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Chanpura A, Gupta RK, Sriwastava SK, Rahmig J. Diagnostic value of soluble Interleukin-2 receptor in patients suffering neurosarcoidosis: A systematic review. J Cent Nerv Syst Dis 2024; 16:11795735241274186. [PMID: 39193252 PMCID: PMC11348353 DOI: 10.1177/11795735241274186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/16/2024] [Accepted: 07/17/2024] [Indexed: 08/29/2024] Open
Abstract
Background Neurosarcoidosis is an inflammatory granulomatous disease. Up to 25% of occult sarcoidosis affecting the nervous system are only detected by autopsy. In addition, in recent years the suspicion arose that the soluble Interleukin-2 Receptor (sIL-2R) might be useful in differentiating between neurosarcoidosis and neurosarcoidosis-like diseases such as neurotuberculosis, multiple sclerosis, or cerebral lymphoma. Objectives Therefore, we aimed to systematically review randomized controlled trials (RCT), observational studies, and case-control studies evaluating sIL-2R levels in neurosarcoidosis patients. Design For this systematic review, a comprehensive literature search of electronic databases including EMBASE, The Web Of Science, The Cochrane Library, MEDLINE, and Google Scholar was conducted. The search was limited to the English language and publication date up to January 08th, 2024. Data Sources and Methods As part of the search strategy conducted, 6 articles met the inclusion criteria. Two independent reviewers extracted the relevant data from each article. In addition, 2 independent reviewers assessed the quality of each study using the Newcastle-Ottawa Scale (NOS). Results We included 6 studies comprising 98 patients suffering from neurosarcoidosis, 525 non-sarcoidosis patients, and 118 healthy controls. Included studies were published between 2010 and 2023. Cerebrospinal fluid (CSF) sIL-2R levels differed significantly between neurosarcoidosis patients and multiple sclerosis, vasculitis, and healthy controls whereas serum sIL-2R levels did not reveal sufficient discriminative power. sIL-2R index was able to discriminate neurosarcoidosis from neurotuberculosis, bacterial/viral meningitis, and healthy controls. Conclusions In this systematic review, we found indications that sIL-2R may be a useful biomarker for the diagnosis of neurosarcoidosis. To determine an additional diagnostic value of sIL-2R, large prospective studies are needed that not only examine absolute sIL-2R levels in serum or CSF but also the dynamic changes as well as the implications of renal function on sIL-2R levels.
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Affiliation(s)
- Aditya Chanpura
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA
| | - Rajesh K. Gupta
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shitiz K. Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jan Rahmig
- Department of Neurology, University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
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Lee KY, Khil EK, Lee SA, Lee JW, Lee E. Neurosarcoidosis involving cervical nerve root with unusual MRI findings: a case report and systematic literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2878-2885. [PMID: 38376559 DOI: 10.1007/s00586-024-08159-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/03/2024] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. METHODS We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. RESULTS A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3-C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. CONCLUSIONS This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course.
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Affiliation(s)
- Kyoung Yeon Lee
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Korea
| | - Eun Kyung Khil
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Korea.
- Department of Radiology, Fastbone Orthopedic Hospital, 127-27, Dongtansunhwan-daero, Hwaseong-si, Gyeonggi-do, Korea.
| | - Seun Ah Lee
- Department of Radiology, Hallym University Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea
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Namba S, Yokota H, Mukai H, Hashiba J, Kogayo N, Nakao T, Sugiyama A, Ogaya E, Aotsuka Y, Kuwabara S, Uno T. Neurosarcoidosis with enlargement of the dorsal root ganglia: A case report. Radiol Case Rep 2024; 19:1718-1721. [PMID: 38384707 PMCID: PMC10877124 DOI: 10.1016/j.radcr.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/23/2024] Open
Abstract
We report the case of a woman in her 40s who presented with sensory disturbances in all 4 limbs and left facial palsy. MRI revealed asymmetric enlargement of the dorsal root ganglia, which was enhanced by gadolinium-a chest CT scan identified enlarged supraclavicular, mediastinal, and hilar lymph nodes. A biopsy of a hilar lymph node showed noncaseating epithelioid granulomas, confirming a sarcoidosis diagnosis. Prednisolone treatment led to symptomatic improvements. In sarcoidosis of the peripheral nervous system, there might be observable enlargement of the dorsal root ganglion alongside enhanced gadolinium contrast. Obtaining a biopsy from the dorsal root ganglion poses challenges, and radiologists should be mindful of this specific imaging characteristic.
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Affiliation(s)
- Sakie Namba
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Hajime Yokota
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroki Mukai
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Jun Hashiba
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Naoki Kogayo
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Tatsushi Nakao
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Atsuhiko Sugiyama
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Etsuko Ogaya
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuya Aotsuka
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Voortman M, Drent M, Stern BJ. Neurosarcoidosis and Neurologic Complications of Sarcoidosis Treatment. Clin Chest Med 2024; 45:91-103. [PMID: 38245373 DOI: 10.1016/j.ccm.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is an immune-mediated multisystem granulomatous disorder. Neurosarcoidosis (NS) accounts for 5% to 35% of cases. The diagnostic evaluation of NS can be a clinical challenge. Gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard to evaluate central nervous system NS. In almost all cases treatment is warranted. Although glucocorticoids remain the first-line therapy in patients with sarcoidosis, in NS timely initiation of second- or third-line treatment is strongly recommended. Of these, tumor necrosis factor-alpha inhibitors are the most promising. However, the treatment itself may be responsible for/associated with developing neurologic symptoms mimicking NS. Thus, it is important to consider the possibility of drug-induced neurologic symptoms in sarcoidosis.
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Affiliation(s)
- Mareye Voortman
- Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands.
| | - Marjolein Drent
- Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; Department of Respiratory Medicine, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands; ILD Care Foundation Research Team, Heideoordlaan 8, Ede 6711NR, The Netherlands
| | - Barney J Stern
- Department of Neurology, School of Medicine, Johns Hopkins University, 601 North Caroline Street, Neurology Room 5066B, Baltimore, MD 21287, USA
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Bekkour I, Courtin E, Dulau-Metras C, Duffau P, Kremer L, Mathey G. Defining the course of neurosarcoidosis according to presentation at onset and disease modifying treatment: a cohort study of 84 patients. Ther Adv Neurol Disord 2023; 16:17562864231205954. [PMID: 38143513 PMCID: PMC10748905 DOI: 10.1177/17562864231205954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 12/26/2023] Open
Abstract
Background Neurosarcoidosis is a rare manifestation of sarcoidosis with heterogeneous presentations. Patient management is challenging due to the current lack of knowledge about the long-term disease course. Objective To identify specific disease courses of neurosarcoidosis according to the clinical and paraclinical presentations at onset. Methods We conducted an observational multicenter cohort study by retrospectively collecting data from the medical records of 84 patients diagnosed with definite, probable, or possible neurosarcoidosis in three tertiary referral centers in France (Nancy, Strasbourg, and Bordeaux). We collected demographic characteristics, clinical and paraclinical data at the beginning of patient management, and during follow-up under the different treatment lines. Two expert neurologists determined disease course profiles. Results The mean follow-up was 6.6 years. Almost every patient (96.4%) received steroids at some point of their follow-up. Tumor Necrosis Factor-alpha blockers were given in 10.7% as first-line treatment and in 33.3% during follow-up. Every patient presented with a relapsing disease, often monophasic (75%) and sometimes polyphasic with the recurrence of identical manifestations (11.9%). Patients developing new neurological symptoms during follow-up were a minority (13.1%). No patients exhibited a progressive course. Patients with isolated cranial nerves injury or aseptic meningitis always exhibited a monophasic course, and 62.5-75% of them had a full recovery after first-line treatments. This proportion was 15.6% in other forms of the disease. Those with peripheral presentations were more likely to present a polyphasic course than patients with other forms of neurosarcoidosis. Spinal cord presentations were monophasic, but resulted in sequelae and exhibited poor response to first-line treatments despite frequent use of TNF-alpha blockers. Conclusion Identification of these disease course profiles, based on the initial clinical and paraclinical presentation, could guide the clinician to select the optimal therapeutic approach and follow-up modalities for their patients with neurosarcoidosis.
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Affiliation(s)
- Inès Bekkour
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Edouard Courtin
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | | | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Bordeaux, France
- CNRS, ImmunoConcEpT, UMR 5164, University of Bordeaux, Bordeaux, France
| | - Laurent Kremer
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- INSERM U1119, Strasbourg, France
| | - Guillaume Mathey
- Service de Neurologie, Hopital Central, CHRU de Nancy, 1 Avenue du Maréchal de Lattre de Tassigny, Nancy 54000, France
- Department of Neurology, Nancy University Hospital, Nancy, France
- CIC-Epidémiologie Clinique, Nancy University Hospital, INSERM, Université de Lorraine, Nancy, France
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6
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Deboutte I, Godts D, Van Lint M. Recurrent multiple eye muscle palsy as a first sign of sarcoidosis. GMS OPHTHALMOLOGY CASES 2023; 13:Doc21. [PMID: 38111471 PMCID: PMC10726560 DOI: 10.3205/oc000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Purpose To report a case of (neuro)sarcoidosis presenting solely with recurrent cranial nerve palsies in a 57-year-old Caucasian female. Methods Case report with clinical imaging. Results A 57-year-old female first presented with a right sixth nerve palsy, which resolved spontaneously after 6 months. Three years later she was diagnosed with a sixth nerve palsy in the fellow eye followed by a complete palsy of the left third cranial nerve four months after. Medical history consisted of migraine and hypercholesterolemia. Further neurological and ophthalmic work-up was unrevealing at first. After repeated magnetic resonance imaging, an enhancing lesion in the left cavernous sinus was seen, which was initially diagnosed as a meningioma. However, imaging of the chest revealed an image of sarcoidosis, and the lesion and ophthalmoplegia of the left eye disappeared with systemic corticosteroid treatment. Discussion Sarcoidosis is the ultimate imitator and the possibility of neurosarcoidosis must be taken into account when presented with unexplained ophthalmoplegia. Neurosarcoidosis has imaging properties very similar to other diseases such as a meningioma, and misdiagnosis occurs easily. Spontaneous recovery of ophthalmoplegia can rarely occur in neurosarcoidosis.
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Affiliation(s)
- Isabel Deboutte
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
- Medical Science Department, University of Antwerp, Belgium
| | - Daisy Godts
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
| | - Michel Van Lint
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
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7
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Zhao JJ, Lau YS, Cheng J, Queck KK, Yap J. Recurrent Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman. Respir Med Case Rep 2023; 46:101939. [PMID: 37942172 PMCID: PMC10628801 DOI: 10.1016/j.rmcr.2023.101939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/01/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023] Open
Abstract
Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, manifesting with bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint or eye lesions. Heerfordt-Waldenström Syndrome - a constellation of facial palsy, fever, uveitis and parotitis - is a rare presentation of this disorder. A 47-year-old Chinese woman presented with unintentional weight loss, lethargy with mediastinal and hilar lymphadenopathy. Biopsy of the right paratracheal lymph node via mediastinoscopy showed mycobacterial granulomatous lymphadenitis consistent with tuberculosis with several acid-fast bacilli identified. Lymphoproliferative disorder was ruled out. She was started on treatment for tuberculosis. Eleven weeks into treatment, she developed a right facial palsy accompanied with fever, uveitis and occipital headache. At this juncture, further history revealed a background of recurrent alternating facial palsy and parotid gland enlargement which was treated for Bell's palsy by three different doctors. New nodules appeared in the left lobe of the thyroid gland. Biopsy of a palpable thyroid nodule and a right supraclavicular lymph nodule showed histological features suggestive of sarcoidosis. Fungal and mycobacterial infections were ruled out. In addition, examination of her cerebral spinal fluid showed lymphocytic inflammation. The serum ACE level was not raised. A diagnosis of sarcoidosis with incomplete features of Heerfordt-Waldenström Syndrome along with thyroid and meningeal involvement was made. The patient was commenced on prednisolone and azathioprine and her symptoms responded shortly after. We present a rare case of Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman.
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Affiliation(s)
- Joseph J. Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yung Sang Lau
- YS Lau Cardiology Clinic, Mount Alvernia Hospital, Singapore
| | - Jacob Cheng
- Eagle Eye Centre, Mount Alvernia Hospital, Singapore
| | | | - Jane Yap
- Jane Yap Chest and Medical Clinic, Mount Alvernia Hospital, Singapore
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8
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Bergner R. [Sarcoidosis]. Z Rheumatol 2023:10.1007/s00393-023-01338-1. [PMID: 37261551 DOI: 10.1007/s00393-023-01338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 06/02/2023]
Abstract
Sarcoidosis is the most common granulomatous disease in northern Europe. A distinction is made between acute forms of sarcoidosis and chronic sarcoidosis. Chronic sarcoidosis can affect practically all organs but the lungs are affected in 90-95% of patients. The clinical appearance varies between asymptomatic and oligosymptomatic courses, which are diagnosed more by chance, to courses with acute organ failure. An extensive organ work-up is necessary at the time of the initial diagnosis in order to record the extent of organ involvement and to make appropriate treatment decisions. Asymptomatic courses with purely pulmonary sarcoidosis do not require treatment and can be observed over the course of the disease, whereas courses with extensive organ involvement or organ dysfunction require treatment. The treatment consists primarily of the administration of glucocorticoids. If the effect of the glucocorticoids is insufficient or if there are side effects, various immunosuppressive agents, including biologics can be added.
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Affiliation(s)
- Raoul Bergner
- Medizinische Klinik A - Nephrologie, Rheumatologie, Hämato-Onkologie, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen, Deutschland.
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9
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Berntsson SG, Elmgren A, Gudjonsson O, Grabowska A, Landtblom AM, Moraes-Fontes MF. A comprehensive diagnostic approach in suspected neurosarcoidosis. Sci Rep 2023; 13:6539. [PMID: 37085608 PMCID: PMC10121682 DOI: 10.1038/s41598-023-33631-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 04/16/2023] [Indexed: 04/23/2023] Open
Abstract
Neurosarcoidosis presents a diagnostic challenge in clinical settings, as it has no pathognomonic symptoms or signs and a wide range of differential diagnoses. The aim of this report is to present the pathological features of our group of patients, obtained through a systematic diagnostic approach. This retrospective cohort study enrolled all adult patients primarily diagnosed with neurosarcoidosis at the neurology department of a tertiary center in Sweden over a period of 30 years, from 1990 to 2021. We identified 90 patients, 54 with possible neurosarcoidosis and 36 with probable neurosarcoidosis. CNS biopsy revealed an alternative diagnosis for 24 patients, who were then excluded. The collected data from medical records included demographic and clinical characteristics, systemic and/or neurological isolated involvement, various laboratory tests, including cerebrospinal fluid (CSF), serum analysis, imaging studies (MRI, FDG-PET/CT, and HRCT), nerve conduction studies, electromyography, and pathology reports of central nervous system (CNS), and extra-neural tissue biopsies. Sixty-six patients were included in our cohort. The median age at onset of symptoms was 49 years, with a similar sex distribution. Cranial neuropathies (38%), motor deficit (32%), headache (16%), and pituitary dysfunction (12%) were the most common presenting features. CSF studies were abnormal in 77% of the patients, who showed lymphocytosis (57%), elevated protein (44%), oligoclonal bands (40%), elevated ACE (28%), and raised T lymphocyte CD4+/CD8+ ratios (13%). Strikingly, MRI showed that 17% of the patients presented with isolated pituitary gland lesions. FDG-PET/CT was performed in 22 patients (33%) and confirmed systemic sarcoidosis in 11. Despite our extensive workup, the final classification for our patients only allowed for a definite diagnosis in 14 patients; the remainder were classified as probable (32) or possible (20) neurosarcoidosis. Since 2007, the employment of a structured laboratory and imaging approach and the increasing number of CNS biopsies have facilitated and improved the process of correct attribution in patients with presumptive neurosarcoidosis, especially in patients with isolated neurological lesions. We highlight a higher frequency of pituitary lesions due to neurosarcoidosis than has been classically described. A detailed laboratory diagnostic workup is included.
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Affiliation(s)
| | - Andreas Elmgren
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
| | - Olafur Gudjonsson
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anna Grabowska
- Department of Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Anne-Marie Landtblom
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
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Spagnolo P, Bernardinello N. Sarcoidosis. Immunol Allergy Clin North Am 2023; 43:259-272. [PMID: 37055088 DOI: 10.1016/j.iac.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Sarcoidosis is a disease of unknown cause characterized by granulomatous inflammation. Although the lung is almost universally involved, any organ can be affected. Complex pathogenesis and protean clinical manifestations are additional features of the disease. The diagnosis is one of exclusion, although the presence of noncaseating granulomas at disease sites is a prerequisite in most cases. The management of sarcoidosis requires a multidisciplinary approach, particularly when the heart, the brain, or the eyes are involved. The paucity of effective therapies and the lack of reliable predictors of disease behavior greatly contribute to making sarcoidosis a challenging disease to manage.
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Affiliation(s)
- Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, via Giustiniani 2, Padova 35128, Italy.
| | - Nicol Bernardinello
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, via Giustiniani 2, Padova 35128, Italy
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Distinguishing CNS neurosarcoidosis from multiple sclerosis and an approach to “overlap” cases. J Neuroimmunol 2022; 369:577904. [DOI: 10.1016/j.jneuroim.2022.577904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022]
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Wong J, Leach L, Chen-Xu M, Truman L. Rare case of sudden onset sensorineural hearing loss in a patient diagnosed with sarcoidosis. BMJ Case Rep 2022; 15:e248969. [PMID: 35820728 PMCID: PMC9277377 DOI: 10.1136/bcr-2022-248969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a woman in her 30s who was referred to the ear, nose and throat department with sudden onset left-sided sensorineural hearing loss (SNHL), left anterior uveitis and erythematous lower limb lesions with bilateral pitting oedema. Based on her symptoms, an underlying inflammatory systemic disease was suspected. Autoantibodies were negative but an X-ray and high-resolution CT scan of the chest were suggestive of sarcoidosis, which was confirmed on endoscopic bronchial biopsy. Following treatment with a course of oral steroids, the patient's hearing has improved but she still suffers from episodes of uveitis. While immune-mediated inner ear disorders are a recognised cause of SNHL, sarcoidosis is a very rare cause. This case demonstrates the importance of screening for systemic autoimmune aetiology in SNHL and highlights the importance of an effective multidisciplinary team in the diagnosis and management of these patients.
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Affiliation(s)
- Jeremy Wong
- Department of Ear, Nose and Throat, West Suffolk Hospitals NHS Trust, Bury Saint Edmunds, UK
| | - Laura Leach
- Department of Ear, Nose and Throat, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Michael Chen-Xu
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Lucy Truman
- Department of Ear, Nose and Throat, West Suffolk Hospitals NHS Trust, Bury Saint Edmunds, UK
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13
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Уханова ЮА, Иловайская ИА, Терпигорев СА. [Panhypopituitarism as the first manifestation of sarcoidosis: case report]. PROBLEMY ENDOKRINOLOGII 2022; 68:46-51. [PMID: 36104964 PMCID: PMC9762432 DOI: 10.14341/probl13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 01/09/2023]
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology characterized by the formation of noncaseating granulomas in various organs and tissues and the activation of T-cells at the site of granulomatous inflammation with the release of various chemokines and cytokines [1]. The incidence on average ranges from 10 to 20 per 100,000 population [2]. Most often in patients with sarcoidosis, lesions of the lungs and intrathoracic lymph nodes are detected. Significantly less often (in about 5-20% of patients) damage to the nervous system is noted [6,7,9]. In 9-18% of patients with neurosarcoidosis, involvement of the pituitary gland, pituitary infundibulum and hypothalamus is found, which is manifested by a variety of clinical symptoms [8,10]. We observed a patient with sarcoidosis whose disease debuted with clinical symptoms of hypogonadism, followed by the development of signs of secondary hypothyroidism, adrenal insufficiency, and diabetes insipidus, which was initially regarded as panhypopituitarism against the background of a hypothalamic lesion of unknown origin. Later, additional examination revealed signs of intrathoracic lymphadenopathy and focal changes in the lung parenchyma on CT, as well as skin lesions. Despite the biochemical compensation of hypopituitarism, the clinical efficacy of hormonal therapy with cabergoline, testosterone, hydrocortisone and levothyroxine sodium was insufficient, and the patient's condition improved after the addition of immunosuppressive and anti-inflammatory therapy with methotrexate and methylprednisolone.
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Affiliation(s)
- Ю. А. Уханова
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - И. А. Иловайская
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - С. А. Терпигорев
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
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14
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Takahashi Y, Kameda H, Miya A, Nomoto H, Cho KY, Nakamura A, Nishimura H, Kimura H, Suzuki M, Konno S, Shimizu A, Matsuno Y, Okamoto M, Motegi H, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Miyoshi H, Atsumi T. Lymphocytic panhypophysitis and anti-rabphilin-3A antibody with pulmonary sarcoidosis. Pituitary 2022; 25:321-327. [PMID: 35088194 DOI: 10.1007/s11102-021-01200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To explore the clinical significance of anti-rabphillin-3A antibody for the differential diagnosis of lymphocytic panhypophysitis. METHODS AND RESULTS A 58-year-old Japanese man developed uveitis of unknown cause in 2017. In 2019, he became aware of polyuria. In August 2020, he noticed transient diplopia and was diagnosed with right abducens nerve palsy. At the same time, he complained of fatigue and loss of appetite. Head magnetic resonance imaging demonstrated enlargement of the pituitary stalk and pituitary gland, corresponding to hypophysitis. Hormone stimulation tests showed blunted responses with respect to all anterior pituitary hormones. Central diabetes insipidus was diagnosed on the basis of a hypertonic saline loading test. Taking these findings together, a diagnosis of panhypopituitarism was made. Computed tomography showed enlargement of hilar lymph nodes. Biopsies of the hilar lymph nodes revealed non-caseating epithelioid cell granulomas that were consistent with sarcoidosis. Biopsy of the anterior pituitary revealed mild lymphocyte infiltration in the absence of IgG4-positive cells, non-caseating granulomas, or neoplasia. Western blotting revealed the presence of anti-rabphilin-3A antibody, supporting a diagnosis of lymphocytic panhypophysitis. Because the patient had no visual impairment or severe uveitis, we continued physiological hormone replacement therapy and topical steroid therapy for the uveitis. CONCLUSION To the best of our knowledge, this is the first case of anti-rabphilin 3A antibody positive lymphocytic panhypophysitis comorbid with sarcoidosis, diagnosed by both pituitary and hilar lymph node biopsy. The utility of anti-rabphilin-3A antibody for the differential diagnosis of hypophysitis like this case should be clarified with further case studies.
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Affiliation(s)
- Yuka Takahashi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiraku Kameda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Aika Miya
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kyu Yong Cho
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Akinobu Nakamura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hiroki Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ai Shimizu
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Michinari Okamoto
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Motegi
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Iwata
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
- Department of Endocrinology and Diabetes, Daido Hospital, Nagoya, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Toyoake, Japan
| | - Hideaki Miyoshi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
- Division of Diabetes and Obesity, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N-15, W-7, Kita-ku, Sapporo, 060-8638, Japan
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15
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Milojevic IG, Sobic-Saranovic D, Milojevic B, Artiko VM. Muscular sarcoidosis in the eyes of 18 F-FDG PET/CT. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:399-404. [PMID: 34951698 DOI: 10.1002/jcu.23120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/24/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE The aim of this study was to determine the frequency, symptoms, activity and pattern of muscle sarcoidosis, correlation with laboratory parameters, and to assess its therapy response with 18 F-FDG PET/CT. METHODS Study included 90 patients with biopsy confirmed sarcoidosis and symptoms/biochemical/imaging findings suggestive of active disease. The exclusion criteria were: presence of cancer or other diseases that resemble sarcoidosis on PET/CT (Wegener syndrome, tuberculosis, aspergillosis), and the glucose level being greater than 11 mmol/L. All patients were screened for muscle sarcoidosis with 18 F-FDG PET/CT examination. Follow-up examination was done 1 year after the baseline in order to evaluate therapy response. RESULTS Disease was very rare and present in only 7/90 patients. Most of the patients had polysymptomatic disease, while muscle pain was less frequent, present only in one-third of the patients. The disease was usually present in the lower limbs, upper limbs, and skeletal striated muscles. The most common pattern of disease was nodular. Disease activity estimated with SUVmax was not in correlation with the ACE findings, creatine kinase, and aldolase levels (p > 0.05). Follow-up PET/CT revealed complete remission in one patient and partial remission in two. CONCLUSION 18 F-FDG PET/CT can be useful in asymptomatic young patients with nodular pattern of disease, who have easily relapsing form of disease. It can help in further management of these patients and can affect prognosis of the disease, since most of the laboratory parameters in this entity are within normal limits.
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Affiliation(s)
- Isidora Grozdic Milojevic
- Center for Nuclear Medicine, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragana Sobic-Saranovic
- Center for Nuclear Medicine, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bogomir Milojevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Urology, Clinical Center of Serbia, Belgrade, Serbia
| | - Vera M Artiko
- Center for Nuclear Medicine, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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16
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Sidorin VS, Zabrodskaya YM, Sitovskaya DA, Potemkina EG, Panaskov AV, Lyapakova MO, Sokolova TV. [Isolated sarcoidosis of the brain]. Arkh Patol 2022; 84:56-61. [PMID: 35880601 DOI: 10.17116/patol20228404156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Sarcoidosis is a granulomatous multisystem disease of unclear etiology. Among the many local lesions of different localization, lesions of the central and peripheral nervous system (neurosarcoidosis) are distinguished as particularly unfavorable manifestations of the disease. Only in rare cases, neurosarcoidosis can manifest as isolated or primary. Biopsy remains the gold standard for the diagnosis of neurosarcoidosis. However, significant difficulties remain in verifying the diagnosis, especially with an isolated variant of the lesion A rare case of isolated neurosarcoidosis with a primary focus in the right hemisphere of the brain is described. The data of histological, histochemical and immunohistochemical examination of the surgical material are presented.
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Affiliation(s)
- V S Sidorin
- Polenov Neurosurgical Institute - Branch of Almazov National Medical Research Center, Saint Petersburg, Russia
| | - Yu M Zabrodskaya
- Polenov Neurosurgical Institute - Branch of Almazov National Medical Research Center, Saint Petersburg, Russia
| | - D A Sitovskaya
- Polenov Neurosurgical Institute - Branch of Almazov National Medical Research Center, Saint Petersburg, Russia
| | - E G Potemkina
- Polenov Neurosurgical Institute - Branch of Almazov National Medical Research Center, Saint Petersburg, Russia
| | - A V Panaskov
- Bayandin Murmansk Regional Clinical Hospital, Murmansk, Russia
| | - M O Lyapakova
- Bayandin Murmansk Regional Clinical Hospital, Murmansk, Russia
| | - T V Sokolova
- Polenov Neurosurgical Institute - Branch of Almazov National Medical Research Center, Saint Petersburg, Russia
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17
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Mehta A, Khan F, Wagner C, Hashemzadeh T, Stemer A, Sloan EA, Mayson D, Amjad F. A Case of Neurosarcoid Presenting as Multiple Intraparenchymal Hemorrhages. Neurohospitalist 2022; 12:162-166. [PMID: 34950407 PMCID: PMC8689526 DOI: 10.1177/19418744211029495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
This report explores the case of a 49-year-old African American male with a six-month history of multifocal neurological deficits who presented to an outside hospital after a generalized seizure. Patient was transferred to our tertiary medical center after brain imaging showed multiple bilateral supratentorial intraparenchymal hemorrhages (IPH). A brain biopsy confirmed parenchymal and perivascular non-caseating granulomas with vasculitis. The patient was definitively diagnosed with neurosarcoidosis (NS) and his condition improved with high dose corticosteroids and additional immunosuppressive therapies. Intracranial hemorrhage in the setting of NS is extremely rare, with fewer than thirty documented cases; however, this is likely an underestimation of its true prevalence. This case illustrates the difficulty in diagnosis as many other etiologies of IPH must be considered. Additionally, the clinical course and manifestations of NS is often quite variable. The uniqueness of this case lies in the rapid progression from seemingly incidental microhemorrhages to multiple large IPHs over two months. While the cause of this progression is not immediately apparent, a possible cause may be inadequate initial treatment due to delayed diagnosis. Our case demonstrates the importance of early recognition and initiation of immunosuppressive therapy, potentially leading to dramatic clinical improvement, as seen in this patient.
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Affiliation(s)
- Amit Mehta
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA,Amit Mehta, Department of Neurology, MedStar Georgetown University Hospital, Washington, DC 20007, USA.
| | - Fahad Khan
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chris Wagner
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Taymour Hashemzadeh
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Andrew Stemer
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Emily A Sloan
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA,Department of Pathology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Douglas Mayson
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faria Amjad
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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18
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Overcoming the Elusiveness of Neurosarcoidosis: Learning from Five Complex Cases. Neurol Int 2021; 13:130-142. [PMID: 33805852 PMCID: PMC8103283 DOI: 10.3390/neurolint13020013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 01/06/2023] Open
Abstract
The involvement of the central nervous system in sarcoidosis can manifest with a variety of neurological symptoms, and most of them can be nonspecific. The diagnosis of neurosarcoidosis (NS) can therefore be very challenging without a tissue biopsy. Both computed tomography (CT) and magnetic resonance imaging (MRI) are important imaging modalities in the diagnosis of NS, and MRI is the modality of choice due to its superior soft-tissue contrast resolution. We present a case series of NS with interesting neuroimaging features, complex neurological presentations, and clinical courses. We identify five cases presenting with clinically isolated neurosarcoidosis (CINS) without any other signs or symptoms of systemic disease which were diagnosed as NS on biopsy. In the first case, we describe a patient with an intramedullary cervical spinal cord lesion. In the second case we describe a patient presenting with inflammatory changes and enhancement in the orbit. The third case demonstrates a lesion with calcification around the region of the foramen of Monro. The fourth case shows multiple ring-enhancing lesions. Lastly, the fifth case exhibits unusual findings with both optic neuritis and a cerebellar nodule. We aim to describe the complicated clinical course with neurological workup, neuro-imaging, and eventual diagnosis and treatment of these challenging cases to highlight the variable presentations of NS. This case series will remind clinicians that NS should always be in the differential diagnosis when a patient presents with nonspecific neurological symptoms with unusual neuroimaging findings.
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19
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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20
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Juneja A, Anand K, Mahajan R. Neurosarcoidosis presenting as recurrent polyneuritis cranialis. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_128_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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21
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Abrantes FF, Moraes MPMD, Rezende Filho FM, Pedroso JL, Barsottini OGP. A clinical approach to hypertrophic pachymeningitis. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:797-804. [PMID: 33295420 DOI: 10.1590/0004-282x20200073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms. OBSERVATIONS HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor. CONCLUSION HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.
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Affiliation(s)
- Fabiano Ferreira Abrantes
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Flávio Moura Rezende Filho
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | - José Luiz Pedroso
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
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22
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Voortman M, Stern BJ, Saketkoo LA, Drent M. The Burden of Neurosarcoidosis: Essential Approaches to Early Diagnosis and Treatment. Semin Respir Crit Care Med 2020; 41:641-651. [PMID: 32777849 DOI: 10.1055/s-0040-1710576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neurosarcoidosis (NS) is an often severe, destructive manifestation with a likely under-reported prevalence of 5 to 15% of sarcoidosis cases, and in its active phase demands timely treatment intervention. Clinical signs and symptoms of NS are variable and wide-ranging, depending on anatomical involvement. Cranial nerve dysfunction, cerebrospinal parenchymal disease, aseptic meningitis, and leptomeningeal disease are the most commonly recognized manifestations. However, non-organ-specific potentially neurologically driven symptoms, such as fatigue, cognitive dysfunction, and small fiber neuropathy, appear frequently.Heterogeneous clinical presentations and absence of any single conclusive test or biomarker render NS, and sarcoidosis itself, a challenging definitive diagnosis. Clinical suspicion of NS warrants a thorough systemic and neurologic evaluation hopefully resulting in supportive extraneural physical exam and/or tissue findings. Treatment targets the severity of the manifestation, with careful discernment of whether NS reflects active potentially reversible inflammatory granulomatous disease versus inactive postinflammatory damage whereby functional impairment is unlikely to be pharmacologically responsive. Non-organ-specific symptoms are poorly understood, challenging in deciphering reversibility and often identified too late to respond to conventional immunosuppressive/pharmacological treatment. Physical therapy, coping strategies, and stress reduction may benefit patients with all disease activity levels of NS.This publication provides an approach to screening, diagnosis, disease activity discernment, and pharmacological as well as nonpharmacological treatment interventions to reduce disability and protect health-related quality of life in NS.
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Affiliation(s)
- Mareye Voortman
- Division of Heart and Lungs, Department of Pulmonology, University Medical Centre Utrecht, The Netherlands.,ILD Care Foundation Research Team, Ede, The Netherlands
| | - Barney J Stern
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, Louisiana.,Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, University Medical Center, New Orleans, Louisiana.,Louisiana State University and Tulane University Schools of Medicine, New Orleans, Louisiana
| | - Marjolein Drent
- ILD Care Foundation Research Team, Ede, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands.,Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
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23
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Solis JG, Olascoaga Lugo A, Rodríguez Florido MA, Sandoval Bonilla BA, Malagón Rangel J. Neurosarcoidosis Presentation as Adipsic Diabetes Insipidus Secondary to a Pituitary Stalk Lesion and Association with Anti-NMDA Receptor Antibodies. Case Rep Neurol Med 2020; 2020:7956350. [PMID: 32670647 PMCID: PMC7334767 DOI: 10.1155/2020/7956350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 11/23/2022] Open
Abstract
Sarcoidosis is a multisystemic inflammatory disease of unknown cause. It is characterized by the presence of noncaseating granuloma on a biopsy specimen. Clinical presentation varies across case report series with myriad of symptoms ranging from fever, respiratory symptoms, and skin lesions, or atypical symptoms like heart block or neurological symptoms. Hence, we report the case of a 22-year-old woman with encephalitis, a pituitary mass, and adipsic diabetes insipidus. The diagnostic approach did not end on the biopsy of the lesion, which reported noncaseating granulomas; on the contrary, it was the beginning of a path to exclude other causes of the central nervous system granulomas that ended with the diagnosis of the isolated central nervous system sarcoidosis. Also, we report the first proven association between anti-NMDA receptor antibodies and sarcoidosis.
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Affiliation(s)
- Jose Gabriel Solis
- Department of Internal Medicine, Hospital de Especialidades “Dr. Bernardo Sepúlveda Gutiérrez”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - Arturo Olascoaga Lugo
- Department of Internal Medicine, Hospital de Especialidades “Dr. Bernardo Sepúlveda Gutiérrez”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - Marco Antonio Rodríguez Florido
- Department of Pathology, Hospital de Pediatría Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - Bayron Alexander Sandoval Bonilla
- Department of Neurosurgery, Hospital de Especialidades “Dr. Bernardo Sepúlveda Gutiérrez”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
| | - Jose Malagón Rangel
- Department of Internal Medicine, Hospital de Especialidades “Dr. Bernardo Sepúlveda Gutiérrez”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, Mexico
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24
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Dias R, Ferreira IH, Faria R. Viscous Leptomeningeal Pseudotumoural Masses and Multiple Cranial Neuropathy - Severe Presentation of Neurosarcoidosis. Eur J Case Rep Intern Med 2020; 7:001453. [PMID: 32206643 PMCID: PMC7083191 DOI: 10.12890/2020_001453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022] Open
Abstract
We present a case of a 56-year-old man with a history of episcleritis (left) and cluster headache (left) who had a penetrating trauma of the left eye leading to amaurosis 1 month previously. Since then, he developed multiple cranial neuropathy of the right side (V, VII, VIII, IX, X, XI and XII cranial pairs). Magnetic resonance imaging (MRI) revealed an infiltrative lesion of the base of the skull which extended to the retropharyngeal and jugular space, which progressed to multiple leptomeningeal masses extending to the clivus, despite aggressive immunosuppression. Rebiopsy of 1 meningeal mass supported the diagnosis of neurosarcoidosis. The patient finally responded to high-dose prolonged infliximab therapy, with complete remission.
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Affiliation(s)
- Rita Dias
- Serviço de Medicina interna do Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | | | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar do Porto,Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine (UMIB) - ICBAS Universidade do Porto, Porto, Portugal
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25
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Wildner P, Stasiołek M, Matysiak M. Differential diagnosis of multiple sclerosis and other inflammatory CNS diseases. Mult Scler Relat Disord 2020; 37:101452. [DOI: 10.1016/j.msard.2019.101452] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/12/2022]
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26
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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: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [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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Saha BK, Saha A, Beegle S. Measurement of cerebrospinal fluid ACE level in aseptic meningitis: diagnostic? BMJ Case Rep 2019; 12:12/8/e230532. [PMID: 31451467 DOI: 10.1136/bcr-2019-230532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Neurosarcoidosis (NS) is a rare disease, affecting only 3%-10% of patients with sarcoidosis. The clinical presentation can be protean and often represents a diagnostic challenge. Cerebrospinal fluid (CSF) ACE level has poor sensitivity, but high specificity for establishing a diagnosis of NS. We present a case of NS in a middle-aged African American woman who presented with dysphagia and dysphonia. An extensive radiological workup was negative for structural brain disease. CSF studies demonstrated lymphocyte predominant pleocytosis with an elevated ACE level. A diagnosis of possible neurosarcoidosis was made. She responded to systemic steroid therapy with complete resolution of her symptoms over the next five months. In the appropriate clinical setting, an elevated CSF ACE level could be of paramount importance for making a diagnosis of NS.
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Affiliation(s)
- Biplab Kumar Saha
- Pulmonary and Critical Care Medicine, Albany Medical Center Hospital, Albany, New York, USA
| | - Aditi Saha
- Internal Medicine, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Scott Beegle
- Pulmonary and Critical Care Medicine, Albany Medical Center Hospital, Albany, New York, USA
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Ungprasert P, Ryu JH, Matteson EL. Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clin Proc Innov Qual Outcomes 2019; 3:358-375. [PMID: 31485575 PMCID: PMC6713839 DOI: 10.1016/j.mayocpiqo.2019.04.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
The focus of this review is current knowledge about the epidemiology, clinical manifestations, diagnosis, and treatment of both pulmonary sarcoidosis and extrapulmonary sarcoidosis. Although intrathoracic involvement is the hallmark of the disease, present in over 90% of patients, sarcoidosis can affect virtually any organ. Clinical presentations of sarcoidosis are diverse, ranging from asymptomatic, incidental findings to organ failure. Diagnosis requires the presence of noncaseating granuloma and compatible presentations after exclusion of other identifiable causes. Spontaneous remission is frequent, so treatment is not always indicated unless the disease is symptomatic or causes progressive organ damage/dysfunction. Glucocorticoids are the cornerstone of treatment of sarcoidosis even though evidence from randomized controlled studies is lacking. Glucocorticoid-sparing agents and biologic agents are often used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects.
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Key Words
- ATS, American Thoracic Society
- AV, atrioventricular
- CMRI, cardiovascular magnetic resonance imaging
- DLCO, diffusing capacity of the lung for carbon monoxide
- DMARD, disease-modifying antirheumatic drugs
- ECG, electrocardiographic
- ERS, European Respiratory Society
- FDG-PET, 18F-fluorodeoxyglucose–positron emission tomography
- FVC, forced vital capacity
- GI, gastrointestinal tract
- LVEF, left ventricular ejection fraction
- NSAID, nonsteroidal anti-inflammatory drug
- PFT, pulmonary function test
- TBB, transbronchial lung biopsy
- TNF-α, tumor necrosis factor α
- WASOG, World Association of Sarcoidosis and other Granulomatous Disorders
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Affiliation(s)
- Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Address to Patompong Ungprasert, MD, MS, Clinical Epidemiology Unit, 3rd Floor, SIMR Bldg, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Jay H. Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eric L. Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Department of Health Sciences Research (E.L.M.), Mayo Clinic, Rochester, MN
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Nakagami F, Hagiya H, Oyama A, Hongyo K, Nagasawa M, Rakugi H. Swollen Extraocular Muscle and Tingling Extremities. Am J Med 2018; 131:e492-e493. [PMID: 30142316 DOI: 10.1016/j.amjmed.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Futoshi Nakagami
- Department of General Internal Medicine, Osaka University Hospital, Japan
| | - Hideharu Hagiya
- Department of General Internal Medicine, Osaka University Hospital, Japan.
| | - Akane Oyama
- Department of General Internal Medicine, Osaka University Hospital, Japan
| | - Kazuhiro Hongyo
- Department of Geriatric Medicine, Osaka University School of Medicine, Japan
| | - Motonori Nagasawa
- Department of Geriatric Medicine, Osaka University School of Medicine, Japan
| | - Hiromi Rakugi
- Department of Geriatric Medicine, Osaka University School of Medicine, Japan
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31
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Blume C, Tuleta I, Nolte K, Eichhorn KW, Jakob M, Clusmann H, Send T. Neurosarcoidosis As a Rare Differential Diagnosis for Single Or Multiple Lesions of the Nervous System. Br J Neurosurg 2018; 34:495-499. [PMID: 30295542 DOI: 10.1080/02688697.2018.1506094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Sarcoidosis is a multisystemic granulomatous disease of unknown cause which affects the lung or bilateral hilar lymphadenopathy in over 90% of the cases. Neurosarcoidosis (NS) is rare and accounts for approximately 5 - 15% of the cases. Involvement of all parts of the central and peripheral nervous system is possible with various clinical symptoms, e. g. seizures, hydrocephalus, optic/facial nerve palsy or hearing loss.Methods: We screened the neuropathological data bases and the medical records of two neurosurgical university hospitals for cases of NS. All these cases had been verified by surgical biopsy. We retrospectively evaluated the patient's records with special regard to the histopathology reports and specific clinical symptoms.Results: We identified 9 cases of NS between 1994 and 2014 (3 female, 6 male patients). The average age at the time of diagnosis of NS was 41,4 years. Various clinical symptoms like hydrocephalus (n = 3), seizures (n = 1), meningitis (n = 1), optical nerve involvment with vision disorder (n = 1), myelitis with paraplegia (n = 1), mastoiditis with hearing loss (n = 1), back pain syndrome (n = 2) were present. 7 patients were treated with corticosteroids, 1 patient with cyclophosphamide and 1 with a combination of corticosteroids and methotrexate.Conclusion: NS is a rare but potentially life-threatening disease. It is difficult to distinguish sarcoidosis from other granulomatous diseases, infectious diseases like tuberculosis, multiple sclerosis or neoplasm. For a definite diagnosis, a neurosurgical biopsy with histological evidence of noncaseating epithelioid cell granulomas is required, followed by multidisciplinary treatment.
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Affiliation(s)
- Christian Blume
- Department of Neurosurgery, University of Aachen (RWTH), Aachen, Germany
| | - Izabela Tuleta
- Department of Internal Medicine II, Cardiology and Pulmonology, University of Bonn, Bonn, Germany
| | - Kay Nolte
- Institute of Neuropathology, University of Aachen (RWTH), Germany
| | - Klaus W Eichhorn
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
| | - Mark Jakob
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University of Aachen (RWTH), Aachen, Germany
| | - Thorsten Send
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
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32
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Girasoli L, Cazzador D, Padoan R, Nardello E, Felicetti M, Zanoletti E, Schiavon F, Bovo R. Update on Vertigo in Autoimmune Disorders, from Diagnosis to Treatment. J Immunol Res 2018; 2018:5072582. [PMID: 30356417 PMCID: PMC6178164 DOI: 10.1155/2018/5072582] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/03/2018] [Indexed: 12/18/2022] Open
Abstract
The prevalence of autoimmune diseases has been increasing over the last 20 years. The clinical presentation of this large and heterogeneous group of disorders depends on whether the involvement is organ-specific or non-organ-specific. Dizziness, vertigo, and disequilibrium are common symptoms reported by patients with vestibulocochlear involvement. The association of vertigo and autoimmune diseases has been largely documented, suggesting that autoimmune disorders could be overrepresented in patients with vertigo in comparison to the general population. The aim of this review is to present the recent literature findings in the field of autoimmune-mediated diseases with cochleovestibular involvement, focusing on the clinical presentation, diagnosis, and treatment of immune-mediated inner ear diseases including autoimmune inner ear disease (AIED), Meniere's disease, and bilateral vestibulopathy, as well as of systemic autoimmune diseases with audiovestibular disorders, namely, Behçet's disease, Cogan's syndrome, sarcoidosis, autoimmune thyroid disease, Vogt-Koyanagi-Harada syndrome, relapsing polychondritis, systemic lupus erythematosus, antiphospholipid syndrome, IgG4-related disease, and ANCA-associated vasculitides.
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Affiliation(s)
- Laura Girasoli
- Department of Neurosciences, Otorhinolaryngology Unit, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Diego Cazzador
- Department of Neurosciences, Otorhinolaryngology Unit, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Roberto Padoan
- Department of Medicine DIMED, Operative Unit of Rheumatology, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Ennio Nardello
- Department of Neurosciences, Otorhinolaryngology Unit, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Mara Felicetti
- Department of Medicine DIMED, Operative Unit of Rheumatology, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Elisabetta Zanoletti
- Department of Neurosciences, Otorhinolaryngology Unit, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Franco Schiavon
- Department of Medicine DIMED, Operative Unit of Rheumatology, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Roberto Bovo
- Department of Neurosciences, Otorhinolaryngology Unit, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
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33
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Vereecken M, Hollanders K, De Bruyn D, Ninclaus V, De Zaeytijd J, De Schryver I. An atypical case of neurosarcoidosis presenting with neovascular glaucoma. J Ophthalmic Inflamm Infect 2018; 8:7. [PMID: 29671151 PMCID: PMC5906415 DOI: 10.1186/s12348-018-0149-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 03/19/2018] [Indexed: 01/27/2023] Open
Abstract
Background Sarcoidosis, a multisystem, granulomatous disorder, sometimes manifests with a neuro-ophthalmic subtype. The latter can pose a diagnostic challenge, especially when ocular symptoms appear before systemic involvement, as the clinical picture then can be non-specific and systemic laboratory and standard imaging investigations can be negative. Findings A 71-year-old woman presented with a 4-month history of sudden-onset visual loss in the left eye. Slit lamp examination revealed anterior chamber cells, iris, and angle neovascularization. Fundoscopy showed a pale edematous optic nerve head surrounded with intraretinal hemorrhages and yellow retinal infiltrates. The vasculature was very narrow to absent. Indeed, fluorescein angiography filling was limited to the (juxta-)papillary region. An extensive systemic work-up revealed a monoclonal gammopathy and absence of any inflammatory markers. On MRI, a mass infiltration of the intraorbital and the intracranial optic nerve was visible. Additional PET-CT scan revealed hilar lymph nodes. A transbronchial biopsy demonstrating a non-caseating granulomatous lesion led to the diagnosis of sarcoidosis and thus neurosarcoidosis. Treatment with high-dose prednisone and azathioprine was started to avoid progression and subsequent visual loss in the other eye. Conclusions A patient with neurosarcoidosis presenting with compressive ischemic optic disc edema and neovascular glaucoma is described, increasing the diversity of clinical presentations and confirming the diagnostic challenge of neurosarcoidosis.
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Affiliation(s)
- Melissa Vereecken
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Karolien Hollanders
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Deborah De Bruyn
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Virginie Ninclaus
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Julie De Zaeytijd
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Ilse De Schryver
- Department of Ophthalmology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
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34
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Galnares-Olalde JA, Berebichez-Fridman R, Gómez-Garza G, Mercado M, Moreno-Sánchez F, Alegría-Loyola MA. Not everything is as it seems: neurosarcoidosis presenting as leptomeningitis. Clin Case Rep 2018; 6:596-602. [PMID: 29636921 PMCID: PMC5889254 DOI: 10.1002/ccr3.1418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 01/01/2018] [Accepted: 01/20/2018] [Indexed: 12/17/2022] Open
Abstract
Involvement of the central nervous system in sarcoidosis is rare; neurosarcoidosis, although unusual, can present as leptomeningitis. The diagnosis is usually difficult because of the vague and broad symptomatology; therefore, a prompt diagnosis should be made, and adequate treatment should be administered to reduce morbidity and mortality.
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Affiliation(s)
- Javier Andrés Galnares-Olalde
- American British Cowdray Medical Center Mexico City Mexico.,School of Medicine Faculty of Health Sciences Anahuac University Mexico North Campus Huixquilucan Mexico
| | - Roberto Berebichez-Fridman
- American British Cowdray Medical Center Mexico City Mexico.,School of Medicine Faculty of Health Sciences Anahuac University Mexico North Campus Huixquilucan Mexico
| | | | - Moisés Mercado
- American British Cowdray Medical Center Mexico City Mexico
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35
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Maskery MP, Cooper PN, Pace A. Neurosarcoidosis associated with intracerebral haemorrhage: a challenge in diagnosis and management. Pract Neurol 2018; 18:246-249. [PMID: 29363557 DOI: 10.1136/practneurol-2017-001794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2017] [Indexed: 11/04/2022]
Abstract
Sarcoidosis is an idiopathic multisystem granulomatous disorder of unknown cause. Nervous system involvement (central and/or peripheral) is uncommon, developing in 5%-10%. The presenting symptoms are variable, reflecting the level of involvement, and frequently fluctuate and progress. Diagnosing neurosarcoidosis in people with previously confirmed systemic disease may be relatively straightforward, but diagnosing primary neurosarcoidosis is challenging. Managing neurosarcoidosis is primarily consensus based; corticosteroid is its mainstay, alongside corticosteroid-sparing agents and emerging novel therapies. We describe a 39-year-old woman who presented with cranial neuropathy. Serial imaging, cerebrospinal fluid sampling and tissue biopsy gave a diagnosis of probable neurosarcoidosis. Her clinical course was complicated by intracerebral haemorrhage following intravenous corticosteroids for neurological relapse. This is a very rare complication of neurosarcoidosis; we discuss its possible causes and suggest ways to reduce its risk.
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Affiliation(s)
- Mark Peter Maskery
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Paul N Cooper
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Adrian Pace
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
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36
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Rudie JD, Rauschecker AM, Nabavizadeh SA, Mohan S. Neuroimaging of Dilated Perivascular Spaces: From Benign and Pathologic Causes to Mimics. J Neuroimaging 2017; 28:139-149. [PMID: 29280227 DOI: 10.1111/jon.12493] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 12/22/2022] Open
Abstract
Perivascular spaces (PVSs), also known as Virchow-Robin spaces, are pial-lined, fluid-filled structures found in characteristic locations throughout the brain. They can become abnormally enlarged or dilated and in rare cases can cause hydrocephalus. Dilated PVSs can pose a diagnostic dilemma for radiologists because of their varied appearance, sometimes mimicking more serious entities such as cystic neoplasms, including dysembryoplastic neuroepithelial tumor and multinodular and vacuolating neuronal tumor, or cystic infections including toxoplasmosis and neurocysticercosis. In addition, various pathologic processes, including cryptococcosis and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids, can spread into the brain via PVSs, resulting in characteristic magnetic resonance imaging appearances. This review aims to describe the key imaging characteristics of normal and dilated PVSs, as well as cystic mimics and pathologic processes that directly involve PVSs.
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Affiliation(s)
- Jeffrey D Rudie
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andreas M Rauschecker
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Seyed A Nabavizadeh
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Suyash Mohan
- Department of Radiology, Division of Neuroradiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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38
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Abstract
Neurosarcoidosis occurs in 3% to 10% of patients with sarcoidosis. Cranial neuropathy and meningeal involvement are the most common manifestations, but any part of the nervous system can be affected. Definite diagnosis requires the presence of noncaseating granuloma in the nervous system, although histopathologic confirmation is often not obtainable. Moderate to high dose of glucocorticoids is the main therapy for neurosarcoidosis. Relapse often occurs after the dose of glucocorticoids is tapered down, often necessitating the use of steroid-sparing immunosuppressive agents.
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Affiliation(s)
- Patompong Ungprasert
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA; Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkok 10700, Thailand.
| | - Eric L Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA; Division of Epidemiology, Department of Health Science Research, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA
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39
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Ungprasert P, Crowson CS, Matteson EL. Characteristics and Long-Term Outcome of Neurosarcoidosis: A Population-Based Study from 1976-2013. Neuroepidemiology 2017; 48:87-94. [PMID: 28601860 DOI: 10.1159/000477300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 05/04/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Neurosarcoidosis is a rare condition with serious health consequences. However, little is known about clinical characteristics and outcome of neurosarcoidosis in the community setting. METHODS Patients with neurosarcoidosis were identified from a previously described cohort of patients with incident sarcoidosis from Olmsted County, Minnesota, United States from 1976 to 2013 using individual medical record review. Data on clinical characteristics, treatment, and outcome were collected. RESULTS Neurological involvement by sarcoidosis occurred in 11 patients (3% of all patients with sarcoidosis). Cranial neuropathy was the most common type of neurological disease (5 patients; 45%) followed by peripheral neuropathy (3 patients; 27%), and meningitis (3 patients; 27%). Cerebrospinal fluid (CSF) pleocytosis and elevated CSF protein levels were observed in patients with meningitis, intramedullary spinal cord sarcoidosis, intracranial mass lesion and some patients with cranial neuropathy but were normal in patients with peripheral neuropathy. All patients received high-dose glucocorticoids as initial treatment and almost all responded to this therapy. Relapse after glucocorticoid dose reduction necessitated subsequent treatment with steroid-sparing agents in 4 patients. CONCLUSION Neurosarcoidosis is an uncommon manifestation of sarcoidosis. Neurosarcoidosis manifestations generally responded well to high-dose glucocorticoids in the majority of patients, but relapse was common.
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Affiliation(s)
- Patompong Ungprasert
- Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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40
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Balevic SJ, Shah A. Islands of Inflammation: Neurosarcoidosis. Am J Med 2017; 130:157-160. [PMID: 27742263 DOI: 10.1016/j.amjmed.2016.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen J Balevic
- Division of Rheumatology, Duke University School of Medicine, Durham, NC.
| | - Ankoor Shah
- Division of Rheumatology, Duke University School of Medicine, Durham, NC; Division of Immunology, Duke University School of Medicine, Durham, NC
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41
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O’Connell K, Williams L, Jones J, McCabe DJH, Murphy D, Killeen R, Tubridy N, O’Riordan S, McGuigan C. Neurosarcoidosis: clinical presentations and changing treatment patterns in an Irish Caucasian population. Ir J Med Sci 2017; 186:759-766. [DOI: 10.1007/s11845-016-1539-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/24/2016] [Indexed: 01/23/2023]
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42
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Bilgin Topçuoğlu Ö, Kavas M, Öztaş S, Arınç S, Afşar G, Saraç S, Midi İ. EEG in Sarcoidosis Patients Without Neurological Findings. Clin EEG Neurosci 2017; 48:54-59. [PMID: 27107024 DOI: 10.1177/1550059416646651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/27/2016] [Accepted: 04/01/2016] [Indexed: 11/15/2022]
Abstract
Sarcoidosis is a multisystem granulomatous disease affecting nervous system in 5% to 10% of patients. Magnetic resonance imaging (MRI) is accepted as the most sensitive method for detecting neurosarcoidosis. However, the most common findings in MRI are the nonspecific white matter lesions, which may be unrelated to sarcoidosis and can occur because of hypertension, diabetes mellitus, smoking, and other inflammatory or infectious disorders, as well. Autopsy studies report more frequent neurological involvement than the ante mortem studies. The aim of this study is to assess electroencephalography (EEG) in sarcoidosis patients without neurological findings in order to display asymptomatic neurological dysfunction. We performed EEG on 30 sarcoidosis patients without diagnosis of neurosarcoidosis or prior neurological comorbidities. Fourteen patients (46.7%) showed intermittant focal and/or generalized slowings while awake and not mentally activated. Seven (50%) of these 14 patients with EEG slowings had nonspecific white matter changes while the other half showed EEG slowings in the absence of MRI changes. We conclude that EEG slowings, when normal variants (psychomotor variant, temporal theta of elderly, frontal theta waves) are eliminated, may be an indicator of dysfunction in brain activity even in the absence of MRI findings. Hence, EEG may contribute toward detecting asymptomatic neurological dysfunction or probable future neurological involvement in sarcoidosis patients.
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Affiliation(s)
- Özgür Bilgin Topçuoğlu
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Neurology, Istanbul, Turkey .,School of Medicine, Marmara University, Department of Neurology, Istanbul, Turkey
| | - Murat Kavas
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Chest Diseases, Istanbul, Turkey
| | - Selahattin Öztaş
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Chest Diseases, Istanbul, Turkey
| | - Sibel Arınç
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Chest Diseases, Istanbul, Turkey
| | - Gülgün Afşar
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Chest Diseases, Istanbul, Turkey
| | - Sema Saraç
- Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, Department of Chest Diseases, Istanbul, Turkey
| | - İpek Midi
- School of Medicine, Marmara University, Department of Neurology, Istanbul, Turkey
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43
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Cohen Aubart F, Galanaud D, Haroche J, Psimaras D, Mathian A, Hié M, Le-Thi Huong Boutin D, Charlotte F, Maillart E, Maisonobe T, Amoura Z. [Neurosarcoidosis: Diagnosis and therapeutic issues]. Rev Med Interne 2016; 38:393-401. [PMID: 27884456 DOI: 10.1016/j.revmed.2016.10.392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/17/2016] [Accepted: 10/24/2016] [Indexed: 12/15/2022]
Abstract
Neurological localizations of sarcoidosis are heterogeneous and may affect virtually every part of the central or peripheral nervous system. They are often the inaugural manifestation of sarcoidosis. The diagnosis may be difficult due to the lack of extra-neurological localization. Diagnosis may be discussed in the presence of an inflammatory neurological disease, in particular in case of suggestive radiological or biological pattern. Cerebrospinal fluid analysis shows lymphocytic pleiocytosis, often with low glucose level. The diagnosis relies on a clinical, biological and radiological presentation consistent with neurosarcoidosis, the presence of non-caseating granuloma and exclusion of differential diagnoses. Screening for other localizations of sarcoidosis, in particular cardiac disease may be obtained during neurosarcoidosis. The treatment of neurosarcoidosis relies on corticosteroids although immunosuppressive drugs are usually added because of the chronic course of this condition and to limit the side effects of steroids. Treatments and follow-up may be prolonged because of the high rate of relapses.
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Affiliation(s)
- F Cohen Aubart
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Paris VI, Sorbonnes universités, 75013 Paris, France.
| | - D Galanaud
- Université Paris VI, Sorbonnes universités, 75013 Paris, France; Service de neuroradiologie, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - J Haroche
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Paris VI, Sorbonnes universités, 75013 Paris, France
| | - D Psimaras
- Service de neurologie, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - A Mathian
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - M Hié
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - D Le-Thi Huong Boutin
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - F Charlotte
- Service d'anatomo-pathologie, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - E Maillart
- Fédération des maladies du système nerveux, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - T Maisonobe
- Départements de neurophysiologie et neuropathologie, hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Z Amoura
- Service de médecine interne 2, institut e3M, hôpital de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Paris VI, Sorbonnes universités, 75013 Paris, France
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Al-Kofahi K, Korsten P, Ascoli C, Virupannavar S, Mirsaeidi M, Chang I, Qaqish N, Saketkoo LA, Baughman RP, Sweiss NJ. Management of extrapulmonary sarcoidosis: challenges and solutions. Ther Clin Risk Manag 2016; 12:1623-1634. [PMID: 27853374 PMCID: PMC5106225 DOI: 10.2147/tcrm.s74476] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Sarcoidosis is a chronic multisystem disease of unknown etiology characterized by noncaseating granulomas that most often involves the lungs, but frequently has extrapulmonary manifestations, which might be difficult to treat in individual patients. Objective To review different disease manifestations, focusing on extrapulmonary organ systems, and to provide treatment options for refractory cases. Materials and methods We performed a literature search using Medline and Google Scholar for individual or combined keywords of “sarcoidosis, extrapulmonary, treatment, kidney, neurosarcoidosis, cardiovascular, gastrointestinal, transplantation, musculoskeletal, rheumatology, arthritis, and skin”. Peer-reviewed articles, including review articles, clinical trials, observational trials, and case reports that were published in English were included. References from retrieved articles were also manually searched for relevant articles. Results and conclusion Isolated involvement of a single organ or organ system is rare in sarcoidosis, and thus all patients must be thoroughly evaluated for additional disease manifestations. Cardiac sarcoidosis and neurosarcoidosis may be life-threatening. Clinicians need to assess patients comprehensively using clinical, laboratory, imaging, and histopathological data to recommend competently the best and least toxic treatment option for the individual patient.
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Affiliation(s)
- Khalid Al-Kofahi
- Department of Molecular Biosciences, University of Kansas, Lawrence, KS, USA
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
| | | | - Mehdi Mirsaeidi
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Ian Chang
- Department of Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Naim Qaqish
- Department of Gastroenterology, Hepatology and Nutrition, University of Buffalo, Buffalo, NY
| | - Lesley A Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Robert P Baughman
- Department of Medicine, University Medical Center of Cincinnati, Cincinnati, OH, USA
| | - Nadera J Sweiss
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL; Division of Rheumatology, University of Illinois at Chicago, Chicago, IL
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Labarca G, Ramirez R, Monsalve X, Mira-Avendano I. Dementia, gait disturbance, and urinary incontinence in a patient with pulmonary sarcoidosis. Respirol Case Rep 2016; 4:e00182. [PMID: 28127435 PMCID: PMC5256957 DOI: 10.1002/rcr2.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/08/2022] Open
Abstract
Hydrocephalus is an uncommon presentation of neurosarcoidosis. We discuss the case of a 67-year-old woman with a prior diagnosis of hypothyroidism, systemic hypertension, and lung sarcoidosis who presented with a 1-month history of progressive impairment of consciousness leading to prostration and loss of sphincter control. At admission, patient was febrile with altered speech and without focalization. Laboratory results showed leucocytosis and mild anaemia. Cerebrospinal fluid (CSF) analysis was characterized by mild elevated protein level, increased cell count, normal glucose and adenosine deaminase (ADA), negative cytology, and no bacterial isolations. Electroencephalogram showed toxic-metabolic encephalopathy. Computed tomography (CT) of the brain revealed hydrocephalus without structural damage, and magnetic resonance imaging of the brain demonstrated non-specific diffuse meningeal enhancement and periventricular changes supporting normal pressure hydrocephalus. Chest X-ray showed mediastinal adenopathy and parenchymatous lesions, consistent with stage II lung sarcoidosis. A ventriculoperitoneal shunt was installed, and the patient experienced rapid improvement in her symptoms.
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Affiliation(s)
- Gonzalo Labarca
- Department of Internal Medicine Complejo Asistencial Victor Rios Ruiz Los Ángeles Chile
| | - Romina Ramirez
- Department of Internal Medicine Pontifical Catholic University Santiago Chile
| | - Ximena Monsalve
- Department of Internal Medicine Hospital Sotero del Río Santiago Chile
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46
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Ferriby D, de Sèze J. Neurosarcoidosi. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)78803-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
INTRODUCTION Numerous biomarkers have been evaluated for the diagnosis, assessment of disease activity, prognosis, and response to treatment in sarcoidosis. In this report, we discuss the clinical and research utility of several biomarkers used to evaluate sarcoidosis. Areas covered: The sarcoidosis biomarkers discussed include serologic tests, imaging studies, identification of inflammatory cells and genetic analyses. Literature was obtained from medical databases including PubMed and Web of Science. Expert commentary: Most of the biomarkers examined in sarcoidosis are not adequately specific or sensitive to be used in isolation to make clinical decisions. However, several sarcoidosis biomarkers have an important role in the clinical management of sarcoidosis when they are coupled with clinical data including the results of other biomarkers.
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Affiliation(s)
- Amit Chopra
- a Division of Pulmonary and Critical Care Medicine , Albany Medical College , Albany , NY , USA
| | - Alexandros Kalkanis
- b Department of Medicine , Division of Pulmonary and Critical Care Medicine , Athens , Greece
| | - Marc A Judson
- a Division of Pulmonary and Critical Care Medicine , Albany Medical College , Albany , NY , USA
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48
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Abstract
Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.
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Anthony J, Esper GJ, Ioachimescu A. Hypothalamic-pituitary sarcoidosis with vision loss and hypopituitarism: case series and literature review. Pituitary 2016; 19:19-29. [PMID: 26267304 DOI: 10.1007/s11102-015-0678-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE Hypothalamic-pituitary (HP) neurosarcoidosis (NS) accounts for 0.5 % cases of sarcoidosis and 1 % of HP masses. Correlative data on endocrine and neurological outcomes is lacking. METHODS Retrospective case series and literature review of presentation, treatment and outcome of HP NS. RESULTS Our series includes 4 men, ages 34-59, followed for a median of 7.3 years (range 1.5-17). All had optic neuropathy, multiple pituitary hormone abnormalities (PHAs) and other organ involvement by sarcoidosis (lung, sino-nasal, brain/spine and facial nerve). Two patients had central diabetes insipidus and one impaired thirst with polydipsia. After treatment with high-dose glucocorticoids, optic neuropathy improved in one case and stabilized in the others. After treatment, HP lesions improved radiologically, but PHAs persisted in all cases. Review of four published series on HP NS in addition to ours yielded 46 patients, age 37 ± 11.8 years, 65 % male. PHAs consisted of anterior hypopituitarism (LH/FSH 88.8 %, TSH 67.4 %, GH 50.0 %, ACTH 48.8 %), hyperprolactinemia (48.8 %) and diabetes insipidus (65.2 %). PHAs were the first sign of disease in 54.3 % patients. Vision problems occurred in 28.3 % patients, but optic neuropathy was not well documented in previous series. Most patients (93.5 %) received high-dose glucocorticoids followed by taper; 50 % also received other immunomodulators, including methotrexate, mycophenolate mofetil, cyclosporine, azathioprine, infliximab and hydrochloroquine. Only 13 % patients showed improvement in PHAs. All-cause mortality was 8.7 %. CONCLUSION HP NS is a serious disease requiring multidisciplinary treatment and lifelong follow-up. Prospective multicentric studies are needed to determine a more standardized approach to HP NS and outline predictors of disease outcome.
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Affiliation(s)
- Jeremy Anthony
- Specialty Care, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
- Division of Endocrinology, Department of Medicine, Emory University, 1365 B Clifton Rd., NE, B6209, Atlanta, GA, 30322, USA
| | | | - Adriana Ioachimescu
- Division of Endocrinology, Department of Medicine, Emory University, 1365 B Clifton Rd., NE, B6209, Atlanta, GA, 30322, USA.
- Department of Neurosurgery, Emory University, Atlanta, GA, USA.
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Lal C, Medarov BI, Judson MA. Interrelationship between sleep-disordered breathing and sarcoidosis. Chest 2016; 148:1105-1114. [PMID: 25996391 DOI: 10.1378/chest.15-0584] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sleep-disordered breathing (SDB) has a high prevalence in sarcoidosis. This high prevalence may be the result of increased upper airways resistance from sarcoidosis of the upper respiratory tract, corticosteroid-induced obesity, or parenchymal lung involvement from sarcoidosis. OSA is a form of SDB that is particularly common in patients with sarcoidosis. Sarcoidosis and SDB share many similar symptoms and clinical findings, including fatigue, gas exchange abnormalities, and pulmonary hypertension (PH). Sarcoidosis-associated fatigue is a common entity for which stimulants may be beneficial. Sarcoidosis-associated fatigue is a diagnosis of exclusion that requires an evaluation for the possibility of OSA. Hypercapnia is unusual in a patient with sarcoidosis without severe pulmonary dysfunction and, in this situation, should prompt evaluation for alternative causes of hypercapnia, such as SDB. PH is usually mild when associated with OSA, whereas the severity of sarcoidosis-associated PH is related to the severity of sarcoidosis. PH caused by OSA usually responds to CPAP, whereas sarcoidosis-associated PH commonly requires the use of vasodilators. Management of OSA in sarcoidosis is problematic because corticosteroid treatment of sarcoidosis may worsen OSA. Aggressive efforts should be made to place the patient on the lowest effective dose of corticosteroids, which involves early consideration of corticosteroid-sparing agents. Because of the significant morbidity associated with SDB, early recognition and treatment of SDB in patients with sarcoidosis may improve their overall quality of life.
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Affiliation(s)
- Chitra Lal
- Pulmonary, Critical Care, and Sleep, Charleston, SC.
| | | | - Marc A Judson
- Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY
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