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Vilayet S, Hayes E, Barakat M, Budisavljevic M, Achanti A. Therapeutic Plasma Exchange for Treatment-Resistant Tumefactive Demyelinating Lesion: A Case Report. Cureus 2024; 16:e53786. [PMID: 38465038 PMCID: PMC10923607 DOI: 10.7759/cureus.53786] [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: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Tumefactive demyelinating lesions (TDLs) can present as an isolated clinical incidence or could represent the initial presentation of multiple sclerosis. Radiological TDLs are characterized by large tumors like >2 cm space-occupying lesions with mass effect and perilesional edema. Diagnosis is based on MRI imaging and extensive work to exclude other causes and a biopsy of the lesion is often required. First-line treatments include pulsed methylprednisolone. We present a case of a refractory TDL treated successfully with therapeutic plasma exchange.
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Affiliation(s)
- Salem Vilayet
- Division of Nephrology, Medical University of South Carolina, Charleston, USA
| | - Eily Hayes
- Division of Nephrology, Medical University of South Carolina, Charleston, USA
| | - Munsef Barakat
- Division of Nephrology, Medical University of South Carolina, Charleston, USA
| | - Milos Budisavljevic
- Division of Nephrology, Medical University of South Carolina, Charleston, USA
| | - Anand Achanti
- Division of Nephrology, Medical University of South Carolina, Charleston, USA
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Vakrakou AG, Brinia ME, Alexaki A, Koumasopoulos E, Stathopoulos P, Evangelopoulos ME, Stefanis L, Stadelmann-Nessler C, Kilidireas C. Multiple faces of multiple sclerosis in the era of highly efficient treatment modalities: Lymphopenia and switching treatment options challenges daily practice. Int Immunopharmacol 2023; 125:111192. [PMID: 37951198 DOI: 10.1016/j.intimp.2023.111192] [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: 09/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 11/13/2023]
Abstract
The expanded treatment landscape in relapsing-remitting multiple sclerosis (MS) has resulted in highly effective treatment options and complexity in managing disease- or drug-related events during disease progression. Proper decision-making requires thorough knowledge of the immunobiology of MS itself and an understanding of the main principles behind the mechanisms that lead to secondary autoimmunity affecting organs other than the central nervous system as well as opportunistic infections. The immune system is highly adapted to both environmental and disease-modifying agents. Immune reconstitution following cell depletion or cell entrapment therapies eliminates pathogenic aspects of the disease but can also lead to distorted immune responses with harmful effects. Atypical relapses occur with second-line treatments or after their discontinuation and require appropriate clinical decisions. Lymphopenia is a result of the mechanism of action of many drugs used to treat MS. However, persistent lymphopenia and cell-specific lymphopenia could result in disease exacerbation, secondary autoimmunity, or the emergence of opportunistic infections. Clinicians treating patients with MS should be aware of the multiple faces of MS under novel, efficient treatment modalities and understand the intricate brain-immune cell interactions in the context of an altered immune system. MS relapses and disease progression still occur despite the current treatment modalities and are mediated either by failure to control effector mechanisms inherent to MS pathophysiology or by new drug-related mechanisms. The multiple faces of MS due to the highly adapted immune system of patients impose the need for appropriate switching therapies that safeguard disease remission and further clinical improvement.
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Affiliation(s)
- Aigli G Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neuropathology, University of Göttingen Medical Center, Göttingen, Germany.
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Alexaki
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Koumasopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Eleftheria Evangelopoulos
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aiginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
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Chew SH, Achmad Sankala HB, Chew E, Md Arif MHB, Mohd Zain NR, Hashim H, Koya Kutty SB, Chee YC, Mohd Saleh NB, Ong BH, Viswanathan S. Tumefactive demyelinating lesions versus CNS neoplasms, a comparative study. Mult Scler Relat Disord 2023; 79:104992. [PMID: 37717306 DOI: 10.1016/j.msard.2023.104992] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/25/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Differentiating tumefactive demyelinating lesions (TDL) from neoplasms of the central nervous system continues to be a diagnostic dilemma in many cases. OBJECTIVE Our study aimed to examine and contrast the clinical and radiological characteristics of TDL, high-grade gliomas (HGG) and primary CNS lymphoma (CNSL). METHOD This was a retrospective review of 66 patients (23 TDL, 31 HGG and 12 CNSL). Clinical and laboratory data were obtained. MRI brain at presentation were analyzed by two independent, blinded neuroradiologists. RESULTS Patients with TDLs were younger and predominantly female. Sensorimotor deficits and ataxia were more common amongst TDL whereas headaches and altered mental status were associated with HGG and CNSL. Compared to HGG and CNSL, MRI characteristics supporting TDL included relatively smaller size, lack of or mild mass effect, incomplete peripheral rim enhancement, absence of central enhancement or restricted diffusion, lack of cortical involvement, and presence of remote white matter lesions on the index scan. Paradoxically, some TDLs may present atypically or radiologically mimic CNS lymphomas. CONCLUSION Careful evaluation of clinical and radiological features helps in differentiating TDLs at first presentation from CNS neoplasms.
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Affiliation(s)
- Sin Hong Chew
- Department of Neurology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia.
| | | | - Elaine Chew
- Department of Neurology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | | | | | - Hilwati Hashim
- Department of Radiology, Faculty of Medicine, Universiti Teknologi Mara, Malaysia
| | | | - Yong Chuan Chee
- Department of Medicine (Neurology), School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | | | - Beng Hooi Ong
- Neurology Unit, Kedah Medical Centre, Alor Setar, Malaysia
| | - Shanthi Viswanathan
- Department of Neurology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
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Fereidan‐Esfahani M, Decker PA, Weigand SD, Lopez Chiriboga AS, Flanagan EP, Tillema J, Lucchinetti CF, Eckel‐Passow JE, Tobin WO. Defining the natural history of tumefactive demyelination: A retrospective cohort of 257 patients. Ann Clin Transl Neurol 2023; 10:1544-1555. [PMID: 37443413 PMCID: PMC10502639 DOI: 10.1002/acn3.51844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVE To describe demographic, clinical, and radiographic features of tumefactive demyelination (TD) and identify factors associated with severe attacks and poor outcomes. METHODS Retrospective review of TD cases seen at Mayo Clinic, 1990-2021. RESULTS Of 257 patients with TD, 183/257 (71%) fulfilled the 2017 multiple sclerosis (MS) McDonald criteria at the last follow-up, 12/257 (5%) had myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), 0 had aquaporin-4-IgG seropositive neuromyelitis optic spectrum disorders (AQP4+ NMOSD), and 62/257 (24%) were cryptogenic. Onset before age 18 was present in 18/257 (7%). Female to male ratio was 1.3:1. Cerebrospinal fluid oligoclonal (CSF) bands were present in 95/153 (62%). TD was the first demyelinating attack in 176/257 (69%). At presentation, 59/126 (47%) fulfilled Barkhof criteria for dissemination in space, 59/100 (59%) had apparent diffusion coefficient (ADC) restriction, and 57/126 (45%) had mass effect. Despite aggressive clinical presentation at onset, 181/257 (70%) of patients remained fully ambulatory (Expanded Disability Status Scale [EDSS] ≤4) after a 3.0-year median follow-up duration. Severe initial attack-related disability (EDSS ≥4) was more common in patients with motor symptoms (81/143 vs. 35/106, p < 0.0001), encephalopathy (20/143 vs. 2/106, p < 0.0001) and ADC restriction on initial MRI (42/63 vs. 15/33, p = 0.04). Poor long-term outcome (EDSS ≥4) was more common in patients with older onset age (41.9 ± 15 vs. 36.8 ± 15.6, p = 0.02) and motor symptoms at onset (49/76 vs. 66/171, p < 0.0001). INTERPRETATION Most TD patients should be considered part of the MS spectrum after excluding MOGAD and NMOSD. Motor symptoms and older age at presentation portend a poor outcome.
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Affiliation(s)
- Mahboubeh Fereidan‐Esfahani
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
- Dell Medical SchoolUniversity of TexasAustinTexasUSA
| | - Paul A Decker
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Stephen D. Weigand
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | | | - Eoin P Flanagan
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
- Department of Laboratory Medicine and PathologyMinneapolisMinnesotaUSA
| | - Jan‐Mendelt Tillema
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Claudia F Lucchinetti
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
| | | | - W. Oliver Tobin
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Center for Multiple Sclerosis and Autoimmune NeurologyMayo ClinicRochesterMinnesotaUSA
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Shiraishi W, Umemura T, Nakayama Y, Yamada Y, Shijo M, Hashimoto T. Case Report: Paraneoplastic Tumefactive Demyelination Associated With Seminoma. Front Neurol 2022; 13:946180. [PMID: 35899265 PMCID: PMC9309514 DOI: 10.3389/fneur.2022.946180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Paraneoplastic tumefactive demyelination (TD) is a rare disorder of the central nervous system that can be challenging to diagnose. Here, we describe a 32-year-old Japanese man with a TD associated with testicular seminoma. He presented with symptoms of right-sided motor and sensory impairment 2 days after vaccination for coronavirus disease 2019 (COVID-19). Brain magnetic resonance imaging (MRI) showed a high-intensity lesion in the left internal capsule. He had a 3-year history of enlargement of the left testicle. Blood examination showed tumor marker elevation and the presence of anti-amphiphysin antibodies. Whole-body computed tomography (CT) revealed mass lesions in the left testicle and enlargement of the retroperitoneal lymph nodes. Radical orchiectomy was performed. As the pathology showed testicular seminoma, chemotherapy was administered. After surgery, his neurological symptoms deteriorated. MRI revealed that the brain lesion had enlarged and progressed to a tumefactive lesion without gadolinium enhancement. The cerebrospinal fluid (CSF) examination was normal without pleocytosis or protein elevation. Steroid pulse therapy was added; however, his symptoms did not improve. A brain stereotactic biopsy was performed and the sample showed demyelinating lesions without malignant cells. As the initial corticosteroid therapy was ineffective, gamma globulin therapy was administered in parallel with chemotherapy, and the clinical symptoms and imaging findings were partially ameliorated. TD seldom appears as a paraneoplastic neurological syndrome. In addition, there are few reports of COVID-19 vaccination-associated demyelinating disease. Clinicians should recognize paraneoplastic TD, and the further accumulation of similar cases is needed.
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Affiliation(s)
- Wataru Shiraishi
- Department of Neurology, Kokura Memorial Hospital, Kitakyushu, Japan
- Department of Internal Medicine, Shiraishi Internal Medicine Clinic, Nogata, Japan
- *Correspondence: Wataru Shiraishi
| | - Takeru Umemura
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yuuki Nakayama
- Department of Urology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yui Yamada
- Department of Pathology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masahiro Shijo
- Department of Internal Medicine, Fukuoka Dental College Medical and Dental Hospital, Fukuoka, Japan
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuya Hashimoto
- Department of Neurology, Kokura Memorial Hospital, Kitakyushu, Japan
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Vakrakou AG, Brinia ME, Svolaki I, Argyrakos T, Stefanis L, Kilidireas C. Immunopathology of Tumefactive Demyelinating Lesions-From Idiopathic to Drug-Related Cases. Front Neurol 2022; 13:868525. [PMID: 35418930 PMCID: PMC8997292 DOI: 10.3389/fneur.2022.868525] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Tumefactive demyelinating lesions (TDL) represent a diagnostic dilemma for clinicians, and in rare atypical cases a collaboration of a neuroradiologist, a neurologist, and a neuropathologist is warranted for accurate diagnosis. Recent advances in neuropathology have shown that TDL represent an umbrella under which many different diagnostic entities can be responsible. TDL can emerge not only as part of the spectrum of classic multiple sclerosis (MS) but also can represent an idiopathic monophasic disease, a relapsing disease with recurrent TDL, or could be part of the myelin oligodendrocyte glycoprotein (MOG)- and aquaporin-4 (AQP4)-associated disease. TDL can appear during the MS disease course, and increasingly cases arise showing an association with specific drug interventions. Although TDL share common features with classic MS lesions, they display some unique features, such as extensive and widespread demyelination, massive and intense parenchymal infiltration by macrophages along with lymphocytes (mainly T but also B cells), dystrophic changes in astrocytes, and the presence of Creutzfeldt cells. This article reviews the existent literature regarding the neuropathological findings of tumefactive demyelination in various disease processes to better facilitate the identification of disease signatures. Recent developments in immunopathology of central nervous system disease suggest that specific pathological immune features (type of demyelination, infiltrating cell type distribution, specific astrocyte pathology and complement deposition) can differentiate tumefactive lesions arising as part of MS, MOG-associated disease, and AQP4 antibody-positive neuromyelitis optica spectrum disorder. Lessons from immunopathology will help us not only stratify these lesions in disease entities but also to better organize treatment strategies. Improved advances in tissue biomarkers should pave the way for prompt and accurate diagnosis of TDL leading to better outcomes for patients.
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Affiliation(s)
- Aigli G. Vakrakou
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Evgenia Brinia
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Svolaki
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Leonidas Stefanis
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Demyelinating Diseases Unit, 1st Department of Neurology, School of Medicine, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Nicoletti T, Bianco A, Lucchini M, Gaudino S, Frisullo G, Mirabella M. Cyclophosphamide in highly aggressive Marburg-like multiple sclerosis. Ther Adv Neurol Disord 2021; 14:17562864211050028. [PMID: 34659455 DOI: 10.1177/17562864211050028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tommaso Nicoletti
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Assunta Bianco
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Matteo Lucchini
- Centro di ricerca per la sclerosi multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Gaudino
- UOC Radiodiagnostica e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia oncologica ed Ematologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Lgo. A. Gemelli 8, 00168 Rome, Italy
| | - Massimiliano Mirabella
- Centro di ricerca per la sclerosi multipla (CERSM), Università Cattolica del Sacro Cuore, Rome, Italy
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