1
|
Chang CK, Mohd Noh M, Liew Sat Lin C, Payus AO. Unusual Presentation of Cerebral Lupus: A Case Report of Parkinsonism in Cerebral Lupus. Case Rep Neurol 2021; 13:591-594. [PMID: 34703447 PMCID: PMC8460959 DOI: 10.1159/000518912] [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: 06/28/2021] [Accepted: 08/03/2021] [Indexed: 11/19/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with multisystem involvement that follows a relapsing and remitting course. It is characterized by an immune-mediated response to own body defense mechanism and mistakenly attacked healthy cells of the skin, joints, kidneys, blood cells, and nervous system. Cerebral lupus refers to a constellation of neurological and/or behavioral clinical syndromes in patients with SLE. The spectrum of presentation can vary widely ranging from mild symptoms such as headaches, slight cognitive dysfunction, and mood disorders to more serious conditions like seizures, stroke, or coma. This case report is about a case of cerebral lupus manifested with symptoms of Parkinsonism. The purpose of this case report is to share an uncommon occurrence of cerebral lupus which manifested as Parkinsonism and to highlight the importance of early diagnosis of the condition which is potentially reversibility with prompt treatment [4].
Collapse
Affiliation(s)
- Chee Keong Chang
- Faculty of Medicine and Health Science, Universiti Malaysia Sabah (UMS), Kota Kinabalu, Malaysia
| | - Malehah Mohd Noh
- Faculty of Medicine and Health Science, Universiti Malaysia Sabah (UMS), Kota Kinabalu, Malaysia
| | - Constance Liew Sat Lin
- Faculty of Medicine and Health Science, Universiti Malaysia Sabah (UMS), Kota Kinabalu, Malaysia
| | - Alvin Oliver Payus
- Faculty of Medicine and Health Science, Universiti Malaysia Sabah (UMS), Kota Kinabalu, Malaysia
| |
Collapse
|
2
|
Bologna M, Truong D, Jankovic J. The etiopathogenetic and pathophysiological spectrum of parkinsonism. J Neurol Sci 2021; 433:120012. [PMID: 34642022 DOI: 10.1016/j.jns.2021.120012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/05/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022]
Abstract
Parkinsonism is a syndrome characterized by bradykinesia, rigidity, and tremor. Parkinsonism is a common manifestation of Parkinson's disease and other neurodegenerative diseases referred to as atypical parkinsonism. However, a growing body of clinical and scientific evidence indicates that parkinsonism may be part of the phenomenological spectrum of various neurological conditions to a greater degree than expected by chance. These include neurodegenerative conditions not traditionally classified as movement disorders, e.g., dementia and motor neuron diseases. In addition, parkinsonism may characterize a wide range of central nervous system diseases, e.g., autoimmune diseases, infectious diseases, cerebrospinal fluid disorders (e.g., normal pressure hydrocephalus), cerebrovascular diseases, and other conditions. Several pathophysiological mechanisms have been identified in Parkinson's disease and atypical parkinsonism. Conversely, it is not entirely clear to what extent the same mechanisms and key brain areas are also involved in parkinsonism due to a broader etiopathogenetic spectrum. We aimed to provide a comprehensive and up-to-date overview of the various etiopathogenetic and pathophysiological mechanisms of parkinsonism in a wide spectrum of neurological conditions, with a particular focus on the role of the basal ganglia involvement. The paper also highlights potential implications in the diagnostic approach and therapeutic management of patients. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.
Collapse
Affiliation(s)
- Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Daniel Truong
- Truong Neuroscience Institute, Orange Coast Memorial Medical Center, Fountain Valley, CA, USA; Department of Neurosciences, UC Riverside, Riverside, CA, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
3
|
Movement disorders in systemic autoimmune diseases: Clinical spectrum, ancillary investigations, pathophysiological considerations. Parkinsonism Relat Disord 2021; 88:116-128. [PMID: 34092506 DOI: 10.1016/j.parkreldis.2021.05.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 02/08/2023]
Abstract
With the advances in neuroimmunology especially due to the discovery of new neuronal antibodies, the recognition of treatable antibody-related movement disorders has recently received much attention. In contrast, the identification and characterisation of movement disorders associated with systemic autoimmune diseases remains a substantially unexplored area. Beyond the classic few associations such as chorea and antiphospholipid syndrome, or ataxia and coeliac disease, movement disorders have been reported in association with several systemic autoimmune diseases, however a clear image of clinical phenotypes, investigations, and treatment outcomes in these conditions has never been drawn. In this review, we analyse data from approximately 300 cases and summarise the epidemiological, clinical and diagnostic features of movement disorders associated with systemic autoimmune diseases, and the available knowledge about treatment and outcomes. We highlight that movement disorders in systemic autoimmune conditions are frequently the only or among a few presenting manifestations and are mostly treatable disorders responding to immunotherapy or dietary modifications. We point out the pertinent combination of clinical features and investigations which can suggest the underlying autoimmune nature of these movement disorders, and thus address the most appropriate treatment.
Collapse
|
4
|
Wantaneeyawong C, Kasitanon N, Kumchana K, Louthrenoo W. Acute parkinsonism in patients with systemic lupus erythematosus: a case report and review of the literature. Int J Neurosci 2020; 132:868-873. [DOI: 10.1080/00207454.2020.1847106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Chayasak Wantaneeyawong
- The Northern Neuroscience Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nuntana Kasitanon
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kullanit Kumchana
- Department of Internal Medicine, Division of Neurology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Sawanpracharak Hospital, Nakhonsawan, Thailand
| | - Worawit Louthrenoo
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
5
|
Tsubouchi S, Hayashi H, Tahara K, Ishii K, Yasuda T, Yamamoto Y, Mizuuchi T, Mori H, Tago M, Kato E, Sawada T. Clinical presentation of a neuropsychiatric lupus patient with symmetrical basal ganglia lesions containing cytotoxic oedema cores surrounded by vasogenic oedema. Mod Rheumatol Case Rep 2020; 4:39-46. [PMID: 33086978 DOI: 10.1080/24725625.2019.1651955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neuropsychiatric (NP) manifestations of systemic lupus erythematosus (SLE) are diverse, but involvement of basal ganglia is rare. We describe here a 28-year-old woman with NPSLE presenting aseptic meningitis accompanied by elevated interleukin-6 levels in the cerebrospinal fluid, who developed symmetrical basal ganglia lesions, containing a cytotoxic oedematous core, surrounded by vasogenic oedema upon magnetic resonance imaging. We were able to observe these lesions from a de novo appearance during the disease onset to its disappearance during immunosuppressive treatment. Reversibility upon immunosuppressive treatment indicated that autoimmune mediated mechanisms could contribute to the basal ganglia lesions in NPSLE.
Collapse
Affiliation(s)
- Syoko Tsubouchi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Haeru Hayashi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Koichiro Tahara
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kayo Ishii
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takuya Yasuda
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yusuke Yamamoto
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takahiro Mizuuchi
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hiroaki Mori
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Mayu Tago
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Eri Kato
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| |
Collapse
|
6
|
Moraes de Moraes MP, Salomão RPA, Felício AC, Abrantes FF, Barsottini OGP, Pedroso JL. Reversible Acute Parkinsonism and Unusual Neuroimaging Findings in Systemic Lupus Erythematosus. Mov Disord Clin Pract 2020; 7:459-461. [PMID: 32373665 DOI: 10.1002/mdc3.12943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 12/16/2022] Open
Abstract
https://onlinelibrary.wiley.com/page/journal/23301619/homepage/mdc312943-sup-v001.htm.
Collapse
Affiliation(s)
- Marianna P Moraes de Moraes
- Department of Neurology, Division of General Neurology Universidade Federal de São Paulo São Paulo SP Brazil
| | - Rubens P A Salomão
- Department of Neurology, Division of General Neurology Universidade Federal de São Paulo São Paulo SP Brazil
| | | | - Fabiano F Abrantes
- Department of Neurology, Division of General Neurology Universidade Federal de São Paulo São Paulo SP Brazil
| | - Orlando G P Barsottini
- Department of Neurology, Division of General Neurology Universidade Federal de São Paulo São Paulo SP Brazil
| | - José L Pedroso
- Department of Neurology, Division of General Neurology Universidade Federal de São Paulo São Paulo SP Brazil
| |
Collapse
|
7
|
Barba C, Alexopoulos H. Parkinsonism in autoimmune diseases. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:419-452. [DOI: 10.1016/bs.irn.2019.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
8
|
Lapin WB, Lyons-Warren AM, Risen SR, Rathore N, Slone JS, Elghetany MT, Marcus M. A 14-Year-Old Boy With Fevers, Cytopenias, and Neurocognitive Decline. Pediatrics 2018; 142:peds.2017-3258. [PMID: 30072574 DOI: 10.1542/peds.2017-3258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/24/2022] Open
Abstract
A 14-year-old boy presented to our institution with a 1-month history of neurocognitive decline and intermittent fevers. His history was significant for fevers, headaches, and a 10-lb weight loss. Previous examinations by multiple medical providers were significant only for bilateral cervical lymphadenopathy. Previous laboratory workup revealed leukopenia, neutropenia, and elevated inflammatory markers. Despite improvement in his laboratory values after his initial presentation, his fevers persisted, and he developed slowed and "jerky" movements, increased sleep, slurred speech, delusions, visual hallucinations, and deterioration in his school performance. A brain MRI performed at an outside hospital before admission at our institution was concerning for patchy, increased T2 and fluid-attenuated inversion recovery signal intensity in multiple areas, including the basal ganglia. After transfer to our institution and admission to the pediatric hospital medicine team, the patient had an acute decompensation. Our subspecialists will discuss the initial evaluation, workup, differential diagnosis, definitive diagnosis, and subsequent management of this patient.
Collapse
Affiliation(s)
| | | | | | - Nisha Rathore
- Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Jeremy S Slone
- Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - M Tarek Elghetany
- Departments of Pathology and Immunology, and.,Pediatrics, Baylor College of Medicine, Houston, Texas
| | | |
Collapse
|
9
|
Romba M, Wang Y, Hu SC, Khot S. Jaw Dystonia and Reversible Basal Ganglia Changes as an Initial Presentation of Systemic Lupus Erythematosus. Neurohospitalist 2017; 8:31-34. [PMID: 29276561 DOI: 10.1177/1941874417698323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Dystonia as a manifestation of neuropsychiatric lupus erythematosus (NPSLE) is uncommon. We report a 25-year-old woman who experienced progressive confusion, reduced speech, and difficulty opening her mouth approximately 2 weeks after development of a facial rash. Brain imaging showed bilateral, symmetric signal abnormalities within the basal ganglia and subcortical white matter. Despite treatment with high-dose steroids, she continued to have difficulty speaking with evidence of jaw dystonia on examination. Jaw dystonia rapidly improved with the initiation of levodopa. Repeat evaluation 3 months later exhibited the absence of jaw dystonia and near resolution of the imaging abnormalities. Our patient demonstrated a unique presentation with jaw dystonia refractory to traditional treatment for NPSLE. Such a presentation likely represents a severe variant of NPSLE requiring both immunosuppressive and symptomatic therapies.
Collapse
Affiliation(s)
- Meghan Romba
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Shu-Ching Hu
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Sandeep Khot
- Department of Neurology, University of Washington, Seattle, WA, USA
| |
Collapse
|
10
|
Benseler SM, Silverman ED. Review: Neuropsychiatric involvement in pediatric systemic lupus erythematosus. Lupus 2016; 16:564-71. [PMID: 17711889 DOI: 10.1177/0961203307078971] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuropsychiatric (NP) manifestations are found in approximately 25% of children and adolescents with pediatric SLE (pSLE). In 70% of those, NP involvement will occur within the first year from the time of diagnosis. Headaches (66%), psychosis (36%), cognitive dysfunction (27%) and cerebrovascular disease (24%) are the most common presentations. The support of a psychiatrist is often required. Anti-phospholipid antibodies are associated with distinct NP disease entities and may be implicated in the pathogenesis of several manifestations of NP-pSLE including chorea, cerebrovascular disease and seizures. The role of novel auto-antibodies and imaging modalities is currently explored. The treatment of NP-pSLE is not based on prospective studies; however, an immunosuppressive combination therapy consisting of high doses of prednisone and a second line agent such as cyclophosphamide or azathioprine is commonly suggested for children with NP-pSLE. The role of novel therapies is currently studied. The outcome of children with NP-pSLE is relatively good. The overall survival is 95—97%, 20% of children experience a disease flare during childhood and 25% have evidence of permanent neuropsychiatric damage. Lupus (2007) 16, 564—571.
Collapse
Affiliation(s)
- S M Benseler
- Divisions of Rheumatology, Department of Paediatrics and Immunology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | |
Collapse
|
11
|
Wu K, Christodoulou L, Siddiqui A, D'Cruz D, Andrews T. Bilateral reversible basal ganglia changes associated with dystonia and hemifacial spasms in central nervous system lupus. Quant Imaging Med Surg 2016; 5:928-9. [PMID: 26807375 DOI: 10.3978/j.issn.2223-4292.2015.03.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
We report a 40-year-old woman with systemic lupus erythematosus (SLE) and associated inflammatory polyarthritis who presented with acute facial dystonic spasms. Her speech was also affected. An MRI brain showed bilateral symmetrical basal ganglia signal change on T2. This movement disorder was due to an acute manifestation of her lupus. Her symptoms resolved rapidly following treatment with (oral) steroids. Repeat MRI brain at 1 month showed complete resolution of the basal ganglia signal change. This is the first time that facial spasms and dystonia with corresponding MRI changes are reported as a presentation of lupus affecting the central nervous system (CNS lupus).
Collapse
Affiliation(s)
- Kit Wu
- 1 Department of Neurology, Guy's & St Thomas' Hospitals NHS Trust, London, UK ; 2 Department of Paediatric Neurology, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK ; 3 Department of Neuroradiology, 4 Department of Rheumatology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| | - Loucas Christodoulou
- 1 Department of Neurology, Guy's & St Thomas' Hospitals NHS Trust, London, UK ; 2 Department of Paediatric Neurology, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK ; 3 Department of Neuroradiology, 4 Department of Rheumatology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| | - Ata Siddiqui
- 1 Department of Neurology, Guy's & St Thomas' Hospitals NHS Trust, London, UK ; 2 Department of Paediatric Neurology, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK ; 3 Department of Neuroradiology, 4 Department of Rheumatology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| | - David D'Cruz
- 1 Department of Neurology, Guy's & St Thomas' Hospitals NHS Trust, London, UK ; 2 Department of Paediatric Neurology, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK ; 3 Department of Neuroradiology, 4 Department of Rheumatology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| | - Thomasin Andrews
- 1 Department of Neurology, Guy's & St Thomas' Hospitals NHS Trust, London, UK ; 2 Department of Paediatric Neurology, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK ; 3 Department of Neuroradiology, 4 Department of Rheumatology, Guy's & St Thomas' Hospitals NHS Trust, London, UK
| |
Collapse
|
12
|
Menezes R, Pantelyat A, Izbudak I, Birnbaum J. Movement and Other Neurodegenerative Syndromes in Patients with Systemic Rheumatic Diseases: A Case Series of 8 Patients and Review of the Literature. Medicine (Baltimore) 2015; 94:e0971. [PMID: 26252269 PMCID: PMC4616569 DOI: 10.1097/md.0000000000000971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Patients with rheumatic diseases can present with movement and other neurodegenerative disorders. It may be underappreciated that movement and other neurodegenerative disorders can encompass a wide variety of disease entities. Such disorders are strikingly heterogeneous and lead to a wider spectrum of clinical injury than seen in Parkinson's disease. Therefore, we sought to stringently phenotype movement and other neurodegenerative disorders presenting in a case series of rheumatic disease patients. We integrated our findings with a review of the literature to understand mechanisms which may account for such a ubiquitous pattern of clinical injury.Seven rheumatic disease patients (5 Sjögren's syndrome patients, 2 undifferentiated connective tissue disease patients) were referred and could be misdiagnosed as having Parkinson's disease. However, all of these patients were ultimately diagnosed as having other movement or neurodegenerative disorders. Findings inconsistent with and more expansive than Parkinson's disease included cerebellar degeneration, dystonia with an alien-limb phenomenon, and nonfluent aphasias.A notable finding was that individual patients could be affected by cooccurring movement and other neurodegenerative disorders, each of which could be exceptionally rare (ie, prevalence of ∼1:1000), and therefore with the collective probability that such disorders were merely coincidental and causally unrelated being as low as ∼1-per-billion. Whereas our review of the literature revealed that ubiquitous patterns of clinical injury were frequently associated with magnetic resonance imaging (MRI) findings suggestive of a widespread vasculopathy, our patients did not have such neuroimaging findings. Instead, our patients could have syndromes which phenotypically resembled paraneoplastic and other inflammatory disorders which are known to be associated with antineuronal antibodies. We similarly identified immune-mediated and inflammatory markers of injury in a psoriatic arthritis patient who developed an amyotrophic lateral sclerosis (ALS)-plus syndrome after tumor necrosis factor (TNF)-inhibitor therapy.We have described a diverse spectrum of movement and other neurodegenerative disorders in our rheumatic disease patients. The widespread pattern of clinical injury, the propensity of our patients to present with co-occurring movement disorders, and the lack of MRI neuroimaging findings suggestive of a vasculopathy collectively suggest unique patterns of immune-mediated injury.
Collapse
Affiliation(s)
- Rikitha Menezes
- From the Division of Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (RM); Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (AP); Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (II); and Division of Rheumatology and Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland (JB)
| | | | | | | |
Collapse
|
13
|
Baizabal-Carvallo JF, Bonnet C, Jankovic J. Movement disorders in systemic lupus erythematosus and the antiphospholipid syndrome. J Neural Transm (Vienna) 2013; 120:1579-89. [PMID: 23580159 DOI: 10.1007/s00702-013-1023-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 04/01/2013] [Indexed: 01/19/2023]
Abstract
Movement disorders (MDs), particularly chorea, may be the presenting neurological complication of systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS), but the association is not often initially recognized. Current evidence suggests an autoimmune mechanism related to antiphospholipid antibodies in these two conditions, although the antigenic target within the central nervous system has not yet been identified. Based on a comprehensive review of the literature, this article summarizes the current knowledge on MDs in SLE and APS. A high index of suspicion is required to make an early diagnosis and initiate appropriate treatment to provide symptomatic relief and to prevent other systemic complications related to the autoimmune process.
Collapse
Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, The Smith Tower, Suite 1801, 6550 Fannin, Houston, TX, 77030, USA,
| | | | | |
Collapse
|
14
|
Dale RC. Immune-mediated extrapyramidal movement disorders, including Sydenham chorea. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1235-41. [DOI: 10.1016/b978-0-444-52910-7.00046-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
|
15
|
Lefèvre G, Zéphir H, Michelin E, Semah F, Warembourg F, Pruvo JP, Hachulla E, Lenfant P, Dubucquoi S, Vermersch P, Hatron PY, Prin L, Launay D. Neurolupus (2e partie). Description des outils diagnostiques et thérapeutiques devant une manifestation psychiatrique ou neurologique centrale au cours du lupus érythémateux systémique. Rev Med Interne 2012; 33:503-13. [DOI: 10.1016/j.revmed.2012.03.354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/02/2012] [Accepted: 03/31/2012] [Indexed: 12/23/2022]
|
16
|
Lefèvre G, Zéphir H, Warembourg F, Michelin E, Pruvo JP, Hachulla E, Semah F, Dubucquoi S, Lenfant P, Vermersch P, Hatron PY, Prin L, Launay D. [Neuropsychiatric systemic lupus erythematosus (1st part). Cases definitions and diagnosis and treatment of central nervous system and psychiatric manifestations of systemic lupus erythematosus]. Rev Med Interne 2012; 33:491-502. [PMID: 22579860 DOI: 10.1016/j.revmed.2012.03.356] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/02/2012] [Accepted: 03/31/2012] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease, which primarily affects skin and joints. Peripheral neurologic syndrome and central nervous system (CNS) manifestations are common in lupus patients but are not always attributable to lupus itself. A classification, published in 1999 by the American College of Rheumatology (ACR) research committee, described 12 CNS syndromes and seven peripheral neurologic syndromes compatible with "neuropsychiatric systemic lupus erythematosus" (NPSLE). Despite this consensus, studies which have been published since 1999 have reported a prevalence of NPSLE varying from 20 to 97 %, which shows the diagnosis difficulty and the heterogeneity of neuropsychiatric manifestations in SLE. In order to understand the limits of this classification, we propose in this first part an exhaustive review of publications describing neuropsychiatric manifestations according to the ACR 1999 classification. We also detail case definitions, prevalence and risk factors, clinical characteristics and diagnosis of each lupus-related psychiatric and CNS manifestation.
Collapse
Affiliation(s)
- G Lefèvre
- Service de médecine interne, université de Lille Nord-de-France, centre de référence maladies auto-immunes rares (sclérodermie), hôpital Claude-Huriez, CHRU de Lille, 1, rue Michel-Polonovski, 59037 Lille, France; EA2686, Institut d'immunologie, université Lille Nord-de-France, faculté de médecine H.-Warembourg, 59037 Lille, France
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Baizabal-Carvallo JF, Jankovic J. Movement disorders in autoimmune diseases. Mov Disord 2012; 27:935-46. [PMID: 22555904 DOI: 10.1002/mds.25011] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 03/09/2012] [Accepted: 03/26/2012] [Indexed: 12/13/2022] Open
Abstract
Movement disorders have been known to be associated with a variety of autoimmune diseases, including Sydenham's chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, systemic lupus erythematosus, antiphospholipid syndrome, gluten sensitivity, paraneoplastic and autoimmune encephalopathies. Tremors, dystonia, chorea, ballism, myoclonus, parkinsonism, and ataxia may be the initial and even the only presentation of these autoimmune diseases. Although antibodies directed against various cellular components of the central nervous system have been implicated, the pathogenic mechanisms of these autoimmune movement disorders have not yet been fully elucidated. Clinical recognition of these autoimmune movement disorders is critically important as many improve with immunotherapy or dietary modifications, particularly when diagnosed early. We discuss here the clinical features, pathogenic mechanisms, and treatments of movement disorders associated with autoimmune diseases, based on our own experience and on a systematic review of the literature.
Collapse
Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | | |
Collapse
|
18
|
Dale RC, Yin K, Ding A, Merheb V, Varadkhar S, McKay D, Singh-Grewal D, Brilot F. Antibody binding to neuronal surface in movement disorders associated with lupus and antiphospholipid antibodies. Dev Med Child Neurol 2011; 53:522-8. [PMID: 21574989 DOI: 10.1111/j.1469-8749.2011.03922.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM Systemic lupus erythematosus is a multi-organ autoimmune disorder associated with autoantibodies of complex diversity. Antiphospholipid antibodies (aPL), which are commonly associated with lupus, create a pro-thrombotic tendency, but are also associated with non-thrombotic neurological features. Movement disorders are rare neuropsychiatric complications of lupus and antiphospholipid syndrome, and autoimmune and thromboembolic disease mechanisms have been proposed. METHOD We describe the clinical features, investigation findings, treatment, and outcome of six paediatric participants with movement disorders associated with lupus and/or aPL (six females, median age 13 y, range 8-15). To examine the autoantibody hypothesis, we used a neuronal cell line with dopaminergic characteristics and measured serum antibody binding to neuronal cell-surface antigens using flow cytometry. For comparison with the six participants, we used serum from healthy individuals (n=12, six females, median age 11 y, range 9-13) and children with other neurological diseases (n=13, seven females, median age 7 y, range 2-15). RESULTS Of the six participants, two had lupus only, two had lupus with aPL, and two had aPL only. The movement disorder was chorea in four and parkinsonism in two. All four participants with chorea had aPL and movement disorder relapses. The two participants with parkinsonism did not have aPL, but had a progressive course until rituximab or plasma exchange resulted in neuropsychiatric remission. All six participants demonstrated elevated serum antibody binding to neuronal cell-surface antigens compared with healthy individuals and those with other neurological diseases. INTERPRETATION This report supports the association of chorea with aPL, but suggests a different autoimmune mechanism operates in lupus parkinsonism. The presence of antibody binding to neuronal cell-surface antigens supports a possible direct action of autoantibodies on neurons in patients with movement disorders associated with lupus and aPL.
Collapse
Affiliation(s)
- Russell C Dale
- Neuroimmunology Group, Institute of Neuroscience and Muscle Research, The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Treatment of non-renal lupus. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00131-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
20
|
Kimura M, Aramaki K, Wada T, Nishi K, Matsushita R, Iizuka N, Hashimoto A, Tanaka S, Ishikawa A, Endo H, Hirohata S. Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature. J Neurol Sci 2008; 272:71-6. [PMID: 18538345 DOI: 10.1016/j.jns.2008.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/11/2008] [Accepted: 04/22/2008] [Indexed: 11/26/2022]
Abstract
We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.
Collapse
Affiliation(s)
- Miho Kimura
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa 228-8555, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Orta Daniel SJ, Ulises RO. Stroke of the substance nigra and parkinsonism as first manifestation of systemic lupus erythematosus. Parkinsonism Relat Disord 2008; 14:367-9. [DOI: 10.1016/j.parkreldis.2007.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 07/26/2007] [Accepted: 08/06/2007] [Indexed: 11/25/2022]
|
22
|
Khubchandani RP, Viswanathan V, Desai J. Unusual neurologic manifestations (I): Parkinsonism in juvenile SLE. Lupus 2008; 16:572-5. [PMID: 17711890 DOI: 10.1177/0961203307081421] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A girl with neuropsychiatric lupus demonstrated Parkinsonian features soon after commencing risperidone. The single photon emission computed tomography scan showed hyperperfusion of the basal ganglia. Symptoms abated with the addition of dopaminergic agents to immunosuppressive therapy. The literature on juvenile Parkinsonism in lupus has been reviewed.
Collapse
|
23
|
Voermans NC, Bloem BR, Janssens G, Vogel WV, Sie LTL. Secondary parkinsonism in childhood: A rare complication after radiotherapy. Pediatr Neurol 2006; 34:495-8. [PMID: 16765832 DOI: 10.1016/j.pediatrneurol.2005.10.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Revised: 09/13/2005] [Accepted: 10/31/2005] [Indexed: 11/28/2022]
Abstract
Secondary parkinsonism is uncommon in children and exceedingly rare after cranial radiotherapy. This report describes a 14-year-old female who presented with growth retardation as a result of a craniopharyngioma, which was partially resected. A secondary hydrocephalus responded well to shunting. She gradually developed a severe hypokinetic-rigid syndrome 6 months after radiotherapy (54 Gray in 30 daily fractions of 1.8 Gray). In addition, her vigilance decreased. Magnetic resonance imaging revealed increased signal intensity on T2-weighted images in the globus pallidus bilaterally. Nuclear scans indicated only a marginal striatal dopaminergic deficit and revealed decreased metabolism in the thalamus bilaterally. Treatment with dopamine agonists resulted in minor improvement in motor function. Magnetic resonance imaging investigations 3 months later disclosed a decrease of signal intensity changes of the globus pallidus. Gradually, bradykinesia diminished slightly and vigilance increased little. In conclusion, secondary and partially reversible parkinsonism can occur in children after radiotherapy. We suggest that focal encephalopathy resulting from postradiation edema secondary to microangiopathy led to dysfunction of the globus pallidus and thalamus.
Collapse
Affiliation(s)
- Nicol C Voermans
- Department of Neurology, Radboud University Nijmegen Medical Centre, the Netherlands.
| | | | | | | | | |
Collapse
|
24
|
Lee YH. Diabetic nephropathy with acute symmetrical changes in the basal ganglia regions. Clin Radiol 2005; 60:815-20. [PMID: 15978894 DOI: 10.1016/j.crad.2005.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Revised: 02/16/2005] [Accepted: 03/08/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Y-H Lee
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan, ROC.
| |
Collapse
|
25
|
Ballok DA, Earls AM, Krasnik C, Hoffman SA, Sakic B. Autoimmune-induced damage of the midbrain dopaminergic system in lupus-prone mice. J Neuroimmunol 2004; 152:83-97. [PMID: 15223241 DOI: 10.1016/j.jneuroim.2004.04.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Revised: 02/20/2004] [Accepted: 04/07/2004] [Indexed: 01/20/2023]
Abstract
Spontaneous development of lupus-like disease is accompanied by impaired dopamine catabolism and degenerating axon terminals in the mesencephalon of MRL-lpr mice. We presently examine the hypothesis that systemic autoimmunity affects the central dopaminergic system in behaviorally impaired animals. The functional damage of the nigrostriatal pathway was assessed from rotational behavior after a single injection of the D1/D2-receptor agonist apomorphine. Neurodegeneration in the midbrain was estimated by Fluoro Jade B (FJB) staining. The causal role of autoimmunity was tested by comparing asymptomatic and diseased MRL-lpr mice, and by employing the immunosuppressive drug cyclophosphamide. Damage of dopaminergic neurons was assessed by tyrosine-hydroxylase (TH) staining of the midbrain. Apomorphine induced significant asymmetry in limb use, which lead to increased circling in the diseased MRL-lpr group. While FJB-positive somas were not seen in the striatum, increased staining in the substantia nigra (SN) and ventral tegmental area (VTA) were detected in behaviorally impaired MRL-lpr mice, but not in age-matched controls. Reduced brain mass and increased levels of TNF-alpha in their cerebrospinal fluid (CSF) suggested cerebral atrophy and inflammation. In addition, CSF was neurotoxic to a dopaminergic progenitor cell line. Immunosuppression attenuated CSF cytotoxicity, TNF-alpha levels, and midbrain neurodegeneration. Supportive of the notion that dying neurons were dopaminergic, the SN of autoimmune mice showed approximately a 35% reduction in the number of TH-positive cells. A three-fold increase in serum brain-reactive antibodies accompanied this loss. Although the source of toxic mediator(s) remains unknown, present results are consistent with the hypothesis that autoimmunity-induced destruction of mesonigral and mesolimbic dopaminergic pathways contributes to the etiology of aberrant behavior in an animal model of neuropsychiatric lupus.
Collapse
Affiliation(s)
- David A Ballok
- Department of Psychiatry and Behavioral Neurosciences, HSC Room 4N81, McMaster University, 1200 Main Street, West, Hamilton, Ontario, Canada L8N 3Z5.
| | | | | | | | | |
Collapse
|
26
|
Abstract
Antiphospholipid antibody syndrome (APS) may present with neurological syndromes. Cerebrovascular disease, chorea/ballismus, epileptic seizures, headache, cognitive impairment, transverse myelopathy, Devic's syndrome and multiple sclerosis-like presentations feature among others. Cerebrovascular disease is one of the most common presenting symptoms of APS, second only to deep vein thrombosis, and accounts for half of neurological manifestations in patients with APS; accelerated atherogenesis and cardioembolism are the most likely mechanisms implicated. Though infrequent, chorea is consistently associated with APS; the pathogenetic role of antiphospholipid antibodies (APLab) in this case might be routed through cerebrovascular disease in some cases and through purely immunological pathways in others. Both ischemic and immunological mechanisms have been demonstrated in the pathogenesis of epileptic seizures, which may account for 7% of neurological manifestations in APS. Although frequent in APS, a causative link between APLab and most common types of headache (migraine and tension-type headache) is more than dubious. Cognitive impairment may derive from a well-defined clinical tableau of multi-infarct dementia. Nevertheless, (highly frequent) less severe cognitive impairment has also been associated with the presence of APLab in the absence of magnetic resonance findings. A relationship between APS and transverse myelopathy seems likely but small numbers in the studies published to date preclude definite statements; routinely testing for APLab patients with neurological manifestations suggestive of multiple sclerosis seems to be unrecommended at the present time.
Collapse
Affiliation(s)
- J Sastre-Garriga
- Unitat de Neuroimmunology Clínica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | |
Collapse
|
27
|
Medaoud S, Lounici A, Zaibek A. [Parkinsonian syndrome during the systemic lupus erythematosus: a case report]. Rev Med Interne 2004; 24:839-41. [PMID: 14656648 DOI: 10.1016/s0248-8663(03)00270-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
28
|
García-Moreno JM, Chacón J. Juvenile parkinsonism as a manifestation of systemic lupus erythematosus: case report and review of the literature. Mov Disord 2002; 17:1329-35. [PMID: 12465077 DOI: 10.1002/mds.10288] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Involvement of the central nervous system in systemic lupus erythematosus (SLE) has been well described. It usually includes psychiatric disturbance, seizures, and cranial nerve disorders. Movement disorders are less common, chorea being the one most frequently described. A parkinsonian syndrome may be an extremely rare manifestation of cerebral lupus. We report on a case of juvenile parkinsonism as a manifestation of SLE and review the literature.
Collapse
|
29
|
Scolding NJ, Joseph FG. The neuropathology and pathogenesis of systemic lupus erythematosus. Neuropathol Appl Neurobiol 2002; 28:173-89. [PMID: 12060342 DOI: 10.1046/j.1365-2990.2002.00406.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, autoimmune disease in which neuropsychiatric involvement occurs in about 50% of patients and carries a poor prognosis. Despite extensive research, the precise mechanisms of nervous tissue injury remain the least well understood. This article summarizes the important clinical neuropsychiatric features of SLE and, reviewing classical histopathological and more recent experimental studies, discusses theories concerning their presumed pathogenesis. The distinctive production of diverse autoantibodies seems to be related to defective clearance of apoptotic cells. Antibody-mediated neural cell injury and rheological disturbances represent the two principal suggested mechanisms of tissue injury. An interplay between these processes, underlying genetic factors, their modification by hormones, complicated by a number of secondary factors, may explain the wide spectrum of features encountered in this disease.
Collapse
Affiliation(s)
- N J Scolding
- University of Bristol, Institute of Clinical Neurosciences, Department of Neurology, Frenchay Hospital, Bristol BS16 1LE, UK
| | | |
Collapse
|
30
|
Abstract
Parkinsonism as a manifestation of central nervous system (CNS) lupus is extremely rare. We report the first patient with systemic lupus erythematosus (SLE) who developed a reversible parkinsonian syndrome associated with enhancing subcortical lesions on magnetic resonance imaging (MRI). Following treatment with prednisolone and cyclophosphamide, her bradyphrenia, bradykinesia, hypophonia, rigidity, and abnormal gait progressively improved. Three months after she commenced treatment, repeat MRI scanning demonstrated resolution of the abnormal subcortical white matter enhancement. Our case illustrates unusual clinico-radiologic correlates of reversible parkinsonism in a SLE patient; these findings suggest that disruption of the subcortical frontal pathways may be a possible pathophysiologic mechanism for parkinsonism in cerebral lupus.
Collapse
Affiliation(s)
- E K Tan
- Department of Neurology, Singapore General Hospital, Outram Road, 169608, Singapore.
| | | | | |
Collapse
|