1
|
Silva GD, Mahler JV, da Silva Junior SRP, Mendonça LO, de Sá Barreto Lima PLG, Nóbrega PR, Kok F, Freua F. Identifying high-risk neurological phenotypes in adult-onset classic monogenic autoinflammatory diseases: when should neurologists consider testing? BMC Neurol 2024; 24:130. [PMID: 38632524 PMCID: PMC11022464 DOI: 10.1186/s12883-024-03621-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/03/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Monogenic autoinflammatory disorders result in a diverse range of neurological symptoms in adults, often leading to diagnostic delays. Despite the significance of early detection for effective treatment, the neurological manifestations of these disorders remain inadequately recognized. METHODS We conducted a systematic review searching Pubmed, Embase and Scopus for case reports and case series related to neurological manifestations in adult-onset monogenic autoinflammatory diseases. Selection criteria focused on the four most relevant adult-onset autoinflammatory diseases-deficiency of deaminase 2 (DADA2), tumor necrosis factor receptor associated periodic fever syndrome (TRAPS), cryopyrin associated periodic fever syndrome (CAPS), and familial mediterranean fever (FMF). We extracted clinical, laboratory and radiological features to propose the most common neurological phenotypes. RESULTS From 276 records, 28 articles were included. The median patient age was 38, with neurological symptoms appearing after a median disease duration of 5 years. Headaches, cranial nerve dysfunction, seizures, and focal neurological deficits were prevalent. Predominant phenotypes included stroke for DADA2 patients, demyelinating lesions and meningitis for FMF, and meningitis for CAPS. TRAPS had insufficient data for adequate phenotype characterization. CONCLUSION Neurologists should be proactive in diagnosing monogenic autoinflammatory diseases in young adults showcasing clinical and laboratory indications of inflammation, especially when symptoms align with recurrent or chronic meningitis, small vessel disease strokes, and demyelinating lesions.
Collapse
Affiliation(s)
- Guilherme Diogo Silva
- Neuroimmunology Group, Division of Neurology, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | | | - Leonardo Oliveira Mendonça
- Division of Clinical Immunology and Allergy, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Paulo Ribeiro Nóbrega
- Division of Neurology, Walter Cantídio University Hospital, Federal University of Ceará, Fortaleza, Brazil.
- Centro Universitário Christus, Fortaleza, Brazil.
| | - Fernando Kok
- Neurogenetics Group, Division of Neurology, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Fernando Freua
- Neurogenetics Group, Division of Neurology, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| |
Collapse
|
2
|
Mahler JV, Solti M, Apóstolos-Pereira SL, Adoni T, Silva GD, Callegaro D. Vitamin D 3 as an add-on treatment for multiple sclerosis: A systematic review and meta-analysis of randomized controlled trials. Mult Scler Relat Disord 2024; 82:105433. [PMID: 38211504 DOI: 10.1016/j.msard.2024.105433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Vitamin D deficiency has been linked to a higher risk of multiple sclerosis (MS) and disease progression. However, the efficacy of vitamin D3 as an adjuvant therapy for MS remains a controversial topic. OBJECTIVE To perform a systematic review and meta-analysis of randomized controlled trials to assess the impact of adjunct high-dose vitamin D3 on clinical and radiological outcomes. METHODS PubMed, Embase, and Cochrane Library were searched for trials published until December 18th, 2022. Authors independently selected randomized controlled trials involving patients with MS, with an intervention group receiving high dose (≥ 1000 IU/day) cholecalciferol and reporting clinical or radiological outcomes. Authors independently extracted data and assessed the risk of bias using a standardized, pilot-tested form. The meta-analysis was conducted using RStudio for EDSS at the last follow-up, ARR, and new T2 lesion count. RESULTS We included 9 studies with 867 participants. No significant reduction of EDSS (MD = 0.02, CI 95 % [-0.37; 0.41], p = 0.91), ARR (MD -0.03, CI 95 % [-0.08; 0.02], p = 0.26), or new T2 lesions (MD -0.59, CI 95 % [-1.24;0.07], p = 0.08) was observed at 6-24 months. We found no evidence of publication bias. CONCLUSION The findings of this meta-analysis strengthen current evidence that vitamin D3 supplementation has no significant impact on clinical outcomes in patients with MS. However, the non-significant reduction of new T2 lesions could precede long-term clinical benefits and should be validated in additional studies.
Collapse
Affiliation(s)
| | - Marina Solti
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Tarso Adoni
- Neuroimmunology Group, Department of Neurology, Hospital of Clinics of the University of São Paulo, São Paulo, Brazil
| | - Guilherme Diogo Silva
- Neuroimmunology Group, Department of Neurology, Hospital of Clinics of the University of São Paulo, São Paulo, Brazil
| | - Dagoberto Callegaro
- Neuroimmunology Group, Department of Neurology, Hospital of Clinics of the University of São Paulo, São Paulo, Brazil
| |
Collapse
|
3
|
Pipek LZ, Mahler JV, Nascimento RFV, Becker J, Apóstolos-Pereira SL, Adoni T, Silva GD, Callegaro D. The myths that drive therapeutic inertia in multiple sclerosis: a cost-effectiveness analysis of high-efficacy drugs in Brazil. Arq Neuropsiquiatr 2024; 82:1-2. [PMID: 38316429 PMCID: PMC10843912 DOI: 10.1055/s-0044-1779036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/03/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Leonardo Zumerkorn Pipek
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - João Vitor Mahler
- Universidade de São Paulo, Faculdade de Medicina, São Paulo SP, Brazil.
| | | | - Jefferson Becker
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Departamento de Neurologia, Porto Alegre RS, Brazil.
| | | | - Tarso Adoni
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Guilherme Diogo Silva
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | - Dagoberto Callegaro
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
| | | |
Collapse
|
4
|
Freua F, Mahler JV, Lima PLGDSB, Neville IS, Portella LB, Marussi VHR, Lancellotti CLP, Nobrega PR, Silva GD. Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS)-Does it Really Exist? Brain Sci 2023; 13:1191. [PMID: 37626547 PMCID: PMC10452368 DOI: 10.3390/brainsci13081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids (SLIPPERS) is a rare variant of the CLIPPERS spectrum with less than ten reports published so far. There is ongoing discussion regarding whether SLIPPERS is a disease entity on its own or just an acronym encompassing many underlying diagnoses, such as sarcoidosis, vasculitis and anti-glial fibrillary acidic protein (GFAP)-associated disease. A 40-year-old woman presented with episodes of language and attention impairment. Magnetic resonance imaging (MRI) revealed T2/FLAIR hyperintense lesions in the subcortical white matter associated with a micronodular, curvilinear perivascular contrast-enhancement. Alternative diagnoses were excluded. There was a remarkable response to steroids. A relapse occurred after six years, and the biopsy showed perivascular T-cell lymphocytic infiltrate, without granulomas, vasculitis, or neoplasia. There was complete resolution of the relapse after steroids. This case represents the longest reported follow-up of a patient diagnosed with SLIPPERS, and brain biopsy after 6 years did not suggest alternative diagnoses. This report contributes to the discussion regarding the possibility that exclusive supratentorial CLIPPERS-like pathology might be an isolated disease entity, but more biopsy-proven cases with a longer follow-up are needed to support this hypothesis. Recently, GFAP astrocytopathy has been characterized and might correspond to a significant number of cases previously diagnosed as CLIPPERS or SLIPPERS.
Collapse
Affiliation(s)
- Fernando Freua
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | - João Vitor Mahler
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Iuri Santana Neville
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| | | | - Victor Hugo Rocha Marussi
- Beneficência Portuguesa Hospital, São Paulo 01323-001, Brazil; (F.F.); (I.S.N.); (L.B.P.); (V.H.R.M.)
| | | | - Paulo Ribeiro Nobrega
- Division of Neurology, Walter Cantidio University Hospital, Federal University of Ceara, Prof. Costa Mendes St., 1608, 4th Floor, Rodolfo Teófilo, Fortaleza 60430-140, Brazil
- Faculty of Medicine, Centro Universitário Christus, Fortaleza 60160-230, Brazil
| | - Guilherme Diogo Silva
- Clinics Hospital, Faculty of Medicine, University of Sao Paulo, São Paulo 05403-010, Brazil; (J.V.M.); (G.D.S.)
| |
Collapse
|
5
|
Pipek LZ, Mahler JV, Nascimento RFV, Apóstolos-Pereira SL, Silva GD, Callegaro D. Cost, efficacy, and safety comparison between early intensive and escalating strategies for multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2023; 71:104581. [PMID: 36848839 DOI: 10.1016/j.msard.2023.104581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND The optimal treatment strategy of multiple sclerosis (MS) is a matter of debate. The classical approach is the escalating (ESC) strategy, which consists of starting with low- to moderate-efficacy disease-modifying drugs (DMDs) and upscale to high-efficacy DMDs when noting some evidence of active disease. Another approach, the early intensive (EIT) strategy, is starting with high-efficiency DMDs as first-line therapy. Our goal was to compare effectiveness, safety, and cost of ESC and EIT strategies. METHODS We searched MEDLINE, EMBASE and SCOPUS until September 2022, for studies comparing EIT and ESC strategies in adult participants with relapsing-remitting MS and a minimum follow-up of 5 years. We examined the Expanded Disability Severity Scale (EDSS), the proportion of severe adverse events, and cost in a 5-year period. Random-effects meta-analysis summarized the efficacy and safety and an EDSS-based Markov model estimated the cost. RESULTS Seven studies with 3,467 participants showed a 30% reduction in EDSS worsening in 5 years (RR 0.7; [0.59-0.83]; p < 0.001) in the EIT group vs in the ESC group. Two studies with 1,118 participants suggested a similar safety profile for these strategies (RR 1.92; [0.38-9.72]; p = 0.4324). EIT with natalizumab in extended interval dosing, rituximab, alemtuzumab, and cladribine demonstrated cost-effectiveness in our model. DISCUSSION EIT presents higher efficacy in preventing disability progression, a similar safety profile, and can be cost-effective within a 5-year timeline.
Collapse
Affiliation(s)
- Leonardo Zumerkorn Pipek
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil.
| | - João Vitor Mahler
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, BR, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP 01246-903, Brazil
| | | | | | - Guilherme Diogo Silva
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
| | - Dagoberto Callegaro
- Department of Neurology Hospital of Clinics, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
6
|
Mahler JV, Silva GD. Letter to the editor: Should we stop using post-contrast sequences in the follow-up MRI of patients with multiple sclerosis? J Neurol Sci 2022; 442:120421. [PMID: 36126371 DOI: 10.1016/j.jns.2022.120421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/11/2022] [Indexed: 11/19/2022]
Affiliation(s)
- João Vitor Mahler
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Guilherme Diogo Silva
- Department of Neurology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
7
|
Boog GHP, Lopes JVZ, Mahler JV, Solti M, Kawahara LT, Teng AK, Munhoz JVT, Levin AS. Diagnostic tools for neurosyphilis: a systematic review. BMC Infect Dis 2021; 21:568. [PMID: 34126948 PMCID: PMC8201870 DOI: 10.1186/s12879-021-06264-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/01/2021] [Indexed: 01/29/2023] Open
Abstract
Purpose Increasing incidences of syphilis highlight the preoccupation with the occurrence of neurosyphilis. This study aimed to understand the current diagnostic tools and their performance to detect neurosyphilis, including new technologies and the variety of existing methods. Methods We searched databases to select articles that reported neurosyphilis diagnostic methods and assessed their accuracy, presenting sensitivity and specificity values. Information was synthesized in tables. The risk of bias was examined using the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy recommendations. Results Fourteen studies were included. The main finding was a remarkable diversity of tests, which had varied purposes, techniques, and evaluation methodologies. There was no uniform criterion or gold standard to define neurosyphilis. The current basis for its diagnosis is clinical suspicion and cerebrospinal fluid analysis. There are new promising tests such as PCR tests and chemokine measurement assays. Conclusions The diagnosis of neurosyphilis is still a challenge, despite the variety of existing and developing tests. We believe that the multiplicity of reference standards adopted as criteria for diagnosis reveals the imprecision of the current definitions of neurosyphilis. An important next step for the scientific community is to create a universally accepted diagnostic definition for this disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06264-8.
Collapse
Affiliation(s)
| | | | | | - Marina Solti
- Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | - Anna S Levin
- Infection Control Department, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
8
|
Abstract
The aryl hydrocarbon receptor (AHR) is a ligand-activated transcription factor initially identified as the receptor for dioxin. Almost half a century after its discovery, AHR is now recognized as a receptor for multiple physiological ligands, with important roles in health and disease. In this review, we discuss the role of AHR in the gut-brain axis and its potential value as a therapeutic target for immune-mediated diseases.
Collapse
Affiliation(s)
- Andreia Barroso
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - João Vitor Mahler
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Henrique Fonseca-Castro
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Francisco J Quintana
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
| |
Collapse
|