Cryptococcal meningitis presenting with isolated sixth cranial nerve palsy in a patient with systemic lupus erythematosus

'When Cryptococcus strikes and lupus is found': a unique covert unveiling of systemic lupus erythematosus presenting as subacute meningitis

Cryptococcal neoformans is a rare fungal pathogen that has been associated with immunocompromised individuals. Due to its rare occurrence, clinicians have a low index of suspicion for diagnosis, which can lead to increased morbidity and mortality. We present an 81-year-old fully functional woman with no known predisposing risk factors or previous immunocompromising conditions who was found to have cryptococcal meningitis on cerebrospinal fluid analysis in the setting of newly diagnosed uncontrolled type 2 diabetes and systemic lupus erythematosus (SLE).

Isolated Cranial Nerve VI Palsy and Neurosyphilis: A Case Report and Review of Related Literature

An isolated cranial nerve VI palsy is a rare initial manifestation of undiagnosed neurosyphilis. A 33-year-old male presented with a one month history of progressive headache and diplopia. Neurologic examination only revealed an isolated abducens palsy on the left. Cranial imaging was unremarkable. Examination of his cerebrospinal fluid revealed lymphocytic predominant leukocytosis and elevated protein. Microbiologic work-up were all negative. Further work-up revealed the patient to be serum Rapid Plasma Reagin and Enzyme Immunoassay reactive. Enzyme-linked immunosorbent assay for Human Immunodeficiency Virus also tested positive. His cerebrospinal fluid was then sent for Rapid Plasma Reagin to confirm the diagnosis of neurosyphilis. He completed 14 days of intravenous penicillin and was eventually discharged with partial resolution of the abducens palsy. We describe the second case of neurosyphilis presenting only with an isolated cranial nerve VI involvement. On further review, ours was the first case documented on an individual who had an undiagnosed Human Immunodeficiency Virus infection. There are various differentials for an isolated cranial neuritis but infectious causes, particularly neurosyphilis, should be considered among young individuals with known risk factors despite their apparently benign medical history.

Wiskott-Aldrich syndrome protein-mediated actin dynamics control type-I interferon production in plasmacytoid dendritic cells

Wiskott-Aldrich Syndrome protein (WASp)–mediated actin polymerization controls intracellular trafficking and compartmentalization of TLR9 ligands in plasmacytoid dendritic cells.

Mutations in Wiskott-Aldrich syndrome (WAS) protein (WASp), a regulator of actin dynamics in hematopoietic cells, cause WAS, an X-linked primary immunodeficiency characterized by recurrent infections and a marked predisposition to develop autoimmune disorders. The mechanisms that link actin alterations to the autoimmune phenotype are still poorly understood. We show that chronic activation of plasmacytoid dendritic cells (pDCs) and elevated type-I interferon (IFN) levels play a role in WAS autoimmunity. WAS patients display increased expression of type-I IFN genes and their inducible targets, alteration in pDCs numbers, and hyperresponsiveness to TLR9. Importantly, ablating IFN-I signaling in WASp null mice rescued chronic activation of conventional DCs, splenomegaly, and colitis. Using WASp-deficient mice, we demonstrated that WASp null pDCs are intrinsically more responsive to multimeric agonist of TLR9 and constitutively secrete type-I IFN but become progressively tolerant to further stimulation. By acute silencing of WASp and actin inhibitors, we show that WASp-mediated actin polymerization controls intracellular trafficking and compartmentalization of TLR9 ligands in pDCs restraining exaggerated activation of the TLR9–IFN-α pathway. Together, these data highlight the role of actin dynamics in pDC innate functions and imply the pDC–IFN-α axis as a player in the onset of autoimmune phenomena in WAS disease.

Cranial nerve VI palsy as a rare initial presentation of systemic lupus erythematosus: case report and review of the literature

A 48-year-old woman presented with isolated sixth cranial nerve palsy. She subsequently developed systemic lupus erythematosus (SLE) based on clinical and laboratory parameters. Three years later, she presented again with sixth cranial nerve palsy affecting the contralateral eye. Within 2 weeks of steroid initiation, complete recovery occurred. The unusual rare presentation of SLE in the current patient, as well as the pathogenesis and treatment of cranial neuropathy in SLE are discussed. Lupus (2010) 19, 201—205.