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Akhavanrezayat A, Matsumiya W, Ongpalakorn P, Ghoraba HH, Or C, Khojasteh Jafari H, Kirimli GU, Yasar C, Than NTT, Karaca I, Zaidi M, Mobasserian A, Yavari N, Bazojoo V, Shin YU, Bromeo AJ, Nguyen QD. Neurosarcoidosis, Coccidioidomycosis, or Both! Int Med Case Rep J 2023; 16:887-895. [PMID: 38164515 PMCID: PMC10758176 DOI: 10.2147/imcrj.s434632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose To report a case of neurosarcoidosis (NS) who was initially diagnosed as Coccidioidomycosis immitis (CI) infection. Observations A 57-year-old diabetic man presented with sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. His vision was 20/20 in the right eye (OD) and 20/40 OS. Ophthalmic examination revealed left relative afferent pupillary defect, blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema. OD examination was non-revealing. Chest CT scan with contrast showed calcified mediastinal lymph nodes, but biopsy of the lymph nodes was normal. Brain and orbit MRI demonstrated soft tissue abnormality with enhancement in left orbital apex with involvement of the extraocular muscles. CSF culture was negative, but complement fixation had positive titer of 1:2 for CI. The patient was diagnosed with CI meningitis, and antifungal therapy was initiated. Slight visual and symptomatic improvement was observed, which was not completely satisfactory. Biopsy of extraocular orbital muscle five months later revealed non-caseating granulomatous inflammation, leading to initiation of prednisone trial therapy. Nine months later, the patient was referred to a tertiary center owing to persistence of optic disc edema OS. PET CT was consistent with a diagnosis of sarcoidosis. Antifungal treatment was discontinued, and oral prednisone with methotrexate was initiated. Subsequently, methotrexate was replaced by infliximab to further manage ocular inflammation and neurologic symptoms which was effective. Vision was 20/20 OD and 20/30 OS at the most recent visit. Conclusion and Importance Signs and symptoms of neurosarcoidosis and coccidioidomycosis can be similar and deceiving. The index case underscores importance of considering appropriate differential diagnoses in patients with similar symptoms and signs who may respond to preliminary designated treatment but not to the optimal extent. Considering such possibility could assist clinicians in managing the patients timely and efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wataru Matsumiya
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Prapatsorn Ongpalakorn
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hashem H Ghoraba
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Chris Or
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hassan Khojasteh Jafari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gunay Uludag Kirimli
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Cigdem Yasar
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ngoc Trong Tuong Than
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Irmak Karaca
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Moosa Zaidi
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Azadeh Mobasserian
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Negin Yavari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vahid Bazojoo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yong Un Shin
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Albert John Bromeo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
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2
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Bekkour I, Courtin E, Dulau-Metras C, Duffau P, Kremer L, Mathey G. Defining the course of neurosarcoidosis according to presentation at onset and disease modifying treatment: a cohort study of 84 patients. Ther Adv Neurol Disord 2023; 16:17562864231205954. [PMID: 38143513 PMCID: PMC10748905 DOI: 10.1177/17562864231205954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 12/26/2023] Open
Abstract
Background Neurosarcoidosis is a rare manifestation of sarcoidosis with heterogeneous presentations. Patient management is challenging due to the current lack of knowledge about the long-term disease course. Objective To identify specific disease courses of neurosarcoidosis according to the clinical and paraclinical presentations at onset. Methods We conducted an observational multicenter cohort study by retrospectively collecting data from the medical records of 84 patients diagnosed with definite, probable, or possible neurosarcoidosis in three tertiary referral centers in France (Nancy, Strasbourg, and Bordeaux). We collected demographic characteristics, clinical and paraclinical data at the beginning of patient management, and during follow-up under the different treatment lines. Two expert neurologists determined disease course profiles. Results The mean follow-up was 6.6 years. Almost every patient (96.4%) received steroids at some point of their follow-up. Tumor Necrosis Factor-alpha blockers were given in 10.7% as first-line treatment and in 33.3% during follow-up. Every patient presented with a relapsing disease, often monophasic (75%) and sometimes polyphasic with the recurrence of identical manifestations (11.9%). Patients developing new neurological symptoms during follow-up were a minority (13.1%). No patients exhibited a progressive course. Patients with isolated cranial nerves injury or aseptic meningitis always exhibited a monophasic course, and 62.5-75% of them had a full recovery after first-line treatments. This proportion was 15.6% in other forms of the disease. Those with peripheral presentations were more likely to present a polyphasic course than patients with other forms of neurosarcoidosis. Spinal cord presentations were monophasic, but resulted in sequelae and exhibited poor response to first-line treatments despite frequent use of TNF-alpha blockers. Conclusion Identification of these disease course profiles, based on the initial clinical and paraclinical presentation, could guide the clinician to select the optimal therapeutic approach and follow-up modalities for their patients with neurosarcoidosis.
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Affiliation(s)
- Inès Bekkour
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Edouard Courtin
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | | | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Bordeaux, France
- CNRS, ImmunoConcEpT, UMR 5164, University of Bordeaux, Bordeaux, France
| | - Laurent Kremer
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- INSERM U1119, Strasbourg, France
| | - Guillaume Mathey
- Service de Neurologie, Hopital Central, CHRU de Nancy, 1 Avenue du Maréchal de Lattre de Tassigny, Nancy 54000, France
- Department of Neurology, Nancy University Hospital, Nancy, France
- CIC-Epidémiologie Clinique, Nancy University Hospital, INSERM, Université de Lorraine, Nancy, France
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3
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Cicilet S, Reddy K S, Kancharla M. Insights into neurosarcoidosis: an imaging perspective. Pol J Radiol 2023; 88:e582-e588. [PMID: 38362019 PMCID: PMC10867949 DOI: 10.5114/pjr.2023.134021] [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: 08/15/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024] Open
Abstract
Neurosarcoidosis is a complex and multifaceted inflammatory disorder affecting the nervous system. The disease, characterized by non-caseating granulomas, primarily involves the central and peripheral nervous systems. Neuro-logical manifestations vary widely and can include cranial nerve palsies, meningeal involvement, parenchymal lesions, hydrocephalus, and more. Diagnosis remains challenging due to the lack of specific imaging features, necessitating a combination of clinical evaluation, cerebrospinal fluid analysis, imaging studies, and sometimes tissue biopsy. This review article underscores the importance of the identification of various imaging features to mitigate the mortality and morbidity associated with neurosarcoidosis.
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Affiliation(s)
- Soumya Cicilet
- St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Shreyas Reddy K
- St. John's Medical College Hospital, Bengaluru, Karnataka, India
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Jung EH, Kim W, Yoon RG, Kim KE. Coexistence of open-angle glaucoma and sarcoidosis-associated optic neuropathy. BMC Ophthalmol 2023; 23:375. [PMID: 37704998 PMCID: PMC10498634 DOI: 10.1186/s12886-023-03104-y] [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] [Received: 12/13/2022] [Accepted: 08/14/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND In cases with advanced glaucomatous disc changes, further changes associated with other optic neuropathies cannot be easily identified. We present a case of preexisting open-angle glaucoma and concurrent involvement of sarcoidosis-associated optic neuropathy. CASE PRESENTATION A 53-year-old man presented with gradual visual loss in his left eye, which began 1 year ago and accelerated 3 months ago. The best-corrected visual acuity in the right eye was 20/20 and counting fingers in the left. Intraocular pressures (IOP) were 12 mmHg in the right eye and 34 mmHg in the left. We diagnosed him with advanced open-angle glaucoma in the left eye based on the advanced glaucomatous cupping of the left optic disc. The IOP in the left eye dropped to 10 mmHg and was well controlled with antiglaucomatous medication; however, his left optic disc developed pallor 3 months after the treatment. The patient was revealed to be diagnosed with sarcoidosis a month ago and had been treated with systemic corticosteroids thereafter by a pulmonologist. Orbital magnetic resonance imaging revealed sarcoidosis-associated optic neuropathy in the left eye. Subsequently, optic neuropathy occurred in his right eye. CONCLUSIONS In eyes with advanced glaucomatous disc change, detecting the coexistence of other optic neuropathies can be difficult. This report highlights the importance of careful ophthalmic examinations and investigation for etiologies of other optic neuropathies if non-glaucomatous changes are suspected even in eyes with advanced glaucoma.
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Affiliation(s)
- Eun Hye Jung
- Department of Ophthalmology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Woonghee Kim
- Department of Ophthalmology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Ra Gyoung Yoon
- Department of Radiology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Ko Eun Kim
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, Korea.
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Alfares K, Han HJ. Neurosarcoidosis-Induced Panhypopituitarism. Cureus 2023; 15:e43169. [PMID: 37692696 PMCID: PMC10484625 DOI: 10.7759/cureus.43169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Sarcoidosis is an inflammatory condition that can impact multiple organs in the body such as the lungs, skin, eyes, and, occasionally, the central nervous system. When sarcoidosis affects the nervous system, it is referred to as neurosarcoidosis and is estimated to occur in approximately 5%-15% of sarcoid patients. When neurosarcoidosis affects the pituitary gland, it can result in panhypopituitarism, which can be life-threatening. A 35-year-old male with a known diagnosis of sarcoidosis by skin biopsies presented to the hospital with altered mental status, hypernatremia, hypotension, and hypothermia. He reported symptoms of polyuria and polydipsia for several weeks before admission. Laboratory workup revealed elevated serum sodium at 167 mmol/L, high serum osmolality at 381 mOsm/kg, and low urine osmolality at 381 mOsm/kg, consistent with diabetes insipidus. Anterior pituitary hormone profile workup revealed low 8 am serum cortisol (1.9 mcg/dL) and inappropriately normal adrenocorticotropic hormone (ACTH) (34 pg/ml), low serum free testosterone (<2.5 ng/dL), low luteinizing hormone (0.7 mIU/ml), low follicular stimulating hormone (< 2.6 mIU/ml), low free T4 at 0.4 ng/dL. and inappropriately normal thyroid-stimulating hormone (TSH) at 2.77 uIU/mL. Serum prolactin was mildly elevated at 86.8 ng/mL. Angiotensin-converting enzyme level was within the normal range at 33 U/L. A diagnosis of panhypopituitarism was made. Brain MRI revealed a 3 cm mass in the suprasellar region involving the hypothalamus and bilateral optic tracts with a mass effect on the anterior third ventricle. No discrete pituitary or stalk lesion was identified. A ventriculostomy tube was placed for developing hydrocephalus. A biopsy of the suprasellar mass revealed non-caseating granuloma, confirming neurosarcoidosis. Treatment was initiated with high-dose IV corticosteroids to manage secondary adrenal insufficiency and neurosarcoidosis. He was also started on IV desmopressin and IV levothyroxine to manage his diabetes insipidus and central hypothyroidism. He was transitioned to oral therapy upon discharge. Panhypopituitarism secondary to neurosarcoidosis is a rare presentation that can occur due to the infiltration of the pituitary gland or the infiltration of the hypothalamus affecting the hypothalamic-pituitary axis. Neurosarcoidosis should be considered a differential when evaluating patients with symptoms consistent with panhypopituitarism. Prompt diagnosis and initiation of corticosteroids and deficient hormones can be lifesaving.
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Affiliation(s)
- Khalid Alfares
- Endocrinology, Diabetes, and Metabolism, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
- Endocrinology, Diabetes, and Metabolism, Henry Ford Health System, Detroit, USA
| | - Hye Jeong Han
- Internal Medicine, Henry Ford Health System, Detroit, USA
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KINOSHITA Y, TAGUCHI A, YAMASAKI F, NAKAMORI M, AMATYA VJ, IIDA K. Isolated Neurohypophysial Sarcoidosis Involving the Cavernous Sinus Mimicking a Malignant Tumor. NMC Case Rep J 2022; 9:31-35. [PMID: 35433166 PMCID: PMC8947814 DOI: 10.2176/jns-nmc.2021-0296] [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] [Received: 09/07/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022] Open
Abstract
Because of nonspecific clinical and radiological findings, it is difficult to diagnose isolated neurosarcoidosis without histological examination. Distinguishing neurosarcoidosis from neoplasm, infectious disease, or granulomatous disease can be challenging. In this study, we present a case of a 61-year-old female who presented with unilateral blindness. Magnetic resonance imaging (MRI) revealed a large invasive mass lesion located in the neurohypophysis with homogeneous enhancement after the injection of gadolinium. The lesion involved the bilateral cavernous sinus, which extended along the dura of the skull base with leptomeningeal lesions. Contrast-enhanced computed tomography (CT) and fluorodeoxyglucose positron emission tomography/CT of the entire body showed no other lesions. Biochemical examinations showed no useful data, including angiotensin-converting enzyme, β-glucan, soluble interleukin-2 receptor, and T-SPOT. Cerebrospinal fluid examination revealed only the elevation of total protein. Under the preoperative diagnosis of a malignant tumor or metastatic tumor, followed by tuberculosis, fungal infection, or granulomatous disease, a biopsy was performed to immediately determine the appropriate therapy, which revealed the histological diagnosis of sarcoidosis. After steroid therapy, the lesions had markedly shrunk as observed on MRI, and the eyesight of the patient's right eye was completely restored. In this case, without a biopsy, discriminating between sarcoidosis and a malignant tumor was difficult. We believe that a prompt histological diagnosis of an invasive isolated neurohypophysial mass lesion involving the bilateral cavernous sinus, which is similar to a malignant tumor, is essential for selecting the appropriate therapy.
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Affiliation(s)
- Yasuyuki KINOSHITA
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Akira TAGUCHI
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Fumiyuki YAMASAKI
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Masahiro NAKAMORI
- Department of Clinical Neuroscience and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Vishwa Jeet AMATYA
- Department of Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Koji IIDA
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
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7
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Stroia A, Priyadarshini S, Meseeha M. Worsening Paraparesis: A Diagnostic Dilemma for Neurosarcoidosis. Cureus 2022; 14:e25958. [PMID: 35720784 PMCID: PMC9203248 DOI: 10.7759/cureus.25958] [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: 06/15/2022] [Indexed: 11/06/2022] Open
Abstract
Sarcoidosis is a chronic granulomatous disorder mostly known to affect the respiratory system. However, about 5-10% of cases develop neurological complications, either de novo or in patients with known sarcoidosis. The most common complications as cited by current literature include cranial nerve palsies, meningitis, and myelopathy. A unilateral thalamic lesion is an extremely rare presentation of disease. As the neurological manifestations of sarcoidosis are uncommon and variable, it poses a diagnostic challenge. We present a challenging case with worsening paraparesis and a step-by-step approach to how it was diagnosed as neurosarcoidosis. We aimed to create awareness about this uncommon manifestation to avoid misdiagnosis and promote early recognition of neurosarcoidosis.
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8
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Balcha TE, Woldeyohannes AM, Aboye AG. Imaging Findings of Concomitant Pulmonary and Central Nervous System Sarcoidosis: A Case Report. Ethiop J Health Sci 2022; 32:661-664. [PMID: 35813678 PMCID: PMC9214749 DOI: 10.4314/ejhs.v32i3.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background Sarcoidosis is a multisystem idiopathic granulomatous disorder characterized by the development of noncaseating infiltrative granulomas in various body organs. The central nervous system (CNS) is one of the sites to be affected by sarcoidosis. We present a case of sarcoidosis with concomitant involvement of lung and CNS with emphasis on neuroimaging findings. Case A 45-year-old Ethiopian male patient was sent to our radiology department at Tikur Anbessa Specialized Hospital for chest computed tomography (CT) and brain Magnetic resonance imaging (MRI) evaluation for an indication of panhypopituitarism, nasal congestion, and decreased vision. The chest CT reveals the perilymphatic distribution of multiple soft tissue attenuating pulmonary nodules which is a pattern seen in sarcoidosis. The brain MRI also revealed thickening and gadolinium enhancement of hypothalamus/optic chiasm which is also a common site of involvement in neurosarcoidosis. The nasal biopsy finding of granulomatous inflammation with the above imaging findings supports the diagnosis of sarcoidosis. Conclusion As sarcoidosis is a systemic disease that can affect any organ in the body, multimodality imaging is important in the diagnosis of sarcoidosis. Brain MRI with gadolinium contrast is a preferred imaging modality that can assess different patterns and areas of CNS involvement in sarcoidosis.
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Affiliation(s)
- Tewodros Endale Balcha
- Department of Radiology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Azmera Gissila Aboye
- Department of Radiology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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9
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Borawski B, Kuca P, Zieliński G, Maksymowicz M, Witek P. PATHOLOGICALLY-CONFIRMED ISOLATED HYPOTHALAMO-PITUITARY SARCOIDOSIS REFRACTORY TO PULSE-DOSE GLUCOCORTICOIDS AND SUCCESSFULLY TREATED WITH METHOTREXATE. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2022; 18:244-249. [PMID: 36212266 PMCID: PMC9512385 DOI: 10.4183/aeb.2022.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Isolated sarcoidosis of the hypothalamic-pituitary system is a very rare form of neurosarcoidosis. A high index of suspicion is required for diagnosis and the choice of therapy embodies another challenge due to lack of standardized protocols. Glucocorticoids are the mainstay of initial treatment, whereas the second and third-line therapy include immunomodulators and cytotoxic drugs, in addition to monoclonal antibodies. This report presents an unusual case of panhypopituitarism in a 32-year-old previously healthy male patient due to isolated hypothalamo-pituitary sarcoidosis confirmed histologically, refractory to pulse-dose glucocorticoids and then successfully treated by methotrexate. Based on our report, in patients requiring additional therapy usage of the methotrexate as the second line agent should be considered, however the time frame and the dosing schedule of methotrexate are still unknown and deserve further investigation.
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Affiliation(s)
- B. Borawski
- Medical University of Warsaw, Department of Internal Medicine, Endocrinology and Diabetes
| | - P. Kuca
- Medical University of Warsaw, Department of Internal Medicine, Endocrinology and Diabetes
| | - G. Zieliński
- Military Institute of Medicine, Department of Neurosurgery
| | - M. Maksymowicz
- “Maria Sklodowska-Curie” Memorial, National Research Institute of Oncology, Department of Pathology and Laboratory Diagnostics, Warsaw, Poland
| | - P. Witek
- Medical University of Warsaw, Department of Internal Medicine, Endocrinology and Diabetes
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10
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Gavoille A, Desbois AC, Joubert B, Durel CA, Auvens C, Berthoux E, Delboy T, Dufour JF, Turcu A, Bonnotte B, Moreau T, Le Guenno G, André M, Ruivard M, Camdessanche JP, Antoine JCG, Marignier R, Chapelon-Abric C, Saadoun D, Seve P. Prognostic Factors and Treatments Efficacy in Spinal Cord Sarcoidosis: An Observational Cohort With Long-term Follow-up. Neurology 2022; 98:e1479-e1488. [PMID: 35145013 DOI: 10.1212/wnl.0000000000200020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal cord sarcoidosis is a rare manifestation of sarcoidosis with a consequent risk of neurological sequelae for the patient. We investigated prognostic factors and efficacy of immunosuppressive treatments in a longitudinal cohort. METHODS We retrospectively studied patients with spinal cord sarcoidosis followed between 1995 and 2021 in seven centers in France. Patients with a definite, probable or possible spinal cord sarcoidosis according to the Neurosarcoidosis Consortium Consensus Group criteria and with a spinal cord involvement confirmed by MRI were included. We analyzed relapse or progression rate with a Poisson model, initial Rankin score with a linear model and change in the Rankin score during follow-up with a logistic model. RESULTS A total of 97 patients were followed for a median of 7.8 years. Overall mean relapse or progression rate was 0.17 per person-year and decreased over time. At last visit, 46 (47.4%) patients had a loss of autonomy (Rankin score ≥ 2). The main prognostic factors significantly associated with relapse or progression rate were gadolinium enhancement (relative rate [95% CI]: 0.61 [0.4, 0.95]) or meningeal involvement (relative rate [95% CI]: 2.05 [1.31, 3.19]) on spinal cord MRI, and cell count (relative rate [95% CI] per 1 log increase: 1.16 [1.01, 1.33]) on CSF analysis. Relapse or progression rate was not significantly associated with initial Rankin score or EDSS. TNF α antagonists significantly decreased relapse or progression rate compared with corticosteroids alone (relative rate [95% CI]: 0.33 [0.11, 0.98]). Azathioprine was significantly less effective than methotrexate on relapse or progression rate (relative rate [95% CI]: 2.83 [1.04, 7.75]) and change in Rankin score (mean difference [95% CI]: 0.65 [0.23, 1.08]). DISCUSSION Regarding the relapse or progression rate, meningeal localization of sarcoidosis was associated with a worse prognosis; TNF α antagonists resulted in a significant decrease compared to corticosteroids alone; and methotrexate was more effective than azathioprine. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that in individuals with spinal cord neurosarcoidosis, TNF α antagonists were associated with decreased relapse or progression rate compared to corticosteroids alone, but other therapies showed no significant benefit.
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Affiliation(s)
- Antoine Gavoille
- Service de Neurologie, Sclérose en Plaques, pathologies de la myéline et neuro-inflammation, hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, 69500 Bron, France.,Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, Lyon 69003 France.,Université de Lyon, Université Lyon 1, 69100 Villeurbanne, France
| | - Anne-Claire Desbois
- Sorbonne Universités, Pitié-Salpêtrière University Hospital, Paris, France.,Department of Internal Medicine and Clinical Immunology, France; AP-HP.,Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; RHU IMAP
| | - Bastien Joubert
- Université de Lyon, Université Lyon 1, 69100 Villeurbanne, France.,Service de Neuro-oncologie, hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, 69500 Bron, France
| | - Cécile-Audrey Durel
- Département de Médecine Interne et Immunologie Clinique, Hôpital Édouard Herriot, Hospices Civils de Lyon, 69003 Lyon, France
| | - Clément Auvens
- Département de Médecine Interne et Maladies Systémiques, CHU Dijon, 21079 Dijon, France
| | - Emilie Berthoux
- Département de Médecine Interne, CH Saint Luc Saint Joseph, 69007 Lyon, France
| | - Thierry Delboy
- Département de Médecine Interne, CH Montluçon, 03100 Montluçon, France
| | - Jean François Dufour
- Département de Médecine Interne, Centre hospitalier Fleyriat, 01012 Bourg-en-Bresse, France
| | - Alin Turcu
- Département de Médecine Interne et Maladies Systémiques, CHU Dijon, 21079 Dijon, France
| | - Bernard Bonnotte
- Département de Médecine Interne et Maladies Systémiques, CHU Dijon, 21079 Dijon, France
| | | | - Guillaume Le Guenno
- Département de Médecine Interne, CHU de Clermont-Ferrand, CHU Estaing, 63003 Clermont-Ferrand, France
| | - Marc André
- Service de Médecine Interne, hôpital Gabriel Montpied, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Marc Ruivard
- Département de Médecine Interne, CHU de Clermont-Ferrand, CHU Estaing, 63003 Clermont-Ferrand, France
| | | | | | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, pathologies de la myéline et neuro-inflammation, hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, 69500 Bron, France.,Université de Lyon, Université Lyon 1, 69100 Villeurbanne, France
| | - Catherine Chapelon-Abric
- Sorbonne Universités, Pitié-Salpêtrière University Hospital, Paris, France.,Department of Internal Medicine and Clinical Immunology, France; AP-HP.,Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; RHU IMAP
| | - David Saadoun
- Sorbonne Universités, Pitié-Salpêtrière University Hospital, Paris, France.,Department of Internal Medicine and Clinical Immunology, France; AP-HP.,Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, F-75013, Paris, France; RHU IMAP
| | - Pascal Seve
- Département de Médecine Interne, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France .,Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
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11
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Ramos-Casals M, Pérez-Alvarez R, Kostov B, Gómez-de-la-Torre R, Feijoo-Massó C, Chara-Cervantes J, Pinilla B, González-García A, Garcia-Morillo JS, López-Dupla M, De-Escalante B, Rascón J, Perez-Guerrero P, Bonet M, Cruz-Caparrós G, Alguacil A, Callejas JL, Calvo E, Soler C, Robles A, de Miguel-Campo B, Oliva-Nacarino P, Estela-Herrero J, Pallarés L, Brito-Zerón P, Blanco Y. Clinical characterization and outcomes of 85 patients with neurosarcoidosis. Sci Rep 2021; 11:13735. [PMID: 34215779 PMCID: PMC8253777 DOI: 10.1038/s41598-021-92967-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/26/2021] [Indexed: 11/09/2022] Open
Abstract
To analyze the frequency and clinical phenotype of neurosarcoidosis (NS) in one of the largest nationwide cohorts of patients with sarcoidosis reported from southern Europe. NS was evaluated according to the Diagnostic Criteria for Central Nervous System and Peripheral Nervous System Sarcoidosis recently proposed by Stern et al. Pathologic confirmation of granulomatous disease was used to subclassify NS into definite (confirmation in neurological tissue), probable (confirmation in extraneurological tissue) and possible (no histopathological confirmation of the disease). Of the 1532 patients included in the cohort, 85 (5.5%) fulfilled the Stern criteria for NS (49 women, mean age at diagnosis of NS of 47.6 years, 91% White). These patients developed 103 neurological conditions involving the brain (38%), cranial nerves (36%), the meninges (3%), the spinal cord (10%) and the peripheral nerves (14%); no patient had concomitant central and peripheral nerve involvements. In 59 (69%) patients, neurological involvement preceded or was present at the time of diagnosis of the disease. According to the classification proposed by Stern et al., 11 (13%) were classified as a definite NS, 61 (72%) as a probable NS and the remaining 13 (15%) as a possible NS. In comparison with the systemic phenotype of patients without NS, patients with CNS involvement presented a lower frequency of thoracic involvement (82% vs 93%, q = 0.018), a higher frequency of ocular (27% vs 10%, q < 0.001) and salivary gland (15% vs 4%, q = 0.002) WASOG involvements. In contrast, patients with PNS involvement showed a higher frequency of liver involvement (36% vs 12%, p = 0.02) in comparison with patients without NS. Neurosarcoidosis was identified in 5.5% of patients. CNS involvement prevails significantly over PNS involvement, and both conditions do not overlap in any patient. The systemic phenotype associated to each involvement was clearly differentiated, and can be helpful not only in the early identification of neurological involvement, but also in the systemic evaluation of patients diagnosed with neurosarcoidosis.
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Affiliation(s)
- Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Belchin Kostov
- Primary Healthcare Transversal Research Group, IDIBAPS, Primary Care Center Les Corts, CAPSBE, Barcelona, Spain.,Department of Statistics and Operational Research, Universitat Politècnica de Catalunya, Barcelona, Spain
| | | | | | | | - Blanca Pinilla
- Department of Internal Medicine, Hospital Gregorio Marañón, Madrid, Spain
| | | | | | | | | | - Javier Rascón
- Department of Internal Medicine, Hospital Son Espases, Palma de Mallorca, Spain
| | | | - Mariona Bonet
- Department of Internal Medicine, Althaia, Xarxa Assistencial de Manresa, Manresa, Spain
| | - Gracia Cruz-Caparrós
- Department of Internal Medicine, Hospital de Poniente de El Ejido, Almería, Spain
| | - Ana Alguacil
- Department of Internal Medicine, Hospital Virgen de la Salud, Toledo, Spain
| | | | - Eva Calvo
- Department of Internal Medicine, Hospital San Jorge, Huesca, Spain
| | - Cristina Soler
- Department of Internal Medicine, Hospital Santa Caterina, Girona, Spain
| | - Angel Robles
- Department of Internal Medicine, Hospital La Paz, Madrid, Spain
| | | | - Pedro Oliva-Nacarino
- Department of Neurology. Hospital, Universitario Central de Asturias (HUCA), Oviedo, Spain
| | | | - Lucio Pallarés
- Department of Internal Medicine, Hospital Son Espases, Palma de Mallorca, Spain
| | - Pilar Brito-Zerón
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital CIMA-Sanitas, Barcelona, Spain.
| | - Yolanda Blanco
- Department of Neurology, Hospital Clínic, Barcelona, Spain
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12
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Sève P, Pacheco Y, Durupt F, Jamilloux Y, Gerfaud-Valentin M, Isaac S, Boussel L, Calender A, Androdias G, Valeyre D, El Jammal T. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells 2021; 10:cells10040766. [PMID: 33807303 PMCID: PMC8066110 DOI: 10.3390/cells10040766] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, 69007 Lyon, France
- Correspondence:
| | - Yves Pacheco
- Faculty of Medicine, University Claude Bernard Lyon 1, F-69007 Lyon, France;
| | - François Durupt
- Department of Dermatology, Lyon University Hospital, 69004 Lyon, France;
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Sylvie Isaac
- Department of Pathology, Lyon University Hospital, 69310 Pierre Bénite, France;
| | - Loïc Boussel
- Department of Radiology, Lyon University Hospital, 69004 Lyon, France
| | - Alain Calender
- Department of Genetics, Lyon University Hospital, 69500 Bron, France;
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Dominique Valeyre
- Department of Pneumology, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, 93008 Bobigny, France;
| | - Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
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13
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Conti MLD, Osaki MH, Sant'Anna AE, Osaki TH. Orbitopalpebral and ocular sarcoidosis: what does the ophthalmologist need to know. Br J Ophthalmol 2021; 106:156-164. [PMID: 33622698 DOI: 10.1136/bjophthalmol-2020-317423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/21/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
Sarcoidosis is a chronic multisystemic disease of unknown aetiology, characterised by non-caseating granulomas. Ocular involvement rate ranges from 30% to 60% among individuals with sarcoidosis, and can vary widely, making the diagnosis a challenge to the ophthalmologist. Cutaneous manifestations occur in about 22% of sarcoidosis cases, but eyelid involvement is rare. Eyelid swelling and nodules are the most frequent forms of eyelid involvement, but other findings have been reported. The joint analysis of clinical history, ancillary exams and compatible biopsy is needed for the diagnosis, as well as the exclusion of other possible conditions. This review aims to describe the different forms of presentations, the clinical reasoning and treatment options for ocular, eyelid and orbital sarcoidosis.
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Affiliation(s)
- Marina Lourenço De Conti
- Department of Ophthalmology and Visual Sciences, Division of Ophthalmic Plastic and Reconstructive Surgery, Paulista School of Medicine / Federal University of S. Paulo - EPM / UNIFESP, S. Paulo, SP, Brazil
| | - Midori Hentona Osaki
- Department of Ophthalmology and Visual Sciences, Division of Ophthalmic Plastic and Reconstructive Surgery, Paulista School of Medicine / Federal University of S. Paulo - EPM / UNIFESP, S. Paulo, SP, Brazil.,Ophthalmology, Osaki Ophthalmology, S. Paulo, SP, Brazil
| | - Ana Estela Sant'Anna
- Department of Ophthalmology and Visual Sciences, Division of Ophthalmic Plastic and Reconstructive Surgery, Paulista School of Medicine / Federal University of S. Paulo - EPM / UNIFESP, S. Paulo, SP, Brazil
| | - Tammy Hentona Osaki
- Department of Ophthalmology and Visual Sciences, Division of Ophthalmic Plastic and Reconstructive Surgery, Paulista School of Medicine / Federal University of S. Paulo - EPM / UNIFESP, S. Paulo, SP, Brazil .,Ophthalmology, Osaki Ophthalmology, S. Paulo, SP, Brazil
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14
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Loft MK, Rafaelsen SR, Pedersen MRV. Spontaneous dissolution of a cyst located within the septum pellucidum in a patient with sarcoidosis: a case report. Acta Radiol Open 2021; 10:2058460120985519. [PMID: 33489313 PMCID: PMC7804360 DOI: 10.1177/2058460120985519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/09/2020] [Indexed: 11/16/2022] Open
Abstract
Sarcoidosis is a granulomatous multisystem disease of unknown etiology. Typically, the disease affects the lungs, causing enlargement of the mediastinal lymph nodes, but other organs can be affected. Neurosarcoidosis is reported in 5-10% of the patients. This case represents a 39-year-old male patient diagnosed with lung sarcoidosis. Due to neurological symptoms, a contrast-enhanced cerebral magnetic resonance imaging was performed. Neurosarcoidosis was presented with meningeal enhancement adjacent to a cyst located within the cavum septum pellucidum. The cyst dissolved spontaneously within six months. The finding of a cyst located within the septum pellucidum is rare.
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Affiliation(s)
- Martina Kastrup Loft
- Department of Radiology, Lillebaelt Hospital, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health, University of Southern Denmark, Odense, Denmark
| | - Søren Rafael Rafaelsen
- Department of Radiology, Lillebaelt Hospital, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health, University of Southern Denmark, Odense, Denmark
| | - Malene Roland V Pedersen
- Department of Radiology, Lillebaelt Hospital, Vejle Hospital, Vejle, Denmark.,Institute of Regional Health, University of Southern Denmark, Odense, Denmark
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15
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Fereos G, Buchanan C, Allen P, Inusa B, Bossley CJ. A mysterious cause of chronic cough. Breathe (Sheff) 2021; 16:200163. [PMID: 33447277 PMCID: PMC7792853 DOI: 10.1183/20734735.0163-2020] [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] [Indexed: 11/13/2022] Open
Abstract
A 15-year-old-girl of African descent with sickle cell anaemia (HbSS) presented with an 18-month history of gradually worsening productive cough. She had a history of a previous pneumonia, acute chest crises and two episodes of acute pancreatitis. She was on regular blood transfusions. She underwent a splenectomy in December 2013. There was no documented history of hypercalcaemia. She had no history of fevers or tuberculosis (TB) contacts. This case alerts professionals to take a broad approach when considering childhood chronic cough in sickle cell disease. Certain respiratory conditions are difficult to recognise in childhood, with many children suffering from delayed diagnosis.https://bit.ly/2GZAgmE
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Affiliation(s)
- George Fereos
- King's College London, School of Medical Education, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | | | - Pamela Allen
- King's College Hospital NHS Foundation Trust, London, UK
| | - Baba Inusa
- Evelina London Children's Hospital, London, UK
| | - Cara J Bossley
- King's College Hospital NHS Foundation Trust, London, UK
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16
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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17
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Optic nerve head sarcoidosis mimicking an intraocular tumour, and occurring as the first manifestation of neuro-ocular sarcoidosis. Am J Ophthalmol Case Rep 2020; 20:100988. [PMID: 33163694 PMCID: PMC7610040 DOI: 10.1016/j.ajoc.2020.100988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose Sarcoidosis is a chronic idiopathic granulomatous inflammatory disease that can affect many major organ systems, primarily the lungs, and hence has remarkable clinical heterogeneity. At least 50% of patients with systemic sarcoidosis develop inflammatory eye disease, and in approximately 21% of cases, it may be the first clinical manifestation. Neuro-ocular involvement occurs in <3% of all sarcoidosis cases, and rarely involves the optic nerve. We describe an unusual case of an intraocular sarcoidosis presenting as an unclear optic nerve mass. Observations A 61-year-old male presented with painful gradual visual loss in the right eye. Previous history included Stage II Hodgkin lymphoma (HL) and concurrent mediastinal sarcoidosis, both in remission 5 years later. On examination, the right eye (RE) vision had no light perception, neovascular glaucoma, attenuated retinal vessels and a non-pigmented optic disc mass. The left eye was normal. The RE showed no response to oral steroids, was painful due to neovascular glaucoma and the concerns of recurrent HL with intraocular manifestations lead to RE enucleation. Macroscopic examination revealed a whitish mass at the optic disc, which histomorphologically showed a non-necrotising granulomatous inflammation consuming the optic nerve head and extending into the optic nerve resection margin. Special stains for microorganisms were negative. The uveal tract was free of inflammation. The morphological features were consistent with optic nerve sarcoidosis. A diagnosis of neuro-ocular sarcoidosis was made, and the patient was commenced on infliximab. Conclusion Neuro-ocular sarcoidosis is known as the ‘great imitator’ because it can cause a variety of non-specific clinical signs and symptoms, mimicking many other conditions, including lymphomas. Intraocular sarcoidosis is not unusual and typically affects the uvea. Isolated optic nerve sarcoidosis is rare. The challenging aspect of intraocular sarcoidosis is the requirement of prompt treatment to reverse any eye damage and prevent permanent visual loss. Here, optic nerve sarcoidosis was very advanced, and was associated with intracerebral manifestations. Importance Neuro-ocular sarcoidosis is a difficult condition to diagnose and treat. Our case was complicated by the previous history of HL and concurrent mediastinal sarcoidosis which were in remission. In patients with a history of sarcoidosis with new loss of vision and neurological weaknesses oculocerebral involvement must be included in the differential diagnosis even in the absence of typical manifestations of ocular sarcoidosis as in uveal tract involvement. Optic nerve head (ONH) sarcoidosis without uveal tract involvement is rare. ONH sarcoidosis can be the first manifestation of systemic sarcoidosis. ONH sarcoidosis may be the first manifestation of neuro-ocular sarcoidosis. ONH masses present diagnostic challenges due to the impact of tissue biopsy. ‘Sarcoid-like’ reaction or sarcoid-lymphoma syndrome may occur with concurrent lymphoma.
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18
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Nicolosi C, Carrera EJ, Heronemus M, Shivers J, Niehaus W. Neurosarcoidosis in acute inpatient rehabilitation: a case study. Spinal Cord Ser Cases 2020; 6:99. [PMID: 33139707 PMCID: PMC7608602 DOI: 10.1038/s41394-020-00350-w] [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] [Received: 08/25/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Sarcoidosis affects the nervous system in ~5-10% of cases. Common presentations for neurosarcoidosis can include facial nerve neuropathy, optic neuritis, meningitis, seizure muscle weakness, and paresthesia. Due to the complex treatment of neurosarcoidosis, few reports exist involving patients' recovery in an acute rehabilitation setting. CASE PRESENTATION We describe a case of neurosarcoidosis affecting the cervical and thoracic spinal cord in an individual with known Chiari I malformation and associated syrinx decompression. DISCUSSION We discuss the diagnosis and treatment of neurosarcoidosis and clinical implications of acute rehabilitation on functional recovery.
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Affiliation(s)
- C Nicolosi
- University of Colorado School of Medicine, Aurora, CO, USA.
| | - E J Carrera
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO, USA
| | - M Heronemus
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO, USA
| | - J Shivers
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO, USA
| | - W Niehaus
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, CO, USA
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19
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Nordström S, Andersson B, Malmeström C. Cerebrospinal fluid CD4 + /CD8 + ratio in diagnosing neurosarcoidosis. Acta Neurol Scand 2020; 142:480-485. [PMID: 32533774 DOI: 10.1111/ane.13297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/13/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neurosarcoidosis affects 5%-10% of patients with sarcoidosis. CD4+ /CD8+ ratio in bronchoalveolar lavage is included in diagnostic routine for pulmonary sarcoidosis. Previously, it has been suggested that a cerebrospinal fluid CD4+ /CD8+ ratio ≥5 can be an aid in diagnosing neurosarcoidosis. MATERIALS AND METHODS This study included 66 cases where neurosarcoidosis was a differential diagnosis and hence subjected to the analysis of CSF CD4+ /CD8+ ratio by flow cytometry. RESULTS Eleven cases of neurosarcoidosis, had a significantly higher median CSF CD4+ /CD8+ ratio than the other group, P = .024. The median CSF CD4+ /CD8+ ratio was 4.2, hence not reaching the suggested level of ≥5 for diagnosing neurosarcoidosis. When combined, the elevated CSF CD4+ /CD8+ ratio ≥5 and an elevated CSF lymphocyte count (>3 lymphocytes/uL) gave a positive predictive value of 57% and a high negative predictive value of 88%, with a specificity of 95% for neurosarcoidosis. CONCLUSION The study confirms that increased CSF CD4+ /CD8+ ratio is associated with neurosarcoidosis but cannot alone distinguish the conditions from other neurological diagnoses. However, a ratio below <5 combined with an absence of pleocytosis in CSF yields a negative predictive value (NPV) of 88% suggesting a role for the analysis in differential diagnosing neuroinflammatory conditions.
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Affiliation(s)
- Sara Nordström
- Department of Neurology University of Gothenburg Gothenburg Sweden
- Institute of neuroscience and physiology University of Gothenburg Gothenburg Sweden
| | - Bengt Andersson
- Laboratory for Clinical Immunology University of Gothenburg Gothenburg Sweden
- Sahlgrenska university hospital University of Gothenburg Gothenburg Sweden
| | - Clas Malmeström
- Department of Neurology University of Gothenburg Gothenburg Sweden
- Institute of neuroscience and physiology University of Gothenburg Gothenburg Sweden
- Laboratory for Clinical Immunology University of Gothenburg Gothenburg Sweden
- Sahlgrenska university hospital University of Gothenburg Gothenburg Sweden
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20
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Alfraji N, Douedi S, Hossain MA. Hydrocephalus and myelopathy: A rare and challenging case of sarcoidosis and review of literature. Clin Case Rep 2020; 8:1890-1894. [PMID: 33088513 PMCID: PMC7562839 DOI: 10.1002/ccr3.3003] [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: 02/19/2020] [Revised: 05/11/2020] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
Neurological involvement is a rare presentation of sarcoidosis. Physicians should consider sarcoid as a cause of myelitis and hydrocephalus as early management with steroid improves patient survival and reduces long-term disability.
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Affiliation(s)
- Nasam Alfraji
- Department of MedicineJersey Shore University Medical CenterHackensack Meridian HealthNeptuneNJUSA
| | - Steven Douedi
- Department of MedicineJersey Shore University Medical CenterHackensack Meridian HealthNeptuneNJUSA
| | - Mohammad A. Hossain
- Department of MedicineJersey Shore University Medical CenterHackensack Meridian HealthNeptuneNJUSA
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21
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Bathla G, Freeman CW, Moritani T, Song JW, Srivastava S, Soni N, Derdeyn C, Mohan S. Retrospective, dual-centre review of imaging findings in neurosarcoidosis at presentation: prevalence and imaging sub-types. Clin Radiol 2020; 75:796.e1-796.e9. [PMID: 32703543 DOI: 10.1016/j.crad.2020.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/06/2020] [Indexed: 01/07/2023]
Abstract
AIM To assess the prevalence of various imaging manifestations in neurosarcoidosis (NS) patients at presentation and to explore if specific imaging findings may cluster in different sub-groups. MATERIALS AND METHODS A retrospective, dual-institution, systematic imaging review was undertaken of the magnetic resonance imaging (MRI) findings in 100 consecutive NS patients who presented over a 15-year period. Clustering analysis (k-mode) was performed to evaluate co-occurrence of imaging findings. RESULTS Non-enhancing white matter (NEWM) lesions were the most common imaging abnormality (56%), followed by leptomeningeal (47%) and pachymeningeal (32%) involvement. Other common manifestations included cranial nerve involvement (30%), parenchymal granulomas (27%), hypothalamic-pituitary-adrenal axis involvement (26%), and hydrocephalus (14%). Additionally, a higher prevalence of perivascular enhancement (23%), cerebrovascular events (including ischaemic and haemorrhagic events; 17%), and ependymal involvement (20%) were noted than recognised previously. Additional k-mode analysis was performed to explore underlying disease sub-clusters. This was evaluated for clusters varying between two though five (k=2-5). For k=4, the analysis revealed that the imaging findings may possibly be divided into disease sub-sets of four groups, each with varying distribution of imaging manifestations and clinical manifestations. CONCLUSION Overall, NEWM lesions and meningeal involvement are the most common imaging manifestations of NS. The prevalence of perivascular enhancement, cerebrovascular events, and ependymal involvement is likely higher than reported previously. Additionally, different imaging findings in NS may cluster together and imaging subtypes in NS possibly exist.
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Affiliation(s)
- G Bathla
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - C W Freeman
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - T Moritani
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - J W Song
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - S Srivastava
- Department of Statistics and Actuarial Science, University of Iowa, Iowa, USA
| | - N Soni
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - C Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - S Mohan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
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22
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Murphy OC, Salazar-Camelo A, Jimenez JA, Barreras P, Reyes MI, Garcia MA, Moller DR, Chen ES, Pardo CA. Clinical and MRI phenotypes of sarcoidosis-associated myelopathy. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:e722. [PMID: 32269072 PMCID: PMC7176244 DOI: 10.1212/nxi.0000000000000722] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/28/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the characteristic clinical and spinal MRI phenotypes of sarcoidosis-associated myelopathy (SAM), we analyzed a large cohort of patients with this disorder. METHODS Patients diagnosed with SAM at a single center between 2000 and 2018 who met the established criteria for definite and probable neurosarcoidosis were included in a retrospective analysis to identify clinical profiles, CSF characteristics, and MRI lesion morphology. RESULTS Of 62 included patients, 33 (53%) were male, and 30 (48%) were African American. SAM was the first clinical presentation of sarcoidosis in 49 patients (79%). Temporal profile of symptom evolution was chronic in 81%, with sensory symptoms most frequently reported (87%). CSF studies showed pleocytosis in 79% and CSF-restricted oligoclonal bands in 23% of samples tested. Four discrete patterns of lesion morphology were identified on spine MRI: longitudinally extensive myelitis (n = 28, 45%), short tumefactive myelitis (n = 14, 23%), spinal meningitis/meningoradiculitis (n = 14, 23%), and anterior myelitis associated with areas of disc degeneration (n = 6, 10%). Postgadolinium enhancement was seen in all but 1 patient during the acute phase. The most frequent enhancement pattern was dorsal subpial enhancement (n = 40), followed by meningeal/radicular enhancement (n = 23) and ventral subpial enhancement (n = 12). In 26 cases (42%), enhancement occurred at locations with coexisting structural changes (e.g., spondylosis). CONCLUSIONS Recognition of the clinical features (chronically evolving myelopathy) and distinct MRI phenotypes (with enhancement in a subpial and/or meningeal pattern) seen in SAM can aid diagnosis of this disorder. Enhancement patterns suggest that SAM may have a predilection for areas of the spinal cord susceptible to mechanical stress.
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Affiliation(s)
- Olwen C Murphy
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Andrea Salazar-Camelo
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Jorge A Jimenez
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Paula Barreras
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Maria I Reyes
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Maria A Garcia
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - David R Moller
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Edward S Chen
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD
| | - Carlos A Pardo
- From the Division of Neuroimmunology (O.C.M., A.S.-C., J.A.J., P.B., M.I.R., M.A.G., C.A.P.), Johns Hopkins Myelitis and Myelopathy Center, Johns Hopkins Hospital; and Division of Pulmonary and Critical Care Medicine (D.R.M., E.S.C.), Johns Hopkins Hospital, Baltimore, MD.
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Lord J, Paz Soldan MM, Galli J, Salzman KL, Kresser J, Bacharach R, DeWitt LD, Klein J, Rose J, Greenlee J, Clardy SL. Neurosarcoidosis: Longitudinal experience in a single-center, academic healthcare system. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/4/e743. [PMID: 32404428 PMCID: PMC7238893 DOI: 10.1212/nxi.0000000000000743] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/13/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize patients with neurosarcoidosis within the University of Utah healthcare system, including demographics, clinical characteristics, treatment, and long-term outcomes. METHODS We describe the clinical features and outcomes of patients with neurosarcoidosis within the University of Utah healthcare system (a large referral center for 10% of the continental United States by land mass). Patients were selected who met the following criteria: (1) at least one International Classification of Diseases Clinical Modification, 9th revision code 135 or International Classification of Diseases Clinical Modification, 10th revision code D86* (sarcoidosis) and (2) at least one outpatient visit with a University of Utah clinician in the Neurology Department within the University of Utah electronic health record. RESULTS We identified 56 patients meeting the study criteria. Thirty-five patients (63%) were women, and most patients (84%) were white. Twelve patients (22%) met the criteria for definite neurosarcoidosis, 36 patients (64%) were diagnosed with probable neurosarcoidosis, and 8 patients (14%) were diagnosed with possible neurosarcoidosis. A total of 8 medications were used for the treatment of neurosarcoidosis. Prednisone was the first-line treatment in 51 patients (91%). Infliximab was the most effective therapy, with 87% of patients remaining stable or improving on infliximab. Treatment response for methotrexate and azathioprine was mixed, and mycophenolate mofetil and rituximab were the least effective treatments in this cohort. CONCLUSIONS This is a comprehensive characterization of neurosarcoidosis within a single healthcare system at the University of Utah that reports long-term response to treatment and outcomes of patients with neurosarcoidosis. Our results suggest the use of infliximab as a first-line therapy for neurosarcoidosis.
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Affiliation(s)
- Jennifer Lord
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - M Mateo Paz Soldan
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Jonathan Galli
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Karen L Salzman
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Jacob Kresser
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Rae Bacharach
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - L Dana DeWitt
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Julia Klein
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - John Rose
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - John Greenlee
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City
| | - Stacey L Clardy
- From the Department of Neurology (J.L., M.M.P.S., J. Galli, R.B., L.D.D., J. Klein, J.R., J. Greenlee, S.L.C.), University of Utah; George E. Wahlen Veterans Affairs Medical Center (J.L., M.M.P.S., J. Galli, S.L.C.); Department of Radiology and Imaging Sciences (K.L.S.), and Departments of Internal Medicine and Bioinformatics (J. Kresser), University of Utah, Salt Lake City.
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Arun T, Pattison L, Palace J. Distinguishing neurosarcoidosis from multiple sclerosis based on CSF analysis: A retrospective study. Neurology 2020; 94:e2545-e2554. [PMID: 32354749 DOI: 10.1212/wnl.0000000000009491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To characterize a cohort of patients with neurosarcoidosis with particular focus on CSF analysis and to investigate whether CSF values could help in distinguishing it from multiple sclerosis (MS). METHODS This retrospective cohort study enrolled 85 patients with a diagnosis of neurosarcoidosis (possible, probable, or definite). CSF total protein, white cell count, and angiotensin-converting enzyme levels were measured. CSF and serum oligoclonal immunoglobulin G (IgG) patterns were analyzed with the use of odds ratios and binary logistic regression. RESULTS Eighty patients had a probable (nonneural positive histology) or definite (neural positive histology) diagnosis of neurosarcoidosis. Most frequent findings on MRI were leptomeningeal enhancement (35%) and white matter and spinal cord involvement (30% and 23%). PET scan showed avid areas in 74% of cases. CSF analysis frequently showed lymphocytosis (63%) and elevated protein (62%), but CSF-selective oligoclonal bands were rare (3%). Serum ACE levels were elevated in 51% of patients but in only 14% of those with isolated neurosarcoidosis. Elevated CSF ACE was not found in any patient. CONCLUSIONS Large elevations in total protein, white cell count, and serum ACE occur in neurosarcoidosis but are rare in MS. The diagnostic use of these tests is, however, limited because minimal changes may occur in both. MS clinical mimics in neurosarcoidosis are not common, and intrathecal synthesis of oligoclonal IgG is a powerful discriminator because it is rare in neurosarcoidosis but occurs in 95% to 98% cases of MS. We suggest caution in making a diagnosis of neurosarcoidosis when intrathecal oligoclonal IgG synthesis is found.
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Affiliation(s)
- Tarunya Arun
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK.
| | - Laura Pattison
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
| | - Jacqueline Palace
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
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25
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Pandit P, Perez RL, Roman J. Sex-Based Differences in Interstitial Lung Disease. Am J Med Sci 2020; 360:467-473. [PMID: 32487327 DOI: 10.1016/j.amjms.2020.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/18/2020] [Accepted: 04/18/2020] [Indexed: 12/16/2022]
Abstract
Interstitial lung diseases comprise a family of progressive pulmonary disorders that are often idiopathic or associated with various systemic diseases and that is characterized by bilateral lung involvement with inflammation and tissue remodeling or fibrosis. The impact of sex, including the anatomic and physiologic traits that one is born with, on the development and progression of interstitial lung diseases is not entirely clear. Variances between men and women are driven by differences in male and female biology and sex hormones, among other differences, but their role remains uncertain. In this review, we summarize sex-related differences in the epidemiology and progression of certain interstitial lung diseases with a focus on the connective tissue related interstitial lung diseases, idiopathic pulmonary fibrosis, and sarcoidosis. We also discuss cellular and pre-clinical studies that might shed light on the potential mechanisms responsible for these differences in the hope of unveiling potential targets for intervention and stimulating research in this needed field of investigation.
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Affiliation(s)
- Pooja Pandit
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Sidney Kimmel College of Medicine; Jane & Leonard Korman Respiratory Institute, Jefferson Health, Thomas Jefferson University, 834 Walnut St, Philadelphia, PA 19107 USA
| | - Rafael L Perez
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Sidney Kimmel College of Medicine; Jane & Leonard Korman Respiratory Institute, Jefferson Health, Thomas Jefferson University, 834 Walnut St, Philadelphia, PA 19107 USA
| | - Jesse Roman
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Sidney Kimmel College of Medicine; Jane & Leonard Korman Respiratory Institute, Jefferson Health, Thomas Jefferson University, 834 Walnut St, Philadelphia, PA 19107 USA.
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Abstract
The current management of acute optic neuritis (ON) is focused on expediting visual recovery through the use of high-dose intravenous corticosteroids. The recent identification of specific autoantibodies associated with central nervous system inflammatory disorders has provided novel insights into immune targets and mechanisms that impact the prognosis, treatment, and recurrence of ON. Therefore, neurologists and ophthalmologists need to be aware of clinical, laboratory, and imaging findings that may provide important clues to the etiology of ON and the potential need for aggressive management. Moving forward, rapid and accurate diagnosis of inflammatory ON will likely be critical for implementing clinical care that optimizes short-term and long-term therapeutic outcomes.
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Chaudhry HS, Ata F, Abdelghani M, Kazman R, Rahil A. Isolated Bulbar Palsy: A Rare Presentation of Neurosarcoidosis. Cureus 2020; 12:e7010. [PMID: 32206474 PMCID: PMC7077743 DOI: 10.7759/cureus.7010] [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] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, which is a non-caseating granulomatous chronic inflammatory disease, can affect virtually any organ system, including the central nervous system (CNS). Very rarely, patients may present solely with neurosarcoidosis. It commonly presents with unilateral or bilateral seventh nerve palsy. Rarely it can present as dangerous progressive bulbar palsy and is a diagnostic and clinical challenge. We present a case of sarcoidosis with a unique presentation of isolated bulbar palsy. A 38-year-old male presented to the emergency with a sudden onset of dysphonia followed by dysphagia for both solids and liquids for one week and 5 kg weight loss in two months. The rest of the CNS exam was unremarkable. On labs, he had hypercalcemia and suppressed parathyroid hormone (PTH) intact. Detailed radiological investigations, lab tests, and lymph node biopsy helped confirm the diagnosis of neurosarcoidosis. The patient did not respond to first-line steroid therapy and hence received intravenous immunoglobulin (IVIG) subsequently with adequate response and complete neurologic recovery, confirmed by a follow-up visit.
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Affiliation(s)
| | - Fateen Ata
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
| | | | - Rashid Kazman
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | - Ali Rahil
- Internal Medicine, Hamad Medical Corporation, Doha, QAT
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28
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Anand P, Chwalisz BK. Inflammatory Disorders of the Skull Base: a Review. Curr Neurol Neurosci Rep 2019; 19:96. [DOI: 10.1007/s11910-019-1016-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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29
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Taschner CA, Doostkam S, Reinacher PC, Urbach H, Rau A, Prinz M. Freiburg Neuropathology Case Conference. Clin Neuroradiol 2019; 29:797-804. [DOI: 10.1007/s00062-019-00849-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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30
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Off Trail, On Track: an Exercise in Clinical Reasoning. J Gen Intern Med 2019; 34:2282-2287. [PMID: 31270781 PMCID: PMC6816762 DOI: 10.1007/s11606-019-05095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 02/05/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
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31
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Abushamat LA, Kerr JM, Lopes MBS, Kleinschmidt-DeMasters BK. Very Unusual Sellar/Suprasellar Region Masses: A Review. J Neuropathol Exp Neurol 2019; 78:673-684. [PMID: 31233145 DOI: 10.1093/jnen/nlz044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/15/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022] Open
Abstract
The cause of sellar region masses in large retrospective series is overwhelmingly pituitary adenomas (84.6%), followed by craniopharyngiomas (3.2%), cystic nonneoplastic lesions (2.8%), inflammatory lesions (1.1%), meningiomas (0.94%), metastases (0.6%), and chordomas (0.5%) (1). While other rare lesions were also identified (collectively 6.0%), single unusual entities in the above-cited series numbered <1-2 examples each out of the 4122 cases, underscoring their rarity. We searched our joint files for rare, often singular, sellar/suprasellar masses that we had encountered over the past several decades in our own specialty, tertiary care specialty pituitary center practices. Cases for this review were subjectively selected for their challenging clinical and/or histological features as well as teaching value based on the senior authors' (MBSL, BKD) collective experience with over 7000 examples. We excluded entities deemed to be already well-appreciated by neuropathologists such as mixed adenoma-gangliocytoma, posterior pituitary tumors, metastases, and hypophysitis. We identified examples that, in our judgment, were sufficiently unusual enough to warrant further reporting. Herein, we present 3 diffuse large cell B cell pituitary lymphomas confined to the sellar region with first presentation at that site, 2 sarcomas primary to sella in nonirradiated patients, and 1 case each of granulomatosis with polyangiitis and neurosarcoidosis with first presentations as a sellar/suprasellar mass. Other cases included 1 of chronic lymphocytic leukemia within a gonadotroph adenoma and 1 of ectopic nerve fascicles embedded within a somatotroph adenoma, neither of which impacted patient care. Our objective was to share these examples and review the relevant literature.
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Affiliation(s)
- Layla A Abushamat
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Janice M Kerr
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - M Beatriz S Lopes
- Department of Pathology (Neuropathology) and Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Bette K Kleinschmidt-DeMasters
- Department of Pathology
- Department of Neurology
- Department of Neurosurgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Deuchler S, Wagner C, Schill M, Schöne B, Scherer D, Singh P, Kohnen T, Koch FHJ. Unusual Primary Ocular Manifestation of Sarcoidosis. Case Rep Ophthalmol 2019; 10:205-212. [PMID: 31692537 PMCID: PMC6760357 DOI: 10.1159/000501302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022] Open
Abstract
A 23-year-old male patient presented with very mild visual disturbances, but a distinct prominence of the optic discs, more pronounced in the right than in the left eye. The ophthalmic symptoms initially seemed trivial, but a large-scale interdisciplinary workup later identified them as the presenting symptoms of sarcoidosis affecting lung and eyes. A standard steroid monotherapy successfully caused regression of the ophthalmic findings.
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Affiliation(s)
- Svenja Deuchler
- Retina and Vitreous Unit, University Eye Clinic, Frankfurt, Germany
| | | | | | | | | | - Pankaj Singh
- Retina and Vitreous Unit, University Eye Clinic, Frankfurt, Germany
| | | | - Frank H J Koch
- Retina and Vitreous Unit, University Eye Clinic, Frankfurt, Germany
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Sehara Y, Otsuka H, Sakamoto S, Ando Y, Sawada M. Neurosarcoidosis Occurring 6 Years after Onset of Vogt-Koyanagi-Harada Disease. Case Rep Ophthalmol 2019; 10:32-40. [PMID: 31097942 PMCID: PMC6489034 DOI: 10.1159/000496384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/16/2018] [Indexed: 12/17/2022] Open
Abstract
A 43-year-old Japanese woman visited a clinic with a 2-week history of visual loss, hyperemia, and bilateral eye pain. Dilated fundus and optical coherence tomography showed hyperemic optic disc and multifocal serous retinal detachments. Fundus fluorescein angiography revealed optic disc leakage and numerous hyperfluorescent pinpoints of leakage, which are typical of Vogt-Koyanagi-Harada disease (VKHD). She also showed tinnitus, poliosis, and alopecia. With a diagnosis of VKHD, steroid therapy was started. At the age of 48, oral prednisolone was tapered off, and only corticosteroid eye drops were continued. Eighteen months later, dysesthesia appeared in the left side of her face and in her left ring and little fingers, which spread to the ulnar side of her forearm. Blood tests indicated elevated serum angiotensin-converting enzyme (ACE) levels. Chest CT showed bilateral lymphadenopathy, and histological analysis of the subcutaneous mass in her right arm showed multinucleated giant cells. Steroid therapy was started under a diagnosis of sarcoidosis. Serum ACE and lysozyme levels decreased in response to steroid therapy. We report a case of the concurrence of VKHD and sarcoidosis, which may share a common pathophysiology. Accumulation of further similar cases is necessary to elucidate the precise mechanism underlying the concurrence of these two diseases.
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Affiliation(s)
- Yoshihide Sehara
- Department of Neurology, Haga Red Cross Hospital, Moka, Japan.,Division of Genetic Therapeutics, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hideaki Otsuka
- Department of Neurology, Haga Red Cross Hospital, Moka, Japan
| | - Shinichi Sakamoto
- Department of Ophthalmology, Haga Red Cross Hospital, Moka, Japan.,Department of Ophthalmology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshihito Ando
- Department of Neurology, Haga Red Cross Hospital, Moka, Japan
| | - Mikio Sawada
- Department of Neurology, Haga Red Cross Hospital, Moka, Japan
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Bathla G, Soni N, Endozo R, Ganeshan B. Magnetic resonance texture analysis utility in differentiating intraparenchymal neurosarcoidosis from primary central nervous system lymphoma: a preliminary analysis. Neuroradiol J 2019; 32:203-209. [PMID: 30789057 DOI: 10.1177/1971400919830173] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Neurosarcoidosis and primary central nervous system lymphomas, although distinct disease entities, can both have overlapping neuroimaging findings. The purpose of our preliminary study was to assess if magnetic resonance texture analysis can differentiate parenchymal mass-like neurosarcoidosis granulomas from primary central nervous system lymphomas. METHODS A total of nine patients was evaluated, four with parenchymal neurosarcoidosis granulomas and five with primary central nervous system lymphomas. Magnetic resonance texture analysis was performed with commercial software using a filtration histogram technique. Texture features of different sizes and variations in signal intensity were extracted at six different spatial scale filters, followed by feature quantification using statistical and histogram parameters and 36 features were analysed for each sequence (T1-weighted, T2-weighted, fluid-attenuated inversion recovery, diffusion-weighted, apparent diffusion coefficient, T1-post contrast). The non-parametric Mann-Whitney test was used to evaluate the differences between different texture parameters. RESULTS The differences in distribution of entropy on T2-weighted imaging, apparent diffusion coefficient and T1-weighted post-contrast images were statistically significant on all spatial scale filters. Magnetic resonance texture analysis using medium and coarse spatial scale filters was especially useful in discriminating neurosarcoidosis from primary central nervous system lymphomas for mean, mean positive pixels, kurtosis, and skewness on diffusion-weighted imaging ( P < 0.004-0.030). At spatial scale filter 5, entropy on T2-weighted imaging ( P = 0.001) was the most useful discriminator with a cut-off value of 6.12 ( P = 0.001, area under the curve (AUC)-1, sensitivity (Sn)-100%, specificity (Sp)-100%), followed by kurtosis and skewness on diffusion-weighted imaging with a cut-off value of -0.565 ( P = 0.011, AUC-0.97, Sn-100%, Sp-83%) and-0.365 ( P = 0.008, AUC-0.98, Sn-100%, Sp-100%) respectively. CONCLUSION Filtration histogram-based magnetic resonance texture analysis appears to be a promising modality to distinguish parenchymal neurosarcoidosis granulomas from primary central nervous system lymphomas.
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Affiliation(s)
- Girish Bathla
- 1 Department of Radiology, University of Iowa Hospitals and Clinics, USA
| | - Neetu Soni
- 2 Department of Radiology, University of Iowa Hospitals and Clinics, USA
| | - Raymondo Endozo
- 3 Institute of Nuclear Medicine, University College London, Institute of Nuclear Medicine, UK
| | - Balaji Ganeshan
- 4 Institute of Nuclear Medicine, University College London, Institute of Nuclear Medicine, UK
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Primary Oral Presentation of Sarcoidosis in a Pediatric Patient. J Oral Maxillofac Surg 2019; 77:1180-1186. [PMID: 30776331 DOI: 10.1016/j.joms.2019.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/13/2019] [Accepted: 01/14/2019] [Indexed: 11/23/2022]
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown etiology that commonly affects the lungs, lymph nodes, and skin. The disease often presents in patients between the third and sixth decade and its pathology is defined by the presence of noncaseating granulomas within organs throughout the body. Oral and neurologic involvement of sarcoid is extremely rare and occurs in approximately 1% and 5% of patients with the disease, respectively. A case of sarcoidosis involving the gingiva and submandibular lymph nodes is described in a 14-year-old girl. Further neural involvement of the disease was recognized after initial biopsy examinations and systemic evaluation. This presentation is especially rare given the patient's lack of symptoms, age at diagnosis, and initial oral manifestations.
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Dorman J, Warrior L, Pandya V, Sun Y, Ninan J, Trick W, Zhang H, Ouyang B. Neurosarcoidosis in a public safety net hospital: a study of 82 cases. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2019; 36:25-32. [PMID: 32476933 DOI: 10.36141/svdld.v36i1.7106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
Objective To characterize clinical presentation, laboratory and imaging data, and treatment outcomes for neurosarcoidosis in an urban safety net hospital. Methods The research database of Cook County Health and Hospitals system was queried for all cases of sarcoidosis from 2006 to 2013. These cases plus those identified through a survey of neurology faculty were reviewed and flagged if suspected to be neurosarcoidosis. Data were extracted in a standardized fashion, upon review by two experienced neurologists; patients were classified as definite, probable or possible neurosarcoidosis. Disagreements on classification were resolved by consensus conference. Results 1706 cases of sarcoidosis were identified, with 82 (4.8%) classified as neurosarcoidosis. The cohort was predominantly African American (89%). Six were classified as definite, 34 as probable, and 42 as possible neurosarcoidosis. Neurosarcoidosis was the presenting symptom of sarcoidosis in 74% of cases. The most common presenting phenotype was myelopathy (21.7%), followed by optic nerve/chiasm involvement (16.0%) and epilepsy (11.3%). The facial nerve was involved in only 2% of cases. Chest x-ray showed abnormalities of sarcoidosis in 43.3% of cases, while chest CT did so in 78.6%. Corticosteroids were the initial treatment in 91% of cases, and outcomes were good in 53% of cases. Conclusion Neurosarcoidosis remains a challenging diagnosis with the majority of patients without a previous diagnosis of systemic sarcoidosis. Chest imaging was supportive of the diagnosis in a majority of patients. Our cohort differs from others in the literature due to a low prevalence of facial nerve involvement. Prospective registry studies are needed.
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Affiliation(s)
- James Dorman
- Neurology.,Neurological Sciences, Rush University
| | | | - Vishal Pandya
- Department of Neurology, Medical College of Wisconsin
| | | | - Jacob Ninan
- Hospital Medicine, Mayo Clinic Health Systems
| | - William Trick
- Internal Medicine, Cook County Health and Hospital System
| | - Helen Zhang
- Collaborative Research Unit, Cook County Health and Hospitals System
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Hypertrophic pachymeningitis as an important neurological complication of granulomatosis with polyangiitis. Reumatologia 2018; 56:399-405. [PMID: 30647488 PMCID: PMC6330683 DOI: 10.5114/reum.2018.80719] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022] Open
Abstract
Headache is a common symptom in patients with granulomatosis with polyangiitis (GPA) mainly due to chronic sinusitis or orbital disease. Meningeal involvement may thus remain unrecognized for a long time. This can lead to a significant delay in accurate diagnosis, serious local damage of the central nervous system and high relapse rates. New diagnostic techniques such as contrast MRI allow one to identify inflammation of the dura mater in the course of GPA more frequently. The objective of this article is to characterize hypertrophic pachymeningitis (HP) in patients with GPA and report diagnostic difficulties associated with this complication.
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Blume C, Tuleta I, Nolte K, Eichhorn KW, Jakob M, Clusmann H, Send T. Neurosarcoidosis As a Rare Differential Diagnosis for Single Or Multiple Lesions of the Nervous System. Br J Neurosurg 2018; 34:495-499. [PMID: 30295542 DOI: 10.1080/02688697.2018.1506094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Sarcoidosis is a multisystemic granulomatous disease of unknown cause which affects the lung or bilateral hilar lymphadenopathy in over 90% of the cases. Neurosarcoidosis (NS) is rare and accounts for approximately 5 - 15% of the cases. Involvement of all parts of the central and peripheral nervous system is possible with various clinical symptoms, e. g. seizures, hydrocephalus, optic/facial nerve palsy or hearing loss.Methods: We screened the neuropathological data bases and the medical records of two neurosurgical university hospitals for cases of NS. All these cases had been verified by surgical biopsy. We retrospectively evaluated the patient's records with special regard to the histopathology reports and specific clinical symptoms.Results: We identified 9 cases of NS between 1994 and 2014 (3 female, 6 male patients). The average age at the time of diagnosis of NS was 41,4 years. Various clinical symptoms like hydrocephalus (n = 3), seizures (n = 1), meningitis (n = 1), optical nerve involvment with vision disorder (n = 1), myelitis with paraplegia (n = 1), mastoiditis with hearing loss (n = 1), back pain syndrome (n = 2) were present. 7 patients were treated with corticosteroids, 1 patient with cyclophosphamide and 1 with a combination of corticosteroids and methotrexate.Conclusion: NS is a rare but potentially life-threatening disease. It is difficult to distinguish sarcoidosis from other granulomatous diseases, infectious diseases like tuberculosis, multiple sclerosis or neoplasm. For a definite diagnosis, a neurosurgical biopsy with histological evidence of noncaseating epithelioid cell granulomas is required, followed by multidisciplinary treatment.
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Affiliation(s)
- Christian Blume
- Department of Neurosurgery, University of Aachen (RWTH), Aachen, Germany
| | - Izabela Tuleta
- Department of Internal Medicine II, Cardiology and Pulmonology, University of Bonn, Bonn, Germany
| | - Kay Nolte
- Institute of Neuropathology, University of Aachen (RWTH), Germany
| | - Klaus W Eichhorn
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
| | - Mark Jakob
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University of Aachen (RWTH), Aachen, Germany
| | - Thorsten Send
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Bonn, Bonn, Germany
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Bathla G, Watal P, Gupta S, Soni N, Capizzano A, Derdeyn C, Moritani T. Cerebrovascular manifestations in neurosarcoidosis: how common are they and does perivascular enhancement matter? Clin Radiol 2018; 73:907.e15-907.e23. [DOI: 10.1016/j.crad.2018.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/15/2018] [Indexed: 10/28/2022]
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Owen CI, Jabeen F, Bhattacharjee A. Application of the modified Zajicek criteria to diagnose probable spinal cord neurosarcoidosis. Clin Case Rep 2018; 6:1718-1722. [PMID: 30214749 PMCID: PMC6132158 DOI: 10.1002/ccr3.1712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022] Open
Abstract
Neurosarcoidosis represents a significant diagnostic challenge, as clinical features overlap with other neuroinflammatory conditions, and biopsy of affected neuronal tissue is often high risk or not feasible. Here we highlight application of the modified Zajicek criteria to diagnose probable spinal neurosarcoidosis in the absence of histology from affected neuronal tissue.
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41
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Wang F, Guo D, Liu Z, Zhou A, Wei C, Jia J. Neurosarcoidosis: clinical characteristics, diagnosis, and treatment in eight Chinese patients. Neurol Sci 2018; 39:1725-1733. [PMID: 30088165 DOI: 10.1007/s10072-018-3491-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 07/03/2018] [Indexed: 12/17/2022]
Abstract
Neurosarcoidosis is relatively rare and has diverse manifestations. The clinical characteristics, diagnosis, treatment, and outcome for neurosarcoidosis in China are poorly understood. We retrospectively analyzed the clinical features, laboratory and imaging results, treatment, and outcomes in patients who met the criteria for definite or probable neurosarcoidosis in Xuan Wu Hospital of Capital Medical University from 2000 to 2015. Eight patients were included in this study, accounting for 5.84% of all cases with sarcoidosis. The mean age at onset was 50.25 years, and 75% of the patients were female. Five cases had a prior diagnosis of extraneurologic sarcoidosis, leading to a shorter lag time between onset of symptoms and diagnosis (3.4 vs. 16.2 months). Neurological symptoms were the first clinical feature of sarcoidosis in three cases, and no patients presented isolated nervous system manifestation. The most common symptom was sensory disturbance, and the most common site of nervous system involvement was brain parenchyma and meninges. Disturbance of consciousness, seizures, hydrocephalus, and abnormal CSF assays were associated with poor prognosis. All patients were treated with corticosteroids and one was also given azathioprine. Five patients had complete or partial improvement, one remained stabilized, and two deteriorated and died. Neurosarcoidosis is difficult to diagnose early and might be associated with a poor prognosis. Tissue biopsy for a definitive diagnosis and aggressive therapy with corticosteroids plus other alternative immunosuppressive treatment should be recommended in China.
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Affiliation(s)
- Fen Wang
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China
| | - Dongmei Guo
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China
| | - Zheng Liu
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China
| | - Aihong Zhou
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China
| | - Cuibai Wei
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China
| | - Jianping Jia
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Changchun Street 45, Xicheng District, Beijing, 100053, People's Republic of China.
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Abstract
Sarcoidosis is a disease with heterogeneous manifestations and outcomes, varying in part on the basis of organ involvement. Specifically, patients with sarcoidosis at risk for poor outcomes include individuals with treatment-resistant pulmonary sarcoidosis, including fibrotic pulmonary disease and pulmonary hypertension, as well as those with cardiac, neurologic, and multiorgan disease. The limited but available data relating to these patients with high-risk sarcoidosis, defined as those patients with presentations requiring medical intervention to avoid progressive disability or premature death, was evaluated as part of the National Heart, Lung, and Blood Institute's workshop to improve understanding of these disease manifestations. In particular, knowledge gaps that preclude a greater understanding of the pathogenesis and management of these severe sarcoidosis clinical phenotypes were identified in the workshop. Research strategies are proposed to address critical knowledge gaps that would further our understanding of these disease manifestations and enhance the care of these patients.
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43
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Affiliation(s)
- Martina Absinta
- Translational Neuroradiology Section, Division of Neuroimmunology and Neurovirology, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
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Abstract
Sarcoidosis is a systemic granulomatous lung disease of unknown origin affecting people of any age, mainly young adults. The disease is extremely heterogeneous with an unpredictable clinical course. Different phenotypes have been identified: an acute syndrome can be distinguished from subacute and chronic variants. About 20% of patients are chronically progressive and may develop lung fibrosis. Sarcoidosis usually involves the lungs and thoracic lymph nodes, although the skin, eyes, bones, liver, spleen, heart, upper respiratory tract and nervous system can also be affected. No reliable indicators of clinical outcome are available, and there is no single serological biomarker with demonstrated unequivocal diagnostic and prognostic value. Diagnosis requires histological confirmation although a presumptive diagnosis may be acceptable in special conditions. This review examines the diagnostic approach to sarcoidosis involving a multidisciplinary team of specialists in which the internist has the task of identifying all pulmonary and extrapulmonary localizations of the disease and of managing complications and comorbidities.
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Affiliation(s)
- Elena Bargagli
- Respiratory Medicine, Department of Clinical and Experimental Medicine, Department of Clinical and Experimental Biomedical Sciences, University Hospital Careggi (AOUC), Largo Brambilla 1, 50134, Florence, Italy.
| | - Antje Prasse
- Medizinische Hochschule Hannover, Abteilung für Pneumologie Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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45
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Geraldes R, Ciccarelli O, Barkhof F, De Stefano N, Enzinger C, Filippi M, Hofer M, Paul F, Preziosa P, Rovira A, DeLuca GC, Kappos L, Yousry T, Fazekas F, Frederiksen J, Gasperini C, Sastre-Garriga J, Evangelou N, Palace J. The current role of MRI in differentiating multiple sclerosis from its imaging mimics. Nat Rev Neurol 2018. [DOI: 10.1038/nrneurol.2018.14] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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46
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Ömerhoca S, Akkaş SY, İçen NK. Multiple Sclerosis: Diagnosis and Differential Diagnosis. ACTA ACUST UNITED AC 2018; 55:S1-S9. [PMID: 30692847 DOI: 10.29399/npa.23418] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnostic criteria for multiple sclerosis (MS) have been continuously evolved since 1950's, and gained speed parallel to the development of detailed laboratory methods. The common aim for all the defined criteria up to now, is to establish the dissemination in space and time of the clinical picture caused by the lesions in the central nervous system (CNS), and to rule out other diseases which might mimic MS. There is no definite measure or laboratory marker for the diagnosis of MS, yet. Both the clinical features of the disease, and laboratory investigations such as magnetic resonance imaging (MRI), and cerebrospinal fluid (CSF) analyses are being used. Clinical and imaging findings that may be seen in MS, can also be mimicked by some infectious, neoplastic, genetic, metabolic, vascular and other idiopathic inflammatory demyelinating disorders (IIDD). In the earlier stages of the disease, especially IIDD's such as neuromyelitis optica spectrum disorders (NMOs) and acute disseminated encephalomyelitis (ADEM) can cause diagnostic difficulty, however, these disorders which have both distinct pathogeneses and clinical courses than MS, should also be treated differently. Therefore, to identify MS-related attacks and determine the final diagnosis is vital for the correct treatment choice and longterm disability prevention. In this manuscript the principal approach for the diagnosis and differential diagnosis of MS has been reviewed regarding the recent guidelines.
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Affiliation(s)
- Sami Ömerhoca
- Department of Neurology, İstanbul Bağcılar Research and Training Hospital, İstanbul, Turkey
| | - Sinem Yazici Akkaş
- Department of Neurology, İstanbul Bağcılar Research and Training Hospital, İstanbul, Turkey
| | - Nilüfer Kale İçen
- Department of Neurology, İstanbul Bağcılar Research and Training Hospital, İstanbul, Turkey
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Systemic autoimmune diseases complicated with hydrocephalus: pathogenesis and management. Neurosurg Rev 2017; 42:255-261. [PMID: 29130124 DOI: 10.1007/s10143-017-0917-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/10/2017] [Accepted: 09/27/2017] [Indexed: 01/17/2023]
Abstract
Systemic autoimmune diseases (SAIDs) represent a group of syndromes involving at least two organ systems. Classical SAIDs include connective tissue diseases, vasculitis, and granulomatous diseases, many of which involve the nervous system and result in different neurological manifestations. Hydrocephalus can be a rare but lethal complication of various SAIDs, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), sarcoidosis, and primary vasculitis. However, the pathogenesis of SAIDs complicated with different types of hydrocephalus is varied and difficult to determine using the existing published data, and various manifestations and expressive forms of the conditions bring a substantial challenge to a timely clinical diagnosis and treatment. The commonly used medical management programs based on the etiology of hydrocephalus are anti-inflammatory or anti-infectious therapies, while surgical management such as ventriculoperitoneal shunts is effective most of the time. Further research should be directed toward improving our understanding of the pathogenesis of these conditions and determining the most effective method for treating this life-threatening condition.
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Kefella H, Luther D, Hainline C. Ophthalmic and neuro-ophthalmic manifestations of sarcoidosis. Curr Opin Ophthalmol 2017; 28:587-594. [PMID: 28759560 DOI: 10.1097/icu.0000000000000415] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Sarcoidosis is a multisystemic inflammatory disease that commonly affects the eye and less often the neuro-ophthalmic pathways. The manifestations can be quite variable but can have characteristic signs and clinical features. This review provides a comprehensive overview of the various ocular and neuro-ophthalmic manifestations of sarcoidosis, emerging diagnostic measures and approach to treatment. Particular focus is given to recent advances in diagnostic approach and available treatment options. RECENT FINDINGS Laboratory investigations, chest and nuclear medicine imaging remain important techniques for helping to diagnose sarcoidosis. Recent evidence suggests a role for aqueous humor analysis in the diagnosis of ocular sarcoidosis. Characteristic neuroimaging may help differentiate neurosarcoidosis from other causes. The role of blind conjunctival biopsy for suspected neurosarcoidosis is discussed. The emerging role and use of biologics is delineated for the treatment of both ocular and neuro-ophthalmic sarcoidosis. SUMMARY Sarcoidosis can affect any part of the visual system: the most common ocular manifestation is uveitis and the most common neuro-ophthalmic manifestation is optic neuropathy. Although diagnosis remains challenging, recent advancements in diagnosis are promising. Emerging biologics with particular efficacy for ocular and neuro-ophthalmic disease provide expanding treatment options for sight-threatening disease.
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Affiliation(s)
- Haben Kefella
- aDepartment of Ophthalmology bDepartment of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
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Yang G, Eishi Y, Raza A, Rojas H, Achiriloaie A, De Los Reyes K, Raghavan R. Propionibacterium acnes
-associated neurosarcoidosis: A case report with review of the literature. Neuropathology 2017; 38:159-164. [DOI: 10.1111/neup.12411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Guang Yang
- Department of Pathology and Laboratory Medicine; Loma Linda University Medical Center; Loma Linda California USA
| | - Yoshinobu Eishi
- Department of Human Pathology; Tokyo Medical and Dental University Graduate School; Tokyo Japan
| | - Anwar Raza
- Department of Pathology and Laboratory Medicine; Loma Linda University Medical Center; Loma Linda California USA
| | - Heather Rojas
- Department of Pathology and Laboratory Medicine; Loma Linda University Medical Center; Loma Linda California USA
| | - Adina Achiriloaie
- Department of Radiology; Loma Linda University Medical Center; Loma Linda California USA
| | - Kenneth De Los Reyes
- Department of Neurosurgery; Loma Linda University Medical Center; Loma Linda California USA
| | - Ravi Raghavan
- Department of Pathology and Laboratory Medicine; Loma Linda University Medical Center; Loma Linda California USA
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50
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Nishida M, Namiki T, Sone Y, Hashimoto T, Tokoro S, Hanafusa T, Yokozeki H. Acquired anhidrosis associated with systemic sarcoidosis: quantification of nerve fibres around eccrine glands by confocal microscopy. Br J Dermatol 2017; 178:e59-e61. [PMID: 28796884 DOI: 10.1111/bjd.15880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Nishida
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - T Namiki
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Y Sone
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - T Hashimoto
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - S Tokoro
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - T Hanafusa
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - H Yokozeki
- Department of Dermatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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