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Larik A, Chiong Y, Lee LC, Ng YS. Longitudinally extensive transverse myelitis associated with dengue fever. BMJ Case Rep 2012; 2012:bcr.12.2011.5378. [PMID: 22605876 DOI: 10.1136/bcr.12.2011.5378] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Longitudinally extensive transverse myelitis (LETM) is usually associated with neuromyelitis optica and other autoimmune and inflammatory disorders but this is the first report linking it with dengue fever. Dengue infection can cause a variety of neurological complications which may result in poor recovery and long-term disability. The authors report here a patient who developed LETM in the para-infectious stage of dengue fever. The patient had a complicated clinical course resulting in severe paraparesis and urinary retention. Treatment with immunoglobulins and antiviral agents supported by a spell of early intensive rehabilitation programme produced excellent results in terms of recovery.
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Affiliation(s)
- Ashfaq Larik
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore.
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52
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Lefèvre G, Zéphir H, Warembourg F, Michelin E, Pruvo JP, Hachulla E, Semah F, Dubucquoi S, Lenfant P, Vermersch P, Hatron PY, Prin L, Launay D. [Neuropsychiatric systemic lupus erythematosus (1st part). Cases definitions and diagnosis and treatment of central nervous system and psychiatric manifestations of systemic lupus erythematosus]. Rev Med Interne 2012; 33:491-502. [PMID: 22579860 DOI: 10.1016/j.revmed.2012.03.356] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/02/2012] [Accepted: 03/31/2012] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease, which primarily affects skin and joints. Peripheral neurologic syndrome and central nervous system (CNS) manifestations are common in lupus patients but are not always attributable to lupus itself. A classification, published in 1999 by the American College of Rheumatology (ACR) research committee, described 12 CNS syndromes and seven peripheral neurologic syndromes compatible with "neuropsychiatric systemic lupus erythematosus" (NPSLE). Despite this consensus, studies which have been published since 1999 have reported a prevalence of NPSLE varying from 20 to 97 %, which shows the diagnosis difficulty and the heterogeneity of neuropsychiatric manifestations in SLE. In order to understand the limits of this classification, we propose in this first part an exhaustive review of publications describing neuropsychiatric manifestations according to the ACR 1999 classification. We also detail case definitions, prevalence and risk factors, clinical characteristics and diagnosis of each lupus-related psychiatric and CNS manifestation.
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Affiliation(s)
- G Lefèvre
- Service de médecine interne, université de Lille Nord-de-France, centre de référence maladies auto-immunes rares (sclérodermie), hôpital Claude-Huriez, CHRU de Lille, 1, rue Michel-Polonovski, 59037 Lille, France; EA2686, Institut d'immunologie, université Lille Nord-de-France, faculté de médecine H.-Warembourg, 59037 Lille, France
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Dierickx D, Beke E, Devos T, Delannoy A. The use of monoclonal antibodies in immune-mediated hematologic disorders. Med Clin North Am 2012; 96:583-619, xi. [PMID: 22703857 DOI: 10.1016/j.mcna.2012.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this article, the evidence on the clinical use of monoclonal antibodies in the treatment of immune-mediated hematologic disorders is described. Insights into pathogenic mechanisms have revealed a major role of both B and T cells. Controlled trials have shown conflicting results, necessitating further research regarding pathogenesis, mechanism of action, and resistance. Although the use of more potent and specific monoclonal antibody therapy, mainly targeting costimulation signals, may improve response rates and long-term outcome, its use should be carefully balanced against potential side effects.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Murine-Derived/pharmacology
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antigens, CD20/immunology
- Basiliximab
- Daclizumab
- Graft vs Host Disease/drug therapy
- Hematologic Diseases/immunology
- Hematologic Diseases/therapy
- Hematopoietic Stem Cell Transplantation/adverse effects
- Humans
- Immunoglobulin G/pharmacology
- Immunoglobulin G/therapeutic use
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Infliximab
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Rituximab
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Affiliation(s)
- Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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White C, Leonard B, Patel A. Longitudinally extensive transverse myelitis: a catastrophic presentation of a flare-up of systemic lupus erythematosus. CMAJ 2011; 184:E197-200. [PMID: 22083679 DOI: 10.1503/cmaj.101213] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Colin White
- Faculty of Medicine, McMaster University, Hamilton, Ont
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Evangelopoulos ME, Koutsis G, Andreadou E, Potagas C, Dimirakopoulos A, Sfagos C. Neuromyelitis optica spectrum disease with positive autoimmune indices: a case report and review of the literature. Case Rep Med 2011; 2011:393568. [PMID: 22110510 PMCID: PMC3206387 DOI: 10.1155/2011/393568] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 08/23/2011] [Accepted: 09/04/2011] [Indexed: 11/17/2022] Open
Abstract
A 45-year-old female suffering from severe thoracic pain was admitted to the emergency department of our hospital. Thorough clinical examination revealed paresis of the left lower limb and sensory deficit at the level of the Th4 vertebra. MRI of the thoracic spine demonstrated a lesion at the level of Th1-Th7. Despite initial improvement following i.v. corticosteroid administration, the patient's clinical status deteriorated, with recurrence of myelitis and extension of the lesion to Th12. She developed paraparesis, hyperreflexia and spasticity of both legs, symmetrical sensory deficit below Th4, and sphincter dysfunction. Differential diagnosis included infectious, metabolic, neoplastic/paraneoplastic, and ischemic causes as well as multiple sclerosis. NMO IgG was found positive and led to the diagnosis of longitudinal extensive transverse myelitis (LETM) in the NMO spectrum disorders. Administration of immunosuppressive therapy resulted in gradual improvement of the patient's clinical status and stabilization for five years. In the setting of LETM, patients with antiaquaporin 4 IgGs can present features of coexisting systemic involvement. A thorough differential diagnosis is required to guide appropriate therapy.
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Affiliation(s)
- M. E. Evangelopoulos
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
| | - G. Koutsis
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
| | - E. Andreadou
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
| | - C. Potagas
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
| | - A. Dimirakopoulos
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
| | - C. Sfagos
- Department of Neurology, Eginition Hospital, University of Athens, 74 Vas. Sophias Avenue, 11528 Athens, Greece
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57
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Piga M, Mathieu A. Managing CNS involvement in systemic lupus erythematosus. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/ijr.11.44] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Eckstein C, Saidha S, Levy M. A differential diagnosis of central nervous system demyelination: beyond multiple sclerosis. J Neurol 2011; 259:801-16. [DOI: 10.1007/s00415-011-6240-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/28/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
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Narváez J, Ríos-Rodriguez V, de la Fuente D, Estrada P, López-Vives L, Gómez-Vaquero C, Nolla JM. Rituximab therapy in refractory neuropsychiatric lupus: current clinical evidence. Semin Arthritis Rheum 2011; 41:364-72. [PMID: 21875742 DOI: 10.1016/j.semarthrit.2011.06.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 05/26/2011] [Accepted: 06/14/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review and summarize published information on the effectiveness and safety of rituximab (RTX) in adult patients with refractory neuropsychiatric systemic lupus erythematosus (NPSLE). METHODS We describe a patient with persistently active NPSLE, despite conventional therapy, who responded dramatically to RTX. Current evidence on the therapeutic use of RTX in this complex situation is also analyzed through a systematic review of the English-language literature, based on a PubMed search. RESULTS Available data on the use of RTX in refractory NPSLE come from a large number of case reports and some open-label studies. Including our case, 35 patients have been well documented. A complete or partial therapeutic response was achieved in 85% of patients after 1 cycle of treatment. A positive correlation between serological markers of disease activity and clinical outcome has also been demonstrated in some of these patients. Clinical improvement was accompanied by a significant reduction in the daily dose of oral corticosteroids. Relapse after RTX treatment was noted in 45% of cases (median 9.5 months; range, 4-33 months). Infections were observed in 29% of patients. CONCLUSION Evidence for the effectiveness of RTX as induction therapy in NPSLE is based solely on several case reports and noncontrolled trials. Although it is not yet possible to make definite recommendations, the global analysis of these cases supports the off-label use of RTX in cases of severe refractory NPSLE.
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Affiliation(s)
- Javier Narváez
- Department of Rheumatology, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain.
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Kitley JL, Leite MI, George JS, Palace JA. The differential diagnosis of longitudinally extensive transverse myelitis. Mult Scler 2011; 18:271-85. [PMID: 21669935 DOI: 10.1177/1352458511406165] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Longitudinally extensive transverse myelitis refers to florid and widespread inflammation of the spinal cord causing T2 hyperintensity on spinal magnetic resonance imaging that is seen to extend over three or more vertebral segments. Whilst rare, longitudinally extensive transverse myelitis is clinically important as it can lead to catastrophic morbidity, and a group of these patients are at risk of further attacks. Early identification and establishment of the underlying aetiology is vital in order to initiate appropriate therapy and optimize outcomes. Whilst longitudinally extensive transverse myelitis is classically associated with neuromyelitis optica, there are many other causes. These include other inflammatory aetiologies, infection, malignancy and metabolic disturbance. Some of these are readily treatable. Laboratory and radiological investigations can help to differentiate these causes. Treatment of longitudinally extensive transverse myelitis hinges on distinguishing inflammatory and non-inflammatory aetiologies and identifying patients who are at high risk of a recurrent course.
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63
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Perrin F, Espitia O, Ponge T, Mussini JM, Hamidou M, Agard C. Myélite longitudinale lupique. Rev Med Interne 2011; 32:302-5. [DOI: 10.1016/j.revmed.2011.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 01/21/2011] [Accepted: 02/03/2011] [Indexed: 10/18/2022]
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Aszalós Z. [Neurological and psychiatric manifestations of systemic lupus erythematosus and antiphospholipid syndrome]. Orv Hetil 2011; 152:597-605. [PMID: 21436024 DOI: 10.1556/oh.2011.29087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neurological or psychiatric symptoms are present in 60% of the cases with systemic lupus erythematosus. Direct lesions of nervous system are associated with the presence of antibodies, vasculitis, thrombosis and impairments mediated by cytokines. Damages caused by injuries of other organs or those due to therapy are known as indirect causes. In the complex pathogenesis the primary cause is neuronal dysfunction mediated by autoantibodies, vasculopathia and coagulopathia. Until now, more than 20 antibodies have been identified in association with damages of the nervous system. These antibodies may impair neurons or astrocytes and may promote thrombotic processes in vessels of the brain. Activation of endothelial cells and disturbance of blood-brain barrier are also pathogenic factors. In patients with systemic lupus erythematosus the most frequent psychiatric manifestations are organic psychosyndrome, particularly deterioration of cognitive functions, and depression, while the most common neurological syndromes are epilepsy and ischemic stroke. In the pathogenesis of antiphospholipid syndrome β2-glycoprotein I plays the most important role; binding to its antibody the complex may interact with cells and modify haemostatic actions. The most frequent neurological manifestations of antiphospholipid syndrome are headache and ischemic stroke.
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Affiliation(s)
- Zsuzsa Aszalós
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest Szentkirályi u. 46. 1088.
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Ye Y, Qian J, Gu Y, Chen X, Ye S. Rituximab in the treatment of severe lupus myelopathy. Clin Rheumatol 2011; 30:981-6. [PMID: 21340494 DOI: 10.1007/s10067-011-1714-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 02/03/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
Abstract
Lupus myelopathy (LM) is a rare but critical condition, and the prognosis is grim for patients with severe initial motor deficits despite aggressive conventional immunosuppressive therapy. In this report, six recent-onset severe LM patients with lower extremity muscle strength less than or equal to grade 3 were treated with rituximab combined with pulse methylprednisolone. Four patients showed complete myelopathy response at 12 months. The safety profile of rituximab was tolerable, with urinary tract infection as the most frequent adverse event. Preliminary data indicated that rituximab could be beneficial in preventing permanent neurological damage in severe LM.
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Affiliation(s)
- Yan Ye
- Department of Rheumatology, Renji Hospital, Shanghai JiaoTong University School of Medicine, 145 Shandong C Rd, Shanghai 200001, China
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66
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Clinical, Radiologic, and Therapeutic Analysis of 14 Patients with Transverse Myelitis Associated with Antiphospholipid Syndrome: Report of 4 Cases and Review of the Literature. Semin Arthritis Rheum 2011; 40:349-57. [DOI: 10.1016/j.semarthrit.2010.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 04/30/2010] [Accepted: 05/04/2010] [Indexed: 11/21/2022]
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67
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Katsiari CG, Giavri I, Mitsikostas DD, Yiannopoulou KG, Sfikakis PP. Acute transverse myelitis and antiphospholipid antibodies in lupus. No evidence for anticoagulation. Eur J Neurol 2010; 18:556-63. [DOI: 10.1111/j.1468-1331.2010.03208.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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68
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Campdelacreu J, Capurro S, Pumarola T. Varón de 52 años con inestabilidad de la marcha. Med Clin (Barc) 2010; 134:260-7. [DOI: 10.1016/j.medcli.2009.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
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