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Lin J, Pulst-Korenberg J, Zamvil SS, Graves J, Newsome SD, Amezcua L. Tuberculous Meningitis or Neurosarcoidosis-a Diagnostic Quandary. From the National Multiple Sclerosis Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200184. [PMID: 38118077 PMCID: PMC10732344 DOI: 10.1212/nxi.0000000000200184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/05/2023] [Indexed: 12/22/2023]
Abstract
Distinguishing granulomatous diseases remains diagnostically challenging. Clinical phenotypes and neuroimaging findings resemble many infectious and noninfectious disorders. We describe a Hispanic/Latino man diagnosed with tuberculous meningitis who deteriorated neurologically after treatments. Additional workup revealed a pathology more consistent with neurosarcoidosis. Care access delays and social circumstances likely complicated his diagnosis.
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Affiliation(s)
- Jia Lin
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
| | - Johannes Pulst-Korenberg
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
| | - Scott S Zamvil
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
| | - Jennifer Graves
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
| | - Scott D Newsome
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
| | - Lilyana Amezcua
- From the Department of Neurology (J.L., J.P.-K., L.A.), University of Southern California, Keck School of Medicine, Los Angeles; Department of Neurology (S.S.Z.), University of California San Francisco; Department of Neurosciences (J.G.), University of California San Diego; and Department of Neurology and Neurosurgery (S.D.N.), Johns Hopkins University, Baltimore, MD
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Vlad B, Neidhart S, Hilty M, Ziegler M, Jelcic I. Differentiating neurosarcoidosis from multiple sclerosis using combined analysis of basic CSF parameters and MRZ reaction. Front Neurol 2023; 14:1135392. [PMID: 37034091 PMCID: PMC10080049 DOI: 10.3389/fneur.2023.1135392] [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] [Received: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Background Neurosarcodosis is one of the most frequent differential diagnoses of multiple sclerosis (MS) and requires central nervous system (CNS) biopsy to establish definite diagnosis according to the latest consensus diagnostic criteria. We here analyzed diagnostic values of basic cerebrospinal fluid (CSF) parameters to distinguish neurosarcoidosis from MS without CNS biopsy. Methods We retrospectively assessed clinical, radiological and laboratory data of 27 patients with neurosarcoidosis treated at our center and compared following CSF parameters with those of 138 patients with relapsing-remitting MS: CSF white cell count (WCC), CSF/serum albumin quotient (Qalb), intrathecal production of immunoglobulins including oligoclonal bands (OCB), MRZ reaction, defined as a polyspecific intrathecal production of IgG reactive against ≥2 of 3 the viruses measles (M), rubella (R), and zoster (Z) virus, and CSF lactate levels. Additional inflammatory biomarkers in serum and/or CSF such as neopterin, soluble interleukin-2 receptor (sIL-2R) and C-reactive protein (CRP) were assessed. Results There was no significant difference in the frequency of CSF pleocytosis, but a CSF WCC > 30/μl was more frequent in patients with neurosarcoidosis. Compared to MS, patients with neurosarcoidosis showed more frequently an increased Qalb and CSF lactate levels as well as increased serum and CSF levels of sIL-2R, but a lower frequency of intrathecal IgG synthesis and positive MRZ reaction. Positive likelihood ratio (PLR) of single CSF parameters indicating neurosarcoidosis was highest, if (a) CSF WCC was >30/μl (PLR 7.2), (b) Qalb was >10 × 10-3 (PLR 66.4), (c) CSF-specific OCB were absent (PLR 11.5), (d) CSF lactate was elevated (PLR 23.0) or (e) sIL-2R was elevated (PLR>8.0). The combination of (a) one of three following basic CSF parameters, i.e., (a.1.) CSF WCC >30/ul, or (a.2.) QAlb >10 × 10-3, or (a.3.) absence of CSF-specific OCB, and (b) absence of positive MRZ reaction showed the best diagnostic accuracy (sensitivity and specificity each >92%; PLR 12.8 and NLR 0.08). Conclusion Combined evaluation of basic CSF parameters and MRZ reaction is powerful in differentiating neurosarcoidosis from MS, with moderate to severe pleocytosis and QAlb elevation and absence of intrathecal IgG synthesis as useful rule-in parameters and positive MRZ reaction as a rule-out parameter for neurosarcoidosis.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Stephan Neidhart
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marc Hilty
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Mario Ziegler
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- *Correspondence: Ilijas Jelcic
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Otto C, Wengert O, Unterwalder N, Meisel C, Ruprecht K. Analysis of soluble interleukin-2 receptor as CSF biomarker for neurosarcoidosis. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e725. [PMID: 32393650 PMCID: PMC7238895 DOI: 10.1212/nxi.0000000000000725] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/26/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To systematically analyze soluble interleukin-2 receptor (sIL-2R) in CSF as a diagnostic and disease activity biomarker in patients with sarcoidosis involving the CNS (neurosarcoidosis). METHODS sIL-2R was determined by chemiluminescent immunoassays in CSF/serum samples from patients with neurosarcoidosis (n = 23), MS (n = 19), neurotuberculosis (n = 8), viral (n = 18) and bacterial (n = 9) meningitis, cerebral lymphoma (n = 15), Guillain-Barré syndrome (n = 8), and 115 patients with noninflammatory neurologic diseases (NINDs) as controls. The sIL-2R index was calculated by dividing the CSF/serum sIL-2R quotient (QsIL-2R) through the CSF/serum albumin quotient (QAlb). sIL-2R quotient diagrams were established by plotting QsIL-2R against QAlb. sIL-2R levels were correlated with clinical, MRI, and CSF disease activity markers of neurosarcoidosis. RESULTS Patients with neurosarcoidosis had higher CSF sIL-2R, QsIL-2R, and sIL-2R index values than patients with NINDs (p < 0.0001 for all pairwise group comparisons). sIL-2R quotient diagrams demonstrated an intrathecal sIL-2R synthesis in >50% of neurosarcoidosis samples. Similar findings were observed in viral/bacterial meningitis, CNS lymphoma, and, most pronounced, in neurotuberculosis, but not in patients with MS. CSF sIL-2R parameters were associated with clinical disease activity, leptomeningeal gadolinium enhancement, and the CSF white cell count in patients with neurosarcoidosis. CONCLUSIONS CSF sIL-2R parameters are elevated in patients with neurosarcoidosis, but this finding is not specific for neurosarcoidosis. Nevertheless, CSF sIL-2R parameters may help distinguishing neurosarcoidosis from MS and are associated with clinical, radiologic, and CSF disease activity markers of neurosarcoidosis. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that CSF sIL-2R parameters distinguish neurosarcoidosis from NINDs and MS.
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Affiliation(s)
- Carolin Otto
- From the Department of Neurology (C.O., O.W., K.R.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Labor Berlin Charité-Vivantes GmbH (N.U., C.M.); and Institute for Medical Immunology (C.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Oliver Wengert
- From the Department of Neurology (C.O., O.W., K.R.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Labor Berlin Charité-Vivantes GmbH (N.U., C.M.); and Institute for Medical Immunology (C.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nadine Unterwalder
- From the Department of Neurology (C.O., O.W., K.R.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Labor Berlin Charité-Vivantes GmbH (N.U., C.M.); and Institute for Medical Immunology (C.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Meisel
- From the Department of Neurology (C.O., O.W., K.R.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Labor Berlin Charité-Vivantes GmbH (N.U., C.M.); and Institute for Medical Immunology (C.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klemens Ruprecht
- From the Department of Neurology (C.O., O.W., K.R.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Labor Berlin Charité-Vivantes GmbH (N.U., C.M.); and Institute for Medical Immunology (C.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Wengert O, Rothenfusser-Korber E, Vollrath B, Bohner G, Scheibe F, Otto C, Hofmann J, Angstwurm K, Ruprecht K. Neurosarcoidosis: Correlation of cerebrospinal fluid findings with diffuse leptomeningeal gadolinium enhancement on MRI and clinical disease activity. J Neurol Sci 2013; 335:124-30. [DOI: 10.1016/j.jns.2013.09.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 12/19/2022]
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