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Samah Y, Sahar B, Mebrouk Y. Clinical, Radiological, and Etiological Aspects of Pachymeningitis: A Study of 24 Cases. Cureus 2024; 16:e61988. [PMID: 38984004 PMCID: PMC11231805 DOI: 10.7759/cureus.61988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction and importance Hypertrophic pachymeningitis (HP) is an uncommon disorder with varied etiological origins and heterogeneous clinical presentation. Establishing the etiological diagnosis poses a challenge, but prompt identification provides a treatment window, potentially leading to a reversal of symptoms. MRI is the reference examination, allowing not only the early diagnosis of pachymeningitis but also the assessment of its extent and importance, detection of possible complications, and suggestion of etiology. Case presentation We conducted a retrospective study involving 24 patients recruited over 5 years for who brain imaging had revealed the presence of pachymeningitis. The average age of the patients was 40 years, with a male-to-female ratio of 0.6. Clinical discussion Headache was present in 54.17% of patients. All the patients underwent MRI examinations utilizing different sequences, with subsequent Gadolinium injection showing localized and asymmetrical meningeal thickening in 13 cases, and diffuse in the rest. The cerebrospinal fluid study unveiled an inflammatory fluid characterized by a lymphocytic predominance and hyperproteinorrhea, noted in 50% of the patients. The histopathological analysis of a stereotactic biopsy conducted on an individual patient revealed non-diagnostic results. The etiological investigation was dominated by tuberculosis, which was detected in 33.3% of cases. Idiopathic origin was identified in 16.7% of patients. Conclusion Meningeal thickening is rare, and the multitude of potential causes makes the etiological investigation challenging unless they fall within the scope of secondary meningeal disorders; otherwise, a dural biopsy becomes necessary, and the prompt initiation of treatment, along with determining the etiology influences the prognosis.
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Affiliation(s)
- Yousfi Samah
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
| | - Boulehoual Sahar
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
| | - Yassine Mebrouk
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
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Rezaee Azandaryani A, Salehi AM. Misleading Rare Case of Idiopathic Hypertrophic Pachymeningitis. Case Rep Med 2024; 2024:5561686. [PMID: 38510534 PMCID: PMC10954357 DOI: 10.1155/2024/5561686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024] Open
Abstract
Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease with diffuse thickening of the dura mater that has no specific clinical symptoms and manifestations and it causes neurosurgeons to misdiagnose. A 4-year-old girl presented at the emergency room of our hospital with speech difficulty and severe headache. Head computed tomography scans (CT scan) on admission revealed a large fluid collection over the right temporoparietal region with mass effect, and the neurosurgeon drained it with the initial diagnosis of subdural hematoma. However, the postoperative CT scan demonstrated the failure of surgical drainage; therefore, magnetic resonance imaging (MRI) was requested for the patient. MRI identified diffuse nodular dural thickening with internal septations and different internal hemorrhagic stages on the right side with no evidence of brain parenchymal involvement and according to the serology and autoimmune screening tests, and IHP was diagnosed for the patient. The patient underwent craniotomy. There was an immediate improvement of neurologic symptoms. The patient had good clinical and radiologic outcome at 3 -months follow-up. IHP should be part of the differential diagnosis of some cases of noncommunicating hydrocephalus; however, the rarity of the disease and the absence of specific clinical symptoms make the diagnosis difficult.
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Affiliation(s)
- Ahmad Rezaee Azandaryani
- Department of Radiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amir Mohammad Salehi
- Student Research Committee, Hamadan University of Medical Sciences, School of Medicine, Hamadan, Iran
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3
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Yoshimura Y, Kanda-Kikuchi J, Hara T, Sugimoto I. Idiopathic hypertrophic pachymeningitis in a patient with a history of diffuse large B cell lymphoma. BMJ Case Rep 2023; 16:e254847. [PMID: 37316284 PMCID: PMC10277052 DOI: 10.1136/bcr-2023-254847] [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: 06/16/2023] Open
Abstract
A man in his early 70s with a 4-year history of diffuse large B cell lymphoma (DLBCL) was admitted to our hospital with diplopia and achromatopsia. Neurological examination revealed visual impairment, ocular motility disorder and diplopia on looking to the left. Blood and cerebrospinal fluid investigations showed no significant findings. MRI revealed diffusely thickened dura mater and contrast-enhanced structures in the left apical orbit, consistent with hypertrophic pachymeningitis (HP). We performed an open dural biopsy to distinguish the diagnosis from lymphoma. The pathological diagnosis was idiopathic HP, and DLBCL recurrence was ruled out. Following methylprednisolone pulse and oral prednisolone therapy, his neurological abnormalities gradually receded. Open dural biopsy played an important role not only in diagnosing idiopathic HP but also in relieving the pressure on the optic nerve.
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Affiliation(s)
- Yusuke Yoshimura
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Junko Kanda-Kikuchi
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Izumi Sugimoto
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
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Civlan S, Harvey C, Herek D, Türkçüer İ, Sabirli R, Pellegrini M, Koseler A. A Hypertrophic Spinal Pachymeningitis Patient With Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, Glycoprotein IIIa L33P Gene Mutations. Cureus 2022; 14:e29937. [PMID: 36348907 PMCID: PMC9634853 DOI: 10.7759/cureus.29937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare clinical entity of diverse etiology, characterized by a chronic inflammation that causes dura thickening. Reports of Idiopathic hypertrophic cranial pachymeningitis (IHCP) were related to infections, trauma, tumors, and rheumatologic conditions. It was first described by Charcot and Joffroy regarding spinal meninges in 1869. HP has three stages; progressive radicular symptoms begin first, then muscle weakness and atrophy start. Findings such as paraplegia, loss of bladder and bowel control, and respiratory distress caused by intercostal and diaphragmatic denervation are considered the third stage of the disease. Especially in the cranial form of the disease, nerve ischemia and various cranial neuropathic findings may occur. Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, and PAI-1 4G-5G gene mutation analysis were measured with an ABI Prism. In this case report, the authors present a case of hypertrophic mutations pachymeningitis with Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, Glycoprotein IIIa L33P gene. In conclusion, we report a case of HP with Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, and Glycoprotein IIIa L33P gene mutations. We emphasize that the identification of pachymeningitis can be easily bypassed with the application of limited laboratory techniques. As in this case report, we think that these mutations should be analyzed in patients diagnosed with pachymeningitis.
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Khalid A, Uche EO. Idiopathic Hypertrophic Cranial Pachymeningitis With Chiari Type I Malformation: Case Report and Review of the Literature. Cureus 2022; 14:e28466. [PMID: 36046060 PMCID: PMC9419626 DOI: 10.7759/cureus.28466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare chronic inflammatory disease characterized by diffuse thickening of the dura mater. Although IHCP mostly presents as a diffuse lesion, it may also occur as focal tumour-like lesions. Here we present the first reported case of IHCP associated with a Chiari type I malformation (CMI). A 65-year-old man presented with a one-year history of chronic headache and vertigo exacerbated by standing and neck flexion. The neurological examination was unremarkable except for tongue wasting and fasciculations. MRI demonstrated features of CMI and findings suggestive of IHCP. Posterior fossa decompression resulted in significant symptomatic improvement and the diagnosis of IHCP was confirmed on histopathology. Though there is no consensus about the management of IHCP in this case, we advocate surgical decompression with prolonged steroid therapy.
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Yao Y, Xu Y, Li X, Song T, Xu W, Duan Y, Liu Y, Zhang X, Tian DC. Clinical, imaging features and treatment response of idiopathic hypertrophic pachymeningitis. Mult Scler Relat Disord 2022; 66:104026. [DOI: 10.1016/j.msard.2022.104026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
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Wu CS, Wang HP, Sung SF. Idiopathic hypertrophic pachymeningitis with anticardiolipin antibody: A case report. Medicine (Baltimore) 2021; 100:e24387. [PMID: 33466222 PMCID: PMC7808507 DOI: 10.1097/md.0000000000024387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/29/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Idiopathic hypertrophic pachymeningitis (IHP) is a rare neurological disorder without a definite etiology. Diagnosis is mainly based on exclusion of other etiologies. PATIENT CONCERNS A 41-year-old male patient presented with insidious onset headache of 3-month duration. DIAGNOSES Contrast-enhanced brain magnetic resonance imaging (MRI) revealed diffuse pachymeningeal enhancement over bilateral cerebral hemispheres and the tentorium cerebelli. Lumbar puncture showed increased pressure, lymphocytic pleocytosis, and elevated protein level with normal glucose concentration. Blood tests detected elevated erythrocyte sedimentation rate (ESR) and C-reactive protein. Pathological examination of the dura mater from the right frontal convexity disclosed coarse collagenous deposition with focal lymphoid aggregation. After malignancy and infectious etiologies were excluded, a diagnosis of IHP was made. INTERVENTIONS Oral prednisolone and azathioprine followed by methotrexate were administered. OUTCOMES During the 7-year follow-up period, although the patient was not totally headache-free, medical therapy significantly reduced the severity of headache. Follow-up MRI studies showed a reduction in meningeal enhancement and serial ESR measurements revealed a trend of improvement. LESSONS Methotrexate therapy may be considered in cases of steroid-resistant IHP. In addition to clinical evaluation, serial ESR testing may be considered to guide the treatment strategy and assess the response to therapy.
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Affiliation(s)
| | - Hung-Ping Wang
- Division of Rheumatology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Taiwan
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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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Park JY, Choi I, Khil EK, Kim WJ, Shin IY. Idiopathic Hypertrophic Spinal Pachymeningitis with Spinal Cord Lesion: A Case Report. Korean J Neurotrauma 2020; 16:367-373. [PMID: 33163452 PMCID: PMC7607016 DOI: 10.13004/kjnt.2020.16.e17] [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: 10/24/2019] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/04/2022] Open
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare, diffuse inflammatory fibrosis of the dura mater that can lead to spinal cord compression. Though the optimal treatment is controversial, some reports recommend decompressive surgery and postoperative steroid therapy. However, we encountered a case of pachymeningitis that worsened after decompressive surgery. A 79-year-old woman presented with gait disturbance and bilateral lower extremity weakness that began 6 months prior. She had radiating pain on the C5 and T1 dermatomes and clumsiness in both hands. Magnetic resonance imaging (MRI) revealed diffuse thickening of the posterior longitudinal ligament of C6 to T4/5 and ligamentum flavum of C3/4 to T4/5, causing central canal stenosis and compressive myelopathy. She underwent posterior decompressive laminectomy from C4 to T1 total (T2 subtotal) and cervicothoracic screw fixation. During surgery, we found severe adhesion of the posterior longitudinal ligament and ligamentum flavum to the dura mater. Chronic inflammation with fibrosis and lymphoplasmacytic infiltration were present. After surgery, the patient's motor weakness worsened. Despite steroid treatment, her symptom severity fluctuated. Follow-up MRI obtained 3 months postoperation revealed high signal intensity from C5 to T2, possibly indicating aggravated compressive myelopathy. Thus, in this case, decompressive surgery and steroid therapy were detrimental.
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Affiliation(s)
- Jae yeon Park
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Il Choi
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Eun Kyung Khil
- Department of Radiology, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Wu Jae Kim
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Il Young Shin
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
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Hypertrophic Pachymeningitis in Chinese Patients: Presentation, Radiological Findings, and Clinical Course. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2926419. [PMID: 32879880 PMCID: PMC7448121 DOI: 10.1155/2020/2926419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/05/2020] [Accepted: 08/04/2020] [Indexed: 11/28/2022]
Abstract
Background Hypertrophic pachymeningitis (HP) is generally regarded as a rare inflammatory disease, which results in a diffuse thickening of the dura mater. We retrospectively collected data from patients with HP. Methods A total of 16 patients with HP were included in our study. The clinical features, laboratory evaluation, imaging findings, treatment, and outcome were reviewed. Results Of the 16 cases, half were male, with a mean age of 52.6 ± 13.2 years. The mean duration from onset to diagnosis was 8.6 months. The most frequent presenting symptoms in HP cases were a recurrently chronic headache (81.3%) and multiple cranial nerve injury (50%). Antineutrophil cytoplasmic antibody- (ANCA-) related HP was found in 5 cases and IgG4-related HP in 1 case. The intracranial pressure was elevated in 4 cases. The cerebrospinal fluid (CSF) had lymphocytosis in 5 cases and increased protein in 12 cases. Immunoglobulins (IgG, IgA, and IgM) and protein showed linear relationships in the CSF. On magnetic resonance imaging (MRI), localized or diffuse dura maters were thickened in all cases. HP combined with subacute subdural hemorrhage or hypertrophic spinal pachymeningitis was also observed in individual cases. Biopsy of the dura mater in one case showed amounts of inflammatory cells infiltrating, with an increased percentage of IgG4-positive plasma cells. Of all cases referring to glucocorticoid treatment, the symptoms have improved significantly in 10 cases. In other 6 cases, mycophenolate mofetil or azathioprine was added. All patients showed clinical improvement at the follow-up visits. Conclusion The clinical characters of HP are chronic onset, recurrently chronic headache, and multiple cranial nerves paralysis. Inflammatory changes in CSF caused by intrathecal synthesis of immunoglobulin, characteristic dural enhancement on MRI, and pathologic biopsy are all helpful for diagnosis. The addition of immunosuppressant, especially mycophenolate mofetil, is a good choice for steroid-resistance HP.
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Zhang X, Fujii T, Ogata H, Yamasaki R, Masaki K, Cui Y, Matsushita T, Isobe N, Kira JI. Cerebrospinal fluid cytokine/chemokine/growth factor profiles in idiopathic hypertrophic pachymeningitis. J Neuroimmunol 2019; 330:38-43. [PMID: 30784775 DOI: 10.1016/j.jneuroim.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurologic disease causing inflammatory fibrous thickening of the brain and spinal dura mater. We investigated the cerebrospinal fluid cytokine profile of HP by measuring 28 cytokines/chemokines/growth factors with a multiplexed fluorescent immunoassay in 8 patients with HP (6 idiopathic, 1 IgG4-related, 1 anti-neutrophil cytoplasmic antibody-related), and 11 with other non-inflammatory neurologic diseases (OND). Interleukin (IL)-4, IL-5, IL-9, IL-10, TNF-α, and CXCL8/IL-8 levels were significantly higher in idiopathic HP (IHP) than OND. Cluster analyses disclosed two major clusters: one mainly consisted of IHP and the other of OND, suggesting a unique cytokine profile in IHP.
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Affiliation(s)
- Xu Zhang
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China. shu-@neuro.med.kyushu-u.ac.jp
| | - Takayuki Fujii
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Katsuhisa Masaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yiwen Cui
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noriko Isobe
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Yacoub HA, Li PM, Bemporad JA, Khaitov D, Brown DF. Hypertrophic cervical spine pachymeningitis due to sarcoidosis: a case report. Hosp Pract (1995) 2019; 47:99-103. [PMID: 30682899 DOI: 10.1080/21548331.2019.1575645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypertrophic pachymeningitis (HP) is a chronic, progressive diffuse inflammatory condition that leads to thickening of the dura mater and can be idiopathic or associated with sarcoidosis among other disorders. In this case report, we present a rare case of cervical spine HP in a 29-year-old woman in the post-partum period, who had a history of pituitary adenoma and juvenile rheumatoid arthritis. Magnetic resonance imaging (MRI) of the spine revealed a soft tissue mass and moderate cord compression. The patient underwent C3-C7 laminectomy. Pathological analysis of the cervical epidural mass demonstrated a reactive inflammatory cell process. Recurrence of symptoms and worsening of pachymeningitis on imaging studies warranted further work-up which revealed mediastinal/hilar lymphadenopathy. Transbronchial biopsy revealed non-caseating granulomatous disease consistent with sarcoidosis. The patient was started on oral steroids and eventually methotrexate with significant clinical and radiographic improvement. Follow-up imaging studies showed minimal dural thickening in the thoracic spine and eventually complete resolution. HP should be considered in a patient with spinal cord compression, myelopathy, and radicular pain of unclear etiology, and sarcoidosis should be considered in idiopathic cases.
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Affiliation(s)
- Hussam A Yacoub
- a Departments of Medicine (Division of Neurology) , Lehigh Valley Health Network , Allentown , PA , USA
| | - P Mark Li
- b Surgery (Division of Neurological/Spine Surgery) , Lehigh Valley Health Network , Allentown , PA , USA
| | | | - Dmitry Khaitov
- a Departments of Medicine (Division of Neurology) , Lehigh Valley Health Network , Allentown , PA , USA
| | - Daniel F Brown
- d Pathology , Lehigh Valley Health Network , Allentown , PA , USA
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Cui Y, Masaki K, Zhang X, Yamasaki R, Fujii T, Ogata H, Hayashida S, Yamaguchi H, Hyodo F, Eto H, Koyama S, Iinuma K, Yonekawa T, Matsushita T, Yoshida M, Yamada K, Kawano M, Malissen M, Malissen B, Kira J. A novel model for treatment of hypertrophic pachymeningitis. Ann Clin Transl Neurol 2019; 6:431-444. [PMID: 30911567 PMCID: PMC6414490 DOI: 10.1002/acn3.715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/05/2018] [Indexed: 12/24/2022] Open
Abstract
Objective Immunoglobulin (Ig)G4‐related disease is a major cause of hypertrophic pachymeningitis (HP), presenting as a progressive thickening of the dura mater. HP lacks an animal model to determine its underlying mechanisms. We developed a suitable animal model for the treatment of HP. Methods We longitudinally evaluated dura in mice with a mutation (Y136F) in the linker for activation of T cells (LAT), which induced type 2 T helper (Th2) cell proliferation and IgG1 (IgG4 human equivalent) overexpression. Mice were therapeutically administered daily oral irbesartan from 3 to 6 weeks of age. Human IgG4‐related, anti‐neutrophil cytoplasmic antibody‐related, and idiopathic HP dura were also immunohistochemically examined. Results LATY136F mice showing dural gadolinium enhancement on magnetic resonance imaging had massive infiltration of B220+ B cells, IgG1+ cells, CD138+ plasma cells, CD3+ T cells, F4/80+ macrophages, and polymorphonuclear leukocytes in the dura at 3 weeks of age, followed by marked fibrotic thickening. In dural lesions, transforming growth factor (TGF)‐β1 was produced preferentially in B cells and macrophages while TGF‐β receptor I (TGF‐βRI) was markedly upregulated on fibroblasts. Quantitative western blotting revealed significant upregulation of TGF‐β1, TGF‐βRI, and phosphorylated SMAD2/SMAD3 in dura of LATY136F mice aged 13 weeks. A similar upregulation of TGF‐βRI, SMAD2/SMAD3, and phosphorylated SMAD2/SMAD3 was present in autopsied dura of all three types of human HP. Irbesartan abolished dural inflammatory cell infiltration and fibrotic thickening in all treated LATY136F mice with reduced TGF‐β1 and nonphosphorylated and phosphorylated SMAD2/SMAD3. Interpretation TGF‐β1/SMAD2/SMAD3 pathway is critical in HP and is a potential novel therapeutic target.
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Affiliation(s)
- Yiwen Cui
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Katsuhisa Masaki
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Xu Zhang
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Ryo Yamasaki
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Takayuki Fujii
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hidenori Ogata
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Shotaro Hayashida
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Hiroo Yamaguchi
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Fuminori Hyodo
- Innovation Center for Medical Redox Navigation Kyushu University Fukuoka Japan
| | - Hinako Eto
- Innovation Center for Medical Redox Navigation Kyushu University Fukuoka Japan
| | - Sachiko Koyama
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kyoko Iinuma
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Tomomi Yonekawa
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Takuya Matsushita
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan.,Department of Neurological Therapeutics Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Mari Yoshida
- Department of Neuropathology Institute for Medical Science of Aging Aichi Medical University Nagakute Aichi Japan
| | - Kazunori Yamada
- Department of Advanced Research in Community Medicine Graduate School of Medical Sciences Kanazawa University Kanazawa Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology Department of Internal Medicine Kanazawa University Graduate School of Medicine Kanazawa Japan
| | - Marie Malissen
- Centre d'Immunologie de Marseille-Luminy Aix Marseille Université INSERM CNRS Marseille 13288 France
| | - Bernard Malissen
- Centre d'Immunologie de Marseille-Luminy Aix Marseille Université INSERM CNRS Marseille 13288 France
| | - Junichi Kira
- Department of Neurology Neurological Institute Graduate School of Medical Sciences Kyushu University Fukuoka Japan
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Cação G, Calejo M, Alves JE, Medeiros PB, Vila-Cha N, Mendonça T, Taipa R, Silva AM, Damásio J. Clinical features of hypertrophic pachymeningitis in a center survey. Neurol Sci 2018; 40:543-551. [PMID: 30588552 DOI: 10.1007/s10072-018-3689-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/17/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is characterized by cranial and/or spinal thickening of the dura mater with or without associated inflammation. Neuroimaging studies reveal dura mater thickening and focal or diffuse contrast enhancement. It is described in association with trauma, infections, tumors, autoimmune/inflammatory diseases, and cerebrospinal fluid hypotension syndrome, with some cases remaining idiopathic. METHODS A retrospective study was conducted with patients' identification through a key terms search within MRI reports in the period of July 2008 to September 2015. Clinical files, MRI, laboratory, and pathology data were reviewed. RESULTS Fifty-three patients were identified and 20 were excluded because they did not meet the inclusion criteria. Of the 33 included, 19 were female, with a mean age at symptoms onset of 51.2 ± 17.6 years. The most common presenting symptoms were headache and cranial nerves palsy, followed by seizures, delirium, lumbar pain, cognitive decline, motor deficit, and language impairment. In 17 patients, a neoplastic etiology was identified; in eight, inflammatory/autoimmune; in six, infectious; and two were classified as idiopathic. Of the eight patients with inflammatory/autoimmune etiology, four had possible IgG4-related disease (IgG4-RD) and the remaining had granulomatosis with polyangiitis, sarcoidosis, rheumatoid arthritis, and Tolosa-Hunt syndrome. Treatment was directed according to the underlying etiology. DISCUSSION In the described series, a female predominance was identified, with symptoms' onset in the 5th decade. Although headache was the most common symptom, clinical presentation was varied, emphasizing the role of MRI in HP diagnosis. The underlying etiologies were diverse, with only a few cases remaining idiopathic, also reflecting the contribution of the recently described IgG4-RD.
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Affiliation(s)
- Gonçalo Cação
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Margarida Calejo
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - José Eduardo Alves
- Neuroradiology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | | | - Nuno Vila-Cha
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Teresa Mendonça
- Internal Medicine Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Taipa
- Neuropathology Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Joana Damásio
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
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Abstract
Idiopathic hypertrophic pachymeningitis (HP) is a rare disorder of diffuse thickening of the cranial or spinal dura mater without an identifiable cause. Most common in adult males, idiopathic HP typically presents with headache with or without varied associated focal neurologic deficits and findings of dural enhancement on magnetic resonance imaging in a linear, nodular, or combined pattern. As it is felt to be an autoimmune disorder, treatment with high-dose corticosteroids is typically recommended, and without intervention, the course is usually progressive. The disease can commonly progress with a relapsing remitting course requiring other immune modulators such as methotrexate, azathioprine, or cyclophosphamide for control. Here, we describe a unique case of idiopathic HP as it presented in a pediatric patient and resolved without immunomodulatory therapy.
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Marked effectiveness of low-dose oral methotrexate for steroid-resistant idiopathic hypertrophic pachymeningitis: Case report. Clin Neurol Neurosurg 2018; 168:30-33. [DOI: 10.1016/j.clineuro.2018.02.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 11/22/2022]
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Abstract
OBJECTIVE To report clinical presentation, management and outcomes of a rare complication of cochlear implant surgery. PATIENT A 68-year-old man, affected by profound bilateral deafness because of superficial cerebral hemosiderosis, presented to Authors' Department 8 days after cochlear implant surgery with vomiting, fever, and mental confusion. Brain computed tomographic (CT) scan showed a massive collection of intracranial air from an osteodural defect in the right tegmen mastoideum because of repeated nose blowing in the postoperative period. INTERVENTION A multilayer reconstruction of the tegmen with obliteration of the mastoid cavity using abdominal subcutaneous adipose tissue was performed, preserving the cochlear implant in place. MAIN OUTCOME AND RESULTS Following surgery the patient showed rapid neurological improvement and CT scan performed 2 days later showed complete resolution of the intracranial air collection. He is currently using the cochlear implant with open set performances. CONCLUSION Pneumocephalus is a rare complication of cochlear implant surgery. In patients with severe neurological signs following cochlear implantation (CI), pneumocephalus should be suspected. Drilling of mastoid air cells may expose dura mater and positive high pressure events may break meningeal layers and force air into the cranial cavity.
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Cubides H, Londono J, Parra V, Saldarriaga E. Possible steroid-resistant IgG4-related pachymeningitis treated with parenteral methotrexate. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rcreu.2016.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Jang Y, Lee ST, Jung KH, Chu K, Lee SK. Rituximab Treatment for Idiopathic Hypertrophic Pachymeningitis. J Clin Neurol 2017; 13:155-161. [PMID: 28271643 PMCID: PMC5392457 DOI: 10.3988/jcn.2017.13.2.155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Hypertrophic pachymeningitis (HP) is a rare disease caused by autoimmunity in the meninx that causes various neurologic symptoms, including headache, seizures, weakness, paresthesia, and cranial nerve palsies. Although the first-line therapy for HP is steroids, many HP cases are refractory to steroids or recur when the steroids are tapered. Here we report three HP cases that were successfully treated with rituximab (RTX). METHODS From an institutional cohort recruited from April 2012 to July 2016, three HP cases that were identified to be steroid-refractory were treated with RTX (four weekly doses of 375 mg/m²). Clinical improvement was assessed by the number of relapses of any neurologic symptom and the largest dural thickness in MRI. RESULTS All three patients were recurrence-free of neurologic symptoms and exhibited prominent decreases in the dural thickness after RTX treatment. No adverse events were observed in the patients. CONCLUSIONS We suggest RTX as a second-line therapy for steroid-refractory HP. Further studies are warranted to confirm this observation in a larger population and to consider RTX as a first-line therapy.
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Affiliation(s)
- Yoonhyuk Jang
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
| | - Keun Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kon Chu
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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Park TJ, Seo WD, Kim SY, Cho JH, Kim DH, Kim KH. Effective Response of Methotrexate for Recurrent Idiopathic Hypertrophic Spinal Pachymeningitis. KOREAN JOURNAL OF SPINE 2017; 13:200-203. [PMID: 28127378 PMCID: PMC5266097 DOI: 10.14245/kjs.2016.13.4.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/19/2022]
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a chronic progressive and diffuse inflammatory fibrosis of the spinal dura mater. Though treatment of IHSP is surgical decompression with steroid therapy, treatment for recurrent IHSP is controversial. Our patient was diagnosed with IHSP based on magnetic resonance imaging (MRI) and underwent laminectomy for decompression following steroid pulse therapy. Despite maintenance of steroid therapy, the patient experienced 3 recurrences. As an alternative immunosuppressant medication, methotrexate was introduced with low-dose steroid. Fortunately, the symptom was resolved, and a decrease of dura thickening was revealed on MRI. We present the case and suggest that methotrexate might be an effective treatment modality for recurrent IHSP.
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Affiliation(s)
- Tae Joon Park
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | | | - Sang Young Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hoon Cho
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hyun Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Hong Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
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Gospodarev V, Câmara J, Chakravarthy V, Perry A, Wood M, Dietz R, Wang J, De Los Reyes K, Raghavan R. Treatment of IgG4-related pachymeningitis in a patient with steroid intolerance: The role of early use of rituximab. J Neuroimmunol 2016; 299:62-65. [DOI: 10.1016/j.jneuroim.2016.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/01/2016] [Accepted: 08/08/2016] [Indexed: 12/17/2022]
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A case of hypertrophic cranial pachymeningitis associated with invasive Aspergillus mastoiditis. Auris Nasus Larynx 2015; 42:488-91. [DOI: 10.1016/j.anl.2015.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 04/06/2015] [Accepted: 04/27/2015] [Indexed: 11/22/2022]
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Kon T, Nishijima H, Haga R, Funamizu Y, Ueno T, Arai A, Suzuki C, Nunomura JI, Baba M, Takahashi T, Tomiyama M. Hypertrophic pachymeningitis accompanying neuromyelitis optica spectrum disorder: A case report. J Neuroimmunol 2015; 287:27-8. [PMID: 26439957 DOI: 10.1016/j.jneuroim.2015.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 07/28/2015] [Accepted: 08/04/2015] [Indexed: 11/29/2022]
Abstract
We report a case of idiopathic cerebral hypertrophic pachymeningitis accompanying neuromyelitis optica spectrum disorder. No other identifiable cause of pachymeningitis was detected. Corticosteroid therapy was effective for both diseases. Hypertrophic pachymeningitis is closely related to autoimmune inflammatory disease of the central nervous system. This case supports the hypothesis that hypertrophic pachymeningitis can be a rare comorbidity of neuromyelitis optica spectrum disorder.
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Affiliation(s)
- Tomoya Kon
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Haruo Nishijima
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Rie Haga
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yukihisa Funamizu
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Chieko Suzuki
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Jin-ichi Nunomura
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masayuki Baba
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Toshiyuki Takahashi
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan; Department of Neurology, Yonezawa National Hospital, Yonezawa, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
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Temporal-spatial pathological changes in the brains of permissive and non-permissive hosts experimentally infected with Angiostrongylus cantonensis. Exp Parasitol 2015; 157:177-84. [PMID: 26299243 DOI: 10.1016/j.exppara.2015.08.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 07/17/2015] [Accepted: 08/16/2015] [Indexed: 11/21/2022]
Abstract
Human cerebral angiostrongyliasis becomes an emerging disease in many parts of the world. By postmortem examination, Angiostrongylus cantonensis have been reported to cause severe pathological changes in the central nervous system. The present study was designed to determine the temporal-spatial pathological changes through experimental infections and histopathological examination of permissive (SD rats) and non-permissive (ICR mice) hosts. After infecting SD rats with 25, 50, or 100 third-stage larvae (L3) and ICR mice with 25 L3, one animal from each group was sacrificed daily from day 1 to day 30 post-infection. Each rat brain was cut into six sections and mouse brain into five sections. These sections were stained with haematoxylin and eosin and examined microscopically. Eosinophilic meningitis was found to be the most commonly pathological change and occurred on day 17 post-infection in rats with 25 L3, day 9 in the 50- or 100-L3 groups, and day 12 in infected mice. Thickness of the meninges increased 9-24 folds in infected rats and 89 folds in an infected mouse on day 28. Encephalitis, congestion, perivascular cuffing, and haemorrhage were revealed in infected mice and rats with 100 L3. Fifth-stage larvae were frequently observed in the meninges but occasionally in the parenchyma. Significant correlations between meningitis and presence of larvae in the meninges were found in the three infected rat groups but not in the infected mice. The results indicate that the clinical course of A. cantonensis infection is not self-limited but becomes more severe with the intensity of infection.
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Subrati N, Vaqas B, Peterson D, Patel MC. Hypertrophic pachymeningitis with sarcoidosis: a rare cause of craniocervical compression. BMJ Case Rep 2015; 2015:bcr-2014-208604. [PMID: 26021381 DOI: 10.1136/bcr-2014-208604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of a 58-year-old woman with a suspected dural tumour. She presented with progressive pyramidal weakness. MRI confirmed compression of the medulla oblongata and spinal cord at the level of C1-3. The localised dural mass lesion homogenously enhanced on T1 MRI and was considered most likely to be a meningioma. Incidentally, CT scan of the chest revealed peribronchial soft tissue thickening, suggestive of pulmonary sarcoidosis. Owing to the progressive nature of her weakness, she had a posterior occipitocervical decompression with a C1-3 laminectomy and resection of the thickened dura. Histology showed densely collagenous tissue with scanty psammoma bodies and multinucleate giant cells, consistent with hypertrophic pachymeningitis (HP)-a rare, chronic inflammatory condition, characterised by thickening and fibrosis of the dura. This case demonstrates that masses in the craniocervical junction can be varied in pathology and when there is evidence of systemic inflammation, HP should be considered.
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Affiliation(s)
- Nagina Subrati
- Department of Neurosurgery, Kings College Hospital, London, UK
| | - Babar Vaqas
- Department of Neurosurgery, Charing Cross Hospital, London, UK
| | - David Peterson
- Department of Neurosurgery, Charing Cross Hospital, London, UK
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George MM, Goswamy J, Solanki K, Bhalla R. Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum. Ann Med Surg (Lond) 2015; 4:103-6. [PMID: 25905016 PMCID: PMC4402385 DOI: 10.1016/j.amsu.2015.03.005] [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: 02/18/2015] [Accepted: 03/24/2015] [Indexed: 11/18/2022] Open
Abstract
Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures. Timely thorough investigation is critical to reduce the risk of irreversible damage. Prompt biopsy is essential to exclude both neoplasia and inflammatory conditions. Early corticosteroid administration is necessary to limit local infiltration.
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Affiliation(s)
- Manish M. George
- Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK
- Corresponding author. Tel.: +44 7737742817.
| | - Jay Goswamy
- Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK
| | - Kohmal Solanki
- Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton, Surrey, SM5 1AA, UK
| | - Rajiv Bhalla
- Manchester Academic Health Sciences Centre, Central Manchester University Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
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Immunoglobulin-G4-related hypertrophic pachymeningitis with antineutrophil cytoplasmatic antibodies effectively treated with rituximab. J Clin Neurosci 2015; 22:1038-40. [PMID: 25861887 DOI: 10.1016/j.jocn.2014.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/18/2014] [Accepted: 12/20/2014] [Indexed: 11/22/2022]
Abstract
We describe a 52-year-old man with hypertrophic pachymeningitis (HP) who was both seropositive for antineutrophil cytoplasmatic antibodies (ANCA) against myeloperoxidase, and had an immunoglobulin G4 (IgG4) positive fibroinflammatory response in meningeal biopsy. HP is a chronic inflammatory thickening of the dura mater which typically presents with headache, cranial nerve dysfunction and other neurological deficits. While first-line treatment with corticosteroids is recommended, many patients relapse and need additional immunosuppression. One recently described etiology is IgG4-related disease and in a subgroup of idiopathic patients, evidence suggests a crucial role of ANCA. To our knowledge, the simultaneous occurrence of IgG4-related disease and ANCA has not been reported so far. This man suffered life-threatening disease progression despite the administration of high dose steroids, cyclophosphamide and azathioprine. Treatment with rituximab was initiated which led to disappearance of clinical symptoms and decrease of dural thickening within weeks. This patient presents a possible disease overlap of IgG4-related and ANCA-associated HP and illustrates the effectiveness of rituximab in refractory IgG4-related HP.
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Auboire L, Boutemy J, Constans JM, Le Gallou T, Busson P, Bienvenu B. Idiopathic hypertrophic pachymeningitis presenting with occipital neuralgia. Afr Health Sci 2015; 15:302-6. [PMID: 25834565 DOI: 10.4314/ahs.v15i1.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although occipital neuralgia is usually caused by degenerative arthropathy, nearly 20 other aetiologies may lead to this condition. METHODS We present the first case report of hypertrophic pachymeningitis revealed by isolated occipital neuralgia. RESULTS AND CONCLUSIONS Idiopathic hypertrophic pachymeningitis is a plausible cause of occipital neuralgia and may present without cranial-nerve palsy. There is no consensus on the treatment for idiopathic hypertrophic pachymeningitis, but the usual approach is to start corticotherapy and then to add immunosuppressants. When occipital neuralgia is not clinically isolated or when a first-line treatment fails, another disease diagnosis should be considered. However, the cost effectiveness of extended investigations needs to be considered.
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Affiliation(s)
- Laurent Auboire
- Université François-Rabelais de Tours, Inserm, Imagerie et Cerveau UMR U930, Tours, France
| | - Jonathan Boutemy
- CHU de Caen, Department of internal medicine, 14000-Caen, France
| | - Jean Marc Constans
- Université de Caen Basse-Normandie, Medical School, 14000-Caen, France ; CHU de Caen, Department of Radiology, 14000-Caen, France
| | - Thomas Le Gallou
- CHU de Caen, Department of internal medicine, 14000-Caen, France
| | - Philippe Busson
- CH d'Avranches, Department of Medicine 2, 50300-Avranches, France
| | - Boris Bienvenu
- CHU de Caen, Department of internal medicine, 14000-Caen, France ; Université de Caen Basse-Normandie, Medical School, 14000-Caen, France
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Vasconcellos LFR, Cunha AM, Marussi VHR, Canedo NHS, Chimelli LMC. A 20-year-old man with hearing loss progressing to tetraparesis. Brain Pathol 2014; 24:551-2. [PMID: 25323672 DOI: 10.1111/bpa.12203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Luiz F R Vasconcellos
- Division of Neurology, Instituto de Neurologia Deolindo Couto, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Zhao M, Geng T, Qiao L, Shi J, Xie J, Huang F, Lin X, Wang J, Zuo H. Idiopathic hypertrophic pachymeningitis: Clinical, laboratory and neuroradiologic features in China. J Clin Neurosci 2014; 21:1127-32. [DOI: 10.1016/j.jocn.2013.09.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/26/2013] [Accepted: 09/30/2013] [Indexed: 10/25/2022]
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See no evil, hear no evil…. Surv Ophthalmol 2014; 59:251-9. [DOI: 10.1016/j.survophthal.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 12/29/2022]
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Sanchez-Garcia ME, Gomez-Delgado F, Gomez-Garduño A, Blanco-Molina A, Puebla RAFDL. Hypertrophic pachymeningitis associated with cerebral spinal fluid hypovolemia as initial presentation of systemic lupus erythematous. Lupus 2013; 23:197-200. [DOI: 10.1177/0961203313517155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a case of a 61-year-old man with thickening of the dura mater associated with the presence of subdural collections as a consequence of cerebral spinal fluid hypovolemia (CSFH) and hypertrophic pachymeningitis (HP) as presentation of systemic lupus erythematous (SLE). The patient complained about fatigue, musculoskeletal pain, headache and skin lesions. In the laboratory tests minimal normocytic anemia, mild leukopenia, polyclonal hypergammaglobulinemia and antinuclear antibodies (ANA), anti-double-stranded DNA antibodies (dsDNA), antibodies against extractable nuclear antigens (ENA) type SSA-Ro, anti-Smith antigen antibodies (anti-Sm) and anti-ribonucleoprotein antibodies (anti-RNP) were detected. Cranial magnetic resonance imaging (MRI), with and without gadolinium enhancement, revealed generalized thickening of the dura mater more severe at the right parieto-occipital lobes with the presence of subdural collections. The patient was diagnosed with SLE associated both with CSFH and HP. A conservative treatment with prednisone 60 mg daily, mycophenolate mofetil (MMF) 1 g daily and hydroxychloroquine 200 mg twice a day was started with significant clinical and radiological improvement (almost complete resolution of the subdural collections and clear decrease of meningeal thickness). The authors emphasize that HP associated with CSFH in the context of SLE is a rare entity, which makes this case unique.
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Affiliation(s)
- ME Sanchez-Garcia
- Internal Medicine Department, Reina Sofia University Hospital/IMIBIC/University of Cordoba, Spain
| | - F Gomez-Delgado
- Internal Medicine Department, Reina Sofia University Hospital/IMIBIC/University of Cordoba, Spain
| | - A Gomez-Garduño
- Internal Medicine Department, Reina Sofia University Hospital/IMIBIC/University of Cordoba, Spain
| | - A Blanco-Molina
- Internal Medicine Department, Reina Sofia University Hospital/IMIBIC/University of Cordoba, Spain
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Tuberculous Pachymeningitis in a Young Child With Spinal Involvement: A Case Report. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2013. [DOI: 10.5812/pedinfect.5351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Elverland HH. From ear to brain. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:1357. [PMID: 22717863 DOI: 10.4045/tidsskr.12.0382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Hans H Elverland
- Ear, Nose and Throat Section, Nordland Hospital Lofoten, Leknes, Norway.
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Bjørke AB, Wahl CM, Kalstad S. A man in his 40s with headache and blurred vision. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2012; 132:1353-6. [PMID: 22717862 DOI: 10.4045/tidsskr.11.0718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Caldas AR, Brandao M, Paula FS, Castro E, Farinha F, Marinho A. Hypertrophic cranial pachymeningitis and skull base osteomyelitis by pseudomonas aeruginosa: case report and review of the literature. J Clin Med Res 2012; 4:138-44. [PMID: 22505989 PMCID: PMC3320125 DOI: 10.4021/jocmr777w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2011] [Indexed: 11/29/2022] Open
Abstract
Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder characterized by localized or diffuse thickening of the dura mater, and it usually presents with multiple cranial neurophaties. It has been associated with a variety of inflammatory, infectious, traumatic, toxic and neoplasic diseases, when no specific cause is found the process is called idiopathic. The infectious cases occur in patients under systemic immunosuppression, which have an evident contiguous source or those who have undergone neurosurgical procedures. We describe a case of a 62-year-old immunosuppressed woman with diabetes and rheumatoid arthritis, which had HCP and osteomyelitis of the skull base caused by pseudomonas aeruginosa, presenting with headache and diplopia. We believe this is the second documented case of pachymeningitis secondary to this microorganism. As a multifactorial disease, it is essencial to determine the specific causative agent of HCP before making treatment decisions, and great care is needed with immunocompromised patients.
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Affiliation(s)
- Ana Rita Caldas
- Medicine Department, Santo Antonios' Hospital, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
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Sánchez-García M, Blanco-Molina Á, Gallego de la Sacristana Á, Ogea J. Un nuevo abordaje terapéutico: remisión de las enfermedades fibrosantes tras la administración de bolos de metilprednisolona a altas dosis. Rev Clin Esp 2012; 212:157-9. [DOI: 10.1016/j.rce.2011.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/19/2011] [Accepted: 05/22/2011] [Indexed: 10/14/2022]
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Lowden MR. Commentary. J Neurosci Rural Pract 2012; 3:195-6. [PMID: 22865980 PMCID: PMC3409999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Max R Lowden
- Department of Neurology, The Pennsylvania State University Milton S. Hershey Medical Center, College of Medicine, USA,Address for correspondence: Dr. Max Lowden, Department of Neurology, Penn State Hershey Medical Center, 30 Hope Drive, PO Box 859, Hershey, PA 17033, USA. E-mail:
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Karakasis C, Deretzi G, Rudolf J, Tsiptsios I. Long-term lack of progression after initial treatment of idiopathic hypertrophic pachymeningitis. J Clin Neurosci 2011; 19:321-3. [PMID: 22133814 DOI: 10.1016/j.jocn.2011.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 05/17/2011] [Accepted: 05/18/2011] [Indexed: 10/14/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare inflammatory disease which is sometimes difficult to diagnose and can lead to misinterpretations of the clinical and imaging findings. The main clinical manifestations are headache, ataxia and cranial nerve palsy. In most of the reported patients continuous medication is needed to avoid disease recurrence. We present a female patient with an 8-year follow-up, no clinical regression and no need for any further medical treatment. Even though most patients with IHCP experience recurrence after diagnosis and initial treatment there were no clinical or imaging signs of relapse in our patient. Our patient is still not under any medical or surgical treatment due to the lack of any significant symptoms.
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Affiliation(s)
- Charalampos Karakasis
- Department of Neurology, Papageorgiou Hospital, Perif. Odos Evosmou, Thessaloniki 56429, Greece.
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41
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Kim EH, Kim SH, Cho JM, Ahn JY, Chang JH. Immunoglobulin G4–related hypertrophic pachymeningitis involving cerebral parenchyma. J Neurosurg 2011; 115:1242-7. [DOI: 10.3171/2011.7.jns1166] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of IgG4-related hypertrophic pachymeningitis that involved cerebral parenchyma. The mass was removed surgically. Histopathological studies showed diffuse infiltration of lymphoplasmacytic cells without evidence of Langerhans histiocytes or meningothelial cells. Immunoglobulin G4 was strongly positive on immunohistochemical staining. The Gd-enhanced lesion deep inside brain parenchyma was completely resolved after 3 months of oral corticosteroid medication. A nodular type of hypertrophic pachymeningitis that mimics a meningioma is rare. Nevertheless, preoperative presumption is very important, and immunohistochemical studies for IgG4 may be helpful in the differential diagnosis.
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Affiliation(s)
- Eui Hyun Kim
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
| | - Se Hoon Kim
- 2Pathology,
- 3Neuro-Oncology Clinic, and
- 4Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Mo Cho
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
| | | | - Jong Hee Chang
- 1Departments of Neurosurgery and
- 3Neuro-Oncology Clinic, and
- 4Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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42
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Hassan KM, Deb P, Bhatoe HS. Idiopathic hypertrophic cranial pachymeningitis: Three biopsy-proven cases including one case with abdominal pseudotumor and review of the literature. Ann Indian Acad Neurol 2011; 14:189-93. [PMID: 22028532 PMCID: PMC3200042 DOI: 10.4103/0972-2327.85891] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 11/05/2010] [Accepted: 12/18/2010] [Indexed: 11/18/2022] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare disorder of diverse etiology. It presents with headaches, cranial neuropathies and ataxia occurring alone or in combination. Dural biopsy is essential to exclude secondary causes of pachymeningitis. There is paucity of data on biopsied cases of HP. We report three biopsy-proven cases of idiopathic hypertrophic cranial pachymeningitis. All our patients had headaches and multiple cranial neuropathies; ataxia was seen in one patient. One patient had recurrent anterior and posterior cranial neuropathies, while one each had recurrent anterior and posterior cranial neuropathies. Two patients had profound irreversible mono-ocular visual loss. All of them showed prominent pachymeningeal thickening on imaging. Infarcts were seen in one patient, which have rarely been documented. All patients showed biopsy evidence of meningeal thickening and nonspecific chronic inflammation of the dura. The disease may have a remitting and relapsing course, and usually responds to steroids. Clinical improvement was excellent in two patients and modest in one on steroid therapy. All our patients required azathioprine during the course of therapy. Early institution and long-term maintenance of steroid therapy prevents neurologic sequelae. Occurrence of abdominal inflammatory pseudotumor in a patient of HP possibly as part of multifocal fibrosclerosis has not been described earlier.
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Affiliation(s)
- K M Hassan
- Department of Neurology, Command Hospital and Armed Forces Medical College, Pune, India
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Chilengi R, Juma R, Abdallah AM, Bashraheil M, Lodenyo H, Nyakundi P, Anabwani E, Salim A, Mwambingu G, Wenwa E, Jemutai J, Kipkeu C, Oyoo GO, Muchohi SN, Kokwaro G, Niehues T, Lang T, Nzila A. A phase I trial to evaluate the safety and pharmacokinetics of low-dose methotrexate as an anti-malarial drug in Kenyan adult healthy volunteers. Malar J 2011; 10:63. [PMID: 21410944 PMCID: PMC3072355 DOI: 10.1186/1475-2875-10-63] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 03/16/2011] [Indexed: 11/11/2022] Open
Abstract
Background Previous investigations indicate that methotrexate, an old anticancer drug, could be used at low doses to treat malaria. A phase I evaluation was conducted to assess the safety and pharmacokinetic profile of this drug in healthy adult male Kenyan volunteers. Methods Twenty five healthy adult volunteers were recruited and admitted to receive a 5 mg dose of methotrexate/day/5 days. Pharmacokinetics blood sampling was carried out at 2, 4, 6, 12 and 24 hours following each dose. Nausea, vomiting, oral ulcers and other adverse events were solicited during follow up of 42 days. Results The mean age of participants was 23.9 ± 3.3 years. Adherence to protocol was 100%. No grade 3 solicited adverse events were observed. However, one case of transiently elevated liver enzymes, and one serious adverse event (not related to the product) were reported. The maximum concentration (Cmax) was 160-200 nM and after 6 hours, the effective concentration (Ceff) was <150 nM. Conclusion Low-dose methotraxate had an acceptable safety profile. However, methotrexate blood levels did not reach the desirable Ceff of 250-400-nM required to clear malaria infection in vivo. Further dose finding and safety studies are necessary to confirm suitability of this drug as an anti-malarial agent.
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Affiliation(s)
- Roma Chilengi
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, PO Box 230, 80108 Kilifi, Kenya
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Cannon PS, Cruz AAV, Pinto CT, Mastropietro DA, Chahud F, Bilyk JR, Selva D, Prabhakaran VC. A multi-centre case series investigating the aetiology of hypertrophic pachymeningitis with orbital inflammation. Orbit 2011; 30:64-69. [PMID: 21322792 DOI: 10.3109/01676830.2010.539766] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION To describe our attempt in establishing a definitive diagnosis in patients with hypertrophic pachymeningitis in combination with orbital inflammatory disease and report on the outcome. MATERIALS AND METHODS This was a retrospective case series of all patients presenting with hypertrophic pachymeningitis in association with orbital inflammation in 4 centres. Ophthalmic and neurological examination data, laboratory data, histology data, treatment plans and clinical outcome data were recorded. Patients underwent orbital/brain computed tomography and magnetic resonance imaging. RESULTS Six patients were identified; the median age was 46.5 years. Headache was the commonest presenting symptom, followed by diplopia and reduced visual acuity. Three patients underwent orbital biopsy, 1 patient underwent dura mater biopsy, 1 patient underwent both and 1 patient underwent nasal biopsy. Four patients were diagnosed with Wegener granulomatosis and 2 patients with tuberculosis. Corticosteroid therapy was initiated in 4 patients, with steroid-sparing drugs added later. Two patients received anti-tuberculosis treatment and 1 patient was commenced on pulsed cyclophosphamide. On follow-up, 1 patient required an exenteration for a painful blind eye and 1 patient's visual acuity remained at no perception to light. One patient had complete resolution of symptoms on treatment, 1 patient had persistent reduced visual acuity and 1 patient was lost to follow-up. CONCLUSION We postulate that the combination of orbital inflammation and pachymeningitis is strongly suggestive of Wegener granulomatosis, although it may take a number of years to confirm. Tuberculosis should also be considered.
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Affiliation(s)
- Paul S Cannon
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide, Adelaide, SA 5000, Australia.
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45
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de Broucker T, Martinez-Almoyna L. Diagnostic des méningites chroniques. Rev Med Interne 2011; 32:159-72. [DOI: 10.1016/j.revmed.2010.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/26/2010] [Accepted: 04/10/2010] [Indexed: 12/26/2022]
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Moulis G, Delavigne K, Alvarez M, Brassat D, Bonneville F, Massip P, Adoue D. [Chronic headaches]. Rev Med Interne 2010; 32:46-7. [PMID: 21145627 DOI: 10.1016/j.revmed.2010.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 04/10/2010] [Indexed: 11/18/2022]
Affiliation(s)
- G Moulis
- Service de médecine interne, CHU de Toulouse-Purpan, université de Toulouse, université Paul-Sabatier, place du Docteur-Baylac, Toulouse cedex, France
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Park IS, Kim H, Chung EY, Cho KW. Idiopathic hypertrophic cranial pachymeningitis misdiagnosed as acute subtentorial hematoma. J Korean Neurosurg Soc 2010; 48:181-4. [PMID: 20856672 DOI: 10.3340/jkns.2010.48.2.181] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/16/2010] [Accepted: 08/03/2010] [Indexed: 11/27/2022] Open
Abstract
A case of idiopathic hypertrophic cranial pachymeningitis (IHCP) misdiagnosed as an acute subdural hematoma is reported. A 37-year-old male patient presented with headache following head trauma 2 weeks earlier. Computerized tomography showed a diffuse high-density lesion along the left tentorium and falx cerebri. Initial chest X-rays revealed a small mass in the right upper lobe with right lower pleural thickening, which suggested lung cancer, such as an adenoma or mediastinal metastasis. During conservative treatment under the diagnosis of a subdural hematoma, left cranial nerve palsies were developed (3rd and 6th), followed by scleritis and uveitis involving both eyes. Magnetic resonance imaging (MRI) revealed an unusual tentorium-falx enhancement on gadolinium-enhanced T1-weighted images. Non-specific chronic inflammation of the pachymeninges was noticed on histopathologic examination following an open biopsy. Systemic steroid treatment was initiated, resulting in dramatic improvement of symptoms. A follow-up brain MRI showed total resolution of the lesion 2 months after steroid treatment. IHCP should be included in the differential diagnosis of subtentorial-enhancing lesions.
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Affiliation(s)
- Ik-Seong Park
- Department of Neurosurgery, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
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48
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A case of subarachnoid hemorrhage with pituitary apoplexy caused by idiopathic hypertrophic pachymeningitis. Neurol Sci 2010; 32:455-9. [DOI: 10.1007/s10072-010-0343-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
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49
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Kim JH, Joo YB, Kim J, Min JK. A case of hypertrophic cranial pachymeningitis presenting with scleritis in a patient with undifferentiated connective tissue disease. J Korean Med Sci 2010; 25:966-9. [PMID: 20514324 PMCID: PMC2877233 DOI: 10.3346/jkms.2010.25.6.966] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 09/10/2009] [Indexed: 11/22/2022] Open
Abstract
Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder that causes a localized or diffuse thickening of the dura mater and has been reported to be infrequently associated with systemic autoimmune disorders such as Wegener's granulomatosis, rheumatoid arthritis, sarcoidosis, Behçet's disease, Sjögren syndrome, and temporal arteritis. Here, we report a case of HCP initially presented with scleritis and headache in a patient with undifferentiated connective tissue disease (UCTD). HCP was initially suspected on brain magnetic resonance imaging and defined pathologically on meningial biopsy. Immunologic studies showed the presence of anti-RNP antibody. After high dose corticosteroid therapy, the patient's symptoms and radiologic abnormalities of brain were improved. Our case suggested that HCP should be considered in the differential diagnosis of headache in a patient with UCTD presenting with scleritis.
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Affiliation(s)
- Ji-Hyeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Holy Family Hospital, Bucheon, Korea
| | - Young-Bin Joo
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Holy Family Hospital, Bucheon, Korea
| | - Jeana Kim
- Department of Anatomical Pathology, College of Medicine, The Catholic University of Korea, Holy Family Hospital, Bucheon, Korea
| | - Jun-Ki Min
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Holy Family Hospital, Bucheon, Korea
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Nzila A, Okombo J, Becker RP, Chilengi R, Lang T, Niehues T. Anticancer agents against malaria: time to revisit? Trends Parasitol 2010; 26:125-9. [PMID: 20056487 PMCID: PMC2927876 DOI: 10.1016/j.pt.2009.12.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 10/23/2009] [Accepted: 12/11/2009] [Indexed: 11/17/2022]
Abstract
The emergence of artemisinin resistance could adversely impact the current strategy for malaria treatment; thus, new drugs are urgently needed. A possible approach to developing new antimalarials is to find new uses for old drugs. Some anticancer agents such as methotrexate and trimetrexate are active against malaria. However, they are commonly perceived to be toxic and thus not suitable for malaria treatment. In this opinion article, we examine how the toxicity of anticancer agents is just a matter of dose or ‘only dose makes the poison’, as coined in Paracelsus’ law. Thus, the opportunity exists to discover new antimalarials using the anticancer pharmacopoeia.
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Affiliation(s)
- Alexis Nzila
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Collaborative Research Programme, Kilifi, Kenya.
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