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Thalhammer J, Kindle G, Nieters A, Rusch S, Seppänen MRJ, Fischer A, Grimbacher B, Edgar D, Buckland M, Mahlaoui N, Ehl S. Initial presenting manifestations in 16,486 patients with inborn errors of immunity include infections and noninfectious manifestations. J Allergy Clin Immunol 2021; 148:1332-1341.e5. [PMID: 33895260 DOI: 10.1016/j.jaci.2021.04.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [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: 12/24/2020] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Inborn errors of immunity (IEI) are rare diseases, which makes diagnosis a challenge. A better description of the initial presenting manifestations should improve awareness and avoid diagnostic delay. Although increased infection susceptibility is a well-known initial IEI manifestation, less is known about the frequency of other presenting manifestations. OBJECTIVE We sought to analyze age-related initial presenting manifestations of IEI including different IEI disease cohorts. METHODS We analyzed data on 16,486 patients of the European Society for Immunodeficiencies Registry. Patients with autoinflammatory diseases were excluded because of the limited number registered. RESULTS Overall, 68% of patients initially presented with infections only, 9% with immune dysregulation only, and 9% with a combination of both. Syndromic features were the presenting feature in 12%, 4% had laboratory abnormalities only, 1.5% were diagnosed because of family history only, and 0.8% presented with malignancy. Two-third of patients with IEI presented before the age of 6 years, but a quarter of patients developed initial symptoms only as adults. Immune dysregulation was most frequently recognized as an initial IEI manifestation between age 6 and 25 years, with male predominance until age 10 years, shifting to female predominance after age 40 years. Infections were most prevalent as a first manifestation in patients presenting after age 30 years. CONCLUSIONS An exclusive focus on infection-centered warning signs would have missed around 25% of patients with IEI who initially present with other manifestations.
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Affiliation(s)
- Julian Thalhammer
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Pediatrics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhard Kindle
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexandra Nieters
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Rusch
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mikko R J Seppänen
- Rare Disease and Pediatric Research Centers, Hospital for Children and Adolescents and Adult Immunodeficiency Unit, Inflammation Center, University of Helsinki and HUS Helsinki, University Hospital, Helsinki, Finland
| | - Alain Fischer
- Pediatric Immuno-Haematology and Rheumatology Unit, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
| | - David Edgar
- St James's Hospital, Dublin, Ireland; Trinity College Dublin, Dublin, Ireland
| | - Matthew Buckland
- Institute of Immunity and Transplantation, University College London, United Kingdom; Department of Immunology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Nizar Mahlaoui
- Pediatric Immuno-Haematology and Rheumatology Unit, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany.
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Floros P, Rao A, McCloy RA, Sim HW, Chin VT, Leavers BC, Crawford JA, Gallagher RM. Altered presentation of oropharyngeal cancer, a 6-year review. ANZ J Surg 2021; 91:1240-1245. [PMID: 33438358 DOI: 10.1111/ans.16537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/21/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) continues to increase in incidence. Patients are younger, non-smokers and most commonly present with a neck mass often with no other symptoms. This altered presentation compared with non-HPV OPSCC may not be recognized by medical practitioners, leading to delayed diagnosis. METHODS Patients with histopathological confirmation of OPSCC and known HPV and/or P16 status who presented to our institution between 2012-2017 inclusive were included in the study. Demographic data, tumour characteristics and presenting symptoms were retrospectivxely obtained from both electronic- and paper-based records. Descriptive statistics were used to report demographic data and the two sample t-test and Fisher's exact test were used to compare groups based on HPV status. Time to diagnosis was also reported. RESULTS A total of 184 patients were included in the study. The majority of patients were male (85.4%) and HPV + (85.3%). The tonsillar complex (53.8%) and tongue base (42.4%) were the most common primary sites. HPV+ patients were less likely to smoke (17.8%) and they commonly presented with a neck mass (39.5% alone or with other symptoms 61.2%). Time to diagnosis in the HPV+ group was longer (15 weeks). CONCLUSION Our review has highlighted the altered presentation of OPSCC due to the increased incidence of HPV infection. We showed a delayed time to diagnosis in HPV+ OPSCC compared with non-HPV disease. This confirms the importance of focusing our efforts on educating medical practitioners and creating further awareness to facilitate early detection and treatment.
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Affiliation(s)
- Peter Floros
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Amshuman Rao
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Rachael A McCloy
- Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Hao-Wen Sim
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Venessa T Chin
- Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Brett C Leavers
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Julia A Crawford
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Richard M Gallagher
- Department of Otolaryngology - Head and Neck Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
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Gugel I, Grimm F, Zipfel J, Teuber C, Ernemann U, Kluwe L, Tatagiba M, Mautner VF, Schuhmann MU. Age at Onset and Presenting Symptoms of Neurofibromatosis Type 2 as Prognostic Factors for Clinical Course of Vestibular Schwannomas. Cancers (Basel) 2020; 12:cancers12092355. [PMID: 32825434 PMCID: PMC7563356 DOI: 10.3390/cancers12092355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 06/14/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/16/2022] Open
Abstract
The presenting symptoms of the tumor suppressor gene syndrome neurofibromatosis type 2 (NF2) are often non-specific and unrelated to the disease hallmark bilateral vestibular schwannomas (VS). However, age at onset and presenting symptoms may have predictive values for the clinical course of VS. In this retrospective single-center study, we addressed this issue by reviewing 106 patients with 194 VS. Presenting symptoms attributable to VS commonly occur in 87% of adults and 31% of children. Age at onset significantly correlates with tumor volumes at presentation (p = 0.034). In addition, age at onset significantly correlates with pure-tone average (p = 0.0001), speech discrimination scores (p = 0.001), age at beginning of hearing loss (p = 0.0001), age at deafness (p = 0.0001), and age at first surgery (p = 0.0001). Patients presenting with VS related symptoms had significantly (p < 0.05) worse hearing values at presentation and after surgery. These patients also exhibited higher growth rates and tumor volumes compared to patients with non-VS related presenting symptoms, but this difference did not reach the significance level of p < 0.05. Due to the late appearance of these symptoms, the time of beginning hearing loss, surgery and deafness is significantly delayed (p < 0.05) compared to patients not presenting with VS. In summary, age at onset and type of presenting symptom provide excellent prognostic parameters for predicting VS- and hearing-related clinical course.
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Affiliation(s)
- Isabel Gugel
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, 72076 Tübingen, Germany;
- Correspondence: ; Tel.: +49-7071-2980325; Fax: +49-7071-295245
| | - Florian Grimm
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
| | - Julian Zipfel
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, 72076 Tübingen, Germany;
- Division of Pediatric Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Christian Teuber
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
| | - Ulrike Ernemann
- Department of Neuroradiology, University Hospital Tübingen, 72076 Tübingen, Germany;
| | - Lan Kluwe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
- Department of Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, 72076 Tübingen, Germany;
| | - Victor-Felix Mautner
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, 72076 Tübingen, Germany;
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Martin Ulrich Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany; (F.G.); (J.Z.); (C.T.); (M.T.); (M.U.S.)
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, 72076 Tübingen, Germany;
- Division of Pediatric Neurosurgery, University Hospital Tübingen, 72076 Tübingen, Germany
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Affiliation(s)
- William H Sipprell
- The Department of Dermatology, University of California, San Francisco, California
| | - Wesley Y Yu
- The Department of Dermatology, University of California, San Francisco, California
| | - Siegrid S Yu
- The Department of Dermatology, University of California, San Francisco, California
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Gugel I, Mautner VF, Kluwe L, Tatagiba MS, Schuhmann MU. Cerebrovascular Insult as Presenting Symptom of Neurofibromatosis Type 2 in Children, Adolescents, and Young Adults. Front Neurol 2018; 9:733. [PMID: 30250447 PMCID: PMC6139325 DOI: 10.3389/fneur.2018.00733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 06/17/2018] [Accepted: 08/13/2018] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Neurofibromatosis Type 2 (NF2) is an autosomal-dominant tumor-prone disorder characterized by the manifestations of central nervous system lesions. However, the first clinical signs of disease are often non-tumorous. Cerebrovascular insults are known in NF2, however, not yet described as first symptom in young NF2 patients. Methods: Magnetic resonance image scans of 298 NF2 patients treated in our neurofibromatosis center in Tübingen from 2003 to 2017 were retrospectively evaluated focusing on presence of aneurysms and ischemic stroke. Clinical data were used to clarify whether or not ischemic stroke or aneurysm rupture were the first presentation of disease. Blood of the patients were subjected to genetic screening for constitutional NF2 mutations. Results: We identified 5 cases under age of 25 years with aneurysms or ischemic stroke. Among them three had ischemic strokes of the brain stem and one aneurysmal subarachnoid hemorrhage as the first symptom of the disease. Incidental finding of 2 intracranial aneurysm occurred in one patient. All aneurysms were clipped. Patients with ischemia suffered from dysarthria, gait disturbances, dizziness, and hemiparesis. Residual signs of hemiparesis and dysarthria persisted in one patient. All others fully recovered from the cerebrovascular insult. Bilateral vestibular schwannomas and intracranial meningiomas were found in all five patients. Conclusions: A cerebrovascular insult in the vertebrobasilar territory may occur as first symptom of disease in young NF2 patients. The brain stem seems to be especially prone to ischemic stroke. Multicenter studies on large NF2 cohorts are needed to determine the prevalence and pattern of cerebrovascular insults and disease in NF2 patients.
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Affiliation(s)
- Isabel Gugel
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Victor-Felix Mautner
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, Tübingen, Germany
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lan Kluwe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcos Soares Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Martin Ulrich Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
- Centre of Neurofibromatosis and Rare Diseases, University Hospital Tübingen, Tübingen, Germany
- Division of Pediatric Neurosurgery, University Hospital Tübingen, Tübingen, Germany
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Posti JP, Bori M, Kauko T, Sankinen M, Nordberg J, Rahi M, Frantzén J, Vuorinen V, Sipilä JOT. Presenting symptoms of glioma in adults. Acta Neurol Scand 2015; 131:88-93. [PMID: 25263022 DOI: 10.1111/ane.12285] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Studies on the presenting symptoms of glioma in adults in the age of readily available MRI imaging are scarce. This study investigates presenting symptoms of glioma and assesses the correlations of the presenting symptoms with patient age and histopathological class of the tumor. MATERIALS AND METHODS A retrospective review of the medical records of histologically verified glioma patients treated in Turku University Hospital, during 2006-2010, was conducted. The associations between the presenting symptoms and other covariates were assessed individually. RESULTS One hundred and fifty patients were ascertained. The most common presenting symptoms of glioma were seizure and cognitive disorder. Patients presenting with seizures were younger than patients with cognitive disorders, and the grade of the tumor was also found to significantly correlate with the most common presenting symptoms. Age group and tumor grade were statistically significant factors of cognitive disorder (P = 0.0037 and P = 0.0069) and age group of seizure (P = 0.0065). The associations between the presenting symptoms and the anatomical location, spread into adjacent brain areas, or laterality of the tumor or site of diagnosis were found to be statistically insignificant. Headache was not a common presenting symptom in glioma patients. CONCLUSIONS The main presenting symptoms of glioma in adults in the MRI age still are seizures and cognitive disorder. Patient age and tumor grade correlate positively with the incidence of cognitive disorder and patient age negatively with incidence of seizure as a presenting symptom. Headache is an uncommon manifestation and does not appear as a sole symptom.
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Affiliation(s)
- J. P. Posti
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - M. Bori
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - T. Kauko
- Department of Biostatistics; University of Turku; Turku Finland
| | - M. Sankinen
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - J. Nordberg
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - M. Rahi
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - J. Frantzén
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - V. Vuorinen
- Division of Clinical Neurosciences; Department of Neurosurgery; Turku University Hospital; Turku Finland
| | - J. O. T. Sipilä
- Division of Clinical Neurosciences; Department of Neurology; Turku University Hospital; Turku Finland
- University of Turku; Depratment of Neurology; Turku Finland
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Abstract
Mutism, defined as an inability or unwillingness to speak, resulting in an absence or marked paucity of verbal output, is a common clinical symptom seen in psychiatric as well as neurology outpatient department. It rarely presents as an isolated disability and often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness. It is often a focus of clinical attention, both for the physician and the relatives. Mutism occurs in a number of conditions, both functional and organic, and a proper diagnosis is important for the management. We hereby present three cases, who presented with mutism as the presenting symptom and the differential diagnosis and management issues related to these cases are discussed. The authors also selectively reviewed the literature on mutism, including psychiatric, neurologic, toxic-metabolic, and drug-induced causes.
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Affiliation(s)
- Ashish Aggarwal
- Department of Psychiatry, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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