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Chae TS, Kim DS, Kim GW, Won YH, Ko MH, Park SH, Seo JH. Immunoglobulin G4-related spinal pachymeningitis: A case report. World J Clin Cases 2024; 12:6551-6558. [DOI: 10.12998/wjcc.v12.i32.6551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/24/2024] [Accepted: 08/28/2024] [Indexed: 09/24/2024] Open
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a complex immune-mediated condition that causes fibrotic inflammation in several organs. A significant clinical feature of IgG4-RD is hypertrophic pachymeningitis, which manifests as inflammation of the dura mater in intracranial or spinal regions. Although IgG4-RD can affect multiple areas, the spine is a relatively rare site compared to the more frequent involvement of intracranial structures.
CASE SUMMARY A 70-year-old male presented to our hospital with a two-day history of fever, altered mental status, and generalized weakness. The initial brain magnetic resonance imaging (MRI) revealed multiple small infarcts across various cerebral regions. On the second day after admission, a physical examination revealed motor weakness in both lower extremities and diminished sensation in the right lower extremity. Electromyographic evaluation revealed findings consistent with acute motor sensory neuropathy. Despite initial management with intravenous immunoglobulin for presumed Guillain-Barré syndrome, the patient exhibited progressive worsening of motor deficits. On the 45th day of hospitalization, an enhanced MRI of the entire spine, focusing specifically on the thoracic 9 to lumbar 1 vertebral level, raised the suspicion of IgG4-related spinal pachymeningitis. Subsequently, the patient was administered oral prednisolone and participated in a comprehensive rehabilitation program that included gait training and lower extremity strengthening exercises.
CONCLUSION IgG4-related spinal pachymeningitis, diagnosed on MRI, was treated with corticosteroids and a structured rehabilitation regimen, leading to significant improvement.
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Affiliation(s)
- Tae-Seok Chae
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
| | - Da-Sol Kim
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
| | - Gi-Wook Kim
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
| | - Yu Hui Won
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
| | - Myoung-Hwan Ko
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
| | - Sung-Hee Park
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
| | - Jeong-Hwan Seo
- Department of Physical Medicine & Rehabilitation, Jeonbuk National University Medical School, Jeonju 54907, South Korea
- Department of Physical Medicine & Rehabilitation, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, South Korea
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Khaladkar SM, KirdatPatil PP, Dhande A, Jhala NA. Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease Complicated by Pachymeningitis: A Case Report. Cureus 2024; 16:e64868. [PMID: 39156322 PMCID: PMC11330373 DOI: 10.7759/cureus.64868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a rare autoimmune disorder that primarily affects the central nervous system (CNS). We present a unique case of MOGAD complicated by pachymeningitis, which is characterized by inflammation of the dura mater. The clinical presentation included vertigo, nausea, and vomiting. A diagnostic workup confirmed MOGAD complicated by pachymeningitis. This case underscores the diverse clinical manifestations of MOGAD and highlights the challenges in diagnosis and management, particularly when complicated by rare manifestations like pachymeningitis.
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Affiliation(s)
- Sanjay M Khaladkar
- Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Prajakta P KirdatPatil
- Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Aryaman Dhande
- Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Neeha A Jhala
- Radiodiagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
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Moura J, Malaquias MJ, Jorge F, Pinto E, Sardoeira A, Laranjinha I, Oliveira V, Sousa AP, Damásio J, Maia L, Vila-Chã N, Samões R, Taipa R, Martins da Silva A, Santos E. Neurological Involvement in a Portuguese Cohort of IgG4-Related Disease. ACTA MEDICA PORT 2024; 37:429-435. [PMID: 38669036 DOI: 10.20344/amp.20767] [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: 10/01/2023] [Accepted: 02/07/2024] [Indexed: 06/09/2024]
Abstract
INTRODUCTION Neurological involvement in immunoglobulin G4-related disease (IgG4-RD) is increasingly recognized. Its diagnosis can be challenging due to clinical mimics and difficulty in obtaining nervous system biopsies. The aim of this study was to describe a cohort of neurological IgG4-RD patients. METHODS Patients were recruited from a neuroimmunology tertiary center. Clinical, laboratory, neuroimaging and histological data were reviewed. RESULTS Fifteen patients (60% women), with a median age of 53 years (48.5 - 65.0) were included: 13 (86.7%) classified as possible IgG4-RD, one (6.7%) as probable and one (6.7%) as definitive. The most common neurological phenotypes were meningoencephalitis (26.7%), orbital pseudotumor (13.3%), cranial neuropathies (13.3%), peripheral neuropathy (13.3%), and longitudinally extensive transverse myelitis (LTEM) (13.3%). Median serum IgG4 concentration was 191.5 (145.0 - 212.0) mg/dL. Seven in 14 patients had CSF pleocytosis (50.0%) and oligoclonal bands restricted to the intrathecal compartment, while most cases presented elevated CSF proteins (64.3%). Magnetic resonance imaging abnormalities included white matter lesions in four (26.7%), hypertrophic pachymeningitis in two (13.3%), and LETM in two (13.3%). Two patients had biopsy-proven IgG4-RD in extra-neurological sites. CONCLUSION This study highlights the phenotypical variability of the neurological IgG4-RD. Biopsy inaccessibility reinforces the importance of new criteria for the diagnosis of this subset of patients.
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Affiliation(s)
- João Moura
- *Shared first co-authorship. Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Maria João Malaquias
- *Shared first co-authorship. Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Firmina Jorge
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Eduarda Pinto
- Neurorradiology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ana Sardoeira
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Inês Laranjinha
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Vanessa Oliveira
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ana Paula Sousa
- Neurophysiology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Joana Damásio
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Center for Predictive and Preventive Genetics (CGPP). Institute for Molecular and Cell Biology (IBMC). Instituto de Investigação e Inovação em Saúde (i3S). Universidade do Porto. Porto. Portugal
| | - Luís Maia
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Nuno Vila-Chã
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Raquel Samões
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Ricardo Taipa
- Portuguese Brain Bank. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ana Martins da Silva
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ernestina Santos
- Neurology Department. Centro Hospitalar Universitário de Santo António. Porto; Unit for Multidisciplinary Research in Biomedicine. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
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Enabi J, Sharif MW, Venkatesan R, Kondakindi H, Faheem M. Hypertrophic Pachymeningitis: An Unusual Cause of Headache. Cureus 2024; 16:e53576. [PMID: 38445136 PMCID: PMC10914404 DOI: 10.7759/cureus.53576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 03/07/2024] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare condition characterized by inflammation and thickening of the dura mater. It can be idiopathic or secondary to various causes, including infections, tumors, or systemic inflammatory diseases. Diagnosis is challenging due to its rarity and the overlap of symptoms with other conditions. We present the case of a 42-year-old Hispanic woman with diabetes mellitus type 2 and end-stage kidney disease who presented with chest pain, dry cough, mild dyspnea, and chronic occipital headaches. Physical examination revealed cranial VI nerve palsy. Imaging showed pulmonary cavitary lesions and mediastinal lymphadenopathy. Elevated inflammatory markers and positive autoimmune tests, including rheumatoid factor and antineutrophil cytoplasmic antibody (ANCA), led to further investigation. Brain imaging revealed dural thickening, confirming HP. The patient's medical history revealed double ANCA positivity and a lung biopsy confirmed granulomatous pneumonitis. A diagnosis of ANCA-associated vasculitis (granulomatosis with polyangiitis (GPA)) was established, and treatment with rituximab and high-dose corticosteroids led to symptom improvement. GPA rarely involves meningeal inflammation, but severe and persistent headaches are common early symptoms. Inflammatory markers are often elevated, and around two-thirds of HP cases related to GPA have positive serum ANCA. MRI is the primary diagnostic tool, with characteristic findings of dural thickening and contrast enhancement. This case highlights HP as a rare cause of chronic headaches and the importance of a comprehensive medical history in diagnosis. Early recognition and treatment are crucial for improving outcomes in GPA-related HP.
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Affiliation(s)
- Joud Enabi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | | | - Raksha Venkatesan
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Hema Kondakindi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Maida Faheem
- Internal Medicine, Midland Memorial Hospital, Midland, USA
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Coelho ADVK, Almeida ACD, Gomes SMCDASMM, Rocha AJD, Neto HRS. IgG4-related hypertrophic pachymeningitis with cerebral venous thrombosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-2. [PMID: 38272042 PMCID: PMC10810699 DOI: 10.1055/s-0043-1772600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/19/2023] [Indexed: 01/27/2024]
Affiliation(s)
| | | | | | - Antonio José da Rocha
- Santa Casa de São Paulo, Faculdade de Ciências Médicas, Departamento de Radiologia, São Paulo SP, Brazil.
| | - Herval Ribeiro Soares Neto
- Hospital do Servidor Público Estadual de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
- Hospital Israelita Albert Einstein, Departamento de Neurologia, São Paulo SP, Brazil.
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Shnyakin PG, Isaeva NV, Severina MI, Karnaukhov DI. [Idiopathic hypertrophic pachymeningitis]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:114-119. [PMID: 38529871 DOI: 10.17116/jnevro2024124031114] [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: 03/27/2024]
Abstract
The article presents a case of idiopathic hypertrophic pachymeningitis of a 61-year-old male patient with severe cephalgia and progressive neuropathy of the oculomotor nerves. The diagnosis was confirmed by MRI with gadolinium, which revealed thickening of the dura mater with accumulation of paramagnetic in the convexital parts of the frontal and temporal regions, as well as on the base of the skull and tentorium. During the use of pulse therapy with glucocorticosteroids (GCS) the symptoms regressed, but when the therapy was stopped, there was a relapse of ptosis and oculomotor abnormalities on the other side followed by a slower effect of GCS therapy. The article also presents a brief review of current knowledge about this pathology.
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Affiliation(s)
- P G Shnyakin
- Voino-Yasenetsky Krasnoyarsk State Medical University, Krasnoyarsk, Russia
- Regional Clinical Hospital, Krasnoyarsk, Russia
| | - N V Isaeva
- Voino-Yasenetsky Krasnoyarsk State Medical University, Krasnoyarsk, Russia
- Regional Clinical Hospital, Krasnoyarsk, Russia
| | - M I Severina
- Voino-Yasenetsky Krasnoyarsk State Medical University, Krasnoyarsk, Russia
- Regional Clinical Hospital, Krasnoyarsk, Russia
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Ikeda J, Shimojima Y, Yamada A, Sekijima Y. Quantitative evaluation of the thickened dura mater impacting clinical signs in immune-mediated hypertrophic pachymeningitis. J Neurol Sci 2023; 453:120780. [PMID: 37689000 DOI: 10.1016/j.jns.2023.120780] [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: 05/06/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE This study evaluated the volume of thickened dura mater lesions and their impact on clinical findings in immune-mediated hypertrophic pachymeningitis (HP). METHODS The volume of contrast-enhanced dura mater on magnetic resonance imaging was evaluated using the imaging feature quantification system in 19 patients with immune-mediated HP, including 12 with antineutrophil cytoplasmic antibody-related, 4 with IgG4-related, and 3 with idiopathic HP, as well as 10 with multiple sclerosis (MS) as controls. The implications of HP volume on neurological manifestations and cerebrospinal fluid (CSF) laboratory markers were statistically analyzed in patients with immune-mediated HP. RESULTS The volumes of the contrast-enhanced dura mater in the convexity, cranial fossa, and tentorium cerebelli were significantly higher in patients with immune-mediated HP than in those with MS. Among patients with immune-mediated HP, those with cranial nerve (CN) VIII neuropathy had a significantly higher volume of the contrast-enhanced dura mater in the cranial fossa than those without CN VIII neuropathy. The volume of the contrast-enhanced dura mater in the tentorium cerebelli was positively correlated with CSF protein levels. CONCLUSION Quantification of the thickened dura mater is useful for elucidating the relationship with the clinical findings in immune-mediated HP. Thickened dura mater lesions in the cranial fossa may be implicated in the development of CN VIII neuropathy. The enlargement of HP lesions in the tentorium cerebelli can increase CSF protein levels.
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Affiliation(s)
- Junji Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Akira Yamada
- Department of Radiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Yu H, Lu C, Duan W, Dong Y, Wang Z, Wang X, Jian F. A selected case series of idiopathic hypertrophic pachymeningitis in a single center: Pathological characteristics and case-oriented review. J Neuroimmunol 2023; 383:578191. [PMID: 37660537 DOI: 10.1016/j.jneuroim.2023.578191] [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: 05/12/2023] [Revised: 07/06/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a relatively rare disease of the central nervous system characterized by local or diffuse fibrous thickening of the dura mater. At present, there is still insufficient research on the pathogenesis and treatment strategies of this disease. We reported a continuous case series of seven patients with idiopathic HP (IHP), and also details one case of immunoglobulin G4-related HP requiring surgical intervention. Early diagnosis and appropriate surgical intervention for IHP could prevent the progression of permanent neurological damage and spinal cord paraplegia.
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Affiliation(s)
- Huaxiao Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Chunli Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Yachao Dong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Zuowei Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China.
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China.
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Shimojima Y, Sekijima Y. Hypertrophic pachymeningitis in ANCA-associated vasculitis: Clinical and immunopathological features and insights. Autoimmun Rev 2023; 22:103338. [PMID: 37062439 DOI: 10.1016/j.autrev.2023.103338] [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: 03/21/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
Hypertrophic pachymeningitis (HP) is an inflammatory disorder characterized by intracranial and spinal thickened dura mater, leading to several neurological manifestations including headaches, cranial neuropathies, seizures, and sensorimotor disorders. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a crucial disease that is implicated in the development of immune-mediated HP. HP is observed throughout the clinical course of AAV, and 3%-4% of patients with AAV experience HP as the initial clinical episode. However, patients with ANCA-related HP are unclassifiable in the classification criteria of AAV when HP is the only manifestation, suggesting that ANCA-related HP can be identified as a central nervous system-limited type of AAV. Among patients with AAV, those who develop HP have predominantly been classified as having granulomatosis with polyangiitis (GPA). Myeloperoxidase-ANCA positivity has been more frequently demonstrated than proteinase 3-ANCA positivity in patients with ANCA-related HP. The ear, nose, and throat manifestations, such as otitis media, sinusitis, and mastoiditis, as well as mucous membranes/eyes manifestations including sudden visual loss, are robustly associated with HP in AAV. The histology of thickened dura mater tissues includes fibrotic changes and infiltration of several immunocompetent cells, but the typical findings of GPA, such as granulomatous inflammation with necrotizing vasculitis, are not observed in all patients with ANCA-related HP. Corticosteroids are the first-line therapy for ANCA-related HP, while the concomitant use of immunosuppressive agents including cyclophosphamide, methotrexate, and mycophenolate mofetil, is an ideal strategy for achieving remission. Rituximab is a useful agent in refractory ANCA-related HP.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Yang F, Liu Z, Zhang Y, Li P, Zhu Y, Zhu Q, Zhang B. Case report: Clinical highlights and radiological classification of IgG4-related spinal pachymeningitis: A rare case series and updated review of the literature. Front Oncol 2023; 12:1035056. [PMID: 36703781 PMCID: PMC9873374 DOI: 10.3389/fonc.2022.1035056] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Purpose Hypertrophic pachymeningitis associated with immunoglobulin G4-related disease (IgG4-RD) has been rarely reported, and there is little information and no clear consensus on the management of IgG4-related spinal pachymeningitis (IgG4-RSP). The present study described its possible clinical features, including the symptoms, imaging, treatment and prognosis of patients with IgG4-RSP. Methods We report three patients who presented with progressive neurological dysfunction due to spinal cord compression. Relevant articles were searched from the PubMed, Web of Science, and Embase databases, and the resulting literature was reviewed. Results The literature review provided a summary of 45 available cases, which included three cases from our center. Progressive worsening of neurological impairment was observed in 22 patients (48.9%). The lesions involved the thoracic spine (n=28, 62.2%), cervical spine (n=26, 57.8%), lumbar spine (n=9, 20.0%), and sacral spine (n=1, 2.2%). Furthermore, the lesions were located in the dura mater (n=18, 40.0%), epidural space (n=17, 37.8%), intradural-extramedullary space (n=9, 20.0%), and intramedullary space (n=1, 2.2%). On magnetic resonance imaging (MRI), the lesions generally appeared as striated, fusiform, or less often lobulated oval changes, with homogeneous (n=17,44.7%) and dorsal (n=15,39.5%) patterns being the most common. Thirty-five patients had homogeneous T1 gadolinium enhancement. Early surgical decompression, corticosteroid treatment, and steroid-sparing agents offered significant therapeutic advantages. A good therapeutic response to disease recurrence was observed with the medication. Conclusion The number of reported cases of IgG4-RSP remains limited, and patients often have progressive worsening of their neurological symptoms. The features of masses identified on the MRI should be considered. The prognosis was better with decompression surgery combined with immunosuppressive therapy. Long-term corticosteroid treatment and steroid-sparing agent maintenance therapy should be ensured. A systemic examination is recommended to identify the presence of other pathologies.
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Rayamajhi S, Shrestha R, Sunuwar N, Shrestha R, Shrestha S, Bartaula J, Kharel G. A rare case report on hypertrophic pachymeningitis: Serum IgG4-related disease. Radiol Case Rep 2022; 17:4371-4375. [PMID: 36188084 PMCID: PMC9520424 DOI: 10.1016/j.radcr.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/09/2022] [Accepted: 08/13/2022] [Indexed: 11/19/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated inflammatory condition of unknown etiology characterized by invasion of tissue by IgG4-producing plasma cells. It can affect almost any organ system, but central nervous system involvement is a rare occurrence. A careful clinicopathological correlation is required to establish the diagnosis. The condition is highly treatable with glucocorticoids, but it is likely that it is underdiagnosed. Although IgG4-related disease responds quickly to glucocorticoids, if left untreated, can lead to end-stage organ failure and even death. We present a case of a 46-year-old female patient who presented with headache, tingling, numbness, flickering movement in her left lower limb gradually extending to torso and head, and loss of consciousness. After radiological and immunohistochemical studies, the diagnosis of IgG4-related hypertrophic pachymeningtis was confirmed. Corticosteroid therapy was administered, and the patient symptomatically improved. Clinicians should be aware of this rare condition, and the importance of early diagnosis and appropriate corticosteroid therapy should be emphasized.
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Affiliation(s)
- Sushil Rayamajhi
- Department of Neurology/Neuroradiology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
- Corresponding author at: Department of Neurology/Neuroradiology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Swayambhu-15, Kathmandu, Nepal
| | - Ramesh Shrestha
- Department of Neurology/Neuroradiology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | - Neela Sunuwar
- Department of Medicine, Kulhudhuffushi Regional Hospital, Kulhudhuffushi, Maldives
| | - Rekha Shrestha
- Universal College of Medical Sciences, Bhairahawa, Nepal
| | - Sunita Shrestha
- Department of Neurology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | - Jasmine Bartaula
- Department of Neurology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | - Ghanashyam Kharel
- Department of Neurology, Upendra Devkota Memorial National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
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Vankadari K, Alwala S, Kumar K, Ram S. Hypertrophic Pachymeningitis Presenting as “Eyebrows” Sign on 18F FDG PET/CT. World J Nucl Med 2022; 21:236-238. [PMID: 36060081 PMCID: PMC9436508 DOI: 10.1055/s-0042-1750014] [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: 11/17/2022] Open
Abstract
Hypertrophic pachymeningitis refers to linear or nodular thickening of the dura mater covering the brain and spinal cord following various inflammatory/infective processes. Usually, magnetic resonance imaging brain shows uniform thickening with enhancement of involved meninges. Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings of pachymeningitis are rarely reported in literature. We describe the PET/CT findings of a patient with hypertrophic pachymeningitis involving the bilateral supraorbital regions depicting as “eyebrows” on brain maximum intensity projection image.
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Affiliation(s)
- Kousik Vankadari
- Department of Nuclear Medicine, Yashoda Hospital, Secunderabad, Telangana, India
| | - Surendar Alwala
- Department of Radiology, Yashoda Hospital, Secunderabad, Telangana, India
| | - Komal Kumar
- Department of Neurology, Yashoda Hospital, Secunderabad, Telangana, India
| | - Sai Ram
- Department of Nuclear Medicine, Yashoda Hospital, Secunderabad, Telangana, India
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13
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Khalid A, Uche EO. Idiopathic Hypertrophic Cranial Pachymeningitis With Chiari Type I Malformation: Case Report and Review of the Literature. Cureus 2022; 14:e28466. [PMID: 36046060 PMCID: PMC9419626 DOI: 10.7759/cureus.28466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare chronic inflammatory disease characterized by diffuse thickening of the dura mater. Although IHCP mostly presents as a diffuse lesion, it may also occur as focal tumour-like lesions. Here we present the first reported case of IHCP associated with a Chiari type I malformation (CMI). A 65-year-old man presented with a one-year history of chronic headache and vertigo exacerbated by standing and neck flexion. The neurological examination was unremarkable except for tongue wasting and fasciculations. MRI demonstrated features of CMI and findings suggestive of IHCP. Posterior fossa decompression resulted in significant symptomatic improvement and the diagnosis of IHCP was confirmed on histopathology. Though there is no consensus about the management of IHCP in this case, we advocate surgical decompression with prolonged steroid therapy.
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Yao Y, Xu Y, Li X, Song T, Xu W, Duan Y, Liu Y, Zhang X, Tian DC. Clinical, imaging features and treatment response of idiopathic hypertrophic pachymeningitis. Mult Scler Relat Disord 2022; 66:104026. [DOI: 10.1016/j.msard.2022.104026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
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15
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Im JY, Sunwoo M. Immunoglobulin G4-Related Disease Involving Various Head and Neck Regions: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:910-917. [PMID: 36238908 PMCID: PMC9514576 DOI: 10.3348/jksr.2021.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/18/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022]
Abstract
Immunoglobulin G4 (IgG4) related disease (IgG4-RD) is currently considered an immune-mediated condition and is recognized as a disorder group with common pathological, hematological, and clinical characteristics. This disease may involve diverse organs of the head and neck, and include mainly the lacrimal gland, orbit, thyroid gland, pituitary gland, and the meninges. Here, we report a case of IgG4-RD in a 65-year-old female showing head- and neck-limited but synchronously and mainly manifesting as otalgia and facial neuritis.
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16
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Maliha M, Roksana Z, Babli SA, Chowdhury K, West D. The Relationship Between Exacerbation of Pachymeningitis and Chemotherapy: A Case Report. Cureus 2022; 14:e25792. [PMID: 35812596 PMCID: PMC9270911 DOI: 10.7759/cureus.25792] [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: 06/09/2022] [Indexed: 11/30/2022] Open
Abstract
Pachymeningitis is a rare disorder that involves the dura mater of the cranial and spinal nerves. It can lead to localized or diffuse thickening of the dura mater as an inflammatory reaction. Very little is known about this uncommon disease, and even less is known about its exacerbating factors and relationship with chemotherapy. In this report, we present a case of an 86-year-old man with metastatic bladder carcinoma on chemotherapy who experienced worsening pachymeningitis with symptoms such as headache, aphasia, weakness, and seizures. The patient responded well to steroids, and his symptoms improved. This association between exacerbation of pachymeningitis and chemotherapy is rarely encountered, and its mechanism of action is poorly understood. We hope this case report will add to the existing literature on this uncommon phenomenon and its exacerbating factors.
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IgG4-related hypertrophic pachymeningitis with tumor-like intracranial and intracerebral lesions. Acta Neurochir (Wien) 2022; 164:2781-2787. [PMID: 35974231 PMCID: PMC9519706 DOI: 10.1007/s00701-022-05340-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/07/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE IgG4-related hypertrophic pachymeningitis is a rare fibroinflammatory disorder that may cause localized or diffused thickening of the dura mater. Misinterpretations of the clinical and imaging findings are common. Clinical manifestations depend on the location of the inflammatory lesion and on compression of neural structures leading to functional deficits. A dural biopsy is commonly needed for a definitive diagnosis. Immunomodulatory therapy is considered the therapy of choice. METHODS Four patients with IgG4-related hypertrophic pachymeningitis were identified over a 5-year period. Patient-related characteristics including age, preoperative workup, signs and symptoms of patients, and diagnostic procedures were evaluated. Furthermore, the surgical treatment and 5-year follow-up outcomes were analyzed. RESULTS There were two adults and two adolescents (mean age 32 years; range 15 to 67 years). Two patients were male, and two were female. No history of disease was known in any of the patients. Clinical symptoms were epilepsy (n = 2), ataxia and nausea (n = 1), and facial nerve palsy (n = 1). MR imaging studies showed contrast enhancing lesions in the temporal region in two patients, and in the cerebellar region in the other two patients. Subtotal resection was performed in two instances and a biopsy via a suboccipital retrosigmoid approach was obtained in the other two patients. Histochemical and immunohistochemical investigations revealed an IgG 4 disease in all of these patients. Immunomodulatorry therapy led to clinical stability during follow-up of 5 years in all four cases. CONCLUSION The diagnosis of IgG4-related hypertrophic pachymeningitis is challenging, but is of great relevance as treatment differs significantly from other forms of pachymeningitis and a specific therapeutic approach may avoid long-term neurological complications. Our series contributes to a better clinical characterization of this rare disease.
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Nomura S, Shimojima Y, Kondo Y, Kishida D, Sekijima Y. Hypertrophic pachymeningitis in polyarteritis nodosa: a case-based review. Clin Rheumatol 2021; 41:567-572. [PMID: 34725743 DOI: 10.1007/s10067-021-05971-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 11/29/2022]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurological disorder with focal or diffuse thickening of the dura mater, which usually causes headache, cranial neuropathies, seizures, and motor or sensory impairments. The development of HP is attributed to an immune-mediated mechanism, and some autoimmune diseases have been implicated in the development of HP. Herein, we describe the case of a 73-year-old woman with persistent headache ascribable to HP, which developed approximately 3 years after a diagnosis of polyarteritis nodosa (PAN). She was treated with high-dose corticosteroid and cyclophosphamide that resulted in immediate disappearance of headache and improved radiological findings of thickened dura mater. In addition, she was subsequently administered methotrexate, ultimately resulting in maintenance of remission and regular reduction of prednisolone. In our review of published English articles, only two cases of HP in patients with PAN have been reported to date, suggesting that HP is a rare complication in PAN. However, it should be recognized that HP may develop as a neurological involvement related to PAN.
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Affiliation(s)
- Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Yasufumi Kondo
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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Shiraishi W, Tsujimoto Y, Shiraishi T. Pathological findings of hypertrophic pachymeningitis associated with eosinophilic granulomatosis with polyangiitis. BMJ Case Rep 2021; 14:14/9/e243395. [PMID: 34544704 PMCID: PMC8454454 DOI: 10.1136/bcr-2021-243395] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The most common neurological manifestation of eosinophilic granulomatosis with polyangiitis (EGPA), formerly called Churg-Strauss syndrome, is mononeuritis multiplex caused by small-vessel vasculitis. In contrast, central nervous system involvement is rare. Among EGPA-associated central nervous system disorders, there are only a few reported cases of hypertrophic pachymeningitis (HP). Here, we report a patient with EGPA with headache and ophthalmoplegia who presented with HP and had a dural biopsy. The biopsy specimen showed lymphocytic inflammatory cell infiltration without EGPA-specific findings, that is, eosinophilic infiltration, granuloma or angiitis. To the best of our knowledge, there are no previous reports of EGPA-associated HP pathology. Here, we report the first case presentation of a patient with EGPA-associated HP with pathological findings.
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Affiliation(s)
- Wataru Shiraishi
- Department of Neurology, Kokura Memorial Hospital, Kitakyushu, Japan
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20
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Parlakpinar H, Gunata M. Transplantation and immunosuppression: a review of novel transplant-related immunosuppressant drugs. Immunopharmacol Immunotoxicol 2021; 43:651-665. [PMID: 34415233 DOI: 10.1080/08923973.2021.1966033] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunosuppressive drugs used in the transplantation period are generally defined as induction and maintenance therapy. The use of immunosuppressants, which are particularly useful and have fewer side effects, decreased both mortality and morbidity. Many drugs such as steroids, calcineurin inhibitors (cyclosporine-A, tacrolimus), antimetabolites (mycophenolate mofetil, azathioprine), and mTOR inhibitors (sirolimus, everolimus) are used as immunosuppressive agents. Although immunosuppressant drugs cause many side effects such as hypertension, infection, and hyperlipidemia, they are the agents that should be used to prevent organ rejection. This shows the importance of individualized drug use. The optimal immunosuppressive therapy post-transplant is not established. Therefore, discovering less toxic but more potent new agents is of great importance, and new experimental and clinical studies are needed in this regard.Our review discussed the mechanism of immunosuppressants, new agents' discovery, and current therapeutic protocols in the transplantation.
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Affiliation(s)
- Hakan Parlakpinar
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
| | - Mehmet Gunata
- Department of Medical Pharmacology, Faculty of Medicine, Inonu University, Malatya, Turkey
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21
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Immunoglobulin G4-related disease: case report and literature review. Immunol Res 2021; 69:415-421. [PMID: 34374950 DOI: 10.1007/s12026-021-09215-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a rare and chronic progressive clinical entity, characterized by elevated serum IgG4 along with tissue infiltration by IgG4 + plasma cells. It is an immune-mediated fibro-inflammatory condition that can affect virtually any organ and tissue. IgG4-related lung disease (IgG4-RLD) occupies 14% of all IgG4-RD, with nonspecific symptoms and various abnormal radiographic patterns. Published data on IgG4-related hypertrophic pachymeningitis (IgG4-RHP), an increasingly recognized central nervous system manifestation of IgG4-RD, is also limited. Both lung and cranial dura involvement have not yet been reported until now. We further entail a review of the literature on the clinicopathologic features and differential diagnosis of this uncommon disease. We herein report an interesting case of a 70-year-old male patient admitted due to headache and fever. A magnetic resonance imaging (MRI) of the brain revealed extensive dural thickening with marked enhancement. Chest computed tomography (CT) scan showed nodular or mass-like consolidation and focal interstitial change. Thoracoscopic lung biopsy and lumbar puncture were conducted. After careful histopathological observation and consideration of alternative differential diagnoses, he was diagnosed with IgG4-related disease with lung and cranial dural involvement based upon significant elevation of serum and cerebrospinal fluid (CSF) IgG4 concentration. The patient was started on oral prednisolone 60 mg/day (1.0 mg/kg/day) for 14 days, and a tapering dose of 5 mg every 2 weeks followed by maintenance therapy at low dose for 3 months. His clinical manifestations, and serologic and imaging findings improved with steroid treatment. Currently, the patient remains well without disease progression. IgG4-RD should be considered as a differential when diagnosing other similar multisystemic lesions. Clinical examination, careful histological observation, and immunostaining for appropriate markers are essential in establishing the diagnosis. Clinicians should become familiar with this alternative differential diagnosis.
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22
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Perez Giraldo GS, Ortiz Garcia JG. Immune-Mediated Disorders Affecting the Spinal Cord and the Spine. Curr Neurol Neurosci Rep 2021; 21:3. [PMID: 33392785 PMCID: PMC7779105 DOI: 10.1007/s11910-020-01088-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW To review the most recent advances and provide a description of the most common autoimmune diseases causing myelitis and selective spine disorders. The ultimate goal of this article is to facilitate the prompt recognition of these diseases. RECENT FINDINGS The recent discovery of biomarkers such as aquaporin 4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies has changed our understanding of autoimmune diseases affecting the spinal cord as well as their treatment and outcomes. Autoimmune neurology is an increasingly evolving field that encompasses a broad spectrum of autoimmune-inflammatory diseases of the central nervous system (CNS) and peripheral nervous system (PNS). Autoimmune disorders of the spinal cord are a heterogeneous group of myelopathies with a broad differential diagnosis and many of them have been recently identified. Prompt recognition of these myelopathies is important as some of them are treatable, which could improve patient outcomes and prevent disability.
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Affiliation(s)
- Gina S Perez Giraldo
- Department of Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
- Division of Critical Care Neurology, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
- Division of Stroke and Cerebrovascular Disorders, The University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd. Suite 2547, Oklahoma City, OK, 73104, USA.
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Xiao X, Fu D, Feng L. Hypertrophic Pachymeningitis in a Southern Chinese Population: A Retrospective Study. Front Neurol 2020; 11:565088. [PMID: 33281701 PMCID: PMC7705170 DOI: 10.3389/fneur.2020.565088] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/07/2020] [Indexed: 11/13/2022] Open
Abstract
Aims: To investigate the causes, clinical characteristics, imaging features, and therapeutic implications of hypertrophic pachymeningitis (HP) in a southern Chinese population. Methods: We retrospectively analyzed 48 patients with HP with different causes from 1 January 2006 to 31 December 2018. Clinical manifestation, laboratory findings, and neuroimaging results were evaluated in all HP patients. Results: The mean age at onset was 50 ± 12 years. The most common diagnosis was idiopathic HP (67%), followed by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (15%), tuberculous meningitis (8%), viral meningitis (6%), and bacterial meningitis (4%). Headache was the most common symptom. The most frequently changed laboratory finding was elevated erythrocyte sedimentation rate (ESR). Imaging was characterized by cerebral or spinal dura mater enhancement in MRI scan with contrast. Enhancements were mainly located in the posterior fossa for idiopathic HP; frontal, parietal, and occipital lobes for ANCA-related HP; and posterior fossa for tuberculous-associated HP. Diffuse enhancement was found in most cases, except for tuberculous-associated HP. Glucocorticoid or immunosuppressive treatment was applied in most cases. Conclusions: The etiology of HP varied among patients, with idiopathic HP being the most common. MRI showed enhancement of the dura mater, which differed according to different etiologies. Glucocorticoid or immunosuppressive agents were the primary drugs for treatment.
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Affiliation(s)
- Xuewen Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Dongni Fu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Li Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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Somani SN, Schneider AL, Welch KC, Alexiev BA, Matsuoka AJ. Probable neurosarcoidosis presenting as acute on chronic otorrhoea: a difficult diagnosis. BMJ Case Rep 2020; 13:13/11/e237676. [PMID: 33139371 DOI: 10.1136/bcr-2020-237676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An elderly African American woman presented to our clinic following 9 months of right-sided unilateral headache, otorrhoea and progressive hearing loss. Despite treatment with topical and oral antibiotics, her clinical condition worsened, and imaging showed mastoid coalescence with an associated subgaleal abscess. She underwent right mastoidectomy and was discharged 3 days later on broad-spectrum intravenous antibiotics despite negative operative cultures. Six weeks later, she was hospitalised with diplopia secondary to a right lateral rectus palsy. Imaging showed abscess resolution but progressive bony remodelling and enhancement of the lateral extending into anterior skull base. Chest CT demonstrated upper lobe predominant pulmonary micronodules, and mastoid biopsy on revision surgery was notable for non-caseating granulomas. Further extensive work-up could not identify an alternative cause, and a presumptive diagnosis of neurosarcoidosis was made. The patient was initiated on intravenous steroids, experienced symptomatic improvement and was thereafter transitioned to oral steroid taper on discharge.
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Affiliation(s)
- Shaan N Somani
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander L Schneider
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin C Welch
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Borislav A Alexiev
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Akihiro J Matsuoka
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA .,Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois, USA.,The Hugh Knowles Center for Clinical and Basic Science in Hearing and Its Disorders, Evanston, Illinois, USA
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Elmaci I, Altinoz MA, Akdemir G, Sari R, Baskan O, Ozpinar A, Hacker E, Sav A. Neurosurgical and neuro-immunological management of IgG4-related hypertrophic sclerosing pachymeningitis. A literature survey and discussion of a unique index case. Clin Neurol Neurosurg 2020; 200:106342. [PMID: 33158629 DOI: 10.1016/j.clineuro.2020.106342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/28/2020] [Accepted: 10/27/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Dural thickening is observed in lymphoma, dural carcinomatosis, meningioma, tuberculosis, and autoimmune diseases. We encountered a patient with dural thickening and complaints of neck and back pain, numbness and loss of strength in the hands. The patient also suffered from polychondritis and had previously received steroid and methotrexate treatment for this indication. The patients' serum was also positive for ANA, yet she did not have any other findings suggesting lupus. Our radiological and pathological analysis revealed IHSP (IgG4-related hypertrophic sclerosing pachymeningitis). In this review study, we provided a detailed literature survey to increase the awareness about IHSP in the neurosurgical community. METHODS MRI (magnetic resonance imaging)-based radiological analyses revealed a posterior extramedullary spinal mass extending from C2 to T2-T3 level. The dural mass was surgically excised and a broad panel of immunohistochemical markers including S100, EMA, CD246/ALK-1, CD45, CD20, CD79a, CD138, CD68, CD1a and CD34 was studied. Immunoglobulin heavy chain/kappa chain gene rearrangement analysis was performed which ruled out a lymphoproliferative disorder. RESULTS MRI and pathological findings suggested IHSP. As the disease relapsed with a new anterior extramedullary multilobulated lesion extending from C5 to T1 level, the patient is now closely monitored for further medical and surgical treatment. CONCLUSIONS IHSP is a relatively novel entity of hypertrophic pachymeningitis and should be included in the differential diagnosis of dural thickening. The fibrosis accompanying IHSP may not respond to medical treatment, which includes steroids and immunosuppressive agents. Additionally, neurological deficits, seizures, spinal decompression, hydrocephalus, or brainstem compression necessitate early surgical intervention. A continued vigilance is also necessary as the disease may relapse long-term following surgical treatment.
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Affiliation(s)
- Ilhan Elmaci
- Department of Neurosurgery, M.A.A. Acibadem University, Maslak Hospital, Istanbul, Turkey
| | - Meric A Altinoz
- Department of Medical Biochemistry, M.A.A. Acibadem University, Istanbul, Turkey.
| | | | - Ramazan Sari
- Department of Neurosurgery, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Ozdil Baskan
- Department of Radiology, Memorial Hospital, Istanbul, Turkey
| | - Alp Ozpinar
- Department of Neurosurgery, University of Pittsburgh, United States
| | - Emily Hacker
- Department of Neurosurgery, University of Pittsburgh, United States
| | - Aydin Sav
- Department of Pathology, Yeditepe University, Istanbul, Turkey
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An Update on Idiopathic Hypertrophic Cranial Pachymeningitis for the Headache Practitioner. Curr Pain Headache Rep 2020; 24:57. [PMID: 32803475 DOI: 10.1007/s11916-020-00893-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW We aim to review idiopathic hypertrophic cranial pachymeninigitis (IHCP), describe common head pain patterns and features associated with the disorder, suggest potential classification of head pain syndromes based on the recently published International Classification of Headache Disorders-3, explore pathophysiology found to be associated with cases of IHCP, and indicate common treatment for the disorder. RECENT FINDINGS It is suggested that a subset of IHCP is an IgG4-related autoimmune disorder. Patients with IHCP were found to have elevated cerebrospinal fluid (CSF) protein and lymphocytic pleocytosis. Corticosteroids are a mainstay of treatment. Other immunosuppressive agents and steroid sparing agents as add-on therapy may have utility in the treatment of cases refractory to corticosteroids alone. Clinical manifestations of IHCP depend upon the location of the inflammatory lesions and compression of the adjacent nervous system structures. Headache and loss of cranial nerve function were the most common presenting features of hypertrophic cranial pachymeninigitis. Several headache diagnoses may result from IHCP. Gadolinium-enhanced MRI is the standard imaging modality for diagnosing. Although the pathophysiology is poorly understood, many cases of hypertrophic pachymeninigitis (HP) are thought to be closely related to inflammatory disorders. Cases of HP previously thought to be idiopathic may have IgG4 pathophysiology. CSF and serological studies are helpful. Treatment involves immunosuppressive agents. Advancement in neuroimaging, assays, tests, and further delineation of inflammatory disorders affecting the nervous system may provide further insight to the etiology of cases of HP previously considered and diagnosed as idiopathic.
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27
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Sbeih I, Darwazeh R, Shehadeh M, Al-Kanash R, Abu-Farsakh H, Sbeih A. Immunoglobulin G4-Related Hypertrophic Pachymeningitis of the Spine: A Case Report and Systematic Review of the Literature. World Neurosurg 2020; 143:445-453. [PMID: 32777395 DOI: 10.1016/j.wneu.2020.07.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spinal immunoglobulin G4-related hypertrophic pachymeningitis (IgG4-HP) is a rare disease. Little information is known regarding the diagnosis, management, and prognosis of patients with spinal IgG4-HP. METHODS The authors present a case of spinal IgG4-HP with a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies (up to April 2020) that reported patients with spinal IgG4-HP, based on the criteria of Japan College of Rheumatology, were identified from the PubMed and Cochrane Library databases. RESULTS This systematic review identified 33 patients, including the present case, of whom 21 were male and 12 were female. The mean value of age was 51.2 (±12.6) years. Eight patients had systemic involvement. In addition, among 33 patients, 13 patients had an elevated serum IgG4. Surgery was performed in 31 patients. Steroid therapy alone and steroid therapy with immunosuppressants were effective in 94% and 100% of the cases, respectively. Furthermore, 31 of 33 patients reported improved outcomes, 1 patient died due to infection, and in 2 patients the data were not available. CONCLUSIONS Spinal IgG4-HP is a rare entity. In addition, it should be considered in the differential diagnosis of space-occupying lesions around the spinal cord. Histopathology with immunohistochemistry results provides the most reliable evidence for diagnosis. Steroid therapy is the first line of treatment. Surgical decompression may be required in patients presenting with nerve root and/or spinal cord compression. Long-term follow-up is necessary for patients with spinal IgG4-HP.
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Affiliation(s)
- Ibrahim Sbeih
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan.
| | - Rami Darwazeh
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan
| | | | - Rasha Al-Kanash
- Endoscopic Spine Department, Razi Spine Clinic, Amman, Jordan
| | | | - Aseel Sbeih
- Neurosurgery Department, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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Cerebrospinal fluid biomarkers implicated in the pathogenesis of anti-neutrophil cytoplasmic antibody-related hypertrophic pachymeningitis. Clin Rheumatol 2020; 39:1803-1811. [PMID: 32036585 DOI: 10.1007/s10067-020-04971-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Hypertrophic pachymeningitis (HP) related to anti-neutrophil cytoplasmic antibody (ANCA) is the most frequently seen immune-mediated HP. We investigated cerebrospinal fluid (CSF) biomarkers related to the pathogenesis of ANCA-related HP (ANCA-HP). METHODS The levels of B cell activation factor of the tumor necrosis factor family (BAFF), a proliferation-inducing ligand (APRIL), and transforming growth factor beta 1 (TGF-β1) in the CSF were compared between patients with ANCA-HP (n = 12), other types of immune-mediated HP (other HP; n = 12), multiple sclerosis (MS; n = 14), and non-inflammatory neurological disorders (NIND; n = 10). In addition, we evaluated whether ANCA would be detected in CSF. RESULTS CSF levels of BAFF, APRIL, and TGF-β1 were significantly increased in ANCA-HP and other HP. In particular, BAFF and APRIL levels were significantly correlated with the IgG index in ANCA-HP. In other HP, BAFF and APRIL levels were significantly correlated with cell counts and protein levels in CSF. Of 12 patients with ANCA-HP, the CSF of 7 patients (58%) tested positive for myeloperoxidase (MPO)- or proteinase 3 (PR3)-ANCA, while none of the CSF samples from other HP, MS, or NIND patients tested positive. CONCLUSION The levels of BAFF, APRIL, and TGF-β1 may serve as useful CSF biomarkers for assessing the disease activity of immune-mediated HP. Moreover, BAFF and APRIL in the CSF may be implicated in the pathogenesis of ANCA-HP via promoting autoreactive B cells, while detecting MPO- or PR3-ANCA in the CSF may be found in some patients with ANCA-HP.Key Points• CSF BAFF, APRIL, and TGF-β1 levels increase significantly in immune-mediated HP.• CSF BAFF and APRIL levels are significantly correlated with IgG index in ANCA-HP.• Detection of MPO- or PR3-ANCA in the CSF is found in some patients with ANCA-HP.• BAFF, APRIL, and ANCA in the CSF may be implicated in the pathogenesis of ANCA-HP.
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Vakrakou AG, Evangelopoulos ME, Boutzios G, Tzanetakos D, Tzartos J, Velonakis G, Toulas P, Anagnostouli M, Andreadou E, Koutsis G, Stefanis L, Fragoulis GE, Kilidireas C. Recurrent myelitis and asymptomatic hypophysitis in IgG4-related disease: case-based review. Rheumatol Int 2020; 40:337-343. [PMID: 31898763 DOI: 10.1007/s00296-019-04502-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/11/2019] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a disorder with various clinical manifestations. Central nervous system (CNS) involvement is well recognized, with hypertrophic pachymeningitis and hypophysitis being the most common manifestations. Spinal cord involvement is an extremely rare manifestation. We present the first case of an IgG4-RD patient with spinal cord parenchymal disease and concurrent hypophysitis. We review also the current literature about CNS parenchymal involvement in the context of IgG4-RD. A young female presented with clinical symptoms of myelitis. Cervical spinal cord magnetic resonance imaging (MRI) displayed features of longitudinally extensive transverse myelitis (LETM). Brain MRI showed a small number of high-intensity lesions in the deep white matter and enlargement of hypophysis with homogeneous gadolinium enhancement (asymptomatic hypophysitis). Diagnostic workup revealed elevated IgG4 serum levels (146 mg/dL). Our patient fulfilled the organ-specific diagnostic criteria of IgG4-hypophysitis. Treatment with intravenous glucocorticoids led to rapid clinical response, and to the substantial resolution of imaging findings. Azathioprine was used as a maintenance treatment. One relapse occurred 2 years after the initial diagnosis and patient was re-treated with glucocorticoids. Three years after relapse, patient is in remission with azathioprine. We present the first case of myelitis with radiological features of LETM associated with increased IgG4 serum levels and the simultaneous presence of asymptomatic IgG4-related hypophysitis.
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Affiliation(s)
- Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece.
| | - Maria-Eleptheria Evangelopoulos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Boutzios
- Endocrine Unit, Department of Pathophysiology, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitrios Tzanetakos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - John Tzartos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Velonakis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Panagiotis Toulas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Elissavet Andreadou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Koutsis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - George E Fragoulis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
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Yoshinaga T, Kurokawa T, Uehara T, Nitta J, Horiuchi T, Sekijima Y. [Optic neuropathy from connected intra- and extraorbital lesions in IgG4-related disease]. Rinsho Shinkeigaku 2019; 59:746-751. [PMID: 31656266 DOI: 10.5692/clinicalneurol.cn-001342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We present the case of a 74-year-old woman complaining of blurred vision in the left eye who was found to have a unilateral, continuous lesion of the optic nerve and nerve sheath accompanied by an intracranial mass next to the cavernous sinus and meninges. Surgical decompression of the left optic nerve in the optic canal and partial resection of the mass followed by prednisolone administration were successful. Immunohistochemical analysis disclosed abundant infiltration of IgG4-positive plasma cells at >10 cells/high power field. These findings indicated a new pattern of compressive optic neuropathy with confirmed IgG4 histopathological findings. Such an extensive lesion may produce visual disturbance.
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Affiliation(s)
- Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine
- Department of NeuroHealth Innovation, Institute for Biomedical Sciences, Shinshu University
| | - Toru Kurokawa
- Department of Ophthalmology, Shinshu University Hospital
| | - Takeshi Uehara
- Department of Biomedical Laboratory Medicine, Shinshu University Hospital
| | - Junpei Nitta
- Department of Neurosurgery, Kobayashi Neurosurgical Hospital
| | | | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine
- Department of NeuroHealth Innovation, Institute for Biomedical Sciences, Shinshu University
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31
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Spinal IgG4-Related Hypertrophic Pachymeningitis with Spinal Cord Compression: Case Report and Literature Review. World Neurosurg 2019; 130:65-70. [DOI: 10.1016/j.wneu.2019.06.130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/18/2019] [Indexed: 12/24/2022]
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32
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Jia H, Xie X, Qi F, Wang L, Wang L, Che F. Anti-NMDAR encephalitis with simultaneous hypertrophic pachymeningitis in a 68-year-old male: a rare case report. BMC Neurol 2019; 19:215. [PMID: 31472692 PMCID: PMC6717633 DOI: 10.1186/s12883-019-1444-x] [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: 05/17/2019] [Accepted: 08/25/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the most frequent types of autoimmune encephalitis. However, the instigating mechanisms are as yet not fully ascertained. Cardinal clinical manifestations of anti-NMDAR encephalitis include acute behavioural change, psychosis, and catatonia. As the level of diagnosis increases, encephalitis becomes more common, but there are never been published in patients with anti-NMDAR encephalitis and simultaneous hypertrophic pachymeningitis. CASE PRESENTATION A sixty-eight-year-old man who presented with mental, behavioral abnormalities, unstable walking, headaches, and erratic hand movements. The neuropsychiatric symptoms and cerebrospinal fluid examination was consistent with the diagnosis criteria of anti-NMDAR encephalitis. Magnetic resonance imaging of the brain showed a thickening of dura mater localized at the left tentorium cerebelli, left cerebral hemisphere, and cerebral falx; the thickening dura mater was characterized by an intense contrast enhancement after the administration of gadolinium. High doses of intravenous methylprednisolone were administrated during his hospitalization. After 5 days, the patient's condition improved. CONCLUSIONS We herein describe a rare case of a 68-year-old man with anti-NMDAR encephalitis presenting with concomitant hypertrophic pachymeningitis. We systematically expounded anti-NMDAR encephalitis and hypertrophic pachymeningitis, and made bold conjectures on the etiology and pathogenesis of these two diseases, hoping to stimulate new ideas from clinicians and basic medical researchers.
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Affiliation(s)
- Huafang Jia
- Department of Neurology, The Eleventh Clinical Medical College of Qingdao University, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China
| | - Xiaoli Xie
- Central Laboratory, Linyi Key Laboratory of Neurophysiology, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China
| | - Faying Qi
- Department of Neurology, The Eleventh Clinical Medical College of Qingdao University, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China
| | - Long Wang
- Central Laboratory, Linyi Key Laboratory of Neurophysiology, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China
| | - Lijuan Wang
- Central Laboratory, Linyi Key Laboratory of Neurophysiology, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China.
| | - Fengyuan Che
- Department of Neurology, The Eleventh Clinical Medical College of Qingdao University, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China. .,Central Laboratory, Linyi Key Laboratory of Neurophysiology, Linyi People's Hospital, 27 East Section of Jiefang Road Lanshan District, Linyi, 276000, Shandong, China.
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Fujino Y, Saito K, Maezono K, Kasai T, Mizuno T. [A case of hypertrophic pachymeningitis associated with probable sarcoidosis with increased serum IgG4]. Rinsho Shinkeigaku 2019; 59:436-441. [PMID: 31243250 DOI: 10.5692/clinicalneurol.cn-001275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We report a 54-year-old man, who presented with an acute onset of diplopia and ptosis on the left side. On admission, neurological examination showed left oculomotor and abducens nerve palsy. Brain MRI showed thickening of the left parieto-temporal dura mater with gadolinium enhancement. Whole-body CT revealed a mass lesion in the right submandibular gland, diffuse goiter, and bilateral hilar lymph node enlargement. Initially, IgG4-related disease was considered because of an elevated serum IgG4 level (240 mg/dl); however, biopsy of the submandibular gland showed non-caseating epithelioid cell granulomas that suggested sarcoidosis, which could be associated with the intracranial lesions causing his neurological manifestation. In cases of hypertrophic pachymeningitis, especially with increased serum IgG4 including our case, a careful assessment with pathological examination is critical for identifying various underlying conditions.
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Affiliation(s)
- Yuzo Fujino
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kozo Saito
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Keiko Maezono
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takashi Kasai
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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McGilvray T, Berner D, Beltran E, Attipa C, Dunkel B. Transient bilateral blindness associated with presumptive idiopathic pachymeningitis in a 22‐year‐old Irish Sport Horse. EQUINE VET EDUC 2019. [DOI: 10.1111/eve.13147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- T. McGilvray
- Department of Clinical Science and Services The Royal Veterinary College North Mymms, Hatfield Hertfordshire UK
| | - D. Berner
- Department of Clinical Science and Services The Royal Veterinary College North Mymms, Hatfield Hertfordshire UK
| | - E. Beltran
- Department of Clinical Science and Services The Royal Veterinary College North Mymms, Hatfield Hertfordshire UK
| | - C. Attipa
- Department of Clinical Science and Services The Royal Veterinary College North Mymms, Hatfield Hertfordshire UK
| | - B. Dunkel
- Department of Clinical Science and Services The Royal Veterinary College North Mymms, Hatfield Hertfordshire UK
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35
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Wong VC, Yung G, Russo R, Reddel SW, Mansberg R. Pachymeningitis Demonstrated on Gallium SPECT/CT Scan. Clin Nucl Med 2019; 44:305-309. [PMID: 30762818 DOI: 10.1097/rlu.0000000000002484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 34-year-old woman presented with a 3-month history of right-sided headaches associated with photophobia and pulsatile tinnitus. Investigations including lumbar puncture revealed elevated opening CSF pressure, increased protein, and presence of monocytosis consistent with an inflammatory/infective process. Brain MRI showed an area of thickened enhancing dura around the venous sinus posteriorly. Ga scintigraphy demonstrated focal intracranial uptake in the posterior occipital region, and biopsy confirmed a chronic inflammatory infiltrate with no granulomas.
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36
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Zhang X, Fujii T, Ogata H, Yamasaki R, Masaki K, Cui Y, Matsushita T, Isobe N, Kira JI. Cerebrospinal fluid cytokine/chemokine/growth factor profiles in idiopathic hypertrophic pachymeningitis. J Neuroimmunol 2019; 330:38-43. [PMID: 30784775 DOI: 10.1016/j.jneuroim.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurologic disease causing inflammatory fibrous thickening of the brain and spinal dura mater. We investigated the cerebrospinal fluid cytokine profile of HP by measuring 28 cytokines/chemokines/growth factors with a multiplexed fluorescent immunoassay in 8 patients with HP (6 idiopathic, 1 IgG4-related, 1 anti-neutrophil cytoplasmic antibody-related), and 11 with other non-inflammatory neurologic diseases (OND). Interleukin (IL)-4, IL-5, IL-9, IL-10, TNF-α, and CXCL8/IL-8 levels were significantly higher in idiopathic HP (IHP) than OND. Cluster analyses disclosed two major clusters: one mainly consisted of IHP and the other of OND, suggesting a unique cytokine profile in IHP.
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Affiliation(s)
- Xu Zhang
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China. shu-@neuro.med.kyushu-u.ac.jp
| | - Takayuki Fujii
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Katsuhisa Masaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yiwen Cui
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noriko Isobe
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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37
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Kosumi Y, Nakamura H, Watanabe R, Watanabe T, Horita T. Glossopharyngeal/vagus nerve disorder due to IgG4-related hypertrophic pachymeningitis. Rheumatology (Oxford) 2019; 58:5304552. [PMID: 30715454 DOI: 10.1093/rheumatology/kez009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yui Kosumi
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | - Hiroyuki Nakamura
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | - Ryosuke Watanabe
- Department of Otolaryngology, Tomakomai City Hospital, Tomakomai, Japan
| | - Toshiyuki Watanabe
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | - Tetsuya Horita
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
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38
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Jeffery DT, Kelly HR. IgG4-Related Disease in the Head and Neck. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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39
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Winkel M, Lawton CD, Sanusi OR, Horbinski CM, Dahdaleh NS, Smith ZA. Neuro-surgical considerations for treating IgG4-related disease with rare spinal epidural compression. Surg Neurol Int 2018; 9:209. [PMID: 30488007 PMCID: PMC6213809 DOI: 10.4103/sni.sni_156_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a group of distinct autoimmune disorders affecting nearly every organ system in the body. Although central nervous system involvement is quite rare, it may present as hypertrophic pachymeningitis more frequently affecting the brain than the spine. In this study, we provide a case of spinal IgG4-RD pseudotumor resulting in cord compression, and a comprehensive review of the literature. Case Description: A patient presented with an extradural mass causing spinal cord compression at the L2-L3 level. Pathologically this proved to be an IgG4-RD pseudotumor. The patient was treated with thecal sac decompression and post-operative steroids that resulted in complete resolution of his symptoms. Conclusion: IgG4-RD is typically under-recognized and under-reported in the spinal literature. The clinical spinal presentation and non-surgical vs. surgical treatment are relatively straightforward. Although most cases can be managed with a course of steroids, surgical decompression may be required in patients presenting with spinal cord and/or nerve root compression. The differential diagnoses for these spinal tumors or pseudotumors should include IgG4-RD. Early detection and appropriate treatment can lead to satisfactory outcomes.
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Affiliation(s)
- Maia Winkel
- Department of Neurological Surgery, Chicago Medical School At Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Cort D Lawton
- Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Olabisi R Sanusi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Craig M Horbinski
- Department of Neurological Surgery and Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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40
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Boisch G, Duda S, Hartmann C, Weßling H. Hypertrophic pachymeningoencephalitis associated with temporal giant cell arteritis. BMJ Case Rep 2018; 2018:bcr-2018-225304. [PMID: 30262524 DOI: 10.1136/bcr-2018-225304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report the rare case of an 80-year-old male patient with hypertrophic pachymeningoencephalitis that may be associated with temporal arteritis. The patient presented to our neurological department with a 2-week history of latent paresis and ataxia affecting his right hand. He had been diagnosed with temporal arteritis 12 years earlier. Brain MRI showed an enhancement of the left-sided frontoparietal meninges with oedema of the adjacent tissue of the precentral and postcentral cortex. A leptomeningeal biopsy was performed. An autoimmune-mediated immunoglobulin G4-associated hypertrophic pachymeningoencephalitis was diagnosed. The patient received a high-dose corticosteroid therapy and his symptoms gradually improved. Our results suggest that hypertrophic pachymeningoencephalitis may occur as a complication of giant cell arteritis and may cause central neurological deficits by cerebral perifocal oedema.
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Affiliation(s)
- Gesine Boisch
- Department of Neurology, Ammerland Klinik GmbH, Westerstede, Germany
| | - Sven Duda
- Department of Neurosurgery, Bundeswehrkrankenhaus Westerstede, Westerstede, Germany
| | - Christian Hartmann
- Department of Neuropathology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Heinrich Weßling
- Department of Neurosurgery, Bundeswehrkrankenhaus Westerstede, Westerstede, Germany
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41
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Mekinian A, Maisonobe L, Boukari L, Melenotte C, Terrier B, Ayrignac X, Scheinlitz N, Sène D, Hamidou M, Konaté A, Guilpain P, Abisror N, Ghrenassia E, Lachenal F, Cevallos R, Roos-Weil R, Du LTH, Lhote F, Larroche C, Bergmann JF, Humbert S, Fraison JB, Piette JC, Guillevin L, Dhote R, Amoura Z, Haroche J, Fain O. Characteristics, outcome and treatments with cranial pachymeningitis: A multicenter French retrospective study of 60 patients. Medicine (Baltimore) 2018; 97:e11413. [PMID: 30045263 PMCID: PMC6078725 DOI: 10.1097/md.0000000000011413] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to determine the characteristics, treatment, and outcome according to each etiology of pachymeningitis.We conducted a retrospective multicenter French nationwide study between 2000 and 2016 to describe the characteristics, outcome, and treatment of pachymeningitis.We included 60 patients (median age 55.5 years; interquartile range [IQR] 30-80, female/male ratio 0.43). Neurologic signs were present in 59 patients (98%) and consisted of headache in 43 (72%), cranial nerve palsy in 33 (55%), confusion in 10 (17%), seizures in 7 (12%), and focal neurologic signs in 9 (15%). Fever and weight loss were present in 8 (13%) and 13 cases (22%), respectively. Cerebral venous thrombosis was present in 8 cases (13%). Analysis of cerebrospinal fluid showed moderate hyperproteinorachia (median 0.68 g/L; IQR 0.46-3.2) with or without pleiocytosis. Diagnosis included idiopathic pachymeningitis (n = 18; 30%); granulomatosis with polyangiitis (n = 13; 17%); Erdheim-Chester disease (n = 10; 17%); IgG4-related disease and tuberculosis (n = 3; 5% each); Rosai-Dofman disease, microscopic polyangiitis, and sarcoidosis (n = 2, 3% each); cryptococcal meningitis, Lyme disease, ear-nose-throat infection, postlumbar puncture, low spinal-fluid pressure syndrome, and lymphoma (n = 1 each). We found no difference in demographics and neurologic presentation among idiopathic pachymeningitis, Erdheim-Chester disease, and granulomatosis with polyangiitis. In contrast, frequencies were lower with idiopathic pachymeningitis than Erdheim-Chester disease for general signs (6% and 40%, respectively, P = .041) and complete neurologic response (0% vs 39%, P = .045).The detection of extraneurologic signs and routine screening are needed to classify the pachymeningitis origin. Prospective studies are warranted to determine the best treatment in each case.
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Affiliation(s)
- Arsene Mekinian
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris
| | - Lucas Maisonobe
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris
| | | | - Cléa Melenotte
- Département de Médecine Interne, CHU de la Timone, Aix-Marseille Université, AP-HM, Marseille
| | - Benjamin Terrier
- Université Paris Descartes, Paris
- AP-HP, Hôpital Cochin, Centre de Référence des Maladies Auto-immunes et Systémiques Rares, Service de Médecine Interne, Paris
| | - Xavier Ayrignac
- Département de Neurologie, Hôpital Gui de Chauliac, CHU de Montpellier
| | - Nicolas Scheinlitz
- Département de Médecine Interne, CHU de la Timone, Aix-Marseille Université, AP-HM, Marseille
| | - Damien Sène
- Département de Médecine Interne, GH Saint-Louis Lariboisière Fernand Widal
- Université Paris Diderot, Paris
| | | | - Amadou Konaté
- Service de Médecine Interne et Vasculaire, CHU Montpellier, Montpellier
| | - Philippe Guilpain
- Service de Médecine Interne et Vasculaire, CHU Montpellier, Montpellier
| | - Noémie Abisror
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris
| | - Etienne Ghrenassia
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris
| | | | - Ramiro Cevallos
- Service de Médecine Interne, Clinique Sainte Anne, rue Philippe Thyss, Strasbourg
| | | | - Le Thi Huong Du
- Service de Médecine Interne, Hôpital Pitié Salpetrière, Université Paris, APHP, Paris
- Université Pierre et Marie Curie, Paris, UPMC
- Centre National de Référence des Maladies Auto-immunes et Systémiques Rares
| | - Francois Lhote
- Service de Médecine Interne, Hôpital Delafontaine, Saint Denis
| | - Claire Larroche
- Service de Médecine Interne, Université Paris, AP-HP, Avicenne, Bobigny
| | - Jean-Francois Bergmann
- Département de Médecine Interne, GH Saint-Louis Lariboisière Fernand Widal
- Université Paris Diderot, Paris
| | | | - Jean Baptiste Fraison
- Université Paris Descartes, Paris
- AP-HP, Hôpital Cochin, Centre de Référence des Maladies Auto-immunes et Systémiques Rares, Service de Médecine Interne, Paris
| | - Jean Charles Piette
- Service de Médecine Interne, Hôpital Pitié Salpetrière, Université Paris, APHP, Paris, France
| | - Loïc Guillevin
- Université Paris Descartes, Paris
- AP-HP, Hôpital Cochin, Centre de Référence des Maladies Auto-immunes et Systémiques Rares, Service de Médecine Interne, Paris
| | - Robin Dhote
- Service de Médecine Interne, Université Paris, AP-HP, Avicenne, Bobigny
| | - Zahir Amoura
- Service de Médecine Interne, Hôpital Pitié Salpetrière, Université Paris, APHP, Paris
- Université Pierre et Marie Curie, Paris, UPMC
- Centre National de Référence des Maladies Auto-immunes et Systémiques Rares
| | - Julien Haroche
- Service de Médecine Interne, Hôpital Pitié Salpetrière, Université Paris, APHP, Paris
- Université Pierre et Marie Curie, Paris, UPMC
- Centre National de Référence des Maladies Auto-immunes et Systémiques Rares
| | - Olivier Fain
- AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris
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Boban J, Ardalı S, Thurnher MM. Leptomeningeal form of Immunoglobulin G4-related hypertrophic meningitis with perivascular spread: a case report and review of the literature. Neuroradiology 2018; 60:769-773. [PMID: 29736618 PMCID: PMC5995998 DOI: 10.1007/s00234-018-2028-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/24/2018] [Indexed: 12/24/2022]
Abstract
Purpose Immunoglobulin G4 (IgG4)-related disease represents a spectrum of fibro-inflammatory disorders that affects various organ systems, including the central nervous system. Methods Here we present the case of lgG4-related hypertrophic meningitis with exclusively leptomeningeal involvement and spread via perivascular spaces. Results A 58-year-old male patient presented with complex partial seizures. Initial computed tomography examination showed left frontal sulcal hyperdensity. Subsequent magnetic resonance examination revealed FLAIR hyperintensity in the central sulcus, with post-contrast enhancement in the form of “dotted line.” Physical examination, routine laboratory, and cerebrospinal fluid analyses were unremarkable. Meningeal biopsy confirmed IgG4-related meningitis. After corticosteroid treatment, a complete resolution of imaging findings was observed. Two months later, the patient presented with relapsing neurological symptoms and radiological findings in postcentral, precentral, and temporal sulci, resembling the form of “dotted line” contrast enhancement. In addition, linear intraparenchymal enhancement that followed perivascular spaces was seen in the left parietal lobe. After repeated steroid therapy, all lesions resolved completely. Conclusion We reported the first case of isolated IgG4-related leptomeningeal involvement with a “dotted line” enhancement and perivascular intraparenchymal spread. Although IgG4-related meningitis represents a rare disease, both clinicians and radiologists should include this condition in the differential diagnosis of unclear leptomeningeal disease.
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Affiliation(s)
- Jasmina Boban
- Faculty of Medicine, Department for Radiology, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Selin Ardalı
- Department of Radiology, Hacettepe University Faculty of Medicine, Sıhhiye, 06100, Ankara, Turkey
| | - Majda M Thurnher
- Section of Neuroradiology and Musculoskeletal Radiology, Department for Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Varrassi M, Gianneramo C, Arrigoni F, Cerrone P, Sucapane P, Marini C, Splendiani A. Neurological involvement of IgG4-related disease: description of a case and review of the literature. Neuroradiol J 2018; 31:196-202. [PMID: 28423973 PMCID: PMC5882050 DOI: 10.1177/1971400917698173] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IgG4-related disease is a recently discovered pathological entity, histologically characterised by fibrosis and IgG4-positive plasma cell infiltration. This condition may virtually involve every site of the organism, with a various range of clinical presentations. The most commonly affected organ is the pancreatic gland, but it can also involve the biliary tract, salivary and lacrimal glands, kidneys, orbital tissues, lymph nodes, lungs and many others. More recently, IgG4-related disease has been demonstrated to involve, in rare cases, also the central nervous system, with a pattern mainly characterised by hypertrophic pachymeningitis. In this paper we evaluated the clinical and magnetic resonance imaging features of the IgG4-related disease in the central nervous system, reporting a case of brain and spinal cord involvement. In our case, in fact, a 62-year-old man complaining of paresthesia, burning dysesthesia and severe hyposthenia in the lower limbs presented with inflammatory pseudotumour with orbital involvement and focal dural and spinal root thickening.
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Affiliation(s)
- Marco Varrassi
- Radiology Department, S. Salvatore Hospital, L'Aquila, Italy
| | - Camilla Gianneramo
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Paolo Cerrone
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Carmine Marini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alessandra Splendiani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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IgG4-related hypertrophic pachymeningitis of the spine with MPO-ANCA seropositivity. Clin Imaging 2017; 46:108-112. [DOI: 10.1016/j.clinimag.2017.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/24/2022]
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Huang K, Xu Q, Ma Y, Zhan R, Shen J, Pan J. Cerebral Venous Sinus Thrombosis Secondary to Idiopathic Hypertrophic Cranial Pachymeningitis: Case Report and Review of Literature. World Neurosurg 2017; 106:1052.e13-1052.e21. [PMID: 28711538 DOI: 10.1016/j.wneu.2017.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/24/2022]
Abstract
BACKGOUND AND IMPORTANCE Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare fibrosing inflammatory process involving the dura mater. Currently, there is no consensus on the treatments for IHCP, and the usefulness of immunosuppressive agents as a first-line option remains controversial. Cerebral venous sinus occlusion (CVSO) and cerebral venous sinus thrombosis (CVST) secondary to IHCP, which may cause progressive intracranial hypertension and venous obstructive parenchymal lesions, make the diagnosis and treatment of IHCP more complicated. METHODS We present a case of IHCP. We also review previous cases of IHCP with secondary CVSO/CVST and then summarize the clinical characteristics of these patients. CLINICAL PRESENTATION A 52-year-old female patient with IHCP developed secondary CVST. She had a severe headache with a hyperintense lesion on computed tomography, which was considered as subarachnoid hemorrhage. Lumbar tapping with a cerebrospinal fluid test, in addition to gadolinium contrast-enhanced magnetic resonance imaging, suggested IHCP. Secondary CVST was identified by digital subtraction angiography and magnetic resonance venography. Fatal intracranial hypertension with severe neurologic deficits occurred, despite mannitol, furosemide, and corticoid therapy. After administration of intravenous pulse cyclophosphamide, she obtained complete remission. CONCLUSIONS We experienced a patient with CVST secondary to IHCP, who was successfully treated with cyclophosphamide pulse therapy. Because IHCP with secondary venous obstruction has various differential diagnoses, venography is necessary to avoid misdiagnosis. The use of immunosuppressive agents may be promising but needs further verification.
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Affiliation(s)
- Kaiyuan Huang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Qingsheng Xu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yuankun Ma
- Department of Cardiology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Renya Zhan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Jian Shen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.
| | - Jianwei Pan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
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Baptista B, Casian A, Gunawardena H, D'Cruz D, Rice CM. Neurological Manifestations of IgG4-Related Disease. Curr Treat Options Neurol 2017; 19:14. [PMID: 28374231 PMCID: PMC5378735 DOI: 10.1007/s11940-017-0450-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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