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Saied Z, Zouari R, Rachdi A, Nabli F, Ben Mohamed D, Ben Sassi S. Cerebral large vessels vasculitis following Guillain-Barré syndrome as first clinical manifestations of primary Sjogren's syndrome: A case based - Review. Heliyon 2024; 10:e30004. [PMID: 38698975 PMCID: PMC11064453 DOI: 10.1016/j.heliyon.2024.e30004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 05/05/2024] Open
Abstract
Background Primary Sjogren's syndrome (pSS) is an autoimmune exocrinopathy in which extraglandular signs of pSS are determinant for the prognosis. Involvement of both peripheral and central nervous system (CNS) are known to be among the sites of high systemic activity in pSS. Case presentation We, herein, report a case of a 57-year-old female patient with pSS presenting with typical Guillan-Barré syndrome (GBS), shortly followed by acute headaches accompanied by cortical blindness. Cerebral magnetic resonance imaging (MRI) demonstrated T2 signal abnormalities on the occipital region with narrowing and irregularities of the cerebral arteries, suggestive of CNS vasculitis.Subtle sicca symptoms occurring prior to neurological symptoms by 8 months together with immunological disturbances (anti-SSA, anti-SSB antibodies positivity, type II cryoglobulins positivity, and C4 hypocomplementemia) allowed us to retain the diagnosis of pSS. Recovery of motor symptoms was possible under the combined use of immunoglobulins and corticotherapy during the initial phase. A three-years follow-up confirmed progressive motor recovery and stabilization under 6-months cyclophosphamide cycles relayed by azathioprine therapy. Conclusions Neurological complications can be inaugural in lead to urgent investigations and treatment. Peripheral and central neurological manifestations can coexist. The approach should integrate careful clinical assessment, as well as radiological and immunological findings.
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Affiliation(s)
- Zakaria Saied
- National Institute Mongi Ben Hamida of Neurology of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
| | - Rania Zouari
- National Institute Mongi Ben Hamida of Neurology of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
| | - Amine Rachdi
- National Institute Mongi Ben Hamida of Neurology of Tunis, Tunisia
| | - Fatma Nabli
- National Institute Mongi Ben Hamida of Neurology of Tunis, Tunisia
| | - Dina Ben Mohamed
- National Institute Mongi Ben Hamida of Neurology of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
| | - Samia Ben Sassi
- National Institute Mongi Ben Hamida of Neurology of Tunis, Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
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Shindo T, Ito M, Sugiyama T, Okuyama T, Kono M, Atsumi T, Fujimura M. Diagnostic Value of Vessel Wall Imaging to Determine the Timing of Extracranial‒Intracranial Bypass for Moyamoya Syndrome Associated with Active Sjögren's Syndrome: A Case Report. J Neurol Surg A Cent Eur Neurosurg 2024; 85:227-232. [PMID: 35453162 DOI: 10.1055/a-1832-3269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Sjögren's syndrome is a chronic autoimmune disorder that predominantly affects exocrine organs. It is characterized by an organ-specific infiltration of lymphocytes. The involvement of the major cerebral arteries in Sjögren's syndrome has rarely been reported. A recent study reported a case of successful extracranial-intracranial (EC-IC) bypass without complications, even in the active inflammatory state, although the optimal timing of such a bypass remains unclear. CASE DESCRIPTION We here report the case of a 43-year-old woman presenting with acute ischemic stroke due to progressive middle cerebral artery (MCA) occlusion and signs of primary Sjögren's syndrome. During intensive immunosuppressive therapy for active Sjögren's syndrome, the patient was monitored using contrast-enhanced magnetic resonance vessel wall imaging (MR-VWI). A couple of intravenous cyclophosphamide injections combined with a methylprednisolone pulse and antiplatelet therapy resulted in clear resolution of vessel wall enhancement, which suggested remission of inflammatory vasculitis. Nevertheless, she still experienced a transient ischemic attack (TIA) due to decreased regional cerebral blood flow by MCA occlusion, as demonstrated by the conventional time-of-flight MR angiography and single-photon emission computed tomography. Considering the increased risk of further stroke, the decision was made to perform an EC-IC bypass as a treatment for medically uncontrollable hemodynamic impairment. Her postoperative course was uneventful without further repeated TIAs, and continued immunosuppressive therapy for Sjögren's syndrome provided effective management. CONCLUSIONS Our findings emphasize the diagnostic value of contrast-enhanced MR-VWI in monitoring the effect of immunosuppressive therapy for the major cerebral artery vasculitis and in determining the timing of EC-IC bypass as a "rescue" treatment for moyamoya syndrome associated with active Sjögren's syndrome.
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Affiliation(s)
- Takafumi Shindo
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
| | - Tomohiro Okuyama
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
| | - Michihito Kono
- Department of Rheumatology, Endocrinology, and Nephrology, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology, and Nephrology, Hokkaido University Hospital, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
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de Boysson H, Pagnoux C. Vasculiti del sistema nervoso centrale. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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de Oliveira FR, Fantucci MZ, Adriano L, Valim V, Cunha TM, Louzada-Junior P, Rocha EM. Neurological and Inflammatory Manifestations in Sjögren's Syndrome: The Role of the Kynurenine Metabolic Pathway. Int J Mol Sci 2018; 19:ijms19123953. [PMID: 30544839 PMCID: PMC6321004 DOI: 10.3390/ijms19123953] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/16/2022] Open
Abstract
For decades, neurological, psychological, and cognitive alterations, as well as other glandular manifestations (EGM), have been described and are being considered to be part of Sjögren's syndrome (SS). Dry eye and dry mouth are major findings in SS. The lacrimal glands (LG), ocular surface (OS), and salivary glands (SG) are linked to the central nervous system (CNS) at the brainstem and hippocampus. Once compromised, these CNS sites may be responsible for autonomic and functional disturbances that are related to major and EGM in SS. Recent studies have confirmed that the kynurenine metabolic pathway (KP) can be stimulated by interferon-γ (IFN-γ) and other cytokines, activating indoleamine 2,3-dioxygenase (IDO) in SS. This pathway interferes with serotonergic and glutamatergic neurotransmission, mostly in the hippocampus and other structures of the CNS. Therefore, it is plausible that KP induces neurological manifestations and contributes to the discrepancy between symptoms and signs, including manifestations of hyperalgesia and depression in SS patients with weaker signs of sicca, for example. Observations from clinical studies in acquired immune deficiency syndrome (AIDS), graft-versus-host disease, and lupus, as well as from experimental studies, support this hypothesis. However, the obtained results for SS are controversial, as discussed in this study. Therapeutic strategies have been reexamined and new options designed and tested to regulate the KP. In the future, the confirmation and application of this concept may help to elucidate the mosaic of SS manifestations.
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Affiliation(s)
- Fabíola Reis de Oliveira
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Marina Zilio Fantucci
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Leidiane Adriano
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Valéria Valim
- Espírito Santo Federal University, Vitoria, ES 29075-910, Brazil.
| | - Thiago Mattar Cunha
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Paulo Louzada-Junior
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
| | - Eduardo Melani Rocha
- Ribeirao Preto Medical School, Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP 14049-900 Brazil.
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Unnikrishnan G, Hiremath N, Chandrasekharan K, Sreedharan SE, Sylaja PN. Cerebral Large-Vessel Vasculitis in Sjogren's Syndrome: Utility of High-Resolution Magnetic Resonance Vessel Wall Imaging. J Clin Neurol 2018; 14:588-590. [PMID: 30284770 PMCID: PMC6172513 DOI: 10.3988/jcn.2018.14.4.588] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/07/2018] [Accepted: 07/10/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Gopikrishnan Unnikrishnan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Nikhil Hiremath
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Kesavadas Chandrasekharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sapna E Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Padmavathy Narayanan Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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Rovira Á, Auger C, Rovira A. Other noninfectious inflammatory disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 135:425-446. [PMID: 27432677 DOI: 10.1016/b978-0-444-53485-9.00021-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Idiopathic inflammatory-demyelinating diseases (IIDDs) represent a broad spectrum of central nervous system (CNS) disorders, including monophasic, multiphasic, and progressive disorders that range from highly localized forms to multifocal or diffuse variants. In addition to the classic multiple sclerosis (MS) phenotypes, several MS variants have been described, which can be differentiated on the basis of severity, clinical course, and lesion distribution. Other forms of IIDD are now recognized as distinct entities and not MS variants, such as acute disseminated encephalomyelitis, and neuromyelitis optica spectrum disorders. The CNS can also be affected by a variety of inflammatory diseases. These include primary angiitis of the CNS (PACNS), a rare disorder specifically targeting the CNS vasculature, and various systemic conditions which, among other organs and systems, can also affect the CNS, such as systemic vasculitis and sarcoidosis. The diagnosis of PACNS is difficult, as this condition may be confused with reversible cerebral vasoconstriction syndrome (RCVS), a term comprising a group of conditions characterized by prolonged but reversible vasoconstriction of the cerebral arteries. Magnetic resonance imaging of the brain and spine is the radiologic technique of choice for diagnosing these disorders, and, together with the clinical and laboratory findings, enables a prompt and accurate diagnosis.
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Affiliation(s)
- Álex Rovira
- MR Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Cristina Auger
- MR Unit, Department of Radiology, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Rovira
- Corporació Sanitària Parc Taulí, CD-UDIAT, Sabadell, Spain
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Recommendations for the treatment of Sjögren's syndrome. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 55:446-57. [PMID: 26360421 DOI: 10.1016/j.rbr.2015.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 07/20/2015] [Accepted: 07/23/2015] [Indexed: 12/15/2022] Open
Abstract
The recommendations proposed by the Sjögren's Syndrome Committee of the Brazilian Society of Rheumatology for the treatment of Sjögren's syndrome were based on a systematic review of literature in Medline (PubMed) and the Cochrane databases until October 2014 and on expert opinion in the absence of studies on the subject. 131 items classified according to Oxford & Grade were included. These recommendations were developed in order to guide the appropriate management and facilitate the access to treatment for those patients with an appropriate indication, considering the Brazilian socioeconomic context and pharmacological agents available in this country.
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Primary and secondary central nervous system vasculitis: clinical manifestations, laboratory findings, neuroimaging, and treatment analysis. Clin Rheumatol 2014; 34:729-38. [DOI: 10.1007/s10067-014-2831-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/09/2014] [Indexed: 12/19/2022]
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Abdel Razek AAK, Alvarez H, Bagg S, Refaat S, Castillo M. Imaging Spectrum of CNS Vasculitis. Radiographics 2014; 34:873-894. [DOI: 10.1148/rg.344135028] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lauvsnes MB, Beyer MK, Appenzeller S, Greve OJ, Harboe E, Gøransson LG, Tjensvoll AB, Omdal R. Loss of cerebral white matter in primary Sjögren's syndrome: a controlled volumetric magnetic resonance imaging study. Eur J Neurol 2014; 21:1324-9. [PMID: 24943133 DOI: 10.1111/ene.12486] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/05/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Although brain involvement is common in primary Sjögren's syndrome (pSS), results from cerebral imaging studies are inconsistent. This study aimed to perform both voxel-wise and global brain volume analyses in a nearly population-based pSS cohort to explore whether the patients displayed any focal or diffuse volume differences compared with healthy subjects. METHODS Global grey matter (GM) and white matter (WM) volumes were measured and compared in 60 patients with pSS and 60 age- and gender-matched healthy subjects. Regression models were constructed with potential explanatory variables for GM and WM volumes. In the same groups, voxel-wise morphometric analyses were performed. RESULTS In analyses of global GM and WM, the patients had lower WM volumes than healthy subjects (540 ± 63 cm(3) vs. 564 ± 56 cm(3), P = 0.02), but no differences in GM. Voxel-wise analyses displayed no localized areas of GM or WM volume differences between pSS patients and healthy subjects. CONCLUSION Individuals with pSS have a diffuse reduction of cerebral WM but no localized loss of WM or GM. This indicates a general deleterious effect on WM due to pSS itself.
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Affiliation(s)
- M B Lauvsnes
- Clinical Immunology Unit, Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway
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Horai Y, Nishino A, Nakashima Y, Suzuki T, Okada A, Kawashiri SY, Tamai M, Yamasaki S, Nakamura H, Origuchi T, Kawakami A. Case of Sjögren's syndrome presenting as trigeminal nerve palsy. ACTA ACUST UNITED AC 2012; 35:199-202. [PMID: 22790581 DOI: 10.2177/jsci.35.199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We herein report the case of a female with Sjogren's syndrome (SS) complicated with trigeminal nerve palsy. Although her sicca symptoms had been unnoticed, head magnetic resonance imaging (MRI) for detecting brain abnormalities revealed parotid gland changes associated with SS. SS should be considerd as a possible cause of trigeminal nerve disturbances. In addition, parotid gland changes related to SS should be aware in examination of cranial nerve disturbances with MRI.
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Affiliation(s)
- Yoshiro Horai
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University, Nagasaki, Japan
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