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Vibha D, Singh RK, Garg A, Tripathi M. Focal CNS vasculitis masquerading as new-onset focal aware seizures. BMJ Case Rep 2023; 16:e255535. [PMID: 37758658 PMCID: PMC10537825 DOI: 10.1136/bcr-2023-255535] [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: 09/29/2023] Open
Abstract
Primary angiitis of the central nervous system (PACNS) is an autoimmune disease with myriad presentations in the form of headache, focal neurological deficits, seizures and rapid cognitive decline. Predilection or isolated and recurrent involvement of one hemisphere is rarely described in literature. This leads to low clinical suspicion and often delayed diagnosis of PACNS, if clinical and radiological involvement is focal. We describe the case of a young man presenting with new-onset focal seizures with imaging suggestive of focal involvement and the brain biopsy clinched an early diagnosis. The 1-year follow-up showed clinical and radiological resolution.
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Affiliation(s)
- Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Kumar Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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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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Nehme A, Boulanger M, Aouba A, Pagnoux C, Zuber M, Touzé E, de Boysson H. Diagnostic and therapeutic approach to adult central nervous system vasculitis. Rev Neurol (Paris) 2022; 178:1041-1054. [PMID: 36156251 DOI: 10.1016/j.neurol.2022.05.003] [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: 04/20/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022]
Abstract
The clinical manifestations of central nervous system (CNS) vasculitis are highly variable. In the absence of a positive CNS biopsy, CNS vasculitis is particularly suspected when markers of both vascular disease and inflammation are present. To facilitate the clinical and therapeutic approach to this rare condition, CNS vasculitis can be classified according to the size of the involved vessels. Vascular imaging is used to identify medium vessel disease. Small vessel disease can only be diagnosed with a CNS biopsy. Medium vessel vasculitis usually presents with focal neurological signs, while small vessel vasculitis more often leads to cognitive deficits, altered level of consciousness and seizures. Markers of CNS inflammation include cerebrospinal fluid pleocytosis or elevated protein levels, and vessel wall, parenchymal or leptomeningeal enhancement. The broad range of differential diagnoses of CNS vasculitis can be narrowed based on the disease subtype. Common mimickers of medium vessel vasculitis include intracranial atherosclerosis and reversible cerebral vasoconstriction syndrome. The diagnostic workup aims to answer two questions: is the neurological presentation secondary to a vasculitic process, and if so, is the vasculitis primary (i.e., primary angiitis of the CNS) or secondary (e.g., to a systemic vasculitis, connective tissue disorder, infection, malignancy or drug use)? In primary angiitis of the CNS, glucocorticoids and cyclophosphamide are most often used for induction therapy, but rituximab may be an alternative. Based on the available evidence, all patients should receive maintenance immunosuppression. A multidisciplinary approach is necessary to ensure an accurate and timely diagnosis and to improve outcomes for patients with this potentially devastating condition.
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Affiliation(s)
- A Nehme
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France.
| | - M Boulanger
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France
| | - A Aouba
- Normandie University, Caen, France; Department of Internal Medicine, Caen University Hospital, Caen, France
| | - C Pagnoux
- Vasculitis clinic, Division of Rheumatology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - M Zuber
- Department of Neurology, Saint-Joseph Hospital, Paris, France; Université Paris Cité, Paris, France
| | - E Touzé
- Normandie University, Caen, France; Department of Neurology, Caen University Hospital, Caen, France; Inserm UMR-S U1237 PhIND/BB@C, Caen, France
| | - H de Boysson
- Normandie University, Caen, France; Department of Internal Medicine, Caen University Hospital, Caen, France
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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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Belachew NF, Diebold M, Reinacher PC, Prinz M, Urbach H, Erny D, Taschner CA. Freiburg Neuropathology Case Conference : A 51-year-old Patient Presenting with Transient Speech Disorder and a Mass Lesion in the Right Parietal White Matter. Clin Neuroradiol 2022; 32:875-881. [PMID: 35881163 PMCID: PMC9424149 DOI: 10.1007/s00062-022-01195-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
Affiliation(s)
- N F Belachew
- Departments of Neuroradiology, University of Freiburg, Breisacherstraße 64, 79106, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M Diebold
- Neuropathology, University of Freiburg, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - P C Reinacher
- Stereotactic & Functional Neurosurgery, University of Freiburg, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Fraunhofer Institute for Laser Technology, Aachen, Germany
| | - M Prinz
- Neuropathology, University of Freiburg, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - H Urbach
- Departments of Neuroradiology, University of Freiburg, Breisacherstraße 64, 79106, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - D Erny
- Neuropathology, University of Freiburg, Freiburg, Germany.,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - C A Taschner
- Departments of Neuroradiology, University of Freiburg, Breisacherstraße 64, 79106, Freiburg, Germany. .,Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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