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Jacobson JR, Piat C, Aksamit AJ, Patane' G, Ross OA, Savica R. Novel RAB39B loss-of-function mutation in patient with typical early-onset Parkinson's disease. Parkinsonism Relat Disord 2024; 123:106038. [PMID: 38503262 DOI: 10.1016/j.parkreldis.2024.106038] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/04/2024] [Accepted: 02/09/2024] [Indexed: 03/21/2024]
Abstract
RAB39B mutations have been identified in X-linked developmental delays. Recently, RAB39B mutations were identified in males with early-onset parkinsonism and intellectual disability. A novel loss-of-function RAB39B mutation was found in a female patient with typical early-onset Parkinson's disease (EOPD). RAB39B mutations may cause EOPD, potentially due to a-synuclein homeostasis disruption.
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Affiliation(s)
| | - Capucine Piat
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Gaia Patane'
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Owen A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Chodnicki KD, Aksamit AJ, Gavrilova RH, Farnsworth PJ, McClelland CM. Optic Neuropathy and Myelopathy in a Teenager With Biotinidase Deficiency. J Neuroophthalmol 2024:00041327-990000000-00570. [PMID: 38324479 DOI: 10.1097/wno.0000000000002088] [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] [Indexed: 02/09/2024]
Abstract
ABSTRACT A 19-year-old man presented with 3 years of gradually progressive, painless vision loss in both eyes. The ophthalmic examination showed bilateral diminished visual acuity, dyschromatopsia, and temporal optic nerve pallor. The neurological examination was consistent with a mild myelopathy with decreased pin-prick sensation starting at T6-T7 and descending through the lower extremities. Hyperreflexia was also present in the lower more than upper extremities. Infectious, inflammatory, and nutritional serum workup and cerebrospinal fluid analysis were both unrevealing. MRI of the brain and spinal cord showed abnormal T2 hyperintensity of the fornix, corpus callosum, optic nerves, and lateral columns of the cervical and thoracic spine, with diffusion restriction in the inferior-posterior corpus callosum and fornix. Biotinidase serum enzyme activity was tested and showed a decreased level of activity. Biotinidase gene testing showed a homozygous pathogenic variant, c.424C>A (p.P142T), confirming the diagnosis of biotinidase deficiency and prompting oral biotin supplementation. Three months after starting treatment, the patient's visual acuity, color vision, visual fields, and MRI spine abnormalities all improved significantly. Biotinidase deficiency is an important diagnostic consideration in patients with unexplained optic neuropathy and/or myelopathy.
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Affiliation(s)
- Kevin D Chodnicki
- Departments of Ophthalmology (KDC), Neurology (AJA, RHG), Clinical Genomics (RHG), and Diagnostic Radiology (PJF), Mayo Clinic, Rochester, Minnesota; and Department of Ophthalmology and Visual Neurosciences (CMM), University of Minnesota, Minneapolis, Minnesota
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McEntire CRS, Fletcher A, Toledano M, Epstein S, White E, Tan CS, Mao-Draayer Y, Banks SA, Aksamit AJ, Gelfand JM, Thakur KT, Anand P, Cortese I, Bhattacharyya S. Characteristics of Progressive Multifocal Leukoencephalopathy Associated With Sarcoidosis Without Therapeutic Immune Suppression. JAMA Neurol 2023; 80:624-633. [PMID: 37093609 PMCID: PMC10126944 DOI: 10.1001/jamaneurol.2023.0841] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/17/2023] [Indexed: 04/25/2023]
Abstract
Importance Progressive multifocal leukoencephalopathy can occur in the context of systemic sarcoidosis (S-PML) in the absence of therapeutic immune suppression and can initially be mistaken for neurosarcoidosis or other complications of sarcoidosis. Earlier recognition of S-PML could lead to more effective treatment of the disease. Objective To describe characteristics of patients with S-PML. Design, Setting, and Participants For this case series, records from 8 academic medical centers in the United States were reviewed from 2004 to 2022. A systematic review of literature from 1955 to 2022 yielded data for additional patients. Included were patients with S-PML who were not receiving therapeutic immune suppression. The median follow-up time for patients who survived the acute range of illness was 19 months (range, 2-99). Data were analyzed in February 2023. Exposures Sarcoidosis without active therapeutic immune suppression. Main Outcomes and Measures Clinical, laboratory, and radiographic features of patients with S-PML. Results Twenty-one patients with S-PML not receiving therapeutic immune suppression were included in this study, and data for 37 patients were collected from literature review. The median age of the 21 study patients was 56 years (range, 33-72), 4 patients (19%) were female, and 17 (81%) were male. The median age of the literature review patients was 49 years (range, 21-74); 12 of 34 patients (33%) with reported sex were female, and 22 (67%) were male. Nine of 21 study patients (43%) and 18 of 31 literature review patients (58%) had simultaneous presentation of systemic sarcoidosis and PML. Six of 14 study patients (43%) and 11 of 19 literature review patients (58%) had a CD4+ T-cell count greater than 200/μL. In 2 study patients, a systemic flare of sarcoidosis closely preceded S-PML development. Ten of 17 study patients (59%) and 21 of 35 literature review patients (60%) died during the acute phase of illness. No meaningful predictive differences were found between patients who survived S-PML and those who did not. Conclusions and Relevance In this case series, patients with sarcoidosis developed PML in the absence of therapeutic immune suppression, and peripheral blood proxies of immune function were often only mildly abnormal. Systemic sarcoidosis flares may rarely herald the onset of S-PML. Clinicians should consider PML in any patient with sarcoidosis and new white matter lesions on brain magnetic resonance imaging.
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Affiliation(s)
| | - Anita Fletcher
- Neuroimmunology Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Michel Toledano
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Samantha Epstein
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Emily White
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - C. Sabrina Tan
- Division of Infectious Diseases, Center for Virology and Vaccines Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, University of Iowa, Iowa City
| | | | - Samantha A. Banks
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Allen J. Aksamit
- Department of Neurology, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Kiran T. Thakur
- Department of Neurology, Columbia University Irving Medical Center–New York Presbyterian Hospital, New York
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Irene Cortese
- Experimental Immunotherapeutics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Shir D, Lazar EB, Graff-Radford J, Aksamit AJ, Cutsforth-Gregory JK, Jones DT, Botha H, Ramanan VK, Prusinski C, Porter A, Day GS. Analysis of Clinical Features, Diagnostic Tests, and Biomarkers in Patients With Suspected Creutzfeldt-Jakob Disease, 2014-2021. JAMA Netw Open 2022; 5:e2225098. [PMID: 35921110 PMCID: PMC9350714 DOI: 10.1001/jamanetworkopen.2022.25098] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Detection of prion proteins in cerebrospinal fluid (CSF) using real-time quaking-induced conversion (RT-QuIC) assays has transformed the diagnostic approach to sporadic Creutzfeldt-Jakob disease (CJD), facilitating earlier and more complete recognition of affected patients. It is unclear how expanded recognition of affected patients may affect the diagnostic and prognostic relevance of clinical features and diagnostic tests historically associated with CJD. OBJECTIVE To evaluate clinical features and diagnostic testing in patients presenting with CJD and determine the associations of these features with prognosis. DESIGN, SETTING, AND PARTICIPANTS This cohort study incorporated data from electronic medical records of patients with CJD treated at Mayo Clinic Enterprise tertiary care centers in Rochester, Minnesota; Jacksonville, Florida; and Scottsdale, Arizona. Participants included patients with definite or probable CJD assessed from 2014 to 2021. Data were analyzed October 2021 to January 2022. EXPOSURES Dominant presentation, clinical features, and diagnostic tests associated with CJD. MAIN OUTCOMES AND MEASURES The outcomes of interest were the sensitivity and prognostic value of clinical features and accessible diagnostic tests at presentation with possible CJD. RESULTS A total of 115 patients were identified, including 40 patients (35%) with definite CJD. Mean (SD) age at symptom onset was 64.8 (9.4) years, and 68 patients were women (59%). The sensitivity of clinical markers (myoclonus) and tests historically considered in patients with suspected CJD was poor (eg, stereotyped electroencephalography anomalies: 17 of 105 patients [16%]; elevated CSF protein 14-3-3 levels: 54 of 90 patients [60%]). By comparison, biomarkers with good diagnostic sensitivity at presentation included RT-QuIC (66 of 71 patients [93%]), CSF total tau (T-tau) level greater than 1149 pg/mL (81 of 92 patients [88%]), and characteristic signal anomalies on magnetic resonance imaging (88 of 115 patients [77%]). Multivariable linear regression confirmed shorter survival in patients with myoclonus (difference, -125.9 [95% CI, -236.3 to -15.5] days; P = .03), visual or cerebellar signs (difference, -180.2 [95% CI, -282.2 to -78.2] days; P < .001), elevated CSF protein 14-3-3 levels (difference, -193 [95% CI, -304.9 to -82.9] days; P < .001), and elevated T-tau level (difference for every 1000 pg/mL elevation, -9.1 [95% CI, -17.7 to -1.0] days; P = .04). CONCLUSIONS AND RELEVANCE These findings suggest that CSF RT-QuIC, elevated CSF T-tau level, and stereotyped magnetic resonance imaging anomalies were associated with the diagnosis of CJD, while other clinical findings (eg, myoclonus), stereotyped electroencephalography anomalies, and CSF protein 14-3-3 levels offered less diagnostic value. Visual or cerebellar features, myoclonus, and CSF 14-3-3 and T-tau levels may be associated with disease duration, justifying continued inclusion in the evaluation of patients suspected to have CJD.
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Affiliation(s)
- Dror Shir
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - David T. Jones
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Hugo Botha
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Amanda Porter
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Gregory S. Day
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
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5
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Mustafa R, Passe TJ, Lopez-Chiriboga AS, Weinshenker BG, Krecke KN, Zalewski NL, Diehn FE, Sechi E, Mandrekar J, Kaufmann TJ, Morris PP, Pittock SJ, Toledano M, Lanzino G, Aksamit AJ, Kumar N, Lucchinetti CF, Flanagan EP. Utility of MRI Enhancement Pattern in Myelopathies With Longitudinally Extensive T2 Lesions. Neurol Clin Pract 2021; 11:e601-e611. [PMID: 34824894 PMCID: PMC8610516 DOI: 10.1212/cpj.0000000000001036] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/02/2020] [Indexed: 01/21/2023]
Abstract
Objective To determine whether MRI gadolinium enhancement patterns in myelopathies with longitudinally extensive T2 lesions can be reliably distinguished and assist in diagnosis. Methods We retrospectively identified 74 Mayo Clinic patients (January 1, 1996–December 31, 2019) fulfilling the following criteria: (1) clinical myelopathy; (2) MRI spine available; (3) longitudinally extensive T2 hyperintensity (≥3 vertebral segments); and (4) characteristic gadolinium enhancement pattern associated with a specific myelopathy etiology. Thirty-nine cases with alternative myelopathy etiologies, without previously described enhancement patterns, were included as controls. Two independent readers, educated on enhancement patterns, reviewed T2-weighted and postgadolinium T1-weighted images and selected the diagnosis based on this knowledge. These were compared with the true diagnoses, and agreement was measured with Kappa coefficient. Results Among all cases and controls (n = 113), there was excellent agreement for diagnosis using postgadolinium images (kappa, 0.76) but poor agreement with T2-weighted characteristics alone (kappa, 0.25). A correct diagnosis was more likely when assessing postgadolinium image characteristics than with T2-weighted images alone (rater 1: 100/113 [88%] vs 61/113 [54%] correct, p < 0.0001; rater 2: 95/113 [84%] vs 68/113 [60%] correct, p < 0.0001). Of the 74 with characteristic enhancement patterns, 55 (74%) were assigned an alternative incorrect or nonspecific diagnosis when originally evaluated in clinical practice, 12 (16%) received immunotherapy for noninflammatory myelopathies, and 2 (3%) underwent unnecessary spinal cord biopsy. Conclusions Misdiagnosis of myelopathies is common. The gadolinium enhancement patterns characteristic of specific diagnoses can be identified with excellent agreement between raters educated on this topic. This study highlights the potential diagnostic utility of enhancement patterns in myelopathies with longitudinally extensive T2 lesions.
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Affiliation(s)
- Rafid Mustafa
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Theodore J Passe
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Alfonso S Lopez-Chiriboga
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Brian G Weinshenker
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Karl N Krecke
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Nicholas L Zalewski
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Felix E Diehn
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Elia Sechi
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Jay Mandrekar
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Timothy J Kaufmann
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Padraig P Morris
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Sean J Pittock
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Michel Toledano
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Giuseppe Lanzino
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Allen J Aksamit
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Neeraj Kumar
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Claudia F Lucchinetti
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
| | - Eoin P Flanagan
- Department of Neurology (RM, BGW, NLZ, ES, SJP, MT, AJA, NK, CFL, EPF), Department of Radiology (TJP, KNK, FED, TJK, PPM), Department of Biostatistics (JM), Department of Laboratory Medicine and Pathology (SJP, EPF), and Department of Neurologic Surgery (GL), Mayo Clinic College of Medicine & Science, Rochester, MN; and Department of Neurology, Mayo Clinic College of Medicine & Science (ASL-C), Jacksonville, FL
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Madhavan AA, Wood CP, Aksamit AJ, Schwartz KM, Atkinson JL, Kumar N. Superficial siderosis associated with an iatrogenic posterior fossa dural leak identified on CT cisternography. Neuroradiol J 2021; 35:403-407. [PMID: 34477007 DOI: 10.1177/19714009211042875] [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] [Indexed: 11/17/2022] Open
Abstract
Superficial siderosis refers to hemosiderin deposition along the pial surface of the brain and spinal cord. It results from chronic and repetitive low-grade bleeding into the subarachnoid space. Dural tears are a common cause of superficial siderosis. Although such tears typically occur in the spine, dural tears can also occur in the posterior fossa. In many cases, posterior fossa dural tears are iatrogenic, and patients may present with neuroimaging evidence of postoperative pseudomeningoceles. We present a case of superficial siderosis caused by a persistent posterior fossa dural leak. The patient presented with superficial siderosis 30 years after a Chiari I malformation repair. A pinhole-sized dural tear was identified preoperatively using computed tomography cisternography. The dural defect was successfully repaired. An additional small tear that was not seen on imaging was also identified at surgery and successfully repaired.
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Abstract
PURPOSE OF REVIEW This article reviews the diagnosis and treatment of infectious meningitis, including updates on newer molecular diagnostic techniques for microbiological diagnosis. RECENT FINDINGS New polymerase chain reaction (PCR)-based molecular diagnostic techniques have improved the timeliness of microbiological diagnosis in meningitis, but clinicians must be aware of the limitations of such tests. Next-generation sequencing can now be applied to CSF, allowing for diagnosis of infections not identifiable by conventional means. SUMMARY Infectious meningitis can be caused by a broad range of organisms. The clinician must be aware of the test characteristics of new molecular techniques for microbiological diagnosis as well as traditional techniques to tailor antimicrobial therapy appropriately in patients with meningitis.
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Kunchok A, Aksamit AJ, Davis JM, Kantarci OH, Keegan BM, Pittock SJ, Weinshenker BG, McKeon A. Association Between Tumor Necrosis Factor Inhibitor Exposure and Inflammatory Central Nervous System Events. JAMA Neurol 2021; 77:937-946. [PMID: 32421186 PMCID: PMC7235930 DOI: 10.1001/jamaneurol.2020.1162] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Question Is exposure to tumor necrosis factor inhibitors associated with risk of inflammatory demyelinating and nondemyelinating central nervous system events in patients with an autoimmune disease? Findings In this case-control study of 212 patients with or without inflammatory CNS events, exposure to tumor necrosis factor inhibitors was associated with an increased risk of inflammatory central nervous system events. The association was similar for both inflammatory demyelinating and nondemyelinating central nervous system events. Meaning The association observed between exposure to tumor necrosis factor inhibitor and increased risk of inflammatory demyelinating and nondemyelinating central nervous system events warrants future research to ascertain whether the association may indicate de novo inflammation or exacerbation of already aberrant inflammatory pathways. Importance Tumor necrosis factor (TNF) inhibitors are common therapies for certain autoimmune diseases, such as rheumatoid arthritis. An association between TNF inhibitor exposure and inflammatory central nervous system (CNS) events has been postulated but is poorly understood. Objective To evaluate whether TNF inhibitor exposure is associated with inflammatory demyelinating and nondemyelinating CNS events in patients with an indication for TNF inhibitor use and to describe the spectrum of those CNS events. Design, Setting, and Participants A nested case-control study was conducted using the medical records of patients with autoimmune diseases treated at 3 Mayo Clinic locations (Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida) between January 1, 2003, and February 20, 2019. Patients were included if their records reported International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnostic codes for US Food and Drug Administration–approved autoimmune disease indication for TNF inhibitor use (ie, rheumatoid arthritis, ankylosing spondylitis, psoriasis and psoriatic arthritis, Crohn disease, and ulcerative colitis) and diagnostic codes for inflammatory CNS events of interest. Patients were matched 1:1 with control participants by year of birth, type of autoimmune disease, and sex. Exposures TNF inhibitor exposure data were derived from the medical records along with type of TNF inhibitor, cumulative duration of exposure, and time of exposure. Main Outcomes and Measures The main outcome was either inflammatory demyelinating (multiple sclerosis and other diseases such as optic neuritis) or nondemyelinating (meningitis, meningoencephalitis, encephalitis, neurosarcoidosis, and CNS vasculitis) CNS event. Association with TNF inhibitor was evaluated with conditional logistic regression and adjusted for disease duration to determine the odds ratios (ORs) and 95% CIs. Secondary analyses included stratification of outcome by inflammatory demyelinating and nondemyelinating CNS events and by autoimmune disease (rheumatoid arthritis and non–rheumatoid arthritis). Results A total of 212 individuals were included: 106 patients with inflammatory CNS events and 106 control participants without such events. Of this total, 136 were female (64%); the median (interquartile range) age at disease onset for patients was 52 (43-62) years. Exposure to TNF inhibitors occurred in 64 patients (60%) and 42 control participants (40%) and was associated with an increased risk of any inflammatory CNS event (adjusted OR, 3.01; 95% CI, 1.55-5.82; P = .001). These results were similar when the outcome was stratified by demyelinating and nondemyelinating CNS events. Secondary analyses found the association was predominantly observed in patients with rheumatoid arthritis (adjusted OR, 4.82; 95% CI, 1.62-14.36; P = .005). Conclusions and Relevance This study found that exposure to TNF inhibitors in patients with autoimmune diseases appeared to be associated with increased risk for inflammatory CNS events. Whether this association represents de novo or exacerbated inflammatory pathways requires further research.
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Affiliation(s)
- Amy Kunchok
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | | | - B Mark Keegan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Webb LM, Chen JJ, Aksamit AJ, Bhattacharyya S, Chwalisz BK, Balaban D, Manzano GS, Ali AS, Lord J, Clardy SL, Samudralwar RD, Mao-Draayer Y, Garrity JA, Bhatti MT, Turner LE, Flanagan EP. A multi-center case series of sarcoid optic neuropathy. J Neurol Sci 2020; 420:117282. [PMID: 33358503 DOI: 10.1016/j.jns.2020.117282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 09/08/2020] [Revised: 11/27/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of sarcoid optic neuropathy is time-sensitive, as delayed treatment risks irreversible vision loss. We sought to analyze its characteristics and outcomes. METHODS We performed a multi-center retrospective study of sarcoid optic neuropathy among 5 USA medical centers. Inclusion criteria were: 1) clinical optic neuropathy; 2) optic nerve/sheath enhancement on neuroimaging; 3) pathological confirmation of systemic or nervous system sarcoidosis. RESULTS Fifty-one patients were included. The median onset age of sarcoid optic neuropathy was 50 years (range, 17-70 years) and 71% were female. The median visual acuity at nadir in the most affected eye was 20/80 (range, 20/20 to no-light-perception). Thirty-four of 50 (68%) patients had radiologic evidence of other nervous system involvement and 20 (39%) patients had symptoms/signs of other cranial nerve dysfunction. Cerebrospinal fluid analysis revealed an elevated white blood cell count in 22 of 31 (71%) patients (median: 14/μL; range: 1-643/μL). Pathologic confirmation of sarcoidosis was by biopsy of systemic/pulmonary site, 34 (67%); optic nerve/sheath, 9 (18%); or other nervous system region, 8 (16%). Forty patients improved with treatment (78%), 98% receiving corticosteroids and 65% receiving steroid-sparing immunosuppressants, yet 11/46 patients (24%) had a visual acuity of 20/200 or worse at last follow-up. CONCLUSIONS Sarcoid optic neuropathy frequently occurs with other clinical and radiologic abnormalities caused by neurosarcoidosis and diagnostic confirmation occasionally requires optic nerve/sheath biopsy. Improvement with treatment is common but most patients have some residual visual disability. Improved recognition and a more expeditious diagnosis and treatment may spare patients from permanent vision loss.
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Affiliation(s)
- Lauren M Webb
- Mayo Clinic Alix School of Medicine, 200 1st St. SW, Rochester, MN, USA
| | - John J Chen
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA; Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Allen J Aksamit
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Shamik Bhattacharyya
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Bart K Chwalisz
- Massachusetts General Hospital, Department of Neurology, Department of Ophthalmology, and Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA, USA
| | - Denis Balaban
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Giovanna S Manzano
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Ahya S Ali
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Jennifer Lord
- University of Utah, Department of Neurology, 50 N. Medical Dr., Salt Lake City, UT, USA
| | - Stacey L Clardy
- University of Utah, Department of Neurology, 50 N. Medical Dr., Salt Lake City, UT, USA
| | - Rohini D Samudralwar
- University of Texas Health Science Center, Department of Neurology, 6410 Fannin St., Houston, TX, USA
| | - Yang Mao-Draayer
- University of Michigan, Department of Neurology, 1500 E. Medical Center Dr., Ann Arbor, MI, USA
| | - James A Garrity
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA
| | - M Tariq Bhatti
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA; Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Lindsey E Turner
- Mayo Clinic, Graduate School of Biomedical Sciences, 200 1st St. SW, Rochester, MN, USA
| | - Eoin P Flanagan
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA.
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11
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Abstract
Viral encephalitis is difficult to treat. Herpes simplex encephalitis has been successfully treated with acyclovir, but is still a cause for significant morbidity even with that treatment. A rare form of autoimmune encephalitis related to NMDA receptor antibody after infection by herpes simplex can be treated with corticosteroid therapy. Arthropod-borne encephalitides, such as West Nile virus encephalitis and Eastern equine encephalitis, are primarily treated with supportive measures. Attempts have been made to use immunoglobulin therapy with limited effects. Progressive multifocal leukoencephalopathy has been treated with an emerging immune activation therapy in a limited number of patients with incomplete success.
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Affiliation(s)
- Allen J Aksamit
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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12
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Affiliation(s)
- Hugh D Simpson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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13
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Zalewski NL, Rabinstein AA, Krecke KN, Brown RD, Wijdicks EFM, Weinshenker BG, Kaufmann TJ, Morris JM, Aksamit AJ, Bartleson JD, Lanzino G, Blessing MM, Flanagan EP. Characteristics of Spontaneous Spinal Cord Infarction and Proposed Diagnostic Criteria. JAMA Neurol 2019; 76:56-63. [PMID: 30264146 DOI: 10.1001/jamaneurol.2018.2734] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research. Objective To describe the characteristics of spontaneous SCI and propose diagnostic criteria. Design, Setting, and Participants An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280). Main Outcomes and Measures A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated. Results Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI. Conclusions and Relevance This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.
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Affiliation(s)
| | | | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - J D Bartleson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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14
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Stern BJ, Royal W, Gelfand JM, Clifford DB, Tavee J, Pawate S, Berger JR, Aksamit AJ, Krumholz A, Pardo CA, Moller DR, Judson MA, Drent M, Baughman RP. Definition and Consensus Diagnostic Criteria for Neurosarcoidosis: From the Neurosarcoidosis Consortium Consensus Group. JAMA Neurol 2019; 75:1546-1553. [PMID: 30167654 DOI: 10.1001/jamaneurol.2018.2295] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The Neurosarcoidosis Consortium Consensus Group, an expert panel of physicians experienced in the management of patients with sarcoidosis and neurosarcoidosis, engaged in an iterative process to define neurosarcoidosis and develop a practical diagnostic approach to patients with suspected neurosarcoidosis. This panel aimed to develop a consensus clinical definition of neurosarcoidosis to enhance the clinical care of patients with suspected neurosarcoidosis and to encourage standardization of research initiatives that address this disease. Observations The work of this collaboration included a review of the manifestations of neurosarcoidosis and the establishment of an approach to the diagnosis of this disorder. The proposed consensus diagnostic criteria, which reflect current knowledge, provide definitions for possible, probable, and definite central and peripheral nervous system sarcoidosis. The definitions emphasize the need to evaluate patients with findings suggestive of neurosarcoidosis for alternate causal factors, including infection and malignant neoplasm. Also emphasized is the need for biopsy, whenever feasible and advisable according to clinical context and affected anatomy, of nonneural tissue to document the presence of systemic sarcoidosis and support a diagnosis of probable neurosarcoidosis or of neural tissue to support a diagnosis of definite neurosarcoidosis. Conclusions and Relevance Diverse disease presentations and lack of specificity of relevant diagnostic tests contribute to diagnostic uncertainty. This uncertainty is compounded by the absence of a pathognomonic histologic tissue examination. The diagnostic criteria we propose are designed to focus investigations on NS as accurately as possible, recognizing that multiple pathophysiologic pathways may lead to the clinical manifestations we currently term NS. Research recognizing the clinical heterogeneity of this diagnosis may open the door to identifying meaningful biologic factors that may ultimately contribute to better treatments.
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Affiliation(s)
- Barney J Stern
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Walter Royal
- Department of Neurobiology and the Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia
| | - Jeffrey M Gelfand
- Department of Neurology, University of California, San Francisco, San Francisco
| | - David B Clifford
- Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Jinny Tavee
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Siddharama Pawate
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph R Berger
- Department of Neurology, University of Pennsylvania, Philadelphia
| | | | - Allan Krumholz
- Department of Neurology, University of Maryland, Baltimore
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - David R Moller
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Marc A Judson
- Department of Medicine, Albany Medical College, Albany, New York
| | - Marjolein Drent
- Department of Pharmacology and Toxicology, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Interstitial Lung Disease Center of Excellence, St. Antonius Hospital, Nieuwegein, the Netherlands
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15
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Masdeu JC, Aksamit AJ, Carver AC, Foley KM, Kass JS, Martin RA, McCusker EA, McQuillen MP, Mehanna R, Payne R, Victor SJ, Warach S. End of life. Neurology 2019; 93:729-734. [PMID: 31530709 PMCID: PMC6946468 DOI: 10.1212/wnl.0000000000008356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 07/30/2019] [Indexed: 11/18/2022] Open
Abstract
In legal physician-hastened death, a physician prescribes medication with the primary intent of causing the death of a willing terminally ill patient. This practice differs radically from palliative sedation, intended to relieve a patient's suffering rather than cause a patient's death. In this position paper, we argue that the practice of physician-hastened death is contrary to the interests of patients, their families, and the sound ethical practice of medicine. Therefore, the American Academy of Neurology should advise its members against this practice, as it had done until 2018.
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Affiliation(s)
- Joseph C Masdeu
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin.
| | - Allen J Aksamit
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Alan C Carver
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Kathleen M Foley
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Joseph S Kass
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Raymond A Martin
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Elizabeth A McCusker
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Michael P McQuillen
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Raja Mehanna
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Richard Payne
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Stephen J Victor
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
| | - Steven Warach
- From the Houston Methodist Neurological Institute (J.C.M), TX; Weill Cornell Medicine (J.C.M, A.C.C., K.M.F), New York, NY; Mayo Clinic (A.J.A.), Rochester, MN; Memorial Sloan Kettering Cancer Center (A.C.C., K.M.F), New York, NY; Baylor College of Medicine (J.S.K); McGovern Medical School (R.A.M., R.M.), University of Texas Health Science Center at Houston; Sydney University Medical School (E.A.M.), Australia; Stanford Health Care (M.P.M), Palo Alto, CA; private practice (S.J.V.), Erwinna, PA; and Dell Medical School (S.W.), University of Texas at Austin
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16
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Parsons AM, Aslam F, Grill MF, Aksamit AJ, Goodman BP. Rheumatoid Meningitis: Clinical Characteristics, Diagnostic Evaluation, and Treatment. Neurohospitalist 2019; 10:88-94. [PMID: 32373270 DOI: 10.1177/1941874419859769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose Due to the potential for high mortality and neurologic complications of rheumatoid meningitis (RM), awaiting biopsy confirmation may delay vital treatment intervention. Our aim was to describe the clinical presentations of RM in our population and determine whether meningeal biopsy impacted diagnosis, treatment, and outcomes. Methods A retrospective chart review was completed for patients at Mayo Clinic with a diagnosis of RM within the last 28 years. Those with identified alternative inflammatory, infectious, or neoplastic causes of pachymeningitis or leptomeningitis were excluded. Results Fourteen patients meeting inclusion/exclusion criteria were identified. All patients were positive for rheumatoid factor or cyclic citrullinated peptide. All patients had magnetic resonance imaging abnormalities characterized by pachymeningeal and/or leptomeningeal enhancement. Of the 10 patients who underwent biopsy, nonspecific findings were seen in 74%. All patients except one were treated with corticosteroids with subsequent symptomatic improvement. Radiographic improvement or resolution was seen in 10 (83%) of 12. Patients improved with corticosteroid treatment, including those who were diagnosed with RM on clinical basis without undergoing a biopsy as well. Conclusions This retrospective review displays the myriad of clinical presentations of RM. It also suggests that with appropriate exclusion of infectious, neoplastic, and other autoimmune etiologies, biopsy may not be necessary to initiate treatment.
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Affiliation(s)
| | - Fawad Aslam
- Division of Rheumatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Marie F Grill
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
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17
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Sechi E, Morris PP, McKeon A, Pittock SJ, Hinson SR, Weinshenker BG, Aksamit AJ, Krecke KN, Kaufmann TJ, Jolliffe EA, Zalewski NL, Zekeridou A, Wingerchuk DM, Jitprapaikulsan J, Flanagan EP. Glial fibrillary acidic protein IgG related myelitis: characterisation and comparison with aquaporin-4-IgG myelitis. J Neurol Neurosurg Psychiatry 2019; 90:488-490. [PMID: 30032117 DOI: 10.1136/jnnp-2018-318004] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Elia Sechi
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - P Pearse Morris
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Allen J Aksamit
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl N Krecke
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Evan A Jolliffe
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Jiraporn Jitprapaikulsan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin P Flanagan
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Dubey D, Pittock SJ, Kelly CR, McKeon A, Lopez-Chiriboga AS, Lennon VA, Gadoth A, Smith CY, Bryant SC, Klein CJ, Aksamit AJ, Toledano M, Boeve BF, Tillema JM, Flanagan EP. Autoimmune encephalitis epidemiology and a comparison to infectious encephalitis. Ann Neurol 2019; 83:166-177. [PMID: 29293273 DOI: 10.1002/ana.25131] [Citation(s) in RCA: 399] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/10/2017] [Accepted: 12/28/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the incidence and prevalence of autoimmune encephalitis and compare it to that of infectious encephalitis. METHODS We performed a population-based comparative study of the incidence and prevalence of autoimmune and infectious encephalitis in Olmsted County, Minnesota. Autoimmune encephalitis diagnosis and subgroups were defined by 2016 diagnostic criteria, and infectious encephalitis diagnosis required a confirmed infectious pathogen. Age- and sex-adjusted prevalence and incidence rates were calculated. Patients with encephalitis of uncertain etiology were excluded. RESULTS The prevalence of autoimmune encephalitis on January 1, 2014 of 13.7/100,000 was not significantly different from that of all infectious encephalitides (11.6/100,000; p = 0.63) or the viral subcategory (8.3/100,000; p = 0.17). The incidence rates (1995-2015) of autoimmune and infectious encephalitis were 0.8/100,000 and 1.0/100,000 person-years, respectively (p = 0.58). The number of relapses or recurrent hospitalizations was higher for autoimmune than infectious encephalitis (p = 0.03). The incidence of autoimmune encephalitis increased over time from 0.4/100,000 person-years (1995-2005) to 1.2/100,000 person-years (2006-2015; p = 0.02), attributable to increased detection of autoantibody-positive cases. The incidence (2.8 vs 0.7/100,000 person-years, p = 0.01) and prevalence (38.3 vs 13.7/100,000, p = 0.04) of autoimmune encephalitis was higher among African Americans than Caucasians. The prevalence of specific neural autoantibodies was as follows: myelin oligodendrocyte glycoprotein, 1.9/100,000; glutamic acid decarboxylase 65, 1.9/100,000; unclassified neural autoantibody, 1.4/100,000; leucine-rich glioma-inactivated protein 1, 0.7/100,000; collapsin response-mediator protein 5, 0.7/100,000; N-methyl-D-aspartate receptor, 0.6/100,000; antineuronal nuclear antibody type 2, 0.6/100,000; and glial fibrillary acidic protein α, 0.6/100,000. INTERPRETATION This study shows that the prevalence and incidence of autoimmune encephalitis are comparable to infectious encephalitis, and its detection is increasing over time. Ann Neurol 2018;83:166-177.
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Affiliation(s)
| | - Sean J Pittock
- Departments of Neurology.,Laboratory Medicine and Pathology
| | | | - Andrew McKeon
- Departments of Neurology.,Laboratory Medicine and Pathology
| | | | - Vanda A Lennon
- Departments of Neurology.,Laboratory Medicine and Pathology.,Immunology
| | | | - Carin Y Smith
- Health Sciences Research, Mayo Clinic, Rochester, MN
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19
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Zalewski NL, Krecke KN, Weinshenker BG, Aksamit AJ, Conway BL, McKeon A, Flanagan EP. Central canal enhancement and the trident sign in spinal cord sarcoidosis. Neurology 2018; 87:743-4. [PMID: 27527540 DOI: 10.1212/wnl.0000000000002992] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Flanagan EP, Hinson SR, Lennon VA, Fang B, Aksamit AJ, Morris PP, Basal E, Honorat JA, Alfugham NB, Linnoila JJ, Weinshenker BG, Pittock SJ, McKeon A. Glial fibrillary acidic protein immunoglobulin G as biomarker of autoimmune astrocytopathy: Analysis of 102 patients. Ann Neurol 2017; 81:298-309. [PMID: 28120349 DOI: 10.1002/ana.24881] [Citation(s) in RCA: 307] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A novel autoimmune central nervous system (CNS) disorder with glial fibrillary acidic protein (GFAP)-IgG as biomarker was recently characterized. Here, 102 patients with GFAP-IgG positivity are described. METHODS The 102 included patients had: (1) serum, cerebrospinal fluid (CSF), or both that yielded a characteristic astrocytic pattern of mouse tissue immunostaining; (2) confirmation of IgG reactive with specific GFAP isoforms (α, ɛ, or κ) by cell-based assays; and (3) clinical data available. Control specimens (n = 865) were evaluated by tissue (n = 542) and cell-based (n = 323) assays. RESULTS Median symptom onset age was 44 years (range = 8-103), and 54% were women. The predominant phenotype (83 patients; 81%) was inflammation of meninges, brain, spinal cord, or all 3 (meningoencephalomyelitis). Among patients, highest specificity for those phenotypes was observed for CSF testing (94%), and highest sensitivity was for the GFAPα isoform (100%). Rare GFAP-IgG positivity was encountered in serum controls by tissue-based assay (0.5%) or cell-based assay (1.5%), and in CSF controls by cell-based assay (0.9%). Among patients, striking perivascular radial enhancement was found on brain magnetic resonance imaging in 53%. Although cases frequently mimicked vasculitis, angiography was uniformly negative, and spinal imaging frequently demonstrated longitudinally extensive myelitic lesions. Diverse neoplasms encountered were found prospectively in 22%. Ovarian teratoma was most common and was predicted best when both N-methyl-D-aspartate receptor-IgG and aquaporin-4-IgG coexisted (71%). Six patients with prolonged follow-up had brisk corticosteroid response, but required additional immunosuppression to overcome steroid dependency. INTERPRETATION GFAPα-IgG, when detected in CSF, is highly specific for an immunotherapy-responsive autoimmune CNS disorder, sometimes with paraneoplastic cause. Ann Neurol 2017;81:298-309.
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Affiliation(s)
- Eoin P Flanagan
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Vanda A Lennon
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Immunology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Boyan Fang
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Allen J Aksamit
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN
| | - P Pearse Morris
- Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Eati Basal
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Josephe A Honorat
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Nora B Alfugham
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Jenny J Linnoila
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Brian G Weinshenker
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Sean J Pittock
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Andrew McKeon
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN.,Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, MN
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Fang B, McKeon A, Hinson SR, Kryzer TJ, Pittock SJ, Aksamit AJ, Lennon VA. Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy: A Novel Meningoencephalomyelitis. JAMA Neurol 2017; 73:1297-1307. [PMID: 27618707 DOI: 10.1001/jamaneurol.2016.2549] [Citation(s) in RCA: 315] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A novel astrocytic autoantibody has been identified as a biomarker of a relapsing autoimmune meningoencephalomyelitis that is immunotherapy responsive. Seropositivity distinguishes autoimmune glial fibrillary acidic protein (GFAP) meningoencephalomyelitis from disorders commonly considered in the differential diagnosis. Objective To describe a novel IgG autoantibody found in serum or cerebrospinal fluid that is specific for a cytosolic intermediate filament protein of astrocytes. Design, Setting, and Participants Retrospective review of the medical records of seropositive patients identified in the Mayo Clinic Neuroimmunology Laboratory from October 15, 1998, to April 1, 2016, in blinded comprehensive serologic evaluation for autoantibody profiles to aid the diagnosis of neurologic autoimmunity (and predict cancer likelihood). Main Outcomes and Measures Frequency and definition of novel autoantibody, the autoantigen's immunochemical identification, clinical and magnetic resonance imaging correlations of the autoantibody, and immunotherapy responsiveness. Results Of 103 patients whose medical records were available for review, the 16 initial patients identified as seropositive were the subject of this study. Median age at neurologic symptom onset was 42 years (range, 21-73 years); there was no sex predominance. The novel neural autoantibody, which we discovered to be GFAP-specific, is disease spectrum restricted but not rare (frequency equivalent to Purkinje cell antibody type 1 [anti-Yo]). Its filamentous pial, subventricular, and perivascular immunostaining pattern on mouse tissue resembles the characteristic magnetic resonance imaging findings of linear perivascular enhancement in patients. Prominent clinical manifestations are headache, subacute encephalopathy, optic papillitis, inflammatory myelitis, postural tremor, and cerebellar ataxia. Cerebrospinal fluid was inflammatory in 13 of 14 patients (93%) with data available. Neoplasia was diagnosed within 3 years of neurologic onset in 6 of 16 patients (38%): prostate and gastroesophageal adenocarcinomas, myeloma, melanoma, colonic carcinoid, parotid pleomorphic adenoma, and teratoma. Neurologic improvement followed treatment with high-dose corticosteroids, with a tendency of patients to relapse without long-term immunosuppression. Conclusions and Relevance Glial fibrillary acidic protein-specific IgG identifies a distinctive, corticosteroid-responsive, sometimes paraneoplastic autoimmune meningoencephalomyelitis. It has a lethal canine equivalent: necrotizing meningoencephalitis. Expression of GFAP has been reported in some of the tumor types identified in paraneoplastic cases. Glial fibrillary acidic protein peptide-specific cytotoxic CD8+ T cells are implicated as effectors in a transgenic mouse model of autoimmune GFAP meningoencephalitis.
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Affiliation(s)
- Boyan Fang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Shannon R Hinson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Thomas J Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Vanda A Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota2Department of Neurology, Mayo Clinic, Rochester, Minnesota3Department of Immunology, Mayo Clinic, Rochester, Minnesota
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Abstract
Two patients with cerebrospinal fluid (CSF) leak, one at the level of fourth thoracic spine and another with undetermined level of leak, presented with paradoxical postural headaches in that the headaches were present when in a horizontal position and resolved if the patients were upright. One patient improved spontaneously and the other responded to a targeted epidural blood patch. Paradoxical postural headache is yet another headache type that can be associated with CSF leak and CSF volume depletion. Its mechanism is uncertain, but it could be related to congestion and dilatation of cerebral venous sinuses and large veins.
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Affiliation(s)
- B Mokri
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.
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Flanagan EP, Kaufmann TJ, Krecke KN, Aksamit AJ, Pittock SJ, Keegan BM, Giannini C, Weinshenker BG. Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol 2016; 79:437-47. [PMID: 26677112 DOI: 10.1002/ana.24582] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 12/01/2015] [Accepted: 12/13/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare longitudinally extensive myelitis in neuromyelitis optica spectrum disorders (NMOSD) and spinal cord sarcoidosis (SCS). METHODS We identified adult patients evaluated between 1996 and 2015 with SCS or NMOSD whose first myelitis episode was accompanied by a spinal cord lesion spanning ≥3 vertebral segments. All NMOSD patients were positive for aquaporin-4-immunoglobulin G, and all sarcoidosis cases were pathologically confirmed. Clinical characteristics were evaluated. Spine magnetic resonance imaging was reviewed by 2 neuroradiologists. RESULTS We studied 71 patients (NMOSD, 37; SCS, 34). Sixteen (47%) SCS cases were initially diagnosed as NMOSD or idiopathic transverse myelitis. Median delay to diagnosis was longer for SCS than NMOSD (5 vs 1.5 months, p < 0.01). NMOSD myelitis patients were more commonly women, had concurrent or prior optic neuritis or intractable vomiting episodes more frequently, had shorter time to maximum deficit, and had systemic autoimmunity more often than SCS (p < 0.05). SCS patients had constitutional symptoms, cerebrospinal fluid (CSF) pleocytosis, and hilar adenopathy more frequently than NMOSD (p < 0.05); CSF hypoglycorrhachia (11%, p = 0.25) and elevated angiotensin-converting enzyme (18%, p = 0.30) were exclusive to SCS. Dorsal cord subpial gadolinium enhancement extending ≥2 vertebral segments and persistent enhancement >2 months favored SCS, and ringlike enhancement favored NMOSD (p < 0.05). Maximum disability was similar in both disorders. INTERPRETATION SCS is an under-recognized cause of longitudinally extensive myelitis that commonly mimics NMOSD. We identified clinical, laboratory, systemic, and radiologic features that, taken together, help discriminate SCS from NMOSD.
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Affiliation(s)
| | | | | | | | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN.,Laboratory Medicine, Mayo Clinic, Rochester, MN
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Singh TD, Fugate JE, Hocker S, Wijdicks EFM, Aksamit AJ, Rabinstein AA. Predictors of outcome in HSV encephalitis. J Neurol 2015; 263:277-289. [DOI: 10.1007/s00415-015-7960-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/25/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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Pichler MR, Flanagan EP, Aksamit AJ, Leavitt JA, Salomão DR, Keegan BM. Conjunctival biopsy to diagnose neurosarcoidosis in patients with inflammatory nervous system disease of unknown etiology. Neurol Clin Pract 2015; 5:216-223. [PMID: 29443212 DOI: 10.1212/cpj.0000000000000133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neurosarcoidosis mimics many neurologic diseases and poses a major diagnostic challenge. Blind conjunctival biopsy is often used to help diagnose neurosarcoidosis when biopsy of affected nervous system tissue is not feasible. While this test is relatively inexpensive and well-tolerated, the diagnostic yield in patients with inflammatory nervous system disease of unknown etiology remained uncertain. We evaluated 440 patients who underwent conjunctival biopsy due to concern for neurosarcoidosis. Only a small minority of patients (3%) had positive conjunctival biopsies consistent with sarcoidosis, and some patients (1%) with positive biopsies were found to have a cause for their neurologic disease other than neurosarcoidosis. Many patients (14%) had negative conjunctival biopsies but were later confirmed to have neurosarcoidosis after additional evaluations. This study demonstrates that conjunctival biopsy has a low diagnostic yield for neurosarcoidosis in patients with inflammatory nervous system disease and suggests that alternative diagnostic means should be pursued.
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Affiliation(s)
- Michael R Pichler
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
| | - Eoin P Flanagan
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
| | - Allen J Aksamit
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
| | - Jacqueline A Leavitt
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
| | - Diva R Salomão
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
| | - B Mark Keegan
- Departments of Neurology (MRP, EPF, AJA, BMK), Ophthalmology (JAL, DRS), and Pathology (DRS), Mayo Clinic, Rochester, MN
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Tobin WO, Lennon VA, Komorowski L, Probst C, Clardy SL, Aksamit AJ, Appendino JP, Lucchinetti CF, Matsumoto JY, Pittock SJ, Sandroni P, Tippmann-Peikert M, Wirrell EC, McKeon A. DPPX potassium channel antibody: frequency, clinical accompaniments, and outcomes in 20 patients. Neurology 2014; 83:1797-803. [PMID: 25320100 DOI: 10.1212/wnl.0000000000000991] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To describe the detection frequency and clinical associations of immunoglobulin G (IgG) targeting dipeptidyl-peptidase-like protein-6 (DPPX), a regulatory subunit of neuronal Kv4.2 potassium channels. METHODS Specimens from 20 patients evaluated on a service basis by tissue-based immunofluorescence yielded a synaptic immunostaining pattern consistent with DPPX-IgG (serum, 20; CSF, all 7 available). Transfected HEK293 cell-based assay confirmed DPPX specificity in all specimens. Sixty-nine patients with stiff-person syndrome and related disorders were also evaluated by DPPX-IgG cell-based assay. RESULTS Of 20 seropositive patients, 12 were men; median symptom onset age was 53 years (range, 13-75). Symptom onset was insidious in 15 and subacute in 5. Twelve patients reported prodromal weight loss. Neurologic disorders were multifocal. All had one or more brain or brainstem manifestations: amnesia (16), delirium (8), psychosis (4), depression (4), seizures (2), and brainstem disorders (15; eye movement disturbances [8], ataxia [7], dysphagia [6], dysarthria [4], respiratory failure [3]). Nine patients reported sleep disturbance. Manifestations of central hyperexcitability included myoclonus (8), exaggerated startle (6), diffuse rigidity (6), and hyperreflexia (6). Dysautonomia involved the gastrointestinal tract (9; diarrhea [6], gastroparesis, and constipation [3]), bladder (7), cardiac conduction system (3), and thermoregulation (1). Two patients had B-cell neoplasms: gastrointestinal lymphoma (1), and chronic lymphocytic leukemia (1). Substantial neurologic improvements followed immunotherapy in 7 of 11 patients with available treatment data. DPPX-IgG was not detected in any of the stiff-person syndrome patients. CONCLUSIONS DPPX-IgG is a biomarker for an immunotherapy-responsive multifocal neurologic disorder of the central and autonomic nervous systems.
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Affiliation(s)
- William Oliver Tobin
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Vanda A Lennon
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Lars Komorowski
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Christian Probst
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Stacey Lynn Clardy
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Allen J Aksamit
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Juan Pablo Appendino
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Claudia F Lucchinetti
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Joseph Y Matsumoto
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Sean J Pittock
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Paola Sandroni
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Maja Tippmann-Peikert
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Elaine C Wirrell
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada
| | - Andrew McKeon
- From the Departments of Neurology (W.O.T., V.A.L., S.L.C., A.J.A., C.F.L., J.Y.M., S.J.P., P.S., M.T.-P., E.C.W., A.M.), Laboratory Medicine and Pathology (V.A.L., S.J.P., A.M.), Immunology (V.A.L.), and Pediatrics (E.C.W.), College of Medicine, Mayo Clinic, Rochester, MN; Euroimmun AG (L.K., C.P.), Lübeck, Germany; and Neurology (J.P.A.), Faculty of Medicine, University of Manitoba, Canada.
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Kaufman GP, Aksamit AJ, Klein CJ, Yi ES, Delone DR, Litzow MR. Progressive multifocal leukoencephalopathy: a rare infectious complication following allogeneic hematopoietic cell transplantation (HCT). Eur J Haematol 2013; 92:83-7. [PMID: 24118404 DOI: 10.1111/ejh.12208] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [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: 09/26/2013] [Indexed: 11/28/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML), a demyelinating disorder caused by brain infection with JC virus, is a neurological complication of immunocompromised states and immunosuppressive therapies. While most commonly seen in the HIV/AIDS population, patients with hematologic malignancies are also at risk following treatment protocols including monoclonal antibodies such as rituximab and after hematopoietic stem cell transplantation. Here, we present the case of PML following allogeneic HCT that highlights potential diagnostic difficulties. We also review the literature regarding PML following HCT and described therapies employed to attempt to treat this disorder.
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Flanagan EP, Aksamit AJ, Kumar N, Morparia NP, Keegan BM, Weinshenker BG. Simultaneous PML-IRIS and myelitis in a patient with neuromyelitis optica spectrum disorder. Neurol Clin Pract 2013; 3:448-451. [PMID: 29473607 DOI: 10.1212/cpj.0b013e3182a78f82] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Neeraj Kumar
- Department of Neurology Mayo Clinic, Rochester, MN
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Leep Hunderfund AN, Zabad RK, Aksamit AJ, Morris JM, Meyer FB, Thorell WE, Parisi JE, Giannini C. Diffuse anaplastic leptomeningeal oligodendrogliomatosis mimicking neurosarcoidosis. Neurol Clin Pract 2013; 3:261-265. [PMID: 23914328 DOI: 10.1212/cpj.0b013e318296f23d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diffuse leptomeningeal oligodendrogliomatosis is a rare, frequently fatal CNS malignancy that most often affects children.1 Although potentially treatable with chemotherapy and radiation, the radiologic findings are nonspecific and pathologic confirmation of the diagnosis is difficult. We describe an adult patient whose initial presentation mimicked neurosarcoidosis. Despite extensive imaging abnormalities, 3 biopsies were required before the diagnosis of diffuse leptomeningeal oligodendrogliomatosis was confirmed.
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Affiliation(s)
- Andrea N Leep Hunderfund
- Departments of Neurology (A.N.L.H., A.J.A.), Neurosurgery (F.B.M.), Radiology (J.M.M.), and Pathology (J.E.P., C.G.), Mayo Clinic College of Medicine, Rochester, MN; and the Department of Neurological Sciences (R.K.Z.) and the Division of Neurosurgery (W.E.T.), Nebraska Medical Center, Omaha
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Berger JR, Aksamit AJ, Clifford DB, Davis L, Koralnik IJ, Sejvar JJ, Bartt R, Major EO, Nath A. PML diagnostic criteria: consensus statement from the AAN Neuroinfectious Disease Section. Neurology 2013; 80:1430-8. [PMID: 23568998 DOI: 10.1212/wnl.0b013e31828c2fa1] [Citation(s) in RCA: 463] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To establish criteria for the diagnosis of progressive multifocal leukoencephalopathy (PML). METHODS We reviewed available literature to identify various diagnostic criteria employed. Several search strategies employing the terms "progressive multifocal leukoencephalopathy" with or without "JC virus" were performed with PubMed, SCOPUS, and EMBASE search engines. The articles were reviewed by a committee of individuals with expertise in the disorder in order to determine the most useful applicable criteria. RESULTS A consensus statement was developed employing clinical, imaging, pathologic, and virologic evidence in support of the diagnosis of PML. Two separate pathways, histopathologic and clinical, for PML diagnosis are proposed. Diagnostic classification includes certain, probable, possible, and not PML. CONCLUSION Definitive diagnosis of PML requires neuropathologic demonstration of the typical histopathologic triad (demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei) coupled with the techniques to show the presence of JC virus. The presence of clinical and imaging manifestations consistent with the diagnosis and not better explained by other disorders coupled with the demonstration of JC virus by PCR in CSF is also considered diagnostic. Algorithms for establishing the diagnosis have been recommended.
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Affiliation(s)
- Joseph R Berger
- Department of Neurology, University of Kentucky, Lexington, USA.
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Abstract
PURPOSE OF REVIEW Progressive multifocal leukoencephalopathy (PML) is an opportunistic viral infection of the human CNS that has gained new importance because of AIDS and newer immunosuppressive therapies. It destroys oligodendrocytes, leading to neurologic deficits associated with demyelination. RECENT FINDINGS PML most commonly occurs in patients who are HIV infected, but increasing numbers of patients are being recognized in the context of immunosuppressive therapies for autoimmune diseases. The precise pathogenesis of infection by JC virus, the etiologic human papovavirus, remains elusive, but much has been learned since the original description of the pathologic entity PML in 1958. Detection and diagnosis of this disorder have become more sophisticated with MRI of the brain and spinal fluid analysis using PCR detection. Immune reconstitution inflammatory syndrome complicates reversal of immunosuppression when PML has established a foothold in the brain. SUMMARY No effective therapy exists, but there is hope for better management of patients by withdrawing exogenous immunosuppression and reconstituting the immune system, with a projection of better long-term survival.
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Affiliation(s)
- Allen J Aksamit
- Mayo Clinic, Department of Neurology, 200 First Street SW, Rochester, MN 55905, USA.
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Graff-Radford J, Rubin MN, Jones DT, Aksamit AJ, Ahlskog JE, Knopman DS, Petersen RC, Boeve BF, Josephs KA. The alien limb phenomenon. J Neurol 2013; 260:1880-8. [PMID: 23572346 DOI: 10.1007/s00415-013-6898-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/13/2013] [Accepted: 03/15/2013] [Indexed: 11/29/2022]
Abstract
Alien limb phenomenon refers to involuntary motor activity of a limb in conjunction with the feeling of estrangement from that limb. Alien limb serves as a diagnostic feature of corticobasal syndrome. Our objective was to determine the differential diagnoses of alien limb and to determine the features in a large group of patients with the alien limb with different underlying etiologies. We searched the Mayo Clinic Medical Records Linkage system to identify patients with the diagnosis of alien limb seen between January 1, 1996, and July 11, 2011. One hundred and fifty patients with alien limb were identified. Twenty-two were followed in the Alzheimer's Disease Research Center. Etiologies of alien limb included corticobasal syndrome (n = 108), stroke (n = 14), Creutzfeldt Jakob disease (n = 9), hereditary diffuse leukoencephalopathy with spheroids (n = 5), tumor (n = 4), progressive multifocal leukoencephalopathy(n = 2), demyelinating disease (n = 2), progressive dementia not otherwise specified (n = 2), posterior reversible encephalopathy syndrome (n = 1), corpus callosotomy (n = 1), intracerebral hemorrhage (n = 1) and thalamic dementia (n = 1). Ten of 14 cerebrovascular cases were right hemisphere in origin. All cases involved the parietal lobe. Of the 44 patients with corticobasal syndrome from the Alzheimer's Disease Research Center cohort, 22 had alien limb, and 73 % had the alien limb affecting the left extremities. Left sided corticobasal syndrome was significantly associated with the presence of alien limb (p = 0.004). These findings support the notion that the alien limb phenomenon is partially related to damage underlying the parietal cortex, especially right parietal, disconnecting it from other cortical areas.
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Klaas JP, Ahlskog JE, Pittock SJ, Matsumoto JY, Aksamit AJ, Bartleson JD, Kumar R, McEvoy KF, McKeon A. Adult-Onset Opsoclonus-Myoclonus Syndrome. ACTA ACUST UNITED AC 2012; 69:1598-607. [DOI: 10.1001/archneurol.2012.1173] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Treatment of progressive multifocal leukoencephalopathy (PML) in a patient with exogenous immunosuppression starts with discontinuation of immunosuppressive medication. The restored host immunity will clear JC virus, the cause of PML, from the brain via cell-mediated immune mechanisms. Patients with solid-organ transplants will lose the transplanted organ, however, and patients who have autoimmune disorders may experience exacerbation of their underlying disease. These factors need to be weighed against the potentially fatal nature of PML. If the patient's immunosuppression is AIDS-related, highly active antiretroviral therapy (HAART) should be initiated if it has not previously been used. If the patient is already receiving HAART, the therapy should be changed to optimize treatment, with the goals of a nondetectable HIV viral load and normalization or near normalization of the CD4 count. For non-AIDS PML patients, daily intravenous cytosine arabinoside for 5 days can be offered if the patient is not pancytopenic and can tolerate a chemotherapeutic agent. For AIDS patients with PML or failing non-AIDS patients with neurologic deterioration, cidofovir can be considered. These therapies can be offered if neurologic stabilization satisfies the quality-of-life goals for the patient. For patients intolerant of other therapies or unsuited to them, oral mirtazapine or risperidone can be considered. The safety of these agents has been established in the treatment of psychiatric disease, but their efficacy has not yet been proven. Small interfering RNA (siRNA) therapy holds the promise of specific antiviral therapy, but delivery methods, safety, and efficacy are yet to be established.
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Affiliation(s)
- Allen J Aksamit
- Allen J. Aksamit, MD Mayo Clinic College of Medicine, Department of Neurology, 200 First Street SW, Rochester, MN 55905, USA.
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Rubin M, Graff-Radford J, Boeve B, Josephs KA, Aksamit AJ. The alien limb phenomenon and Creutzfeldt-Jakob disease. Parkinsonism Relat Disord 2012; 18:842-6. [PMID: 22575235 DOI: 10.1016/j.parkreldis.2012.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/22/2012] [Accepted: 04/07/2012] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Alien limb phenomenon (ALP) has been rarely reported as a presenting feature of Creutzfeldt-Jakob disease (CJD), though neurologists may not recognize it as a prompt to search for CJD. OBJECTIVE This report demonstrates the clinical features of patients with ALP and CJD. METHODS All patients with the ALP between 1/1/1996 - 7/28/2011 were identified by the Mayo Clinic Medical Record Linkage system and cross-referenced with a diagnosis of CJD in that same time span. This yielded 13 patients, including six women. RESULTS The median age at onset of CJD symptoms was 69 years. Two patients were classified as possible CJD, five as probable CJD, and six as definite CJD based on research diagnostic criteria for CJD. The median time to onset of ALP symptoms was 0.5 weeks. The ALP afflicted the left side in nine patients. The median time to death from CJD symptom onset was 10.5 weeks. In four patients ALP was the initial and sole neurologic sign. In four others it was the initial manifestation coexisting with other deficits. ALP related symptoms initially prompted three other patients to seek medical evaluation. ALP was either initially or eventually accompanied by ipsilateral hemineglect, ideomotor apraxia and/or cortical sensory loss in nine patients. Imaging of the contralateral parietal lobe demonstrated cortical T2 hyperintensity and/or restricted diffusion in all eight patients who had abnormal MRI neuroimaging. CONCLUSIONS ALP should trigger suspicion of CJD. The neuroanatomic correlate of ALP in CJD appears to be the contralateral parietal lobe.
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Affiliation(s)
- Mark Rubin
- Department of Neurology, E8A, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55901, USA.
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Quek AML, Britton JW, McKeon A, So E, Lennon VA, Shin C, Klein C, Watson RE, Kotsenas AL, Lagerlund TD, Cascino GD, Worrell GA, Wirrell EC, Nickels KC, Aksamit AJ, Noe KH, Pittock SJ. Autoimmune epilepsy: clinical characteristics and response to immunotherapy. Arch Neurol 2012; 69:582-93. [PMID: 22451162 PMCID: PMC3601373 DOI: 10.1001/archneurol.2011.2985] [Citation(s) in RCA: 228] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe clinical characteristics and immunotherapy responses in patients with autoimmune epilepsy. DESIGN Observational, retrospective case series. SETTING Mayo Clinic Health System. PATIENTS Thirty-two patients with an exclusive (n=11) or predominant (n=21) seizure presentation in whom an autoimmune etiology was suspected (on the basis of neural autoantibody [91%], inflammatory cerebrospinal fluid [31%], or magnetic resonance imaging suggesting inflammation [63%]) were studied. All had partial seizures: 81% had failed treatment with 2 or more antiepileptic drugs and had daily seizures and 38% had seizure semiologies that were multifocal or changed with time. Head magnetic resonance imaging was normal in 15 (47%) at onset. Electroencephalogram abnormalities included interictal epileptiform discharges in 20; electrographic seizures in 15; and focal slowing in 13. Neural autoantibodies included voltage-gated potassium channel complex in 56% (leucine-rich, glioma-inactivated 1 specific, 14; contactin-associated proteinlike 2 specific, 1); glutamic acid decarboxylase 65 in 22%; collapsin response- mediator protein 5 in 6%; and Ma2, N-methyl-D-aspartate receptor, and ganglionic acetylcholine receptor in 1 patient each. INTERVENTION Immunotherapy with intravenous methylprednisolone; intravenous immune globulin; and combinations of intravenous methylprednisolone, intravenous immune globulin, plasmapheresis, or cyclophosphamide. MAIN OUTCOME MEASURE Seizure frequency. RESULTS After a median interval of 17 months (range, 3-72 months), 22 of 27 (81%) reported improvement postimmunotherapy; 18 were seizure free. The median time from seizure onset to initiating immunotherapy was 4 months for responders and 22 months for nonresponders (P<.05). All voltage-gated potassium channel complex antibody-positive patients reported initial or lasting benefit (P<.05). One voltage-gated potassium channel complex antibody-positive patient was seizure free after thyroid cancer resection; another responded to antiepileptic drug change alone. CONCLUSION When clinical and serological clues suggest an autoimmune basis for medically intractable epilepsy, early-initiated immunotherapy may improve seizure outcome.
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Affiliation(s)
- Amy M L Quek
- Department of Laboratory Medicine and Pathology, Mayo Clinic, College of Medicine, Rochester, MN 55905, USA
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Mateen FJ, Muralidharan R, Carone M, van de Beek D, Harrison DM, Aksamit AJ, Gould MS, Clifford DB, Nath A. Progressive multifocal leukoencephalopathy in transplant recipients. Ann Neurol 2011; 70:305-22. [PMID: 21823157 DOI: 10.1002/ana.22408] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), a rare demyelinating disorder caused by oligodendrocyte destruction by JC virus. METHODS Reports of PML following transplantation were found using PubMed Entrez (1958-July 2010). A multicenter, retrospective cohort study also identified all cases of PML among transplant recipients diagnosed at Mayo Clinic, Johns Hopkins University, Washington University, and Amsterdam Academic Medical Center. At 1 institution, the incidence of posttransplantation PML was calculated. RESULTS A total of 69 cases (44 solid organ, 25 bone marrow) of posttransplantation PML were found including 15 from the 4 medical centers and another 54 from the literature. The median time to development of first symptoms of PML following transplantation was longer in solid organ vs bone marrow recipients (27 vs 11 months, p = 0.0005, range of <1 to >240). Median survival following symptom onset was 6.4 months in solid organ vs 19.5 months in bone marrow recipients (p = 0.068). Case fatality was 84% (95% confidence interval [CI], 70.3-92.4%) and survival beyond 1 year was 55.7% (95% CI, 41.2-67.2%). The incidence of PML among heart and/or lung transplant recipients at 1 institution was 1.24 per 1,000 posttransplantation person-years (95% CI, 0.25-3.61). No clear association was found with any 1 immunosuppressant agent. No treatment provided demonstrable therapeutic benefit. INTERPRETATION The risk of PML exists throughout the posttransplantation period. Bone marrow recipients survive longer than solid organ recipients but may have a lower median time to first symptoms of PML. Posttransplantation PML has a higher case fatality and may have a higher incidence than reported in human immunodeficiency virus (HIV) patients on highly-active antiretroviral therapy (HAART) or multiple sclerosis patients treated with natalizumab.
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Affiliation(s)
- Farrah J Mateen
- Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA.
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Abstract
CNS WD is fatal if antibiotics are not begun early, but knowledge regarding the variety of presentations on MR imaging is limited. In order to more effectively recognize this entity on MR imaging, the Mayo Clinic medical records were reviewed for subjects diagnosed with CNS WD from 1992-2006 who had also undergone MR imaging of the neuraxis. Seven subjects were identified and their imaging findings were reviewed by the authors. Four of 7 had head MR imaging findings indicative of WD. Two subjects demonstrated high T2 signal within the corticospinal tracts. CNS WD may demonstrate high T2 signal with minimal enhancement and no restricted diffusion, primarily in the midline of the midbrain, hypothalamus, and mesial temporal lobes and occasionally the corticospinal tracts. MR imaging may also be normal. Radiologists should be aware of these presentations and be prepared to mention CNS WD as a diagnostic possibility since early antibiotic therapy may significantly impact morbidity and mortality.
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Affiliation(s)
- D F Black
- Department of Radiology, Mayo Clinic Radiology, Rochester, MN 55905, USA.
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Akkara Veetil BM, Yee AH, Warrington KJ, Aksamit AJ, Mason TG. Aseptic meningitis in adult onset Still’s disease. Rheumatol Int 2010; 32:4031-4. [DOI: 10.1007/s00296-010-1529-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 05/05/2010] [Indexed: 12/01/2022]
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Affiliation(s)
- Allen J Aksamit
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Jicha GA, Glantz J, Clarke MJ, Lehwald LM, Russo DP, Giannini C, Wald JT, Uhm J, Kumar N, Aksamit AJ, Wetmore CJ. Primary diffuse leptomeningeal gliomatosis. Eur Neurol 2009; 62:16-22. [PMID: 19407451 DOI: 10.1159/000216838] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 01/04/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare presentation of a primary central nervous system glial tumor. METHODS Four case reports of PDLG in young males aged 14-24 years are presented. These reports are discussed in the context of the existing literature. RESULTS The clinical presentation of 4 new cases of PDLG resembled chronic meningitis with and without polyradiculopathy. Spinal fluid studies are typically nondiagnostic, but characteristically show elevated opening pressure, an elevated protein level, and a relative paucity of cellular reaction. An accurate antemortem diagnosis required contrast-enhanced imaging and meningeal biopsy in all 4 of our cases. Treatment strategies including craniospinal radiation and chemotherapeutic approaches, alone or in combination, have not been proven to alter the course of the disease. Initial responses to temozolomide and radiation treatments in all 4 of our cases were promising, resulting in temporary stabilization of the disease and prolonging life expectancy over what was previously reported in the literature. CONCLUSION Total neuroaxis contrast-enhanced MRI scanning is required for directing biopsy confirmation and detecting the extent of the disease. More effective therapeutic strategies are needed, but the combination of temozolomide and radiation therapy may slow disease progression.
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Affiliation(s)
- Gregory A Jicha
- Department of Neurology and Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
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Rahmlow M, Shuster EA, Dominik J, Deen HG, Dickson DW, Aksamit AJ, Robles HA, Freeman WD. Leflunomide-associated progressive multifocal leukoencephalopathy. ACTA ACUST UNITED AC 2008; 65:1538-9. [PMID: 19001176 DOI: 10.1001/archneur.65.11.1538] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Megan Rahmlow
- Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA
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Kumar N, Hagan JB, Abraham RS, Aksamit AJ. Common variable immunodeficiency-associated myelitis: report of treatment with infliximab. J Neurol 2008; 255:1821-4. [PMID: 18677641 DOI: 10.1007/s00415-008-0898-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 01/08/2008] [Accepted: 02/07/2008] [Indexed: 11/28/2022]
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Affiliation(s)
- Kenneth L Tyler
- Department of Neurology, University of Colorado Health Sciences Center, Denver, CO, USA
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Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML), a destructive demyelinating infection which lytically infects oligodendrocytes, has occurred in patients treated with natalizumab. Magnetic resonance imaging (MRI) scan imaging of the brain gives clues to diagnosis but is nonspecific in distinguishing multiple sclerosis from PML. Spinal fluid detection of JC virus is specific but incompletely sensitive. Associated immunosuppression is typically of the cell-mediated type but can be poorly defined on clinical grounds. REVIEW SUMMARY It is apparent that natalizumab is a predisposing factor for developing PML from the 3 cases of natalizumab-treated patients. There is no reliable presymptomatic way to detect PML or JC virus infection of the brain by virologic or imaging surveillance techniques. One patient with multiple sclerosis and natalizumab treatment has survived, indicating that withdrawal of antibody, possibly in combination with antiviral therapy, may permit survival. However, immune reconstitution disease is a risk after immune restoration and withdrawal of natalizumab. PML deficits would be expected to be permanent. The estimate of incidence of PML in natalizumab-treated patients is 1 per 1000. The duration of natalizumab treatment may be an independent risk factor for development of PML. CONCLUSION PML, a usually fatal neurologic infection, should be considered as a risk factor when using natalizumab. The treatment of multiple sclerosis patients with natalizumab is a matter of informed risk, individualized for each multiple sclerosis patient.
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Affiliation(s)
- Allen J Aksamit
- Mayo Clinic College of Medicine, Department of Neurology, Rochester, Minnesota 55905, USA.
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Burns TM, Dyck PJB, Aksamit AJ, Dyck PJ. The natural history and long-term outcome of 57 limb sarcoidosis neuropathy cases. J Neurol Sci 2006; 244:77-87. [PMID: 16524595 DOI: 10.1016/j.jns.2006.01.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 12/12/2005] [Accepted: 01/04/2006] [Indexed: 11/19/2022]
Abstract
Fifty-seven patients with biopsy-proven sarcoidosis causing limb neuropathy were reviewed in order to delineate the characteristic symptoms, impairments, disability, course, outcome and response to corticosteroid treatment of limb sarcoid neuropathy. Typically the neuropathy had a definite date of symptomatic onset. Prominent were positive neuropathic sensory symptoms (P-NSS), especially pain, overshadowing weakness and sensory loss. P-NSS were the main cause of disability. Almost always the pattern was asymmetric and not length-dependent (unlike distal polyneuropathy). We inferred (from kind and distribution of symptoms, signs and electrophysiologic and other test results) that the pathologic process was focal or multifocal, involving most classes of nerve fibers and variable levels of proximal to distal levels of roots and peripheral nerves. Additional features aiding in diagnosis were: systemic symptoms such as fatigue, malaise, arthralgia, fever and weight loss; involvement of multiple tissues (i.e. skin, lymph nodes and eye); the patterns of neuropathy; MRI features; and ultimately tissue diagnosis. Axonal degeneration predominated, although an acquired demyelinating process was observed in 3 patients. For most cases, the disease had a chronic, monophasic course. MRI studies done in later years of affected neural structures were helpful in identifying leptomeningeal thickening, hilar adenopathy; and enlargement and T2 enhancement of nerve roots, plexuses, and limb nerves. Corticosteroid treatment appeared to ameliorate symptoms more than impairments. Several variables were associated with neuropathic improvement: CSF pleocytosis, short duration between symptom onset and treatment, and a higher grade of disability at first evaluation-a possible rationale for future earlier diagnosis and treatment.
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Affiliation(s)
- T M Burns
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Abstract
This study characterizes the type and timing of psychiatric manifestations in sporadic Creutzfeldt-Jakob disease (sCJD). Historically, sCJD has been characterized by prominent neurological symptoms, while the variant form (vCJD) is described as primarily psychiatric in presentation and course: A retrospective review of 126 sCJD patients evaluated at the Mayo Clinic from 1976-2001 was conducted. Cases were reviewed for symptoms of depression, anxiety, psychosis, behavior dyscontrol, sleep disturbances, and neurological signs during the disease course. Eighty percent of the cases demonstrated psychiatric symptoms within the first 100 days of illness, with 26% occurring at presentation. The most commonly reported symptoms in this population included sleep disturbances, psychotic symptoms, and depression. Psychiatric manifestations are an early and prominent feature of sporadic CJD, often occurring prior to formal diagnosis.
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Affiliation(s)
- Christopher A Wall
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Building-W11A, 200 First Street SW, Rochester, MN 55905, USA.
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Bakleh M, Aksamit AJ, Tleyjeh IM, Marshall WF. Successful Treatment of Cerebral Blastomycosis with Voriconazole. Clin Infect Dis 2005; 40:e69-71. [PMID: 15825017 DOI: 10.1086/429319] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Accepted: 12/23/2004] [Indexed: 11/03/2022] Open
Abstract
Blastomycosis can occasionally involve the central nervous system (CNS). Amphotericin B deoxycholate is considered the drug of choice for the treatment of CNS blastomycosis. Significant toxicity may be associated with its use. We describe a case of cerebral blastomycoma that was successfully treated with voriconazole.
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Affiliation(s)
- Mohanad Bakleh
- Division of Infectious Diseases, Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Abstract
BACKGROUND Whipple disease (WD) is an infectious disease, which may affect the central nervous system. Central nervous system symptoms are eventually present in as many as 43% of the cases. To our knowledge, cerebellar ataxia in WD has never been formally studied in any large series. OBJECTIVE To determine the prevalence of cerebellar ataxia in central nervous system WD. RESULTS Between January 1974 and December 2003, we identified 11 patients who met criteria for definite central nervous system WD, the second largest series to date. Surprisingly, while oculomasticatory myorrhythmia was recorded in only 1 patient (9%), cerebellar ataxia had been documented in 5 cases (45%). CONCLUSION Our data suggest that cerebellar ataxia should be considered a more common feature of central nervous system WD.
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Affiliation(s)
- Brandy R Matthews
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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