1
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Richter JE, Rourk KS, Stewart MW, Raymond MJ. Fatal Presentation of Susac Syndrome in a Congenitally Deaf Patient With a Cochlear Implant. Otol Neurotol 2024; 45:e468-e471. [PMID: 38865723 DOI: 10.1097/mao.0000000000004201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To report a fatal case of Susac syndrome in a congenitally deaf patient with a cochlear implant and a history of migraines, emphasizing the diagnostic challenges in patients with preexisting conditions. PATIENT A 33-year-old male with congenital hearing loss, a cochlear implant, and chronic migraines who presented with mild subacute auditory disturbance and headaches that later progressed to severe encephalopathy. INTERVENTION Explantation of a non-magnetic resonance imaging (MRI) compatible cochlear implant followed by MRI, fundoscopy, and the administration of immunosuppressive medications. MAIN OUTCOME MEASURES Diagnosis was confirmed by characteristic MRI appearance and the presence of a hemi-retinal artery occlusion. RESULTS After weeks of immunosuppressive treatment, the patient died of a global cerebral ischemic event of unknown origin. CONCLUSIONS For patients with preexisting sensorineural hearing loss and cochlear implants, Susac syndrome poses a diagnostic challenge. Auditory disturbances in the absence of cochlear implant failure should prompt further evaluation for visual disturbances and encephalopathy. MRI and fundoscopy should be performed to detect other features of the disease.
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Affiliation(s)
- John E Richter
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | | | - Michael W Stewart
- Mayo Clinic Florida, Department of Ophthalmology, Jacksonville, Florida
| | - Mallory J Raymond
- Mayo Clinic Florida, Department of Otolaryngology-Head and Neck Surgery, Jacksonville, Florida
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2
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Cviková M, Štefela J, Všianský V, Dufek M, Doležalová I, Vinklárek J, Herzig R, Zemanová M, Červeňák V, Brichta J, Bárková V, Kouřil D, Aulický P, Filip P, Weiss V. Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature. Front Neurol 2024; 15:1339438. [PMID: 38434197 PMCID: PMC10904644 DOI: 10.3389/fneur.2024.1339438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.
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Affiliation(s)
- Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jakub Štefela
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vít Všianský
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Michal Dufek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jan Vinklárek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czechia
| | - Markéta Zemanová
- Department of Ophthalmology and Optometry, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vladimír Červeňák
- Department of Medical Imaging, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Brichta
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Veronika Bárková
- Department of Clinical Pharmacology, St. Anne's University Hospital, Brno, Czechia
| | - David Kouřil
- Department of Neurology, Blansko Hospital, Blansko, Czechia
| | - Petr Aulický
- Department of Anesthesiology, Hospital of the Brothers of Charity Brno, Brno, Czechia
| | - Pavel Filip
- Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czechia
- Center for Magnetic Resonance Research (CMRR), University of Minnesota, Minneapolis, MN, United States
| | - Viktor Weiss
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
- Department of Neurology, Charles University Faculty of Medicine, Hradec Králové, Czechia
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3
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Plantone D, Sabatelli E, Locci S, Marrodan M, Laakso SM, Mateen FJ, Feresiadou A, Buelens T, Bianco A, Fiol MP, Correale J, Tienari P, Calabresi P, De Stefano N, Iorio R. Clinically relevant increases in serum neurofilament light chain and glial fibrillary acidic protein in patients with Susac syndrome. Eur J Neurol 2023; 30:3256-3264. [PMID: 37335505 DOI: 10.1111/ene.15939] [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: 04/18/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND PURPOSE Serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising neuro-axonal damage and astrocytic activation biomarkers. Susac syndrome (SS) is an increasingly recognized neurological condition and biomarkers that can help assess and monitor disease evolution are highly needed for the adequate management of these patients. sNfL and sGFAP levels were evaluated in patients with SS and their clinical relevance in the relapse and remission phase of the disease was assessed. METHODS As part of a multicentre study that enrolled patients diagnosed with SS from six international centres, sNfL and sGFAP levels were assessed in 22 SS patients (nine during a relapse and 13 in remission) and 59 age- and sex-matched healthy controls using SimoaTM assay Neurology 2-Plex B Kit. RESULTS Serum NfL levels were higher than those of healthy controls (p < 0.001) in SS patients and in both subgroups of patients in relapse and in remission (p < 0.001 for both), with significantly higher levels in relapse than in remission (p = 0.008). sNfL levels showed a negative correlation with time from the last relapse (r = -0.663; p = 0.001). sGFAP levels were slightly higher in the whole group of patients than in healthy controls (p = 0.046) and were more pronounced in relapse than in remission (p = 0.013). CONCLUSION In SS patients, both sNFL and sGFAP levels increased compared with healthy controls. Both biomarkers had higher levels during clinical relapse and much lower levels in remission. sNFL was shown to be time sensitive to clinical changes and can be useful to monitor neuro-axonal damage in SS.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Eleonora Sabatelli
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | - Sara Locci
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Sini M Laakso
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amalia Feresiadou
- Department of Neurology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Section of Neurology, Uppsala University, Uppsala, Sweden
| | - Tom Buelens
- Department of Ophthalmology, CHU St Pierre and Brugmann, Brussels, Belgium
| | - Assunta Bianco
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | | | - Jorge Correale
- Neurology Department, Fleni, Buenos Aires, Argentina
- Institute of Biological Chemistry and Biophysics (IQUIFIB) CONICET, University of Buenos Aires, Buenos Aires, Argentina
| | - Pentti Tienari
- Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Research Program of Translational Immunology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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4
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Cardozo P, Marrodán M, Gilmore A, Fiol MP, Chaves H. Leptomeningeal Interfoliar Enhancement on Vessel Wall MR Imaging as a Unique Radiologic Finding of Susac Syndrome. AJNR Am J Neuroradiol 2023; 44:271-273. [PMID: 36797034 PMCID: PMC10187801 DOI: 10.3174/ajnr.a7801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
Susac syndrome is a rare disorder affecting the brain, retina, and inner ear, probably triggered by an immune-mediated endotheliopathy. Diagnosis is based on clinical presentation and ancillary test findings (brain MR imaging, fluorescein angiography, and audiometry). Recently, vessel wall MR imaging has shown increased sensitivity in the detection of subtle signs of parenchymal, leptomeningeal, and vestibulocochlear enhancement. In this report, we describe a unique finding identified using this technique in a series of 6 patients with Susac syndrome and discuss its potential value for diagnostic work-up and follow-up.
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Affiliation(s)
- P Cardozo
- From the Diagnostic Imaging Department (P.C., A.G., H.C.)
| | - M Marrodán
- Neurology Departments (M.M., M.P.F.), Fleni, Buenos Aires, Argentina
| | - A Gilmore
- From the Diagnostic Imaging Department (P.C., A.G., H.C.)
| | - M P Fiol
- Neurology Departments (M.M., M.P.F.), Fleni, Buenos Aires, Argentina
| | - H Chaves
- From the Diagnostic Imaging Department (P.C., A.G., H.C.)
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5
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Ahmed S, Khan TA, Liaqat T, Ijaz U, Sarfaraz H. A young soldier with Susac syndrome: a case report. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Susac syndrome is a rare disease with multisystem manifestations. While the exact pathogenesis is not known, it has been proposed to be an autoimmune endotheliopathy affecting the microvasculature of the brain, retina, and inner ear. The disease is characterized by a triad of encephalopathy, vision loss, and hearing loss. However, patients may not have the triad at initial presentation and present with only a single finding.
Case presentation
A 25-year-old male resident of Panu Akil presented to Combined Military Hospital Lahore with complaints of dizziness and vertigo associated with severe migraine like headaches. He experienced sudden painless loss of vision in his right eye and was admitted to the medical intensive care unit. On examination, he had right-beating nystagmus and diplopia along with scintillating scotoma. After his admission, contrast-enhanced magnetic resonance imaging (MRI) was done which showed numerous enhancing bilateral white matter internal capsule micro-infarcts indicating typical “string of pearls” sign and a snowball lesion on the corpus callosum. His fundus fluorescein angiography (FFA) did not exhibit any branched retinal artery occlusions (BRAO). Fundoscopy showed the presence of drusen spots. His pure tone audiometry was unremarkable. Based on the highly characteristic findings present on the MRI, a diagnosis of Susac syndrome was made. He was started on injection methylprednisolone 1 gm IV in 500 ml normal saline over 1 h once a day for 5 days and then once a week for 8 weeks. He was also started on tablet mycophenolate mofetil 500 mg once daily for 7 days. Patient showed marked clinical improvement afterwards.
Conclusions
Susac syndrome is a rare multisystem illness with an often insidious presentation. Patients can be misdiagnosed due to the nonspecific nature of the early complaints present in the disease. High index of suspicion is required for timely diagnosis and adequate management. Although no specific guidelines exist, management consists mainly of immunosuppressants.
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6
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Susac Syndrome: Description of a Single-Centre Case Series. J Clin Med 2022; 11:jcm11216549. [PMID: 36362776 PMCID: PMC9656090 DOI: 10.3390/jcm11216549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
This study describes the clinical characteristics, diagnostic results, treatment regimens, and clinical course of a cohort of patients with Susac syndrome (SS). It is a retrospective observational study of all patients with the diagnosis of SS evaluated at the Hospital Clinic (Barcelona, Spain) between March 2006 and November 2020. Nine patients were diagnosed with SS. The median time from the onset of the symptoms to diagnosis was five months (IQR 9.0), and the median follow-up time was 44 months (IQR 63.5). There was no clear predominance of sex, and mean age of symptoms onset was 36 years (range 19–59). Six patients (67%) presented with incomplete classical clinical triad, but this eventually developed in six patients during the disease course. Encephalopathy, focal neurological signs, visual disturbances, and hearing loss were the most frequent manifestations. Brain magnetic resonance imaging showed callosal lesions in all patients. Most were in remission within two years. Only four patients met the proposed criteria for definite SS. When SS is suspected, a detailed diagnostic workup should be performed and repeated over time to identify the clinical manifestations that will lead to a definite diagnosis.
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7
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Characteristics and management of Susac syndrome in an emergent country: a multi-center case series from Brazil. Neurol Sci 2022; 43:6449-6460. [DOI: 10.1007/s10072-022-06320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 07/31/2022] [Indexed: 10/15/2022]
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8
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Srichawla BS. Susac Syndrome With Livedo Reticularis: Pathogenesis and Literature Review. Cureus 2022; 14:e27352. [PMID: 36046280 PMCID: PMC9417326 DOI: 10.7759/cureus.27352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 12/26/2022] Open
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9
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Barbero P, Vecchio D, Virgilio E, Naldi P, Comi C, Cantello R. Susac Syndrome: an uncommon cause of impaired vision. Neurol Sci 2022; 43:3919-3922. [PMID: 35006444 PMCID: PMC9119872 DOI: 10.1007/s10072-022-05865-8] [Citation(s) in RCA: 2] [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] [Received: 10/12/2021] [Accepted: 12/30/2021] [Indexed: 11/25/2022]
Abstract
A 35-year-old Caucasian woman presented an abrupt onset of bilateral impaired vision, and arrived to our attention two weeks later. She had a previous episode of mild dizziness. She underwent a fluorescein angiography showing branch retinal artery occlusions and a brain magnetic resonance imaging (MRI) revealing several supraand infratentorial FLAIR-hyperintense white matter lesions, two with contrast enhancement. Thrombophilic, autoimmune and infective (including Human Immunodeficiency Virus, Borrelia burgdorferi, Hepatitis B Virus, Hepatitis C Virus, Herpes Simplex Virus 1-2, Varicella Zoster Virus) screening was negative. Cerebrospinal fluid analysis showed intrathecal IgG synthesis. We suspected a Primary Central Nervous System Vasculitis, and intravenous steroids were started. Three months later a second brain MRI showed seven new lesions without contrast enhancement, and she revealed a cognitive impairment and bilateral hearing loss. Reviewing the clinical history and MRI, she fulfilled diagnostic criteria for Susac syndrome. She had two cycles of cyclophosphamide, and recovered in 6 months and then remained stable with metotrexate.
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Affiliation(s)
- Paolo Barbero
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy.
| | - Domizia Vecchio
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Eleonora Virgilio
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Neurology Unit, S. Andrea Hospital, Department of Translational Medicine, University of Piemonte Orientale, Vercelli, Italy
| | - Paola Naldi
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
| | - Cristoforo Comi
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
- Neurology Unit, S. Andrea Hospital, Department of Translational Medicine, University of Piemonte Orientale, Vercelli, Italy
| | - Roberto Cantello
- Neurology Unit, Maggiore Della Carità Hospital, Department of Translational Medicine, University of Piemonte Orientale, Ospedale Maggiore Della Carità, via Mazzini 18, Novara, Italy
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10
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Hoogewoud F, Kawasaki A, Borruat FX, Guex-Crosier Y. Susac Syndrome: A Case Series. Klin Monbl Augenheilkd 2022; 239:518-522. [PMID: 35472796 DOI: 10.1055/a-1766-6243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Susac syndrome (SS) is an autoimmune disorder that involves the eyes, the brain, and the ears. It is a rare cause of recurrent branch retinal artery occlusion. The purpose of this study was to report cases of SS, highlighting the clinical presentations, therapeutic options, and their outcome. PATIENTS AND METHODS Retrospective case series of patients seen at our institution for SS between 2005 and 2020. Demographics, clinical characteristics, treatment, and outcome were studied. RESULTS Four patients (3 females, mean age 29 years old) were included in the study. According to the recently revised diagnostic criteria, three patients had definite and one patient had probable SS (distinctive ophthalmological and brain involvement without ear involvement). Initial visual acuity (VA) was normal in all eyes, but two patients had unilateral visual field impairment. Gass plaques (defined as yellow-white plaques found in the arteriolar wall away from arterial bifurcations) were observed on fundus examination in all patients. Fluorescein angiography revealed arteriolar wall hyperfluorescence and branch retinal arterial occlusions (BRAOs) in the absence of other signs of intraocular inflammation in all patients. Initial treatment consisted of a high-dose corticosteroid (intravenous or oral) with additional immunosuppressive therapy (azathioprine, intravenous immunoglobulins, mycophenolate mofetil, and/or cyclophosphamide). Residual symptoms were present in all patients and included scotoma (n = 2) and hearing loss (n = 3). CONCLUSION SS is a rare disease with characteristic ophthalmological manifestation. The majority of patients present a crude form of the triad, and retinal findings may be the first initial manifestation. Ophthalmologists should consider the possibility of an SS in all young patients presenting with BRAOs.
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Affiliation(s)
- Florence Hoogewoud
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | - Aki Kawasaki
- Neuro-ophtalmology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | | | - Yan Guex-Crosier
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
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11
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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12
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Triplett JD, Qiu J, O'Brien B, Gopinath S, Trewin B, Spring PJ, Shaffi M, Ip J, Chan F, Chen L, Wilson I, Muller C, Beadnall HN, Boggild M, Van der Walt A, Roxburgh R, Seery N, Kalincik T, Barnett MH, Parratt JDE, Reddel SW, Tsang B, Hardy TA. Diagnosis, differential diagnosis and misdiagnosis of Susac syndrome. Eur J Neurol 2022; 29:1771-1781. [PMID: 35262238 PMCID: PMC9314104 DOI: 10.1111/ene.15317] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 11/28/2022]
Abstract
Background and purpose Susac syndrome (SuS) is an inflammatory condition of the brain, eye and ear. Diagnosis can be challenging, and misdiagnosis is common. Methods This is a retrospective review of the medical records of 32 adult patients from an Australasian cohort of SuS patients. Results An alternative diagnosis prior to SuS was made in 30 patients (94%) with seven patients receiving two or more diagnoses. The median time to diagnosis of SuS was 3 months (range 0.5–100 months). The commonest misdiagnoses were migraine in 10 patients (31%), cerebral vasculitis in six (19%), multiple sclerosis in five (16%) and stroke in five (16%). Twenty‐two patients were treated for alternative diagnoses, 10 of whom had further clinical manifestations prior to SuS diagnosis. At presentation seven patients (22%) met criteria for definite SuS, 19 (59%) for probable SuS and six (19%) for possible SuS. Six patients (19%) presented with brain–eye–ear involvement, 14 with brain–ear (44%), six with brain–eye (19%) and six (19%) with only brain involvement. In patients with the complete triad of symptoms the median delay to diagnosis was 3 months (range 1–9 months) compared to 5.25 months (range 0.5–100 months) for patients with encephalopathy and ocular symptoms at presentation. Conclusions Susac syndrome patients are frequently misdiagnosed at initial presentation, despite many having symptoms or radiological features that are red flags for the diagnosis. Delayed diagnosis can lead to patient morbidity. The varied ways in which SuS can present, and clinician failure to consider or recognize SuS, appear to be the main factors leading to misdiagnosis.
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Affiliation(s)
- James D Triplett
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Jessica Qiu
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Sumana Gopinath
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Benjamin Trewin
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Penelope J Spring
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | | | - Jerome Ip
- Section of Neurology, Sydney Adventist Hospital, Sydney, NSW, Australia
| | - Fiona Chan
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Luke Chen
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Ian Wilson
- Department of Neurology, Cairns Hospital, Cairns, Qld, Australia
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Heidi N Beadnall
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mike Boggild
- Department of Neurology, Townsville Hospital, Townsville, Qld, Australia
| | - Anneke Van der Walt
- Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Richard Roxburgh
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Nabil Seery
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
| | - Tomas Kalincik
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michael H Barnett
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John D E Parratt
- Department of Neurology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Benjamin Tsang
- Department of Neurology, Sunshine Coast Hospital, Sunshine Coast, Qld, Australia
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia.,Brain & Mind Centre, University of Sydney, NSW, Australia
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13
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OUP accepted manuscript. Brain 2022; 145:858-871. [DOI: 10.1093/brain/awab476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
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14
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Sudden onset hearing loss as initial presentation of Susac syndrome: a rare case report and brief review. Neurol Sci 2021; 43:683-686. [PMID: 34480640 DOI: 10.1007/s10072-021-05581-9] [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: 05/01/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
Susac syndrome is a rare disease presenting with a classic triad of symptoms. These are sensorineural hearing loss, encephalopathy, and branch retinal artery occlusions. Initial presentation is usually headache and symptoms of encephalopathy. Hearing loss is unusual in the early stages but, when it does present, can often lead to a misdiagnosis of sudden sensorineural hearing loss. Hence, neurological and retinal examinations are essential to an accurate diagnosis. In this study, we aimed to raise awareness of Susac syndrome among physicians and facilitate recognition of its manifestation, especially in those patients presenting with hearing loss alone. Identifying Susac syndrome that presents as sudden sensorineural hearing loss can be challenging but a number of case reviews have been reported in recent years and treatment guidelines are available.
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15
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Yalçınkaya BÇ, Ertürk Çetin Ö, Kılıç H, Demirci O, Çokyaman T, Uygunoğlu U. A rare presentation of Susac syndrome: Report of three pediatric cases. Mult Scler Relat Disord 2021; 53:103074. [PMID: 34139460 DOI: 10.1016/j.msard.2021.103074] [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: 03/01/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/25/2022]
Abstract
Susac syndrome is a rare disorder that is clinically characterized by encephalopathy, retinopathy and hearing loss. Most of the reported cases in the literature are adult patients, pediatric presentation is extremely rare. Here we present three pediatric patients aged between 10-15; diagnosed as Susac syndrome. They all had thalamic involvement in addition to typical callosal lesions. All of the three patients had a monophasic course and good treatment response.
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Affiliation(s)
| | - Özdem Ertürk Çetin
- University of Health Sciences, Sancaktepe Sehit Prof.Dr.Ilhan Varank Training and Research Hospital, Department of Neurology, Istanbul, Turkey.
| | - Hüseyin Kılıç
- Istanbul University-Cerrahpasa; Department of Pediatrics, Division of Pediatric Neurology, Istanbul, Turkey.
| | - Onat Demirci
- Vehbi Koc Foundation, American Hospital, Department of Neurology, Sisli, Turkey.
| | - Turgay Çokyaman
- Canakkale Onsekiz Mart University, Faculty of Medicine, Deparment of Pediatrics, Division of Pediatric Neurology.
| | - Uğur Uygunoğlu
- Istanbul University-Cerrahpasa; Department of Neurology, Istanbul, Turkey.
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16
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Abstract
PURPOSE To evaluate the effect of tumor necrosis factor (TNF) inhibitor therapy on ocular relapses in patients with Susac syndrome. METHODS Multicenter retrospective cohort study of patients diagnosed with Susac syndrome according to classical clinical criteria. We evaluated the disease activity before and after introduction of anti-TNF therapy and its value as a steroid-sparing agent. RESULTS Five patients were included. All were initially treated with a combination of corticosteroids and classical immunosuppressive drugs. Infliximab was started in three patients, and adalimumab was started in two patients. Patients had on average 5 ocular relapses during a mean follow-up time of 2.59 years before introducing a TNF inhibitor, corresponding with on average 1.93 relapses per year. After the introduction of an anti-TNF agent, this number was reduced by factor 5.51 to an average of 0.35 relapses per year for a mean follow-up of 2.86 years (P = 0.10). Before anti-TNF introduction ocular relapses occurred at a mean daily dose of 34 mg of prednisone, whereas with anti-TNF treatment, corticosteroid administration could be completely stopped in four patients with one patient still needing 5 mg daily (P = 0.10). Infliximab and adalimumab generally were well tolerated, and no serious adverse events were reported. CONCLUSION Although not statistically significant, our results suggest that anti-TNF therapy can be a valuable option for the treatment of ocular Susac syndrome and may especially be considered in those patients unresponsive to more conventional immunosuppressive treatment.
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Pérez PL, McCall AA, Hirsch BE. Scoping review of cochlear implantation in Susac's syndrome. World J Otorhinolaryngol Head Neck Surg 2021; 7:126-132. [PMID: 33997722 PMCID: PMC8103525 DOI: 10.1016/j.wjorl.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac’s Syndrome(SS) who have undergone cochlear implantation (CI). Data sources All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. Methods A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac’s Syndrome, Cochlear Implantation. Results Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19–46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. Conclusion Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.
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Affiliation(s)
- Philip L Pérez
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Andrew A McCall
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Barry E Hirsch
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Pereira S, Vieira B, Maio T, Moreira J, Sampaio F. Susac's Syndrome: An Updated Review. Neuroophthalmology 2021; 44:355-360. [PMID: 33408428 DOI: 10.1080/01658107.2020.1748062] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Susac's syndrome is a rare immune-mediated endotheliopathy that mainly affects young women. It is characterised by the presence of encephalopathy, retinal vaso-occlusive disease and hearing loss. Diagnosis is based on the clinical presentation, brain magnetic resonance imaging, retinal fluorescein angiography, and audiometry. Treatment consists of immunosuppressive therapy. This review focuses on recent developments in the diagnosis and management of the condition.
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Affiliation(s)
- Sara Pereira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Bruna Vieira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Tiago Maio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Jorge Moreira
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipa Sampaio
- Department of Ophthalmology, Hospital Pedro Hispano, Matosinhos, Portugal
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19
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020; 30:393-399. [PMID: 33337398 DOI: 10.3233/ves-200007] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse and the cervical vestibular-evoked myogenic potentials (cVEMPs). OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cVEMPs and the vHIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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20
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020:VES200720. [PMID: 33164965 DOI: 10.3233/ves-200720] [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: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse. OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cervical vestibular-evoked myogenic potentials (cVEMPs), and the v-HIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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21
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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22
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Papasavvas I, Teuchner B, Herbort CP. Susac syndrome (Retino-cochleo-cerebral vasculitis), the ophthalmologist in the role of the whistleblower. J Ophthalmic Inflamm Infect 2020; 10:27. [PMID: 33125601 PMCID: PMC7599291 DOI: 10.1186/s12348-020-00217-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Susac syndrome is a rare microangiopathy of suspected autoimmune origin affecting arteries of the retina, the cochlea and the brain. The aim of the study was to give a review of the disease entity and determine the proportion of cases and their characteristics in a uveitis referral centre. PATIENTS AND METHODS Charts of patients with the diagnosis of Susac syndrome seen in the Uveitis Clinic of the Centre for Ophthalmic Specialised Care (COS), Lausanne, Switzerland were reviewed retrospectively to determine the frequency of such cases in a uveitis referral centre. Clinical symptoms and signs, functional data, imaging signs and evolution were analysed in the 3 COS cases and one case shared with the Uveitis Clinic of the Department of Ophthalmology, University of Innsbruck, Austria. Characteristic signs were searched possibly allowing a prompt diagnosis. RESULTS During the period from 1994 to 2019 (24 years, 2045 patients), 3 charts with the diagnosis of Susac syndrome were found (0.15%). The whole collective, including the additional case, comprised three women aged 28, 32 and 63 at presentation and one man, aged 42. None of the 3 cases that were referred were diagnosed beforehand. The characteristic item found in all 4 cases was the abrupt arterial stop or segmental interruption of arteries and increased staining of arterial wall on angiography more clearly shown on indocyanine green angiography that can potentially be proposed as a crucial diagnostic element. All 4 cases responded to dual steroidal and non-steroidal immunosuppression. Under treatment, all four patients did not show any further evolution. CONCLUSION Susac syndrome is a multilocation arteritis of the head that can involve the eye, ear and brain often first diagnosed by the ophthalmologist. The diagnosis is rapidly reached in uveitis referral centres but seems to be missed otherwise, A helpful angiographic sign to be searched is an abrupt or segmental arterial stop and increased staining of the arterial wall more clearly seen on indocyanine green angiography. Patients often present first to the ophthalmologist who should be acting as a whistleblower to avoid severe involvement of the brain.
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Affiliation(s)
- Ioannis Papasavvas
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland
| | - Barbara Teuchner
- Department of Ophthalmology, University of Innsbruck, Innsbruck, Austria
| | - Carl Peter Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland.
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23
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Ralli M, Campo F, Angeletti D, Minni A, Artico M, Greco A, Polimeni A, de Vincentiis M. Pathophysiology and therapy of systemic vasculitides. EXCLI JOURNAL 2020; 19:817-854. [PMID: 32665772 PMCID: PMC7355154 DOI: 10.17179/excli2020-1512] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022]
Abstract
Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.
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Affiliation(s)
- Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Flaminia Campo
- Department of Sense Organs, Sapienza University of Rome, Italy
| | | | - Antonio Minni
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Antonella Polimeni
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy
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24
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García-Serrano J, Muñoz de Escalona-Rojas J, Callejas-Rubio J, Barrero-Hernández F. Optical coherence tomography angiography in the early diagnosis of Susac syndrome. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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De Groot M, Compter A, De Langen AJ, Brandsma D. Susac's syndrome as an immune-related adverse event after pembrolizumab: a case report. J Neurol 2019; 267:282-284. [PMID: 31701330 DOI: 10.1007/s00415-019-09587-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/26/2022]
Affiliation(s)
- M De Groot
- Department of Neuro-Oncology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, PO Box 90203, 1006 BE, Amsterdam, The Netherlands.
| | - A Compter
- Department of Neuro-Oncology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
| | - A J De Langen
- Department of Thoracic Oncology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - D Brandsma
- Department of Neuro-Oncology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
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26
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Russo FY, Ralli M, De Seta D, Mancini P, Lambiase A, Artico M, de Vincentiis M, Greco A. Autoimmune vertigo: an update on vestibular disorders associated with autoimmune mechanisms. Immunol Res 2019; 66:675-685. [PMID: 30270399 DOI: 10.1007/s12026-018-9023-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of the immune system in mediating cochleovestibular pathologies has received increasing attention in recent years. Autoimmune vertigo may be an invalidating condition and may worsen the quality of life of affected patients, especially in the cases of delayed diagnosis. Since the etiopathogenesis is still not clear, also the treatment is not yet completely delineated. According to the clinical presentation, autoimmune vertigo can present as an isolated disorder or in association with systemic autoimmune diseases. The main feature in autoimmune vertigo is the presence of an abnormal immune response, in either absence or presence of systemic autoimmune disease, directed against delicate components of the inner ear. This may determine a functional or anatomical alteration, with an inflammatory reaction often devastating for hearing and balance. Being the exact pathogenesis unknown, the diagnosis of autoimmune vertigo is based either on clinical criteria or on a positive response to steroids. The earlier the diagnosis is made, the sooner the therapy can be installed, giving a chance to the recovery of inner ear damages. Corticosteroids represent the most effective and universally accepted treatment, even if other immunomodulatory drugs are now having a more extensive use. HIGHLIGHTS: Vertigo is relatively frequent in autoimmune diseases; however, it is often misdiagnosed or attributed to central nervous system alterations rather to specific inner ear involvement. Vertigo and other audiovestibular symptoms may be the first manifestation of an autoimmune disease and if correctly addressed could significantly contribute to early diagnosis of the underlying autoimmune disease. Early diagnosis of immune-related vertigo can lead to prompt initiation of targeted therapy with elevate chances of preventing irreversible damages to the inner ear. The presence of alternating phases of well-being and disabling symptoms in patients with vertigo should always been considered, as they could suggest an underlying autoimmune condition.
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Affiliation(s)
- Francesca Yoshie Russo
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daniele De Seta
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy.
| | - Patrizia Mancini
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
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27
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Patel VA, Dunklebarger M, Zacharia TT, Isildak H. Otologic manifestations of Susac syndrome. ACTA ACUST UNITED AC 2019; 38:544-553. [PMID: 30623900 PMCID: PMC6325654 DOI: 10.14639/0392-100x-2166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
Susac syndrome, a rare autoimmune disorder first described as a classic triad (encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss) in 1979 by renowned physician John O. Susac, has been an advancing area of clinical interest and scientific research over the last several decades. This comprehensive review aims to succinctly highlight the breadth and detail of this enigmatic disease, with a primary focus on otologic manifestations. Topics discussed include epidemiology, pathophysiology, clinical manifestations, differential diagnoses, classification schema, laboratory investigations, characteristic audiometric findings, high-yield radiographic imaging, temporal bone histopathology, treatment strategies and overall prognosis.
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Affiliation(s)
- V A Patel
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - M Dunklebarger
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - T T Zacharia
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - H Isildak
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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28
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Pérez-Lombardo M, Alberdi-Páramo Í, Ramos-Barragán B, Gimeno-Álvarez D. Confusion, dissociation and bizarre behaviour as the onset of an early Susac syndrome. BMJ Case Rep 2019; 12:12/8/e229422. [DOI: 10.1136/bcr-2019-229422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 47-year-old woman presented an episode of confusion and disorientation. According to remarkable psychiatric records, she had been treated for major depression and obsessive-compulsive disorder; however, no other relevant background was known. After preliminary examinations, blood analysis and neurological tests were unspecific and inconclusive. Therefore, the case was treated as a possible psychiatric episode related to her previous psychiatric disorders. However, due to the atypical presentation of the case, a cerebral MRI was performed, which demonstrated multiple central lesions of the corpus callosum (‘snowball lesions’), as well as several supratentorial white matter lesions. As a result of the follow-up of the case, sensorineural hearing loss and branch retinal artery were detected, which concluded in the classic triad and the confirmation of the diagnosis of a Susac syndrome.
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29
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Triplett JD, Buzzard KA, Lubomski M, Riminton DS, Barnett MH, Welgampola MS, Halmagyi GM, Nguyen M, Landau K, Lee AG, Plant GT, Fraser CL, Reddel SW, Hardy TA. Immune-mediated conditions affecting the brain, eye and ear (BEE syndromes). J Neurol Neurosurg Psychiatry 2019; 90:882-894. [PMID: 30852493 DOI: 10.1136/jnnp-2018-319002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 12/19/2022]
Abstract
The triad of central nervous system symptoms, visual disturbance and hearing impairment is an oft-encountered clinical scenario. A number of immune-mediated diseases should be considered among the differential diagnoses including: Susac syndrome, Cogan syndrome or Vogt-Koyanagi-Harada disease; demyelinating conditions such as multiple sclerosis or neuromyelitis optica spectrum disorder; systemic diseases such as systemic lupus erythematosus, Sjögren syndrome or Behcet disease and granulomatous diseases such as sarcoidosis. In this article, we coin the term 'BEE syndromes' to draw attention to the various immune-mediated diseases that affect the brain, eye and ear. We present common disease manifestations and identify key clinical and investigation features.
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Affiliation(s)
- James D Triplett
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Katherine A Buzzard
- Department of Neurosciences, Eastern Health, Monash University, Clayton, Victoria, Australia
| | - Michal Lubomski
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - D Sean Riminton
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Michael H Barnett
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Miriam S Welgampola
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - G Michael Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - MaiAnh Nguyen
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Klara Landau
- Department of Ophthalmology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital in Houston, Houston, Texas, USA.,Weill Cornell Medical College, Cornell University, New York City, New York, USA.,University of Texas Medical Branch (UTMB), Baylor College of Medicine, The UT MD Anderson Cancer Center, Texas A and M College of Medicine (AGL), Houston, Texas, USA
| | - Gordon T Plant
- National Hospital for Neurology and Neurosurgery and Moorfield's Eye Hospital, University College London, London, UK
| | - Clare L Fraser
- Brain and Mind Centre, University of Sydney, Syndey, New South Wales, Australia
| | - Stephen W Reddel
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Todd A Hardy
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
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Marrodan M, Laffue A, Fiol MP, Correale J, Gualtieri F. Video head impulse test contributes to Susac syndrome diagnosis. J Neurol 2019; 266:2070-2072. [PMID: 31065784 DOI: 10.1007/s00415-019-09357-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022]
Affiliation(s)
- M Marrodan
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina.
| | - A Laffue
- Department of Neuro-Otology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Buenos Aires, Argentina
| | - M P Fiol
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina
| | - J Correale
- Department of Neurology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Montañeses 2325, 1428, Buenos Aires, Argentina
| | - F Gualtieri
- Department of Neuro-Otology, Institute for Neurological Research Dr. Raúl Carrea, FLENI, Buenos Aires, Argentina
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31
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Sánchez Aliaga E. Vasculitis and Other Inflammatory Disorders. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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32
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Vasculitis and Other Inflammatory Disorders. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-61423-6_45-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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33
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Marrodan M, Acosta J, Alessandro L, Fernandez V, Carnero Contentti E, Arakaki N, Kohler A, Fiol M, Ameriso S, Correale J. Clinical and imaging features distinguishing Susac syndrome from primary angiitis of the central nervous system. J Neurol Sci 2018; 395:29-34. [DOI: 10.1016/j.jns.2018.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 11/16/2022]
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34
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Audiovestibular Symptoms in Systemic Autoimmune Diseases. J Immunol Res 2018; 2018:5798103. [PMID: 30211232 PMCID: PMC6120292 DOI: 10.1155/2018/5798103] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.
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Salvanos P, Moe MC, Utheim TP, Bragadóttir R, Kerty E. ULTRA-WIDE-FIELD FUNDUS IMAGING IN THE DIAGNOSIS AND FOLLOW-UP OF SUSAC SYNDROME. Retin Cases Brief Rep 2018; 12:234-239. [PMID: 27828899 DOI: 10.1097/icb.0000000000000470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To present the use of ultra-wide-field (UW) fundus imaging in the diagnosis and follow-up of a patient with Susac syndrome. METHODS Case report of a myopic patient presenting initially with rhegmatogenous retinal detachment. A significant portion of the retina was found to be avascular bilaterally at presentation. Surgery was performed with scleral buckle. Then, UW color and autofluorescent imaging and UW fluorescein angiography were obtained. RESULTS Successful retinal reattachment was obtained. Enlargement of the avascular area with neovascularization was observed at eight-month follow-up. In addition, the patient presented severe neurosensory hearing loss and clinical depression postoperatively. The results of UW fluorescein angiography revealed hyperfluorescent macular spots, arteriolar wall hyperfluorescence, leakage from retinal neovascularization, and confirmed the avascularity of two thirds of the retina, whereas the results of UW autofluorescence showed absence of the normal hypofluorescent retinal vessels outside the posterior pole. Findings of UW imaging in combination with systemic involvement led to the diagnosis of Susac syndrome. Appropriate treatment stopped the disease progress, ameliorated symptoms, and some of the occluded retinal vessels were reperfused. CONCLUSION In conclusion, UW fundus imaging is a valuable modality in the diagnosis and follow-up of patients with Susac syndrome. Early diagnosis and treatment is critical, particularly as it can lead to reperfusion of occluded retinal vessels.
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Affiliation(s)
- Panagiotis Salvanos
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
- Department of Ophthalmology, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- University of Oslo, Oslo, Norway
| | - Morten C Moe
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Tor P Utheim
- Department of Ophthalmology, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
- University of Oslo, Oslo, Norway
- Departments of Medical Biochemistry
- Oral Biology, and
| | - Ragnheiður Bragadóttir
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Emilia Kerty
- University of Oslo, Oslo, Norway
- Neurology, Oslo University Hospital, Oslo, Norway
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Greco A, De Virgilio A, Ralli M, Ciofalo A, Mancini P, Attanasio G, de Vincentiis M, Lambiase A. Behçet's disease: New insights into pathophysiology, clinical features and treatment options. Autoimmun Rev 2018; 17:567-575. [PMID: 29631062 DOI: 10.1016/j.autrev.2017.12.006] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 12/12/2022]
Abstract
Behçet's disease (BD) is a rare systemic vasculitis characterized by oral aphthous ulcers, genital ulcers, ocular lesions and other systemic manifestations. BD occurs most frequently in Eurasian populations along the ancient trading route known as the "Silk Road" which extends from eastern Asia to the Mediterranean basin. The causes of BD are unknown: it is believed to be due to an autoimmune process triggered by an infectious or environmental agent in genetically predisposed individuals. HLA-B51 allele located in the MHC locus, on chromosome 6p, has been the most strongly associated risk factor for BD in areas along the Old Silk Route. Herpes simplex virus-1 and Streptococcus have been postulated as possible environmental triggers of BD. T cell homeostasis perturbation, especially Th1 and Th17 expansion and decreased regulation by Tregs are now supposed to be the cornerstone of BD pathogenesis. The histology shows vasculitis that involves both arteries and veins, and vessels of any size. BD is a systemic vasculitis with significant neutrophil infiltration, endothelial cell swelling, and fibrinoid necrosis. The diagnosis of BD is only supported by clinical criteria and requires the exclusion of other diagnoses based on clinical presentation. There are no pathognomonic laboratorial findings of BD. This rare disease often leads to blindness and fatal systemic involvement. Main causes of death include major vessel disease and central nervous system involvement. Corticosteroids are commonly used to treat clinical manifestations of BD in combination with immunosuppressant drugs. Tumor necrosis factor (TNF)-blocking agents such as Infliximab, Etanercept, and Adalimumab have been reported to have success in patients with BD.
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Affiliation(s)
- Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Armando De Virgilio
- Department of Otolaryngology-Head and Neck Surgery, Humanitas Clinical and Research Center, via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Massimo Ralli
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Andrea Ciofalo
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Patrizia Mancini
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Giuseppe Attanasio
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Marco de Vincentiis
- Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100 Rome, Italy.
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Yang YS, Zhang L, Asdaghi N, Henry CR, Davis JL. ACUTE MACULAR NEURORETINOPATHY IN SUSAC SYNDROME: A NEW ASSOCIATION. Retin Cases Brief Rep 2018; 14:310-314. [PMID: 29596114 DOI: 10.1097/icb.0000000000000738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report a case of acute macular neuroretinopathy in a patient with Susac syndrome. METHODS Case report. RESULTS A 39-year-old male patient presented with severe headache, photopsias, and a sudden onset of hearing loss in the right ear. Fluorescein angiography of the right eye revealed multiple branch retinal artery occlusions. Clinical presentation of encephalopathy, hearing loss, and branch retinal artery occlusions, along with characteristic magnetic resonance imaging findings, led to a diagnosis of Susac syndrome. Despite aggressive immunosuppression for four months, the patient later presented with acute macular neuroretinopathy in the left eye. CONCLUSION Acute macular neuroretinopathy and Susac is a new association of two well-defined disorders. The concurrence of both disorders supports retinal ischemia as the proximate cause of acute macular neuroretinopathy and inflammation as a potential etiology.
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Affiliation(s)
- Yong-Sheng Yang
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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38
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Optical coherence tomography angiography in the early diagnosis of Susac syndrome. Neurologia 2017; 35:62-63. [PMID: 28958398 DOI: 10.1016/j.nrl.2017.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/24/2017] [Indexed: 11/24/2022] Open
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Betend R, Humm AM, Medlin F. Delirium as presentation of late-onset and relapsing Susac syndrome. BMJ Case Rep 2017; 2017:bcr-2017-220494. [PMID: 28784886 DOI: 10.1136/bcr-2017-220494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old patient, only known for bilateral presbycusis, presented with subacute onset of delirium. Clinical examination showed multifocal neurological deficits, all together suggesting subcortical frontal dysfunction together with cerebellar and corpus callosum involvement.Cerebral MRI demonstrated supratentorial and infratentorial subcortical and periventricular T2-hyperintense lesions with cerebellar gadolinium enhancement and multiple central lesions of the corpus callosum (snowball lesions). The diagnosis of Susac syndrome was made and the patient treated with intravenous methylprednisolone, followed by a prednisone maintenance dose over 8 weeks. After a clinical improvement, a relapse was noticed during corticosteroid tapering. The patient was again treated with intravenous methylprednisolone followed by a prednisone maintenance therapy with simultaneous introduction of mycophenolate mofetil acid and one cycle of intravenous rituximab. The patient recovered rapidly. At 11-month follow-up, only mild executive dysfunction and persistent right postural tremor was noted, MRI showed partial regression of subcortical and juxtacortical lesions.
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Affiliation(s)
- Romain Betend
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland
| | - Andrea M Humm
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland.,Department of Neurology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Friedrich Medlin
- Department of Internal Medicine, Unit of Neurology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland.,Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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40
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Cadasil. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)85562-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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41
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Marrodan M, Correale J, Alessandro L, Amaya M, Fracaro M, Köhler A, Fiol M. Susac Syndrome: A differential diagnosis of white matter lesions. Mult Scler Relat Disord 2017. [DOI: 10.1016/j.msard.2017.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
OBJECTIVE Susac syndrome, a rare disorder, is thought to be mediated by autoantibodies. One of the potential targets of these autoantibodies could be an antigen in the microvessels of the brain, the retina, and the inner ear leading to central nervous system (CNS) alterations, visual disturbances, and hearing deficits. Our aim is to expand clinicians' diagnostic options when facing psychosis due to medical conditions. METHODS A case report was conducted for this study. RESULTS This paper reports the case of a young male drug user who presented with psychosis, confusion and CNS vasculitis. First deemed to be drug-induced CNS vasculitis, it was finally diagnosed as Susac syndrome. CONCLUSIONS Although an infrequent entity, Susac syndrome should remain an option in the differential diagnosis of several neurological and psychiatric presentations.
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Affiliation(s)
- Pablo Barrio
- a Addictive Behaviours Unit , Clinical Neuroscience Institute, Clinic Hospital of Barcelona , Barcelona , Spain
| | - Mercè Balcells
- a Addictive Behaviours Unit , Clinical Neuroscience Institute, Clinic Hospital of Barcelona , Barcelona , Spain
| | - Delón La Puma
- b Neurology Department , Clinical Neuroscience Institute, Clinic Hospital of Barcelona , Barcelona , Spain
| | - Carles Gaig
- b Neurology Department , Clinical Neuroscience Institute, Clinic Hospital of Barcelona , Barcelona , Spain
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43
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Kola M, Erdöl H, Ertuğrul Atasoy S, Türk A. Evaluation of Retinal Changes Using Optical Coherence Tomography in a Pediatric Case of Susac Syndrome. Turk J Ophthalmol 2017; 47:59-62. [PMID: 28182173 PMCID: PMC5282545 DOI: 10.4274/tjo.27482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/15/2015] [Indexed: 12/01/2022] Open
Abstract
Susac syndrome is a rare occlusive vasculopathy affecting the retina, inner ear and brain. The cause is unknown, although it generally affects young women. This syndrome can be difficult to diagnose because its signs can only be revealed by detailed examination. These signs are not always concomitant, but may appear at different times. This report describes a pediatric case who was diagnosed with Susac syndrome when retinal lesions were identified in the inactive period with the help of optical coherence tomography (OCT). The purpose of this case report is to emphasize the importance of OCT in clarifying undefined retinal changes in Susac syndrome.
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Affiliation(s)
- Mehmet Kola
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Hidayet Erdöl
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Sevil Ertuğrul Atasoy
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
| | - Adem Türk
- Karadeniz Technical University Faculty of Medicine, Department of Ophthalmology, Trabzon, Turkey
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44
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Dutra LA, de Souza AWS, Grinberg-Dias G, Barsottini OGP, Appenzeller S. Central nervous system vasculitis in adults: An update. Autoimmun Rev 2017; 16:123-131. [PMID: 28087351 DOI: 10.1016/j.autrev.2016.12.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 11/27/2022]
Abstract
Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.
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Affiliation(s)
- Lívia Almeida Dutra
- General Neurology Division, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Simone Appenzeller
- Rheumatology Division, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil.
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45
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Characteristics of headache in relation to the manifestation of Susac syndrome. Medicina (B Aires) 2017; 53:420-425. [DOI: 10.1016/j.medici.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 12/12/2022] Open
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46
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Vishnevskia-Dai V, Chapman J, Sheinfeld R, Sharon T, Huna-Baron R, Manor RS, Shoenfeld Y, Zloto O. Susac syndrome: clinical characteristics, clinical classification, and long-term prognosis. Medicine (Baltimore) 2016; 95:e5223. [PMID: 27787385 PMCID: PMC5089114 DOI: 10.1097/md.0000000000005223] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [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
Susac syndrome is a rare condition characterized by the clinical triad of central nervous system (CNS) dysfunction, sensorineural hearing impairment, and branch retinal artery occlusion (BRAO). The purpose of this study is to examine the demographics, clinical characteristics, treatment, and long-term prognosis of Susac syndrome. The data recorded for all Susac syndrome patients treated at the Sheba Medical Center between 1998 and 2014 included demographics, clinical signs at presentation and during the disease course, imaging findings, treatment, and prognosis.Susac syndrome was diagnosed in 10 patients (age range 30-45 years). Only 2 patients presented with the full triad and 7 patients developed the full triad during mean follow-up period of 35 months. The average time to full triad was 7 months. Based on our observations at presentation, we divided the disease course into suspected, incomplete, and complete Susac syndrome. All 10 patients were treated at diagnosis with a pulse of high-dose intravenous methylprednisolone. There was improvement in visual acuity and visual field at the end of follow-up compared to baseline, but it was not statistically significant (P = 0.479 and P = 0.053, respectively). Five patients remained with neurological damage, and 5 patients had no improvement of their hearing loss at study closure. In conclusion, Susac syndrome is a rare condition that can mimic other disorders. The diagnosis is challenging because most patients do not initially present with the definitive triad. We suggest a clinical classification for the syndrome that may assist in early diagnosis.
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Affiliation(s)
- Vicktoria Vishnevskia-Dai
- Goldschleger Eye Institute
- Correspondence: Vicktoria Vishnevskia-Dai, Goldschleger Eye Institute; Department of Ophthalmology, Sheba Medical Center, Tel Hshomer, Tel Aviv University, Israel. 52621, Israel (e-mail: )
| | - Joav Chapman
- Department of Neurology, Sagol Neuroscience Center, Tel Hashomer
| | - Roee Sheinfeld
- Department of Neurology, Sagol Neuroscience Center, Tel Hashomer
| | | | | | - Riri S. Manor
- Department of Ophthalmology, Sheba Medical Center, Tel Hshomer
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, are affiliated to the Sackler faculty of medicine Tel Aviv University, Israel
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Abstract
Our PubMed search for peer-reviewed articles published in the 2014 solar year retrieved a significantly higher number of hits compared to 2013 with a net 28 % increase. Importantly, full articles related to autoimmunity constitute approximately 5 % of immunology articles. We confirm that our understanding of autoimmunity is becoming a translational paradigm with pathogenetic elements rapidly followed by new treatment options. Furthermore, numerous clinical and pathogenetic elements and features are shared among autoimmune diseases, and this is well illustrated in the recent literature. More specifically, the past year witnessed critical revisions of our understanding and management of antiphospholipid syndrome with new exciting data on the pathogenicity of the serum anti-beta2 glycoprotein autoantibody, a better understanding of the current and new treatments for rheumatoid arthritis, and new position papers on important clinical questions such as vaccinations in patients with autoimmune disease, comorbidities, or new classification criteria. Furthermore, data confirming the important connections between innate immunity and autoimmunity via toll-like receptors or the critical role of T regulatory cells in tolerance breakdown and autoimmunity perpetuation were also reported. Lastly, genetic and epigenetic data were provided to confirm that the mosaic of autoimmunity warrants a susceptible individual background which may be geographically determined and contribute to the geoepidemiology of diseases. The 2014 literature in the autoimmunity world should be cumulatively regarded as part of an annus mirabilis in which, on a different level, the 2014 Annual Meeting of the American College of Rheumatology in Boston was attended by over 16,000 participants with over selected 3000 abstracts.
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Affiliation(s)
- Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, via A. Manzoni 56, 20089 Rozzano, Milan, Italy. .,BIOMETRA Department, University of Milan, Milan, Italy.
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48
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McGinley M, Morales-Vidal S, Ruland S. Leucine-Rich Glioma Inactivated-1 and Voltage-Gated Potassium Channel Autoimmune Encephalitis Associated with Ischemic Stroke: A Case Report. Front Neurol 2016; 7:68. [PMID: 27242653 PMCID: PMC4860679 DOI: 10.3389/fneur.2016.00068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/22/2016] [Indexed: 12/03/2022] Open
Abstract
Autoimmune encephalitis is associated with a wide variety of antibodies and clinical presentations. Voltage-gated potassium channel (VGKC) antibodies are a cause of autoimmune non-paraneoplastic encephalitis characterized by memory impairment, psychiatric symptoms, and seizures. We present a case of VGKC encephalitis likely preceding an ischemic stroke. Reports of autoimmune encephalitis associated with ischemic stroke are rare. Several hypotheses linking these two disease processes are proposed.
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Affiliation(s)
- Marisa McGinley
- Department of Neurology, Loyola University Medical Center , Maywood, IL , USA
| | | | - Sean Ruland
- Department of Neurology, Loyola University Medical Center , Maywood, IL , USA
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49
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Description de troubles vésico-sphinctériens dans un syndrome de Susac. Prog Urol 2016; 26:432-3. [DOI: 10.1016/j.purol.2016.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/23/2016] [Accepted: 02/23/2016] [Indexed: 11/24/2022]
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Merayo-Chalico J, Apodaca E, Barrera-Vargas A, Alcocer-Varela J, Colunga-Pedraza I, González-Patiño A, Arauz A, Abud-Mendoza C, Martínez-Martínez M, Gómez-Martín D. Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study. J Neurol Neurosurg Psychiatry 2016; 87:287-94. [PMID: 25804426 DOI: 10.1136/jnnp-2014-310145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors. PATIENTS AND METHODS We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes. RESULTS Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4). CONCLUSIONS This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.
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Affiliation(s)
- Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Apodaca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Iris Colunga-Pedraza
- Department of Rheumatology, Hospital Universitario Dr José E González, Monterrey, Nuevo León, Mexico
| | - Alejandra González-Patiño
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Marco Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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