161-167. [PMID: 37364057 DOI: 10.1080/09273948.2023.2226203] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/17/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND To evaluate the contribution of chest X-ray and chest CT for the diagnosis of sarcoid uveitis. METHODS Retrospective study on consecutive patients with uveitis of unknown etiology, who underwent both chest X-ray and CT during uveitis diagnosis workup in a tertiary French university hospital. RESULTS A total of 914 patients were included. Systemic sarcoidosis was identified in 23.1%. The probability of discordance between chest X-ray and CT increased with age at diagnosis (p < 0.001). In patients 30 years of age and younger, the probability of discordance was 5% or less, and 0.8% if the ACE level was normal. After 78.3 years of age, the probability of discordance was 20% or more. CONCLUSION We recommend not to perform CT in patients under 30 years of age with a normal chest X ray and ACE level, and suggest performing chest CT first in the elderly.
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Affiliation(s)
- Caroline Borciuch
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Thomas El-Jammal
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire UMR-CNRS 5303: Laboratory of Tissue Biology and Therapeutic Engineering, Institute of Biology and Protein Chemistry, Lyon, France
| | - Laurent Kodjikian
- Department of Ophthalmology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Laboratoire UMR-CNRS 5510 Matéis, Université Claude Bernard Lyon 1, INSA Lyon, Villeurbanne, France
| | - Loïc Boussel
- Department of Radiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Romain-Scelle
- Department of Biostatistics and Public Health, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Mikail Nourredine
- Department of Biostatistics and Public Health, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Unité U1290: Research on Healthcare Performance (RESHAPE), Université Claude Bernard Lyon 1, INSERM, Lyon, France
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Patel M, Shiwlani S, Kachhadia MP, Abdalla M, Samreen I, Mohamed AS, Nasir H. Neurosarcoidosis and Transverse Myelitis: Life-Threatening Manifestations of Sarcoidosis. Cureus 2024; 16:e52629. [PMID: 38374863 PMCID: PMC10876160 DOI: 10.7759/cureus.52629] [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] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Sarcoidosis, a systemic granulomatous disorder, typically involves the lungs, skin, and lymph nodes. Neurological manifestations are diverse and may include longitudinally extensive transverse myelitis (LETM), an uncommon inflammatory disorder of the spinal cord. We present a case of a 62-year-old female with LETM as the initial manifestation of sarcoidosis. The patient exhibited progressive bilateral lower extremity weakness, urinary retention, and sensory disturbances. Diagnostic workup revealed characteristic findings on spinal magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and thoracic biopsy. Treatment with high-dose corticosteroids and subsequent immunomodulatory therapy resulted in significant improvement. Our case highlights the importance of including sarcoidosis in the differentials of LETM, particularly in patients with no respiratory manifestations.
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Affiliation(s)
- Mitwa Patel
- Internal Medicine, David Tvildiani Medical University, Tbilisi, GEO
| | | | | | | | - Iqra Samreen
- Internal Medicine, Augusta University, Augusta, USA
| | | | - Hira Nasir
- Internal Medicine, Mayo Hospital, Lahore, PAK
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Akhavanrezayat A, Matsumiya W, Ongpalakorn P, Ghoraba HH, Or C, Khojasteh Jafari H, Kirimli GU, Yasar C, Than NTT, Karaca I, Zaidi M, Mobasserian A, Yavari N, Bazojoo V, Shin YU, Bromeo AJ, Nguyen QD. Neurosarcoidosis, Coccidioidomycosis, or Both! Int Med Case Rep J 2023; 16:887-895. [PMID: 38164515 PMCID: PMC10758176 DOI: 10.2147/imcrj.s434632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose To report a case of neurosarcoidosis (NS) who was initially diagnosed as Coccidioidomycosis immitis (CI) infection. Observations A 57-year-old diabetic man presented with sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. His vision was 20/20 in the right eye (OD) and 20/40 OS. Ophthalmic examination revealed left relative afferent pupillary defect, blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema. OD examination was non-revealing. Chest CT scan with contrast showed calcified mediastinal lymph nodes, but biopsy of the lymph nodes was normal. Brain and orbit MRI demonstrated soft tissue abnormality with enhancement in left orbital apex with involvement of the extraocular muscles. CSF culture was negative, but complement fixation had positive titer of 1:2 for CI. The patient was diagnosed with CI meningitis, and antifungal therapy was initiated. Slight visual and symptomatic improvement was observed, which was not completely satisfactory. Biopsy of extraocular orbital muscle five months later revealed non-caseating granulomatous inflammation, leading to initiation of prednisone trial therapy. Nine months later, the patient was referred to a tertiary center owing to persistence of optic disc edema OS. PET CT was consistent with a diagnosis of sarcoidosis. Antifungal treatment was discontinued, and oral prednisone with methotrexate was initiated. Subsequently, methotrexate was replaced by infliximab to further manage ocular inflammation and neurologic symptoms which was effective. Vision was 20/20 OD and 20/30 OS at the most recent visit. Conclusion and Importance Signs and symptoms of neurosarcoidosis and coccidioidomycosis can be similar and deceiving. The index case underscores importance of considering appropriate differential diagnoses in patients with similar symptoms and signs who may respond to preliminary designated treatment but not to the optimal extent. Considering such possibility could assist clinicians in managing the patients timely and efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wataru Matsumiya
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Prapatsorn Ongpalakorn
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hashem H Ghoraba
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Chris Or
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hassan Khojasteh Jafari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gunay Uludag Kirimli
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Cigdem Yasar
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ngoc Trong Tuong Than
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Irmak Karaca
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Moosa Zaidi
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Azadeh Mobasserian
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Negin Yavari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vahid Bazojoo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yong Un Shin
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Albert John Bromeo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
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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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Janssen MTHF, Landewé RBM, Post MC, Erckens RJ, Mostard RLM. Organ involvement and assessment in sarcoidosis. Curr Opin Pulm Med 2023; 29:485-492. [PMID: 37461850 DOI: 10.1097/mcp.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW In recent years new recommendations have been published about organ assessment in the diagnosis of sarcoidosis. RECENT FINDINGS Screening for pulmonary, cardiac, ocular, neurologic and renal involvement and hypercalcemia is recommended in the work-up for sarcoidosis, additionally, screening for hypercalciuria at the time of the diagnosis might be beneficial. SUMMARY One of the goals in the work-up of sarcoidosis is to assess the extent and severity of organ involvement. Timely and accurate assessment leads to determination of treatment indication. Screening for pulmonary involvement should include pulmonary imaging and pulmonary function tests. Screening for cardiac involvement should include a clear history including palpitations and collapse and a baseline electrocardiogram or 24-h Holter monitoring. At diagnosis, ophthalmological assessment is recommended. Furthermore, serum calcium level and serum creatinine level should be obtained. Although routine 24-h urinary calcium excretion is not included in the guidelines, performing this test routinely can be considered. On indication, neurologic, rheumatologic or dermatologic assessment can be performed.
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Affiliation(s)
| | - Robert B M Landewé
- Department of Rheumatology, Zuyderland Medical Centre, Heerlen, Limburg
- Department of Clinical Immunology & Rheumatology, Amsterdam Rheumatology Centre, Amsterdam
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital Nieuwegein and Utrecht
- Department of Cardiology, University Medical Centre Utrecht, Utrecht
| | | | - Rémy L M Mostard
- Department of Pulmonology
- Department of Pulmonology, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
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Takeshima S, Furuya T, Yamamoto M, Noma M, Kawate N. Planning and effectiveness of intensive rehabilitation as a treatment for a patient with neurosarcoidosis: A case report. Medicine (Baltimore) 2023; 102:e34519. [PMID: 37565862 PMCID: PMC10419337 DOI: 10.1097/md.0000000000034519] [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: 05/12/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Neurosarcoidosis tends to prolong the duration of treatment and may result in a decline in physical function requiring rehabilitation. Because of a rare disease, the adjustment of oral steroid dosage, which is the cornerstone of treatment, is highly dependent on professional experience in general. Therefore, the number of hospitals that can perform dosage adjustment is very limited, and it is difficult to provide concurrent intense rehabilitation at the same hospital over a long period of time, and there are no reports that mention this. PATIENT CONCERNS A 49-year-old man, who presented with impaired consciousness, dysphagia and right hemiplegia, was diagnosed with neurosarcoidosis based on a previous diagnosis of sarcoidosis, laboratory test results, and clinical symptoms. High-dose oral steroid therapy was initiated and he was transferred to our rehabilitation hospital for progressive disuse approximately 2 months after the disease onset. DIAGNOSES This case was diagnosed as "probable" neurosarcoidosis. INTERVENTIONS The steroid dose was not reduced during rehabilitation treatment in our hospital considering the risk of relapse of the primary disease due to steroid reduction. His training regimen focused on minimum activities of daily living was performed, and its effectiveness was determined during approximately 60 days after the initiation of rehabilitation. OUTCOMES Two months after admission, he was independently eating, transferring, and toileting under supervision. He was discharged home 3 months after admission. LESSONS Intensive rehabilitation can be one of the effective comprehensive treatment strategy for patients with neurosarcoidosis. On the other hand, since there is no consensus treatment method, the duration of rehabilitation and goal setting should be adjusted based on an understanding of the characteristics of the disease and the overall treatment plan.
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Affiliation(s)
- Shinichi Takeshima
- Department of Rehabilitation Medicine, Showa University School of Medicine, Kanagawa, Japan
- Department of Internal medicine, Sakuragaoka Central Hospital, Kanagawa, Japan
| | - Toshiki Furuya
- Center for Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Mariko Yamamoto
- Center for Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Marie Noma
- Center for Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Kanagawa, Japan
| | - Nobuyuki Kawate
- Department of Rehabilitation Medicine, Showa University School of Medicine, Kanagawa, Japan
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11
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Alfares K, Han HJ. Neurosarcoidosis-Induced Panhypopituitarism. Cureus 2023; 15:e43169. [PMID: 37692696 PMCID: PMC10484625 DOI: 10.7759/cureus.43169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Sarcoidosis is an inflammatory condition that can impact multiple organs in the body such as the lungs, skin, eyes, and, occasionally, the central nervous system. When sarcoidosis affects the nervous system, it is referred to as neurosarcoidosis and is estimated to occur in approximately 5%-15% of sarcoid patients. When neurosarcoidosis affects the pituitary gland, it can result in panhypopituitarism, which can be life-threatening. A 35-year-old male with a known diagnosis of sarcoidosis by skin biopsies presented to the hospital with altered mental status, hypernatremia, hypotension, and hypothermia. He reported symptoms of polyuria and polydipsia for several weeks before admission. Laboratory workup revealed elevated serum sodium at 167 mmol/L, high serum osmolality at 381 mOsm/kg, and low urine osmolality at 381 mOsm/kg, consistent with diabetes insipidus. Anterior pituitary hormone profile workup revealed low 8 am serum cortisol (1.9 mcg/dL) and inappropriately normal adrenocorticotropic hormone (ACTH) (34 pg/ml), low serum free testosterone (<2.5 ng/dL), low luteinizing hormone (0.7 mIU/ml), low follicular stimulating hormone (< 2.6 mIU/ml), low free T4 at 0.4 ng/dL. and inappropriately normal thyroid-stimulating hormone (TSH) at 2.77 uIU/mL. Serum prolactin was mildly elevated at 86.8 ng/mL. Angiotensin-converting enzyme level was within the normal range at 33 U/L. A diagnosis of panhypopituitarism was made. Brain MRI revealed a 3 cm mass in the suprasellar region involving the hypothalamus and bilateral optic tracts with a mass effect on the anterior third ventricle. No discrete pituitary or stalk lesion was identified. A ventriculostomy tube was placed for developing hydrocephalus. A biopsy of the suprasellar mass revealed non-caseating granuloma, confirming neurosarcoidosis. Treatment was initiated with high-dose IV corticosteroids to manage secondary adrenal insufficiency and neurosarcoidosis. He was also started on IV desmopressin and IV levothyroxine to manage his diabetes insipidus and central hypothyroidism. He was transitioned to oral therapy upon discharge. Panhypopituitarism secondary to neurosarcoidosis is a rare presentation that can occur due to the infiltration of the pituitary gland or the infiltration of the hypothalamus affecting the hypothalamic-pituitary axis. Neurosarcoidosis should be considered a differential when evaluating patients with symptoms consistent with panhypopituitarism. Prompt diagnosis and initiation of corticosteroids and deficient hormones can be lifesaving.
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Affiliation(s)
- Khalid Alfares
- Endocrinology, Diabetes, and Metabolism, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
- Endocrinology, Diabetes, and Metabolism, Henry Ford Health System, Detroit, USA
| | - Hye Jeong Han
- Internal Medicine, Henry Ford Health System, Detroit, USA
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Shen J, Lackey E, Shah S. Neurosarcoidosis: Diagnostic Challenges and Mimics A Review. Curr Allergy Asthma Rep 2023; 23:399-410. [PMID: 37256482 PMCID: PMC10230477 DOI: 10.1007/s11882-023-01092-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis. RECENT FINDINGS Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.
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Affiliation(s)
- Jeffrey Shen
- Duke Department of Medicine, Division of Rheumatology and Immunology, Duke University, 40 Duke Medicine Cir Clinic 1J, Durham, NC, 27710, USA.
| | - Elijah Lackey
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
| | - Suma Shah
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
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13
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Heard S, Miller Machado F, Juganya Ponnusamy J. Neurosarcoidosis Presenting With Confusion and Speech Alteration. Cureus 2023; 15:e42627. [PMID: 37641764 PMCID: PMC10460636 DOI: 10.7759/cureus.42627] [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] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Neurosarcoidosis (NS) is a rare manifestation of sarcoidosis, a multisystem inflammatory granulomatous disease. We describe a unique case of NS with confusion and speech alteration as presenting symptoms. A 65-year-old male with a history of Ramsay Hunt syndrome and Lyme infection presented to the emergency room after an acute episode of disorientation, garbled speech, and left facial droop, along with months of worsening generalized fatigue, gait ataxia, left-sided periorbital headaches, bilateral peripheral neuropathy, and bladder disturbance. A recent CT scan of his chest showed mediastinal lymphadenopathy, and a lymph node biopsy revealed non-necrotizing granulomas, Langhans giant cells, and focal Schaumann bodies. A brain MRI revealed a mildly enlarged anterior pituitary gland, mild prominent enhancement of the trigeminal nerves bilaterally, and right frontal, parietal, and superior temporal leptomeningeal enhancement. Lumbar puncture cerebrospinal fluid analyses were consistent with aseptic meningitis. A diagnosis of probable NS was made. The patient received IV methylprednisolone 1 g for three days, followed by a prednisone taper with clinical improvement. NS is a diagnostic challenge due to the variability of clinical presentations of the disease. This case demonstrates how vague chronic neurologic symptoms preceding an unusual acute clinical presentation delayed the diagnosis of NS in a patient with sarcoidosis.
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Affiliation(s)
- Sara Heard
- Internal Medicine, MetroWest Medical Center/Tufts School of Medicine, Framingham, USA
| | | | - Jai Juganya Ponnusamy
- Internal Medicine, MetroWest Medical Center/Tufts School of Medicine, Framingham, USA
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Mandyam S, Sibyala S, Dasarathan P, Chirrareddy Y, Kalluru PKR. Neurosarcoidosis: A Rare Presentation as a Seizure. Cureus 2023; 15:e40227. [PMID: 37435272 PMCID: PMC10332791 DOI: 10.7759/cureus.40227] [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] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Neurosarcoidosis is a rare disorder that can develop in patients with a history of sarcoidosis or can develop even when sarcoidosis is not diagnosed. It is a granulomatous disease of the nervous system that causes different neurological disorders based on its location. However, diagnosing neurosarcoidosis remains a challenge as it mimics many other neurological disorders and does not have any biochemical markers of high specificity. A tissue-proven biopsy is the gold standard but is difficult to obtain in neurological illnesses. Thus, diagnosis is established based on the clinical syndrome and imaging, which mostly show meningeal/parenchymal lesion enhancement, in addition to the exclusion of other causes. Glucocorticoids, immunosuppressants, and anti-tumour necrosis factor (TNF) drugs are the mainstays of treatment. We discuss a case of neurosarcoidosis in a 52-year-old woman with a known history of sarcoidosis.
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Affiliation(s)
- Saikiran Mandyam
- Graduate Medical Education (GME) Internal Medicine, Southeast Health Medical Center, Dothan, USA
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15
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Kafai Golahmadi A, Craven CL, Watkins LD. Neurosarcoidosis Mimicking Normal Pressure Hydrocephalus. Cureus 2023; 15:e40281. [PMID: 37448383 PMCID: PMC10336621 DOI: 10.7759/cureus.40281] [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] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Two female patients, aged 46 and 51, were referred to the National Hospital for Neurology and Neurosurgery with symptoms resembling normal pressure hydrocephalus (NPH) and with ventriculomegaly on the MRI. Both had a definite diagnosis of neurosarcoidosis (NS) on biopsy, and they underwent the medical and surgical management reserved for NPH. At follow-up, their presenting symptoms had resolved and they had clinically improved. Neurosarcoidosis can mimic NPH, and it should be excluded in patients presenting with NPH.
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Affiliation(s)
| | - Claudia L Craven
- Neurosurgery, National Hospital for Neurology and Neurosurgery, London, GBR
| | - Laurence D Watkins
- Neurosurgery, National Hospital for Neurology and Neurosurgery, London, GBR
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16
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Mirmosayyeb O, Mohammadzamani M, Bagherieh S, Ghaffary EM, Azimi ES, Shaygannejad A, Shaygannejad V. Neurosarcoidosis in an adult man with a family history of MS: A case report. Clin Case Rep 2023; 11:e7605. [PMID: 37361664 PMCID: PMC10288071 DOI: 10.1002/ccr3.7605] [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: 05/25/2022] [Revised: 04/13/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Key clinical message According to this report, a biopsy revealed a diagnosis of neurosarcoidosis in a patient with a history of MS. The development of the disease can be slowed down by early diagnosis and appropriate treatment. Abstract Neurosarcoidosis is a rare type of sarcoidosis that affects the central nervous system (CNS). Herein, we present a case of neurosarcoidosis with a history of multiple sclerosis (MS). Based on the pathological findings of the biopsy, a diagnosis of neurosarcoidosis was established. The administration of appropriate treatment at an early stage can assist in decelerating its progression.
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Affiliation(s)
- Omid Mirmosayyeb
- Department of Neurology, School of MedicineIsfahan University of Medical SciencesIsfahanIran
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Mahtab Mohammadzamani
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Sara Bagherieh
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Elham Moases Ghaffary
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Elham Sadat Azimi
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Aysa Shaygannejad
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Vahid Shaygannejad
- Department of Neurology, School of MedicineIsfahan University of Medical SciencesIsfahanIran
- Isfahan Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
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Vialatte de Pémille C, Noël N, Adam C, Labeyrie C, Not A, Beaudonnet G, Echaniz-Laguna A, Adams D, Cauquil C. Red Flags for Chronic Inflammatory Demyelinating Polyradiculoneuropathy Associated with Sarcoidosis or Connective Tissue Diseases. J Clin Med 2023; 12:jcm12093281. [PMID: 37176720 PMCID: PMC10179067 DOI: 10.3390/jcm12093281] [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: 03/02/2023] [Revised: 04/21/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare autoimmune disorder of the peripheral nervous system. Diagnosis relies on clinical and electrophysiological criteria. Various disorders requiring specific treatment regimens may be associated with CIDP, including sarcoidosis (SAR-CIDP) and connective tissue disease (CTD-CIDP). Therefore, it is important to distinguish between CIDP, SAR-CIDP and CTD-CIDP. In this retrospective monocentric study, we analyzed 16 patients with SAR-CIDP and 11 with CTD-CIDP and compared them with a group of 17 patients with idiopathic CIDP. SAR-CIDP patients had a frequently acute or subacute CIDP onset. CTD-CIDPs were mostly Sjögren's syndrome and lupus, and patients had a chronic onset. An older age at onset (64.5 vs. 54 years, p = 0.04), more atypical presentation (19/25 (76%) vs. 6/17 (35%), p = 0.008), acute/subacute onset of symptoms (15/25 (60%) vs. 1/17 (6%), p = 0.0004) and more frequent weight loss (7/16 (44%) vs. 0/17 (0%), p = 0.017) were identified SAR-CIDP and CTD-CIDP groups. Response to intravenous immunoglobulin therapy was lower in the combined SAR-CIDP and CTD-CIDP group (44% versus 82%, p = 0.005). As sarcoidosis and CTDs might be associated with CIDP and require specific management, the "red flags" mentioned above should be kept in mind by clinicians managing patients with CIDP.
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Affiliation(s)
| | - Nicolas Noël
- Internal Medicine Departement, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- Faculty of Medicine, Paris Saclay University, 63 Rue Gabriel Peri, 94270 Le Kremlin Bicetre, France
| | - Clovis Adam
- Pathology Laboratory, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - Céline Labeyrie
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
| | - Adeline Not
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
| | - Guillemette Beaudonnet
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
- Neurophysiology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - Andoni Echaniz-Laguna
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- Faculty of Medicine, Paris Saclay University, 63 Rue Gabriel Peri, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
- INSERM U1195, Paris Saclay University, 94276 Le Kremlin Bicetre, France
| | - David Adams
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- Faculty of Medicine, Paris Saclay University, 63 Rue Gabriel Peri, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
- INSERM U1195, Paris Saclay University, 94276 Le Kremlin Bicetre, France
| | - Cécile Cauquil
- Neurology Department, AP-HP, CHU de Bicêtre, 78 Rue du General Leclerc, 94270 Le Kremlin Bicetre, France
- French National Reference Center for Rare Neuropathies (NNERF), CHU de Bicêtre, 78 Rue du General Leclerc, 94275 Le Kremlin Bicetre, France
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18
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Sumi K, Masuda T, Kimura N, Akiyoshi Y, Obayashi K, Matsubara E. Cerebrospinal fluid B-cell activating factor levels as a novel biomarker in patients with neurosarcoidosis. J Neurol Sci 2023; 449:120668. [PMID: 37148776 DOI: 10.1016/j.jns.2023.120668] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/08/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVES Neurosarcoidosis (NS) is a severe complication of sarcoidosis. Patients with NS often have poor outcomes. To improve both the quality of life and prognosis in patients with NS, accurate and reliable methods for early diagnosis and determining the efficacy of treatment are needed. This study aims to investigate B-cell-activating factor of the tumor necrosis factor family (BAFF) in cerebrospinal fluid (CSF) and elucidate the relationship between CSF BAFF levels and various parameters of NS. METHODS We studied 20 patients with NS and 14 control subjects. We measured CSF BAFF levels in all subjects and investigated the relationship with clinical findings, serum and CSF measures, and magnetic resonance imaging (MRI) findings. RESULTS CSF BAFF levels were significantly increased in patients with NS compared with controls (median 0.089 vs 0.04 ng/mL, p = 0.0005). CSF BAFF values were correlated with CSF findings-cell count, protein, angiotensin-converting enzyme, lysozyme, soluble interleukin-2 receptor, and immunoglobulin G-but not with serum parameters. CSF BAFF levels were especially higher in patients with abnormal intraparenchymal lesions of the brain and abnormal spinal MRI findings. CSF BAFF levels decreased significantly after immunosuppressive therapy. CONCLUSION CSF BAFF may aid the quantitative evaluation of NS and may serve as a biomarker for this disease.
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Affiliation(s)
- Kaori Sumi
- Department of Neurology, Faculty of Medicine, Oita University, Oita, Japan
| | - Teruaki Masuda
- Department of Neurology, Faculty of Medicine, Oita University, Oita, Japan.
| | - Noriyuki Kimura
- Department of Neurology, Faculty of Medicine, Oita University, Oita, Japan
| | - Yuko Akiyoshi
- Department of Neurology, Faculty of Medicine, Oita University, Oita, Japan
| | - Konen Obayashi
- Department of Morphological and Physiological Sciences, Graduate School of Health Sciences, Kumamoto University, Kumamoto, Japan
| | - Etsuro Matsubara
- Department of Neurology, Faculty of Medicine, Oita University, Oita, Japan
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Gupta P, Saxena S, Sharma V, Thirunavukkarasu B, Tiwari S, Goyal A. Neurosarcoidosis - A diagnostic challenge? Indian J Otolaryngol Head Neck Surg 2023:1-4. [PMID: 37362102 PMCID: PMC10148611 DOI: 10.1007/s12070-023-03801-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Sarcoidosis is an inflammatory granulomatous multisystem disease with an unknown etiology. Neurosarcoidosis is a cryptogenic neuroinflammatory manifestation of sarcoidosis. Objective: This article aims at better understanding of one of the rarer diseases whose diagnosis may be difficult leading to delay in definitive management of the patient. Method: We describe a case of neurosarcoidosis with initial presentation similar to acute invasive fungal rhinosinusitis, whose diagnosis was challenging and delayed owing to the presenting symptoms. Conclusion: The diagnosis of neurosarcoidosis becomes challenging when it presents as isolated clinical neurological symptoms. We want to highlight the variable nature of neurosarcoidosis and its consideration as diagnosis after excluding other common infectious and inflammatory conditions.
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Affiliation(s)
- Palak Gupta
- Department of ENT, AIIMS Jodhpur, Jodhpur, Rajasthan 342005 India
| | - Suvinay Saxena
- Department of Diagnostic & Interventional Radiology AIIMS Jodhpur, Jodhpur, Rajasthan 342005 India
| | - Vidhu Sharma
- Department of ENT, AIIMS Jodhpur, Jodhpur, Rajasthan 342005 India
| | | | - Sarbesh Tiwari
- Department of Diagnostic & Interventional Radiology AIIMS Jodhpur, Jodhpur, Rajasthan 342005 India
| | - Amit Goyal
- Department of ENT, AIIMS Jodhpur, Jodhpur, Rajasthan 342005 India
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20
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Berntsson SG, Elmgren A, Gudjonsson O, Grabowska A, Landtblom AM, Moraes-Fontes MF. A comprehensive diagnostic approach in suspected neurosarcoidosis. Sci Rep 2023; 13:6539. [PMID: 37085608 PMCID: PMC10121682 DOI: 10.1038/s41598-023-33631-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 04/16/2023] [Indexed: 04/23/2023] Open
Abstract
Neurosarcoidosis presents a diagnostic challenge in clinical settings, as it has no pathognomonic symptoms or signs and a wide range of differential diagnoses. The aim of this report is to present the pathological features of our group of patients, obtained through a systematic diagnostic approach. This retrospective cohort study enrolled all adult patients primarily diagnosed with neurosarcoidosis at the neurology department of a tertiary center in Sweden over a period of 30 years, from 1990 to 2021. We identified 90 patients, 54 with possible neurosarcoidosis and 36 with probable neurosarcoidosis. CNS biopsy revealed an alternative diagnosis for 24 patients, who were then excluded. The collected data from medical records included demographic and clinical characteristics, systemic and/or neurological isolated involvement, various laboratory tests, including cerebrospinal fluid (CSF), serum analysis, imaging studies (MRI, FDG-PET/CT, and HRCT), nerve conduction studies, electromyography, and pathology reports of central nervous system (CNS), and extra-neural tissue biopsies. Sixty-six patients were included in our cohort. The median age at onset of symptoms was 49 years, with a similar sex distribution. Cranial neuropathies (38%), motor deficit (32%), headache (16%), and pituitary dysfunction (12%) were the most common presenting features. CSF studies were abnormal in 77% of the patients, who showed lymphocytosis (57%), elevated protein (44%), oligoclonal bands (40%), elevated ACE (28%), and raised T lymphocyte CD4+/CD8+ ratios (13%). Strikingly, MRI showed that 17% of the patients presented with isolated pituitary gland lesions. FDG-PET/CT was performed in 22 patients (33%) and confirmed systemic sarcoidosis in 11. Despite our extensive workup, the final classification for our patients only allowed for a definite diagnosis in 14 patients; the remainder were classified as probable (32) or possible (20) neurosarcoidosis. Since 2007, the employment of a structured laboratory and imaging approach and the increasing number of CNS biopsies have facilitated and improved the process of correct attribution in patients with presumptive neurosarcoidosis, especially in patients with isolated neurological lesions. We highlight a higher frequency of pituitary lesions due to neurosarcoidosis than has been classically described. A detailed laboratory diagnostic workup is included.
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Affiliation(s)
| | - Andreas Elmgren
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
| | - Olafur Gudjonsson
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anna Grabowska
- Department of Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Anne-Marie Landtblom
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
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Bee SWL, Hoe RHM, Goh AGW, Goh Y, Chan VEY, Yong C, Lim MC, Kee CK, Kei PL. Cauda equina thickening: an approach to MRI findings. Clin Radiol 2023:S0009-9260(23)00141-1. [PMID: 37179144 DOI: 10.1016/j.crad.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023]
Abstract
There are many causes of cauda equina (CE) thickening on neuroimaging of the lumbar spine. The imaging features of CE thickening for the various conditions often overlap and are non-specific to clinch a definite diagnosis. Hence, the imaging findings have to be discerned in accordance with the patient's presenting history, clinical examination findings, and results from electrophysiology and laboratory studies. In this review, the authors aim to supplement the existing literature on imaging findings of CE thickening with a diagnostic framework for clinical workup. The authors also aim to familiarise readers with the interpretation of CE thickening on magnetic resonance imaging (MRI) and would like to illustrate the normal variants and pitfalls that could be mistaken for abnormal results.
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Affiliation(s)
- S W L Bee
- Department of Diagnostic Imaging, National University Hospital, Singapore.
| | - R H M Hoe
- Department of Neurology, National Neuroscience Institute, Singapore
| | - A G W Goh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Y Goh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - V E Y Chan
- Department of Neuroradiology, National Neuroscience Institute, Singapore
| | - C Yong
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - M C Lim
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - C K Kee
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - P L Kei
- Department of Diagnostic Imaging, Ng Teng Fong General Hospital, Singapore
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22
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Nagahori T, Shiraishi W, Nishikawa M, Matsuyoshi A, Ogura T, Yamada Y, Takahashi K, Suzuki T, Nakamichi K, Hashimoto T, Hatano T. A human T-lymphotropic virus-1 carrier who developed progressive multifocal leukoencephalopathy following immunotherapy for sarcoidosis: a case report. BMC Neurol 2023; 23:52. [PMID: 36726087 PMCID: PMC9893603 DOI: 10.1186/s12883-023-03094-w] [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: 08/19/2022] [Accepted: 01/27/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a devastating demyelinating disorder of the central nervous system caused by opportunistic infection of the JC virus (JCV). CASE PRESENTATION A 58-year-old Japanese woman was admitted to our hospital for aphasia. She had a 5-year history of untreated sarcoidosis and was a human T cell lymphotropic virus-1 (HTLV-1) carrier. Serum angiotensin-converting enzyme, soluble interleukin-2 receptor, lysozyme, and calcium levels were elevated. JCV-DNA was not detected in cerebrospinal fluid by PCR testing. Skin biopsy revealed noncaseating granuloma formation. Bilateral multiple nodular lesions were present on chest X-ray. Brain magnetic resonance imaging showed left frontal and temporal lesions without gadolinium enhancement. As we suspected that systemic sarcoidosis had developed into neurosarcoidosis, we started steroid and infliximab administration. After treatment, the chest X-ray and serum abnormalities ameliorated, but the neurological deficits remained. At 1 month after immunotherapy, she developed right hemiparesis. Cerebrospinal fluid was positive for prototype (PML-type) JCV on repeated PCR testing. Brain biopsy revealed demyelinating lesions with macrophage infiltration, atypical astrocytes, and JCV antigen-positive cells. We diagnosed her with PML and started mefloquine, leading to partial remission. CONCLUSIONS Sarcoidosis and HTLV-1 infection both affect T cell function, especially CD4+ T cells, and may developped the patient's PML. The comorbidity of sarcoidosis, PML, and HTLV-1 infection has not been reported, and this is the world's first report of PML associated with HTLV-1 infection and sarcoidosis.
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Affiliation(s)
- Takashi Nagahori
- grid.415432.50000 0004 0377 9814Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Wataru Shiraishi
- grid.415432.50000 0004 0377 9814Department of Neurology, Kokura Memorial Hospital, Fukuoka, Japan ,Shiraishi Internal Medicine Clinic, Fukuoka, Japan
| | - Masafumi Nishikawa
- grid.415432.50000 0004 0377 9814Department of Neurology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Ayano Matsuyoshi
- grid.415432.50000 0004 0377 9814Department of Neurology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Takenori Ogura
- grid.415432.50000 0004 0377 9814Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Yui Yamada
- grid.415432.50000 0004 0377 9814Department of Pathology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Kenta Takahashi
- grid.410795.e0000 0001 2220 1880Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Tadaki Suzuki
- grid.410795.e0000 0001 2220 1880Department of Pathology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuo Nakamichi
- grid.410795.e0000 0001 2220 1880Department of Virology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Tetsuya Hashimoto
- grid.415432.50000 0004 0377 9814Department of Neurology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Taketo Hatano
- grid.415432.50000 0004 0377 9814Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan
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Cutler C, Azab MA, Lucke-Wold B, Khan M, Henson JC, Gill AS, Alt JA, Karsy M. Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations. World Neurosurg 2023; 173:136-145.e30. [PMID: 36639102 DOI: 10.1016/j.wneu.2022.12.108] [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: 10/20/2022] [Revised: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations. METHODS We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit. RESULTS A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence. CONCLUSIONS This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.
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Affiliation(s)
- Christopher Cutler
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, Nevada, USA
| | - J Curran Henson
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Amarbir S Gill
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah A Alt
- Division of Otolaryngology, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Vlad B, Neidhart S, Hilty M, Ziegler M, Jelcic I. Differentiating neurosarcoidosis from multiple sclerosis using combined analysis of basic CSF parameters and MRZ reaction. Front Neurol 2023; 14:1135392. [PMID: 37034091 PMCID: PMC10080049 DOI: 10.3389/fneur.2023.1135392] [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: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Background Neurosarcodosis is one of the most frequent differential diagnoses of multiple sclerosis (MS) and requires central nervous system (CNS) biopsy to establish definite diagnosis according to the latest consensus diagnostic criteria. We here analyzed diagnostic values of basic cerebrospinal fluid (CSF) parameters to distinguish neurosarcoidosis from MS without CNS biopsy. Methods We retrospectively assessed clinical, radiological and laboratory data of 27 patients with neurosarcoidosis treated at our center and compared following CSF parameters with those of 138 patients with relapsing-remitting MS: CSF white cell count (WCC), CSF/serum albumin quotient (Qalb), intrathecal production of immunoglobulins including oligoclonal bands (OCB), MRZ reaction, defined as a polyspecific intrathecal production of IgG reactive against ≥2 of 3 the viruses measles (M), rubella (R), and zoster (Z) virus, and CSF lactate levels. Additional inflammatory biomarkers in serum and/or CSF such as neopterin, soluble interleukin-2 receptor (sIL-2R) and C-reactive protein (CRP) were assessed. Results There was no significant difference in the frequency of CSF pleocytosis, but a CSF WCC > 30/μl was more frequent in patients with neurosarcoidosis. Compared to MS, patients with neurosarcoidosis showed more frequently an increased Qalb and CSF lactate levels as well as increased serum and CSF levels of sIL-2R, but a lower frequency of intrathecal IgG synthesis and positive MRZ reaction. Positive likelihood ratio (PLR) of single CSF parameters indicating neurosarcoidosis was highest, if (a) CSF WCC was >30/μl (PLR 7.2), (b) Qalb was >10 × 10-3 (PLR 66.4), (c) CSF-specific OCB were absent (PLR 11.5), (d) CSF lactate was elevated (PLR 23.0) or (e) sIL-2R was elevated (PLR>8.0). The combination of (a) one of three following basic CSF parameters, i.e., (a.1.) CSF WCC >30/ul, or (a.2.) QAlb >10 × 10-3, or (a.3.) absence of CSF-specific OCB, and (b) absence of positive MRZ reaction showed the best diagnostic accuracy (sensitivity and specificity each >92%; PLR 12.8 and NLR 0.08). Conclusion Combined evaluation of basic CSF parameters and MRZ reaction is powerful in differentiating neurosarcoidosis from MS, with moderate to severe pleocytosis and QAlb elevation and absence of intrathecal IgG synthesis as useful rule-in parameters and positive MRZ reaction as a rule-out parameter for neurosarcoidosis.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Stephan Neidhart
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marc Hilty
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Mario Ziegler
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- *Correspondence: Ilijas Jelcic
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Abata J, Bazer D, Koroneos N, Syritsyna O. Isolated Neurosarcoidosis Presenting as Chronic Progressive Pachymeningitis. Case Rep Neurol Med 2023; 2023:2140740. [PMID: 36936604 PMCID: PMC10019966 DOI: 10.1155/2023/2140740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 03/12/2023] Open
Abstract
Neurologic manifestations of sarcoidosis are rare, and even rarer still are cases of isolated neurosarcoidosis. The clinical presentation of isolated neurosarcoidosis can be highly variable, and diagnosis is particularly challenging, the gold standard being tissue biopsy. We describe a patient with a history of atypical parkinsonian syndrome and chronic right frontal lobe infarct who developed weakness, imbalance, and gait disequilibrium in 2008, with magnetic resonance imaging at that time showing leptomeningeal and nodular enhancements in the bilateral frontal and parietal lobes. The patient had an extensive negative workup in 2010 but ultimately did not receive a definitive diagnosis with a tissue biopsy until 2020. The patient also notably failed a 3-month course of steroids after his biopsy due to a lack of symptomatic improvement. This case highlights the clinical variability and diagnostic difficulties of isolated neurosarcoidosis. We also highlight that our patient did not have any symptomatic improvement on steroids, which do typically provide some relief for patients.
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Affiliation(s)
- Joshua Abata
- Stony Brook University Hospital, 1101 Nicolls Rd, Stony Brook, NY 11794, USA
| | - Danielle Bazer
- Stony Brook University Hospital, 1101 Nicolls Rd, Stony Brook, NY 11794, USA
| | - Nicholas Koroneos
- Stony Brook University Hospital, 1101 Nicolls Rd, Stony Brook, NY 11794, USA
| | - Olga Syritsyna
- Stony Brook University Hospital, 1101 Nicolls Rd, Stony Brook, NY 11794, USA
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Silva GD, Guedes BF, Junqueira IR, Gomes HR, Vidal JE. Diagnostic and therapeutic approach to chronic meningitis in Brazil: a narrative review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1167-1177. [PMID: 36577417 PMCID: PMC9797267 DOI: 10.1055/s-0042-1758645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic meningitis (CM) is characterized by neurological symptoms associated with the evidence of cerebrospinal fluid pleocytosis lasting > 4 weeks. Studies on the management of CM in Brazil are scarce. OBJECTIVE To critically review the literature on CM and propose a rational approach in the Brazilian scenario. METHODS Narrative literature review discussing the epidemiology, clinical evaluation, basic and advanced diagnostic testing, and empirical and targeted therapy for the most relevant causes of CM. The present review was contextualized with the local experience of the authors. In addition, we propose an algorithm for the management of CM in Brazil. RESULTS In Brazil, tuberculosis and cryptococcosis are endemic and should always be considered in CM patients. In addition to these diseases, neurosyphilis and other endemic conditions should be included in the differential diagnosis, including neurocysticercosis, Baggio-Yoshinari syndrome, and endemic mycosis. After infectious etiologies, meningeal carcinomatosis and autoimmune diseases should be considered. Unbiased and targeted methods should be used based on availability and clinical and epidemiological data. CONCLUSION We propose a rational approach to CM in Brazil, considering the epidemiological scenario, systematizing the etiological investigation, and evaluating the timely use of empirical therapies.
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Affiliation(s)
- Guilherme Diogo Silva
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.,Address for correspondence Guilherme Diogo Silva
| | - Bruno Fukelmann Guedes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Ióri Rodrigues Junqueira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Hélio Rodrigues Gomes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - José Ernesto Vidal
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Doenças Infecciosas, São Paulo SP, Brazil.,Instituto de Infectologia Emílio Ribas, Departamento de Neurologia, São Paulo SP, Brazil.
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Lymphomas mimicking neuroinflammatory diseases - A diagnostic conundrum worth revisiting. J Neuroimmunol 2022; 372:577970. [PMID: 36137305 DOI: 10.1016/j.jneuroim.2022.577970] [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: 05/08/2022] [Revised: 08/23/2022] [Accepted: 09/10/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) lymphomas (CNSLs) have varied clinical presentations which can mimic neuroinflammatory disease, leading to a diagnostic dilemma for clinicians. RECENT FINDINGS This report describes two patients who initially received a diagnosis of neuroinflammatory disorders but were refractory to treatment over a protracted time course. In both cases, biopsy revealed diffuse large B cell lymphoma (DLBCL) as the final diagnosis. SUMMARY The analysis of these cases provides an opportunity for increased recognition of CNS lymphomas for earlier diagnosis and treatment. It also calls for increased clinical suspicion for CNSLs in such circumstances. And possibly the search for new biomarker development for identifying and tracking CNSLs.
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Sambon P, Sellimi A, Kozyreff A, Gheysens O, Pothen L, Yildiz H, van Pesch V. Epidemiology, clinical presentation, treatment, and outcome of neurosarcoidosis: A mono-centric retrospective study and literature review. Front Neurol 2022; 13:970168. [PMID: 36388212 PMCID: PMC9641157 DOI: 10.3389/fneur.2022.970168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Neurosarcoidosis is a rare granulomatous disorder, and treatment guidelines are mainly based on retrospective studies. Materials and methods This retrospective study was performed to provide a detailed description of the clinical characteristics and treatment outcomes of patients with neurosarcoidosis followed at Cliniques Universitaires Saint Luc in Belgium. The second objective of our study was to perform a comparative literature review of neurosarcoidosis, with a focus on treatment outcomes with the use of TNF-α antagonist. Results Among 180 patients with sarcoidosis followed in our hospital, 22 patients with neurosarcoidosis were included in the final analysis. Our literature research identified 776 articles of which 35 articles met our inclusion criteria, including 1,793 patients diagnosed with neurosarcoidosis. In our cohort, the majority of patients (86%) were diagnosed with systemic sarcoidosis which was similar to that reported in the literature (83%). Serum CRP and calcemia were elevated only in 33 and 18% of patients, respectively. Serum lysozyme and angiotensin-converting enzyme were elevated in 79 and 16% of patients, respectively. Lumbar puncture and CSF fluid analysis were performed in 15/22 patients and were abnormal in all patients. Brain MRI was performed in 21/22 patients and showed abnormalities in 16 patients consisting of parenchymal lesions in 63%, hypothalamic-pituitary axis lesions in 38%, and meningeal enhancement in 31%. In both cohort patients, methotrexate was the most frequently used treatment (>45% of cases) with a favorable outcome in an average of 50% of patients. A TNF-α antagonist was administered in 9% of patients in our cohort and in 27% of patients in the literature review. The proportion of favorable outcomes in literature research was significantly higher in patients treated with TNF-α antagonists compared to methotrexate (p < 0.0001), mycophenolate mofetil (p < 0.0001), or azathioprine (p < 0.0001). Conclusion The results of our cohort and literature review confirm that neurosarcoidosis occurred most frequently in the context of systemic sarcoidosis. Methotrexate is the most frequent second-line therapy. The effectiveness of therapy with TNF-α antagonists is well-demonstrated and associated with a better outcome. Their earlier use during the disease course among aggressive and/or refractory neurosarcoidosis should be considered.
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Affiliation(s)
- Pauline Sambon
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Amina Sellimi
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandra Kozyreff
- Department of Ophthalmology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Lucie Pothen
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- *Correspondence: Vincent van Pesch
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Gosselin J, Roy-Hewitson C, Bullis SSM, DeWitt JC, Soares BP, Dasari S, Nevares A. Neurosarcoidosis: Phenotypes, Approach to Diagnosis and Treatment. Curr Rheumatol Rep 2022; 24:371-382. [PMID: 36223002 DOI: 10.1007/s11926-022-01089-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update of clinical presentation, diagnosis, differential diagnoses, and treatment according to recent evidence. RECENT FINDINGS Neurosarcoidosis remains a diagnosis of exclusion, with infectious and malignant etiologies recognized as important mimickers. Corticosteroids remain as first-line therapy. In recent years, however, studies have demonstrated the effectiveness of anti-tumor necrosis factor (anti-TNF) therapy in the treatment of neurosarcoidosis, leading to improved outcomes. Neurosarcoidosis is a granulomatous disease with protean manifestations that may affect any part of the central and peripheral nervous system. It has many mimickers, and potentially devastating complications necessitating long-term follow-up. Early initiation of treatment, particularly with anti-TNF therapy, may lead to better outcomes and fewer relapses. There is an unmet need for randomized controlled trials that provide robust data to guide therapy and the long-term management of neurosarcoidosis patients.
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Affiliation(s)
- Jeanne Gosselin
- Division of Rheumatology and Clinical Immunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT, 05401, USA.
| | - Chantal Roy-Hewitson
- Department of Neurosciences, Division of Neuroimmunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Sean S M Bullis
- Division of Infectious Disease, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - John C DeWitt
- Department of Pathology and Laboratory Medicine, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Bruno P Soares
- Division of Neuroradiology, Department of Radiology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Sidarth Dasari
- Department of Neurosciences, Division of Neuroimmunology, University of Vermont Medical Center, Burlington, VT, USA
| | - Alana Nevares
- Division of Rheumatology and Clinical Immunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT, 05401, USA
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Etemadifar M, Mehri A, Sedaghat N, Salari M, Tavassoli Naini P. Multiple sclerosis in sarcoidosis patients: Two case reports. Clin Case Rep 2022; 10:e6332. [PMID: 36172327 PMCID: PMC9468654 DOI: 10.1002/ccr3.6332] [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: 02/26/2022] [Revised: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
Abstract
Two cases of sarcoidosis referred to our clinic with neurological symptoms. They were diagnosed with multiple sclerosis using non‐invasive studies. The first patient refused treatment and died of myocardial infarction 6 months after visiting our clinic. The second received interferon‐beta and methotrexate with a favorable outcome after 3 years. Since the possible similar presentation of the two conditions could appear indistinct for certain diagnosis, accurate evaluation of symptoms and paraclinical data can provide the best approach to each condition.
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Affiliation(s)
- Masoud Etemadifar
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Armin Mehri
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Nahad Sedaghat
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Mehri Salari
- Functional Neurosurgery Research Center Shohada Tajrish Comprehensive Neurosurgical Center of Excellence Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Parsa Tavassoli Naini
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
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Distinguishing CNS neurosarcoidosis from multiple sclerosis and an approach to “overlap” cases. J Neuroimmunol 2022; 369:577904. [DOI: 10.1016/j.jneuroim.2022.577904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022]
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Cicia A, Nociti V, Bianco A, De Fino C, Carlomagno V, Mirabella M, Lucchini M. Neurosarcoidosis presenting as longitudinally extensive myelitis: Diagnostic assessment, differential diagnosis, and therapeutic approach. Transl Neurosci 2022; 13:191-197. [PMID: 35959214 PMCID: PMC9328025 DOI: 10.1515/tnsci-2022-0231] [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: 03/30/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Neurosarcoidosis is an uncommon and multiform clinical entity. Its presentation as an isolated longitudinal extensive transverse myelitis (LETM) is rare and challenging to identify. We report a case of LETM in a 60-year-old patient with no significant systemic symptoms nor relevant medical history. The peculiar spinal magnetic resonance imaging finding characterized by a posterior and central canal subpial contrast enhancement, the so-called “trident sign,” together with chest computed tomography scan and lymph node biopsy led to the diagnosis of sarcoidosis. We also discuss the main differential diagnoses of LETM and therapeutic options for sarcoidosis-related myelitis.
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Affiliation(s)
- Alessandra Cicia
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Viviana Nociti
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Assunta Bianco
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Chiara De Fino
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
| | - Vincenzo Carlomagno
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Matteo Lucchini
- Fondazione Policlinico Universitario Agostino Gemellli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Neurologia, Centro di Ricerca per la Sclerosi Multipla (CERSM), Largo Agostino Gemelli 8, 00168, Rome, Italy
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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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Byg KE, Illes Z, Sejbaek T, Nguyen N, Möller S, Lambertsen KL, Nielsen HH, Ellingsen T. A prospective, one-year follow-up study of patients newly diagnosed with neurosarcoidosis. J Neuroimmunol 2022; 369:577913. [PMID: 35717739 DOI: 10.1016/j.jneuroim.2022.577913] [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] [Received: 11/11/2021] [Revised: 02/07/2022] [Accepted: 06/06/2022] [Indexed: 10/18/2022]
Abstract
METHODS Twenty patients with newly diagnosed neurosarcoidosis were examined for multiple outcomes in an observational cohort study with 12-month follow-up. RESULTS The patients' contrast-enhancing lesions on MRI scans reduced during treatment (p < 0.0001). The mean modified Rankin Score improved from 3.0 to 1.8 (p < 0.0001), and 75% of patients experienced clinically important improvement. Patients improved on the Symbol Digit Modalities Test (p < 0.0001) and on SF-36 Physical (p = 0.003) and Mental Component Summary scores (p = 0.03). Proportions of patients with substantial fatigue (75%) and high depression score (35%) were unchanged. CONCLUSIONS 12-month immunosuppression improved several outcomes, and 75% of patients experienced clinically important improvement.
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Affiliation(s)
- Keld-Erik Byg
- Rheumatology Research Unit, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark; Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark; BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark.
| | - Zsolt Illes
- Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark; BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, 5000 Odense, Denmark
| | - Tobias Sejbaek
- BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Department of Neurology, South West Jutland University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark; Department of Regional Health Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark
| | - Nina Nguyen
- Department of Radiology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Open Patient data Explorative Network, Odense University Hospital, J.B. Winsloewsvej 9a, 5000 Odense, Denmark
| | - Kate L Lambertsen
- BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, 5000 Odense, Denmark
| | - Helle H Nielsen
- Department of Neurology, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark; BRIDGE-Brain Research-Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark; Department of Neurobiology Research, Institute of Molecular Medicine, University of Southern Denmark, J.B. Winsloewsvej 21, 5000 Odense, Denmark
| | - Torkell Ellingsen
- Rheumatology Research Unit, Odense University Hospital, J.B. Winsloewsvej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsloewsvej 19, 5000 Odense, Denmark
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Bilateral Facial Palsy as the Onset of Neurosarcoidosis: A Case Report and a Revision of Literature. NEUROSCI 2022. [DOI: 10.3390/neurosci3020023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Unilateral facial nerve palsy (FNP) is one of the most common cranial mononeuropathies. Among rare etiologies, neurosarcoidosis (NS) can cause bilateral involvement (both recurring and simultaneous) only in 15% to 25% of cases. The rarity of this systemic disease and its clinical heterogeneity, due to granulomatous inflammation that may affect many anatomic substrates, frequently make the diagnosis a real challenge for the clinician. Based on laboratory and instrumental tests, a careful diagnostic algorithm must be adopted to avoid misdiagnosis and delay in treatment. We present a 52-year-old woman with an acute onset of unilateral right FNP, rapidly developing contralateral involvement (simultaneous bilateral FNP). Lung findings pointed towards a systemic disease, and then lymph node biopsy confirmed NS. Corticosteroid therapy was started. After three years of follow-up, the patient is still in remission with a low prednisone dose. We discuss the differential diagnosis of bilateral FNP, focusing on clinical presentation, diagnosis, and treatment of NS. We have performed a literature revision, confirming bilateral FNP, outside Heerfordt syndrome, to be rare and sometimes represent the only neurological manifestation of NS onset.
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Nwebube CO, Bou GA, Castilho AJ, Hutto SK. Facial nerve palsy in neurosarcoidosis: clinical course, neuroinflammatory accompaniments, ancillary investigations, and response to treatment. J Neurol 2022; 269:5328-5336. [PMID: 35583659 DOI: 10.1007/s00415-022-11189-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Facial nerve palsy is a cardinal manifestation of neurosarcoidosis, but dedicated studies of this disease feature have not been conducted. We sought to clarify the impact of facial palsy on the diagnosis of neurosarcoidosis, its subsequent clinicoradiographic evolution, and eventual treatment decisions. METHODS A single-center retrospective analysis of patients with neurosarcoidosis and facial palsy was conducted over the preceding 10 years (01/01/2011-08/12/2021). RESULTS 23/218 (10.6%) patients with neurosarcoidosis developed facial neuropathy. It was the inaugural manifestation of neurosarcoidosis in 17/23 (73.9%) and presented in isolation of other neurologic deficits or extra-facial MRI abnormalities in 12/23 (52.2%). At onset, facial palsy was unilateral in 20/23 (87.0%), and multiple cranial neuropathies were seen in 8/23 (34.8%). Non-facial inflammatory MRI abnormalities were observed in 6/15 (40.0%) patients at onset with leptomeningitis being most common (5/15, 33.3%). 13/23 (56.5%) experienced a second attack of neurosarcoidosis at a median of 8 months, including 3/23 (13.0%) with recurrent facial palsies. In the 12 patients with isolated facial paresis at onset, 4/12 (33.3%) remained free of new deficits or neuroimaging abnormalities by last follow-up. 17/23 (73.9%) eventually required initiation of steroid-sparing immunosuppressants, almost all for development of non-facial disease. The final median House-Brackmann score was 1. CONCLUSION Facial neuropathy occurred less commonly than historically reported, and it often acts as a forerunner to systemic sarcoidosis and more widespread neurologic disease. Recurrent attacks of neurosarcoidosis occur early at high frequency following facial palsy. Recovery of facial nerve function is typically excellent.
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Affiliation(s)
- Chineze O Nwebube
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Gabriela A Bou
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Alexander J Castilho
- Division of Neuroradiology, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA.
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Spinal cord sarcoidosis in Japan: utility of cerebrospinal fluid examination and nerve conduction study for diagnosis and prognosis prediction. J Neurol 2022; 269:4783-4790. [DOI: 10.1007/s00415-022-11113-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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Takahashi Y, Kameda H, Miya A, Nomoto H, Cho KY, Nakamura A, Nishimura H, Kimura H, Suzuki M, Konno S, Shimizu A, Matsuno Y, Okamoto M, Motegi H, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Miyoshi H, Atsumi T. Lymphocytic panhypophysitis and anti-rabphilin-3A antibody with pulmonary sarcoidosis. Pituitary 2022; 25:321-327. [PMID: 35088194 DOI: 10.1007/s11102-021-01200-0] [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] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To explore the clinical significance of anti-rabphillin-3A antibody for the differential diagnosis of lymphocytic panhypophysitis. METHODS AND RESULTS A 58-year-old Japanese man developed uveitis of unknown cause in 2017. In 2019, he became aware of polyuria. In August 2020, he noticed transient diplopia and was diagnosed with right abducens nerve palsy. At the same time, he complained of fatigue and loss of appetite. Head magnetic resonance imaging demonstrated enlargement of the pituitary stalk and pituitary gland, corresponding to hypophysitis. Hormone stimulation tests showed blunted responses with respect to all anterior pituitary hormones. Central diabetes insipidus was diagnosed on the basis of a hypertonic saline loading test. Taking these findings together, a diagnosis of panhypopituitarism was made. Computed tomography showed enlargement of hilar lymph nodes. Biopsies of the hilar lymph nodes revealed non-caseating epithelioid cell granulomas that were consistent with sarcoidosis. Biopsy of the anterior pituitary revealed mild lymphocyte infiltration in the absence of IgG4-positive cells, non-caseating granulomas, or neoplasia. Western blotting revealed the presence of anti-rabphilin-3A antibody, supporting a diagnosis of lymphocytic panhypophysitis. Because the patient had no visual impairment or severe uveitis, we continued physiological hormone replacement therapy and topical steroid therapy for the uveitis. CONCLUSION To the best of our knowledge, this is the first case of anti-rabphilin 3A antibody positive lymphocytic panhypophysitis comorbid with sarcoidosis, diagnosed by both pituitary and hilar lymph node biopsy. The utility of anti-rabphilin-3A antibody for the differential diagnosis of hypophysitis like this case should be clarified with further case studies.
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Affiliation(s)
- Yuka Takahashi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Aika Miya
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroki Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ai Shimizu
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Michinari Okamoto
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Iwata
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
- Department of Endocrinology and Diabetes, Daido Hospital, Nagoya, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Hideaki Miyoshi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
- Division of Diabetes and Obesity, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
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Yates WB, McCluskey PJ, Fraser CL. Neuro-ophthalmological manifestations of sarcoidosis. J Neuroimmunol 2022; 367:577851. [DOI: 10.1016/j.jneuroim.2022.577851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
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Sève P, Jamilloux Y, Bert A, El Jammal T, Valeyre D. Qu’apportent les nouvelles recommandations sur le diagnostic et le traitement de la sarcoïdose ? Rev Med Interne 2022; 43:199-205. [DOI: 10.1016/j.revmed.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022]
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Bernier R, Gavoille A, Chirpaz N, Jamilloux Y, Kodjikian L, Mathis T, Sève P. Diagnostic value of lumbar puncture for the etiological assessment of uveitis: a retrospective cohort of 188 patients. Graefes Arch Clin Exp Ophthalmol 2022; 260:1651-1662. [PMID: 34988612 DOI: 10.1007/s00417-021-05514-4] [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: 08/14/2021] [Revised: 11/19/2021] [Accepted: 11/24/2021] [Indexed: 11/28/2022] Open
Abstract
AIM To assess the relevance of lumbar puncture (LP) for the etiological diagnosis of uveitis and to establish predictive factors associated with its contributory use. METHODS We performed a retrospective study of patients with de novo uveitis who were referred to our tertiary hospital for etiological diagnosis of uveitis, between January 2003 and July 2018. We included patients who underwent a LP as part of the etiological assessment of uveitis. LP was considered as contributory if it led to the etiological diagnosis or to correct the initially suspected diagnosis. RESULTS One hundred eighty eight of the 1211 patients referred for evaluation (16%) had an LP, among these patients, 93 (49.4%) had abnormal results including 69 (36.7%) patients with hypercellularity, 69 (36.7%) with hyperproteinorachia, and 28 (14.9%) with oligoclonal bands and/or increased IgG index. LP was considered as contributing to the diagnosis in only 31 (16.4%) cases, among which there were 10 (5.3%) contributions to the etiological diagnosis and 21 (11.2%) modifications in the diagnosis classification. Multivariate analysis established that African ethnicity (p < 0.001), bilateral uveitis (p = 0.01), presence of macular edema or retinal serous detachment (p = 0.048), presence of retinal vasculitis (p < 0.001), presence of neurological signs or symptoms (p = 0.01), and contributing cerebral MRI (p < 0.001) were all significantly associated with a contributory LP. LP did not lead to any therapeutic modification. CONCLUSION LP direct contribution to the diagnosis was rare and most often detected non-specific abnormalities. LP should be performed only in cases of neurological clinical signs or symptoms, suspicion of multiple sclerosis, Vogt-Koyanagi-Harada, or syphilis.
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Affiliation(s)
- R Bernier
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, F-69004, Lyon, France.,Department of Ophthalmology, Croix-Rousse Teaching Hospital, Hospices Civils de Lyon, , Lyon, France
| | - A Gavoille
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, F-69004, Lyon, France
| | - N Chirpaz
- Department of Ophthalmology, Croix-Rousse Teaching Hospital, Hospices Civils de Lyon, , Lyon, France
| | - Y Jamilloux
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, F-69004, Lyon, France
| | - L Kodjikian
- Department of Ophthalmology, Croix-Rousse Teaching Hospital, Hospices Civils de Lyon, , Lyon, France.,UMR-CNRS 5510 Matéis, Villeurbanne, Université Claude Bernard Lyon 1, Universités de Lyon, Lyon, France
| | - T Mathis
- Department of Ophthalmology, Croix-Rousse Teaching Hospital, Hospices Civils de Lyon, , Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 grande rue de la Croix-Rousse, F-69004, Lyon, France. .,Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.
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Moszczyńska E, Kunecka K, Baszyńska-Wilk M, Perek-Polnik M, Majak D, Grajkowska `W. Pituitary Stalk Thickening: Causes and Consequences. The Children's Memorial Health Institute Experience and Literature Review. Front Endocrinol (Lausanne) 2022; 13:868558. [PMID: 35669693 PMCID: PMC9163297 DOI: 10.3389/fendo.2022.868558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pituitary stalk thickening (PST) is a rare abnormality in the pediatric population. Its etiology is heterogeneous. The aim of the study was to identify important clinical, radiological and endocrinological manifestations of patients with PST and follow the course of the disease. MATERIALS AND METHODS It is a study conducted in 23 patients (13 boys) with PST with/without central diabetes insipidus (CDI) diagnosed between 1990 and 2020 at Children's Memorial Health Institute (CMHI) in Warsaw, Poland. We analyzed demographic data, clinical signs and symptoms, radiological findings, tumor markers, hormonal results, treatment protocols and outcomes. RESULTS The median age at the diagnosis of PST was 9.68 years (IQR: 7.21-12.33). The median time from the onset of the symptoms to the diagnosis was 2.17 years (IQR: 1.12-3.54). The most common initially reported manifestations were polydipsia, polyuria and nocturia (82.6%); most of the patients (56.5%) also presented decreased growth velocity. Hormonal evaluation at the onset of PST revealed: CDI (91.3%), growth hormone deficiency (GHD) (56.5%), hyperprolactinemia (39%), central hypothyroidism (34.8%), adrenal insufficiency (9%), precocious puberty (8.7%). The majority of the patients were diagnosed with germinoma (seventeen patients - 73.9%, one of them with teratoma and germinoma). Langerhans cell histiocytosis (LCH) was identified in three patients (multisystem LCH in two patients, and unifocal LCH in one patient). A single case of atypical teratoid rhabdoid tumor, suspected low-grade glioma (LGG) and lymphocytic infundibuloneurohypophysitis (LINH). The overall survival rate during the observational period was 87.0%. CONCLUSIONS The pituitary infundibulum presents a diagnostic imaging challenge because of its small size and protean spectrum of disease processes. Germinoma should be suspected in all children with PST, especially with CDI, even when neurological and ophthalmological symptoms are absent.
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Affiliation(s)
- Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Karolina Kunecka
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marta Baszyńska-Wilk
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
- *Correspondence: Marta Baszyńska-Wilk,
| | - Marta Perek-Polnik
- Department of Oncology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Majak
- Department of Diagnostic Imaging, The Children’s Memorial Health Institute, Warsaw, Poland
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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Mehta A, Khan F, Wagner C, Hashemzadeh T, Stemer A, Sloan EA, Mayson D, Amjad F. A Case of Neurosarcoid Presenting as Multiple Intraparenchymal Hemorrhages. Neurohospitalist 2022; 12:162-166. [PMID: 34950407 PMCID: PMC8689526 DOI: 10.1177/19418744211029495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
This report explores the case of a 49-year-old African American male with a six-month history of multifocal neurological deficits who presented to an outside hospital after a generalized seizure. Patient was transferred to our tertiary medical center after brain imaging showed multiple bilateral supratentorial intraparenchymal hemorrhages (IPH). A brain biopsy confirmed parenchymal and perivascular non-caseating granulomas with vasculitis. The patient was definitively diagnosed with neurosarcoidosis (NS) and his condition improved with high dose corticosteroids and additional immunosuppressive therapies. Intracranial hemorrhage in the setting of NS is extremely rare, with fewer than thirty documented cases; however, this is likely an underestimation of its true prevalence. This case illustrates the difficulty in diagnosis as many other etiologies of IPH must be considered. Additionally, the clinical course and manifestations of NS is often quite variable. The uniqueness of this case lies in the rapid progression from seemingly incidental microhemorrhages to multiple large IPHs over two months. While the cause of this progression is not immediately apparent, a possible cause may be inadequate initial treatment due to delayed diagnosis. Our case demonstrates the importance of early recognition and initiation of immunosuppressive therapy, potentially leading to dramatic clinical improvement, as seen in this patient.
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Affiliation(s)
- Amit Mehta
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA,Amit Mehta, Department of Neurology, MedStar Georgetown University Hospital, Washington, DC 20007, USA.
| | - Fahad Khan
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chris Wagner
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Taymour Hashemzadeh
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Andrew Stemer
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Emily A Sloan
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA,Department of Pathology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Douglas Mayson
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faria Amjad
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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Chiou CA, Liou VD, Lee NG. Bilateral Panuveitis and Myeloradiculopathy in a 12-Year-Old Girl. JAMA Ophthalmol 2021; 140:203-204. [PMID: 34940793 DOI: 10.1001/jamaophthalmol.2021.3076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Victor D Liou
- Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Boston
| | - Nahyoung G Lee
- Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Boston
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Ray BK, Thakur RK, Shah AK, Adhikari B, Mandal DK, Pandey R. Neurosarcoidosis Presenting as Young-Onset Chronic Headache: A Case Report. Case Rep Neurol 2021; 13:687-692. [PMID: 34899253 PMCID: PMC8613588 DOI: 10.1159/000519771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/20/2021] [Indexed: 11/19/2022] Open
Abstract
Sarcoidosis causes granulomatous inflammation in multiple organ systems. Lungs are the most commonly affected organs. In 50% of the cases with lung involvement, other organs are also involved. The central nervous system is one of the rarer organ systems involved - comprising 5-15% of all the cases. Neurological involvement, when present, can affect virtually every part of the central and peripheral nervous system. We present an interesting case of a 30-year-old nonalcoholic, nonsmoker man who presented with a chronic headache of 6 years. He had a recent swaying of the body for 6 months and mild forgetfulness for 4 months. The patient had 2 episodes of facial nerve palsy in the past - which had responded to the treatment of Bell's palsy; however, the patient had some residual findings on presentation. While CSF findings suggested meningeal tuberculosis, the radiological evidence and biopsy confirmed the diagnosis of neurosarcoidosis. On follow-up after 6 weeks of steroid therapy, the patient displayed a marked improvement in headache, cognitive function, and a good response on imaging studies. Our case emphasizes that neurosarcoidosis should be considered in the differential diagnosis of chronic headaches and recurrent facial nerve palsy despite being very rare.
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Affiliation(s)
- Barun Kumar Ray
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rahul Kumar Thakur
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Anish Kumar Shah
- Department of Internal Medicine, Bronxcare Hospital, New York, New York, USA
| | - Biplov Adhikari
- Department of Internal Medicine, Medstar Union Memorial Hospital, Baltimore, Maryland, USA
| | | | - Ranjit Pandey
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Vertebral sarcoidosis with associated Darier-Roussy disease manifesting as acute back pain. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Multiple Cranial Neuropathies and Pachymeningitis in a Patient With a Pathogenic Nucleotide-Binding Oligomerization Domain 2 Polymorphism. J Neuroophthalmol 2021; 41:547-552. [PMID: 34788239 DOI: 10.1097/wno.0000000000001342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT An 11-year-old boy presented with 2 weeks of intermittent headache, right orbital pain, and constant diplopia. Brain MRI showed dural thickening and enhancement of the right lateral cavernous sinus, right orbital apex, and tentorium. Initial cerebral spinal fluid analysis showed only mild pleocytosis, and serum diagnostics were unrevealing. The working diagnosis was Tolosa-Hunt syndrome. His pain and sixth nerve palsy resolved with corticosteroids. Five months after initial presentation, he developed new numbness of the right cheek, complete right ophthalmoplegia, and weakness and numbness of his right hand and leg, all of which were responsive to steroids. Fifteen months later, he returned to the emergency department with 2 weeks of left-sided headaches and acute diplopia. On examination, he had a left cranial nerve 6 palsy. Dural biopsy showed diffuse mononuclear inflammatory cell reaction consisting mostly of lymphocytes with no signs of granuloma formation, nor any epithelioid or giant cells. His clinical course was consistent with an autoinflammatory condition of unknown etiology. Genetic testing with an immunodeficiency panel showed a risk allele in NOD2 (nucleotide-binding oligomerization domain 2) c.3019dup (p.Leu1007Prof*2) that is associated with an increased risk for Crohn disease. His clinical condition had similarities to central nervous system sarcoidosis. Because of the similarities between our patient's clinical, imaging, and genetic findings and neurosarcoidosis, he was switched to a more targeted therapy-infliximab. His condition has since been stable for nearly 2 years. In conclusion, genetic testing should be considered in patients with suspected occult autoimmunity.
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Lundkvist A, Kullberg S, Arkema EV, Cedelund K, Eklund A, Grunewald J, Darlington P. Differences in disease presentation between men and women with sarcoidosis: A cohort study. Respir Med 2021; 191:106688. [PMID: 34839065 DOI: 10.1016/j.rmed.2021.106688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/19/2021] [Accepted: 11/21/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sarcoidosis is an elusive disease due to its heterogeneity. It is well recognized that the clinical picture is dependent on ethnicity, organ involvement and age. However, data on the role of sex is inconsistent. We aimed to study the gender-related differences in disease presentation in Swedish patients with sarcoidosis. SUBJECTS AND METHODS Clinical data was collected between 1996 and 2020, yielding a register with 1429 cases with sarcoidosis in a pulmonary clinic. The diagnosis was met according to WASOG criteria. Data on age, radiologic stage at the time of disease onset, and potential extra-pulmonary manifestations, was retrieved. Differences between men and women were analyzed with Fisher's Exact Test and t-test where appropriate. RESULTS In the register there were 61% men and they were approximately three years younger than the women at the time of diagnosis. Men presented with a more advanced radiographic stage on chest imaging compared to women, radiographic stage II (46% vs 36%, p < 0.001), while women compared to men more often had stage 0-I disease on pulmonary x-rays (6% vs 2%, p < 0.001 for stage 0 and 46% vs 38%, p < 0.01 for stage I). Women had more cutaneous involvement (13% vs 8%, p < 0.01) and more often involvement of salivary glands (3% vs 1%, p < 0.05). CONCLUSIONS In this cohort with sarcoidosis patients, there was a predominance of men. They presented with more severe disease at a younger age, while women more often were found to have involvement of the skin and salivary glands.
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Affiliation(s)
- Amanda Lundkvist
- Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Kullberg
- Department of Respiratory Medicine, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden; Respiratory Medicine Division, Department of Medicine, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth V Arkema
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kerstin Cedelund
- Department of Clinical Science, Intervention and Technology, Division of Medical Imaging and Technology at Karolinska Institutet, Stockholm, Sweden
| | - Anders Eklund
- Respiratory Medicine Division, Department of Medicine, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Johan Grunewald
- Department of Respiratory Medicine, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden; Respiratory Medicine Division, Department of Medicine, Center for Molecular Medicine (CMM), Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Darlington
- Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
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Seifelnasr M, Theodorsson M, Hart J, O'Sullivan E. Rare presentation of sarcoidosis with optic neuropathy and third nerve palsy. BMJ Case Rep 2021; 14:e246024. [PMID: 34764122 PMCID: PMC8587621 DOI: 10.1136/bcr-2021-246024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/04/2022] Open
Abstract
Sarcoidosis is a systemic, idiopathic and granulomatous disease, which most commonly affects the skin, lungs and lymph nodes but can affect virtually any organ. Neurosarcoidosis can be the presenting or the only clinical manifestation accounting for 5%-15% of sarcoid diagnoses. In contrast to uveitis which is the most common ophthalmic manifestation, neuro-ophthalmic signs are uncommon in sarcoidosis. Optic neuropathy is the most common neuro-ophthalmic sign (70% in one series). Sarcoid-related optic neuropathy commonly presents with a picture similar to optic neuritis. Less commonly, optic nerve involvement occurs secondary to compressive lesions, or from direct granulomatous infiltration. Neuroimaging is crucial to identify the location of the lesion. We describe a case of sarcoid-related compressive optic neuropathy and third nerve palsy and highlight the challenging nature of neurosarcoidosis in a patient without a prior diagnosis of the disease.
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Affiliation(s)
- Mohamed Seifelnasr
- Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK
- Ophthalmology, Alexandria University, Alexandria, Egypt
| | | | - Jonathan Hart
- Radiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Eoin O'Sullivan
- Ophthalmology, King's College Hospital NHS Foundation Trust, London, UK
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