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Gao M, Kwon GT, Amin MR. Neurosarcoidosis manifesting as cavernous sinus syndrome in systemic sarcoidosis. BMJ Case Rep 2024; 17:e259714. [PMID: 39013621 DOI: 10.1136/bcr-2024-259714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024] Open
Abstract
Neurosarcoidosis can manifest in various neurological presentations. The occurrence of cavernous sinus involvement in neurosarcoidosis is rare, which can complicate the diagnostic process. We present a case of neurosarcoidosis demonstrating progressively deteriorating right cavernous sinus syndrome in a woman in her 50s, affecting the oculomotor, abducens and the ophthalmic division of the trigeminal nerves. MRI demonstrated meningeal thickening along the lateral wall of the right cavernous sinus, and a pan-CT scan of the chest, abdomen and pelvis revealed disseminated sarcoidosis involving the lungs and the liver. Histopathological analysis of the liver lesion ultimately confirmed the diagnosis of sarcoidosis. This case underscores the significance of considering neurosarcoidosis as a potential cause of cavernous sinus syndrome. In such cases, early initiation of corticosteroid treatment, with or without steroid-sparing agents, is crucial to prevent disease progression and relapse.
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Affiliation(s)
- Manxin Gao
- Nepean Blue Mountains Local Health District, Penrith, New South Wales, Australia
| | - Gi Tae Kwon
- Nepean Blue Mountains Local Health District, Penrith, New South Wales, Australia
| | - Mohammad Ruhul Amin
- Nepean Blue Mountains Local Health District, Penrith, New South Wales, Australia
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2
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Shen J, Sugita M, Linares-Lopez A, Shah S, Eckstein C, Lackey E. Adalimumab as treatment for neurosarcoidosis: A case series. J Neurol Sci 2024; 460:123018. [PMID: 38640580 DOI: 10.1016/j.jns.2024.123018] [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: 01/08/2024] [Revised: 03/14/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
Sarcoidosis is a disease characterized by non-caseating granulomas that can involve the central nervous system as neurosarcoidosis. This challenging disease is currently managed with high dose steroids, and sometimes the addition of infliximab. Other TNA-alpha inhibitors have not been studied as rigorously. We discovered ten neurosarcoidosis patients who were on an alternative TNA-alpha inhibitor, adalimumab. Eight patients had a positive response clinically and radiographically to adalimumab.
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Affiliation(s)
- Jeffrey Shen
- Duke University Hospital, Department of Rheumatology, United States
| | - Megumi Sugita
- Duke University Hospital, Department of Neurology, United States
| | | | - Suma Shah
- Duke University Hospital, Department of MS and Neuroimmunology, United States
| | | | - Elijah Lackey
- Duke University Hospital, Department of MS and Neuroimmunology, United States.
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3
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Li L, Lu J, Liu J, Wu J, Zhang X, Meng Y, Wu X, Tai Z, Zhu Q, Chen Z. Immune cells in the epithelial immune microenvironment of psoriasis: emerging therapeutic targets. Front Immunol 2024; 14:1340677. [PMID: 38239345 PMCID: PMC10794746 DOI: 10.3389/fimmu.2023.1340677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/15/2023] [Indexed: 01/22/2024] Open
Abstract
Psoriasis is a chronic autoimmune inflammatory disease characterized by erroneous metabolism of keratinocytes. The development of psoriasis is closely related to abnormal activation and disorders of the immune system. Dysregulated skin protective mechanisms can activate inflammatory pathways within the epithelial immune microenvironment (EIME), leading to the development of autoimmune-related and inflammatory skin diseases. In this review, we initially emphasized the pathogenesis of psoriasis, paying particular attention to the interactions between the abnormal activation of immune cells and the production of cytokines in psoriasis. Subsequently, we delved into the significance of the interactions between EIME and immune cells in the emergence of psoriasis. A thorough understanding of these immune processes is crucial to the development of targeted therapies for psoriasis. Finally, we discussed the potential novel targeted therapies aimed at modulating the EIME in psoriasis. This comprehensive examination sheds light on the intricate underlying immune mechanisms and provides insights into potential therapeutic avenues of immune-mediated inflammatory diseases.
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Affiliation(s)
- Lisha Li
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai University, School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Jiaye Lu
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai University, School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Jun Liu
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Junchao Wu
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai University, School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Xinyue Zhang
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Yu Meng
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Xiying Wu
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Zongguang Tai
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Quangang Zhu
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai University, School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
| | - Zhongjian Chen
- Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China
- Shanghai University, School of Medicine, Shanghai, China
- Shanghai Engineering Research Center of External Chinese Medicine, Shanghai, China
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Basheer M, Waked H, Jeries H, Azrilin O, Paz D, Assy N, Naffaa ME, Badarny S. Neurosarcoidosis: The Presentation, Diagnosis and Treatment Review of Two Cases. Life (Basel) 2023; 14:69. [PMID: 38255684 PMCID: PMC10820900 DOI: 10.3390/life14010069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/13/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Sarcoidosis is a chronic granulomatous disease of unknown cause characterized by the presence of non-caseating granulomas. The disease can affect any organ including the nervous system. Neurosarcoidosis occurs in about 5% patients with sarcoidosis. The clinical presentation of neurosarcoidosis is varied, and it can involve the brain, spinal cord and peripheral nervous system, separately or in different combinations. The diagnosis of neurosarcoidosis is challenging, as biopsies from the nervous system are not readily available. Anti-TNFα agents are becoming one of the cornerstone treatments for neurosarcoidosis. In this case-based review, we discuss two cases of neurosarcoidosis with different clinical presentations. The first patient presented with confusion, while the second presented with walking difficulty and neurogenic bladder. Both patients were treated with methylprednisolone pulse therapy with rapid, but non-complete, improvement. Therefore, infliximab was initiated in both cases with subsequent improvement in the clinical manifestations and imaging findings, emphasizing the effectiveness and safety of infliximab in cases of severe neurosarcoidosis. In conclusion, the goal of neurosarcoidosis management is to prevent organ system damage and minimize the toxic cumulative adverse effects of glucocorticoid use. In this case-based review we discuss the various presentations, the diagnosis and the treatment of neurosarcoidosis.
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Affiliation(s)
- Maamoun Basheer
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
| | - Hamd Waked
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
| | - Helana Jeries
- Rheumatology Unit, Galilee Medical Center, Nahariya 221001, Israel;
| | - Olga Azrilin
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
| | - Dan Paz
- Radiology Department, Galilee Medical Center, Nahariya 221001, Israel; (D.P.); (M.E.N.)
| | - Nimer Assy
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Mohammad E. Naffaa
- Radiology Department, Galilee Medical Center, Nahariya 221001, Israel; (D.P.); (M.E.N.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Samih Badarny
- Neurology Department, Galilee Medical Center, Nahariya 221001, Israel; (O.A.); (S.B.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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5
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Bou GA, El Sammak S, Chien LC, Cavanagh JJ, Hutto SK. Tumefactive brain parenchymal neurosarcoidosis. J Neurol 2023; 270:4368-4376. [PMID: 37219604 DOI: 10.1007/s00415-023-11782-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/12/2023] [Accepted: 05/13/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Enhancing brain parenchymal disease, and especially tumefactive lesions, are an uncommon manifestation of neurosarcoidosis. Little is known about the clinical features of tumefactive lesions and their impact on management and outcomes, which this study aims to characterize. METHODS Patients with pathologically-confirmed sarcoidosis were retrospectively reviewed and included if brain lesions were: (1) intraparenchymal, (2) larger than 1 cm in diameter, and (3) associated with edema and/or mass effect. RESULTS Nine patients (9/214, 4.2%) were included. Median onset age was 37 years. Diagnosis was confirmed by brain parenchymal biopsies in 5 (55.6%). Median modified Rankin scale (mRS) score was 2 (range 1-4) at initial presentation. Common manifestations included headache (77.8%), cognitive dysfunction (66.7%), and seizures (44.4%). Sixteen lesions were present in 9 patients. The frontal lobe (31.3%) was most affected, followed by the subinsular region (12.5%), basal ganglia (12.5%%), cerebellum (12.5%), and pons (12.5%). MRI characteristics of the dominant lesions included spherical morphology (77.8%), perilesional edema (100.0%), mass effect (55.6%), well-demarcated borders (66.7%), and contrast enhancement (100.0%; 55.6% heterogeneous). Leptomeningitis was frequently present (77.8%). All required corticosteroid-sparing treatments, and most (55.6%) needed at least a third line of treatment (infliximab used in 44.4%). All patients relapsed (median 3 relapses, range 1-9). Median last mRS was 1.0 after median follow-up of 86 months, with significant residual deficits in 55.6%. CONCLUSION Tumefactive brain parenchymal lesions are uncommon, usually affect the supratentorial brain along with leptomeningitis, and are refractory to initial treatments with a high risk of relapse. Significant sequelae were encountered despite a favorable median last mRS.
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Affiliation(s)
- Gabriela A Bou
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Sally El Sammak
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Ling-Chen Chien
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Julien J Cavanagh
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA.
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6
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Gonzalez Caldito N. Role of tumor necrosis factor-alpha in the central nervous system: a focus on autoimmune disorders. Front Immunol 2023; 14:1213448. [PMID: 37483590 PMCID: PMC10360935 DOI: 10.3389/fimmu.2023.1213448] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/14/2023] [Indexed: 07/25/2023] Open
Abstract
Tumor necrosis factor-alpha (TNF-α) is a pleiotropic immune cytokine that belongs to the TNF superfamily of receptor ligands. The cytokine exists as either a transmembrane or a soluble molecule, and targets two distinct receptors, TNF-α receptor 1 (TNFR1) and TNF-α receptor 2 (TNFR2), which activate different signaling cascades and downstream genes. TNF-α cellular responses depend on its molecular form, targeted receptor, and concentration levels. TNF-α plays a multifaceted role in normal physiology that is highly relevant to human health and disease. In the central nervous system (CNS), this cytokine regulates homeostatic functions, such as neurogenesis, myelination, blood-brain barrier permeability and synaptic plasticity. However, it can also potentiate neuronal excitotoxicity and CNS inflammation. The pleiotropism of TNF-α and its various roles in the CNS, whether homeostatic or deleterious, only emphasizes the functional complexity of this cytokine. Anti-TNF-α therapy has demonstrated effectiveness in treating various autoimmune inflammatory diseases and has emerged as a significant treatment option for CNS autoimmune diseases. Nevertheless, it is crucial to recognize that the effects of this therapeutic target are diverse and complex. Contrary to initial expectations, anti-TNF-α therapy has been found to have detrimental effects in multiple sclerosis. This article focuses on describing the various roles, both physiological and pathological, of TNF-α in the CNS. Additionally, it discusses the specific disease processes that are dependent or regulated by TNF-α and the rationale of its use as a therapeutic target.
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Affiliation(s)
- Natalia Gonzalez Caldito
- Department of Neurology, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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7
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Desbois AC, Shor N, Chapelon C, Maillart E, Touitou V, Cacoub P, Saadoun D. [Neurological involvement of sarcoidosis: current diagnostic and therapeutic strategies]. Rev Med Interne 2023; 44:123-132. [PMID: 36804049 DOI: 10.1016/j.revmed.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/15/2023] [Accepted: 01/20/2023] [Indexed: 02/18/2023]
Abstract
Neurosarcoidosis (NS) is a rare but severe form of sarcoidosis. NS is associated with significant morbidity and mortality. Mortality is about 10% at 10 years with more than 30% of patients who have a significant disability. The most frequent features are cranial neuropathy (the facial and optic nerve most commonly affected), cranial parenchymal lesions, meningitis, spinal corn abnormalities (20-30%) and more rarely peripheral neuropathy (approximately 10-15%). The challenge of diagnosis is to eliminate other diagnoses. Atypical presentations should make to discuss the need for cerebral biopsy in order to highlight the presence of granulomatous lesions while eliminating alternative diagnosis. Therapeutic management is based on corticosteroid therapy and immunomodulators. There are no comparative prospective study to allow us to define the first-line immunosuppressive treatment and the therapeutic strategy in refractory patients. Conventional immunosuppressants such as methotrexate, mycophenolate mofetil and cyclophosphamide are commonly used. Data on the efficacy of anti-TNFα (including infliximab) in refractory and/or severe forms are increasing during the last ten years. Additional data is necessary to assess their interest in first line in patients with severe involvement and a significant risk of relapse.
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Affiliation(s)
- A C Desbois
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France.
| | - N Shor
- AP-HP, groupe hospitalier Pitié-Salpêtrière, service de neuroradiologie, France
| | - C Chapelon
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
| | - E Maillart
- AP-HP, Groupe hospitalier Pitié-Salpétrière, service d'ophtalmologie, France
| | - V Touitou
- AP-HP, groupe hospitalier Pitié-Salpêtrière, service de neurologie, France
| | - P Cacoub
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
| | - D Saadoun
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
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8
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Ischemic stroke in neurosarcoidosis: A retrospective cohort analysis. Mult Scler Relat Disord 2022; 68:104227. [PMID: 36240703 DOI: 10.1016/j.msard.2022.104227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cerebrovascular disease is rarely reported in neurosarcoidosis and constitutes one of its least well-described forms, though recognition for it has grown in the last decade with recent studies estimating a higher frequency of occurrence than previously known. METHODS Patients with ischemic stroke were included if the mechanism was directly attributable to sarcoidosis of the CNS. Patients were excluded if an alternative stroke etiology was of equal or higher likelihood than CNS sarcoidosis. RESULTS Neurologic disease was the initial presenting manifestation of sarcoidosis in 8/11 (72.7%), and ischemic stroke was an inaugural manifestation of sarcoidosis in 4/11 (36.4%). Small vessel disease was the predominant ischemia subtype (10/11, 90.9%) with pontine perforating vessels (6/11, 54.5%) and lenticulostriate arteries (3/11, 27.3%) being the vasculature most often affected. Vessels with a more rostral supratentorial distribution were uncommonly affected. Common neuroinflammatory accompaniments included leptomeningitis (10/11, 90.9%) and cranial nerve disease (3/11, 27.3%). Recurrent strokes occurred in 8/11 (72.7%), and recurrent neuroinflammation occurred in 7/11 (63.6%). Antiplatelet drugs were used in 6/11 (54.5%) patients. Most (10/11, 90.9%) required at least two lines of immunosuppression to achieve inflammatory disease remission in this context; infliximab was the most successfully employed immunosuppressant (7/8 treatment courses, 87.5%). Recurrent strokes occurred in 8/11 (72.7%) patients, and a second inflammatory attack occurred in 7/11 (63.6%) patients. The presenting median modified Rankin Scale score of 4.0 improved to 2.0 over a median period of follow-up of 52.0 months. CONCLUSION Ischemic strokes in neurosarcoidosis occur in a caudal-to-rostral distribution, tend to affect small caliber blood vessels that lack collateral blood flow, and typically associate with inflammatory leptomeningeal disease. The risk for relapse in the forms of stroke or neuroinflammation are high in this neurosarcoidosis phenotype.
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9
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Kidd DP. Management of neurosarcoidosis. J Neuroimmunol 2022; 372:577958. [PMID: 36162337 DOI: 10.1016/j.jneuroim.2022.577958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 12/31/2022]
Abstract
This is a brief and purposefully practical approach to the therapeutic and rehabilitative management of patients affected by neurological complications of systemic sarcoidosis. The review notes the drugs used and their monitoring, and their role in the series of clinical subgroups identified to form the condition. Treatment guidelines for individual clinical subtypes of the disorder are provided, and the importance of rehabilitative measures and lifestyle changes are emphasised.
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Affiliation(s)
- Desmond P Kidd
- Centre for Neurosarcoidosis, Neuroimmunology unit, Royal Free Hospital, London NW3 1PF, United Kingdom.
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10
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Chakales PA, Herman MC, Chien LC, Hutto SK. Pachymeningitis in Biopsy-Proven Sarcoidosis. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/6/e200028. [PMID: 36163175 PMCID: PMC9513981 DOI: 10.1212/nxi.0000000000200028] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives Meningeal inflammation is one of the most common manifestations of neurosarcoidosis, occurring in 16%–69% of affected patients. While the clinical and radiographic features of leptomeningitis in neurosarcoidosis are well known, those of pachymeningitis are far less clear. Our primary aim was to study the clinicoradiographic features of pachymeningeal involvement in neurosarcoidosis and its evolution over time in response to treatment. Methods Patients with a diagnosis of neurosarcoidosis seen at Emory University (January 2011–August 2021) were included if pachymeningeal involvement was evident by MRI and the patient's sarcoidosis was pathologically confirmed (from a CNS or non-CNS site). Results Twenty-six of 215 (12.1%) patients with neurosarcoidosis qualified for inclusion. Pathologic confirmation came from CNS tissue in 50%. The median age of onset was 43.5 years; most were male (16/26, 61.5%). Symptoms were primarily related to pachymeningitis in 20/26 (76.9%). Headache (19/26, 73.1%), visual dysfunction (12/26, 46.2%), and seizures (7/26, 26.9%) were the most common symptoms. All patients had cranial pachymeningitis; only a single patient undergoing spinal imaging (1/11, 9.1%) had spinal pachymeningitis. The falx cerebri (16/26, 61.5%) was the most commonly affected dural structure, but the anterior and middle cranial fossae and tentorium cerebelli were frequently involved (12/26 each, 46.2%). The pachymeningeal lesions were unifocal (11/26, 42.3%) or multifocal (15/26, 57.7%) in distribution, nodular morphologically (23/25, 92.0%), and homogeneously enhancing (24/25, 96.0%). Symptomatic improvement occurred with steroids initially in 22/25 (88.0%). Ultimately, 23/26 (88.5%) required initiation of steroid-sparing immunosuppressants, including 8/26 (30.8%) eventually undergoing TNF inhibition. Pachymeningeal relapses occurred in 7/26 (26.9%). The median clinical follow-up was 48 months. The median modified Rankin scale score at last follow-up improved to 1.0 from 2.0 at presentation. Discussion Pachymeningitis due to sarcoidosis often presents with headaches, visual dysfunction, and seizures; it usually affects the dura of the falx cerebri, anterior and middle cranial fossae, and tentorium cerebelli and tends to require steroid-sparing immunosuppressants. It has the potential to relapse, but the prospect for recovery is good.
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Sambon P, Sellimi A, Kozyreff A, Gheysens O, Pothen L, Yildiz H, van Pesch V. Epidemiology, clinical presentation, treatment, and outcome of neurosarcoidosis: A mono-centric retrospective study and literature review. Front Neurol 2022; 13:970168. [PMID: 36388212 PMCID: PMC9641157 DOI: 10.3389/fneur.2022.970168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Neurosarcoidosis is a rare granulomatous disorder, and treatment guidelines are mainly based on retrospective studies. Materials and methods This retrospective study was performed to provide a detailed description of the clinical characteristics and treatment outcomes of patients with neurosarcoidosis followed at Cliniques Universitaires Saint Luc in Belgium. The second objective of our study was to perform a comparative literature review of neurosarcoidosis, with a focus on treatment outcomes with the use of TNF-α antagonist. Results Among 180 patients with sarcoidosis followed in our hospital, 22 patients with neurosarcoidosis were included in the final analysis. Our literature research identified 776 articles of which 35 articles met our inclusion criteria, including 1,793 patients diagnosed with neurosarcoidosis. In our cohort, the majority of patients (86%) were diagnosed with systemic sarcoidosis which was similar to that reported in the literature (83%). Serum CRP and calcemia were elevated only in 33 and 18% of patients, respectively. Serum lysozyme and angiotensin-converting enzyme were elevated in 79 and 16% of patients, respectively. Lumbar puncture and CSF fluid analysis were performed in 15/22 patients and were abnormal in all patients. Brain MRI was performed in 21/22 patients and showed abnormalities in 16 patients consisting of parenchymal lesions in 63%, hypothalamic-pituitary axis lesions in 38%, and meningeal enhancement in 31%. In both cohort patients, methotrexate was the most frequently used treatment (>45% of cases) with a favorable outcome in an average of 50% of patients. A TNF-α antagonist was administered in 9% of patients in our cohort and in 27% of patients in the literature review. The proportion of favorable outcomes in literature research was significantly higher in patients treated with TNF-α antagonists compared to methotrexate (p < 0.0001), mycophenolate mofetil (p < 0.0001), or azathioprine (p < 0.0001). Conclusion The results of our cohort and literature review confirm that neurosarcoidosis occurred most frequently in the context of systemic sarcoidosis. Methotrexate is the most frequent second-line therapy. The effectiveness of therapy with TNF-α antagonists is well-demonstrated and associated with a better outcome. Their earlier use during the disease course among aggressive and/or refractory neurosarcoidosis should be considered.
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Affiliation(s)
- Pauline Sambon
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Amina Sellimi
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandra Kozyreff
- Department of Ophthalmology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Lucie Pothen
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- *Correspondence: Vincent van Pesch
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Gosselin J, Roy-Hewitson C, Bullis SSM, DeWitt JC, Soares BP, Dasari S, Nevares A. Neurosarcoidosis: Phenotypes, Approach to Diagnosis and Treatment. Curr Rheumatol Rep 2022; 24:371-382. [PMID: 36223002 DOI: 10.1007/s11926-022-01089-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update of clinical presentation, diagnosis, differential diagnoses, and treatment according to recent evidence. RECENT FINDINGS Neurosarcoidosis remains a diagnosis of exclusion, with infectious and malignant etiologies recognized as important mimickers. Corticosteroids remain as first-line therapy. In recent years, however, studies have demonstrated the effectiveness of anti-tumor necrosis factor (anti-TNF) therapy in the treatment of neurosarcoidosis, leading to improved outcomes. Neurosarcoidosis is a granulomatous disease with protean manifestations that may affect any part of the central and peripheral nervous system. It has many mimickers, and potentially devastating complications necessitating long-term follow-up. Early initiation of treatment, particularly with anti-TNF therapy, may lead to better outcomes and fewer relapses. There is an unmet need for randomized controlled trials that provide robust data to guide therapy and the long-term management of neurosarcoidosis patients.
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Affiliation(s)
- Jeanne Gosselin
- Division of Rheumatology and Clinical Immunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT, 05401, USA.
| | - Chantal Roy-Hewitson
- Department of Neurosciences, Division of Neuroimmunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Sean S M Bullis
- Division of Infectious Disease, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - John C DeWitt
- Department of Pathology and Laboratory Medicine, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Bruno P Soares
- Division of Neuroradiology, Department of Radiology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, Burlington, VT, USA
| | - Sidarth Dasari
- Department of Neurosciences, Division of Neuroimmunology, University of Vermont Medical Center, Burlington, VT, USA
| | - Alana Nevares
- Division of Rheumatology and Clinical Immunology, Robert Larner, MD College of Medicine at the University of Vermont and University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT, 05401, USA
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13
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Seishima M, Sasaki M, Sugie S. Successful treatment of pyoderma gangrenosum using adalimumab in a patient undergoing hemodialysis. J Dermatol 2022; 49:e435-e436. [PMID: 35862244 DOI: 10.1111/1346-8138.16526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/24/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Mariko Seishima
- Department of Dermatology, Asahi University Hospital, Gifu, Japan
| | - Makiko Sasaki
- Department of Dermatology, Asahi University Hospital, Gifu, Japan
| | - Shigeyuki Sugie
- Department of Pathology, Asahi University Hospital, Gifu, Japan
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14
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Valencia-Sanchez C, Flanagan EP. Uncommon inflammatory/immune-related myelopathies. J Neuroimmunol 2021; 361:577750. [PMID: 34715593 DOI: 10.1016/j.jneuroim.2021.577750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/16/2021] [Accepted: 10/10/2021] [Indexed: 01/03/2023]
Abstract
The differential diagnosis for immune-mediated myelopathies is broad. Although clinical manifestations overlap, certain presentations are suggestive of a particular myelopathy etiology. Spine MRI lesion characteristics including the length and location, and the pattern of gadolinium enhancement, help narrow the differential diagnosis and exclude an extrinsic compressive cause. The discovery of specific antibodies that serve as biomarkers of myelitis such as aquaporin-4-IgG and myelin-oligodendrocyte -glycoprotein-IgG (MOG-IgG), has improved our understanding of myelitis pathophysiology and facilitated diagnosis. In this review we will focus on the pathophysiology, clinical presentation, imaging findings and treatment and outcomes of uncommon immune-mediated myelopathies.
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