1
|
Juncker AS, Appenzeller S, de Souza JM. Central Nervous System Involvement in Systemic Autoimmune Rheumatic Diseases-Diagnosis and Treatment. Pharmaceuticals (Basel) 2024; 17:1044. [PMID: 39204149 PMCID: PMC11357437 DOI: 10.3390/ph17081044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/19/2024] [Accepted: 08/02/2024] [Indexed: 09/03/2024] Open
Abstract
Central nervous system (CNS) involvement in autoimmune rheumatic diseases represents a significant challenge for clinicians across all specialties. While most reviews on the subject focus on neurological manifestations within a specific rheumatic disease, few descriptions shift from neurological clinical syndromes to achieve rheumatological diagnoses. This narrative review aims to synthesize current knowledge on the diagnosis and management of CNS manifestations occurring in the most prevalent rheumatic conditions in adults. We searched the MEDLINE database using the terms "central nervous system", "rheumatic diseases", "systemic lupus erythematosus", "rheumatoid arthritis", "Sjögren syndrome", and "vasculitis". The search strategy included review articles from 2019 to 2024, published in English, Spanish, or Portuguese. We explored the pathophysiological mechanisms linking autoimmunity to CNS pathology, emphasizing the role of syndromic reasoning, autoantibody profiles, and imaging modalities as tools for diagnosis and determination of inflammatory activity. The review also discusses differential diagnoses through a stepwise approach to neurological syndromes, summarized in diagnostic flowcharts, and presents updated treatment options. Although our approach is primarily semiology-based, the complexity of the subject invites future endeavors involving new technologies, such as functional MRI, MR spectroscopy, and nuclear medicine.
Collapse
Affiliation(s)
- Aline Santana Juncker
- Department of Internal Medicine, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-881, Brazil;
- Post-Graduate Program in Medical Sciences, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas 13000-000, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-887, Brazil;
| | - Jean Marcos de Souza
- Department of Internal Medicine, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-881, Brazil;
| |
Collapse
|
2
|
Samah Y, Sahar B, Mebrouk Y. Clinical, Radiological, and Etiological Aspects of Pachymeningitis: A Study of 24 Cases. Cureus 2024; 16:e61988. [PMID: 38984004 PMCID: PMC11231805 DOI: 10.7759/cureus.61988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
Introduction and importance Hypertrophic pachymeningitis (HP) is an uncommon disorder with varied etiological origins and heterogeneous clinical presentation. Establishing the etiological diagnosis poses a challenge, but prompt identification provides a treatment window, potentially leading to a reversal of symptoms. MRI is the reference examination, allowing not only the early diagnosis of pachymeningitis but also the assessment of its extent and importance, detection of possible complications, and suggestion of etiology. Case presentation We conducted a retrospective study involving 24 patients recruited over 5 years for who brain imaging had revealed the presence of pachymeningitis. The average age of the patients was 40 years, with a male-to-female ratio of 0.6. Clinical discussion Headache was present in 54.17% of patients. All the patients underwent MRI examinations utilizing different sequences, with subsequent Gadolinium injection showing localized and asymmetrical meningeal thickening in 13 cases, and diffuse in the rest. The cerebrospinal fluid study unveiled an inflammatory fluid characterized by a lymphocytic predominance and hyperproteinorrhea, noted in 50% of the patients. The histopathological analysis of a stereotactic biopsy conducted on an individual patient revealed non-diagnostic results. The etiological investigation was dominated by tuberculosis, which was detected in 33.3% of cases. Idiopathic origin was identified in 16.7% of patients. Conclusion Meningeal thickening is rare, and the multitude of potential causes makes the etiological investigation challenging unless they fall within the scope of secondary meningeal disorders; otherwise, a dural biopsy becomes necessary, and the prompt initiation of treatment, along with determining the etiology influences the prognosis.
Collapse
Affiliation(s)
- Yousfi Samah
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
| | - Boulehoual Sahar
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
| | - Yassine Mebrouk
- Department of Neurology, Mohamed VI University Hospital, Mohamed First University, Faculty of Medicine, Oujda, MAR
| |
Collapse
|
3
|
D’Aniello S, Rustici A, Gramegna LL, Godi C, Piccolo L, Gentile M, Zini A, Carrozzi A, Lodi R, Tonon C, Dall’Olio M, Simonetti L, Chieffo R, Anzalone N, Cirillo L. The Contribution of Vessel Wall Magnetic Resonance Imaging to the Diagnosis of Primary and Secondary Central Nervous System Vasculitis. Diagnostics (Basel) 2024; 14:927. [PMID: 38732340 PMCID: PMC11083696 DOI: 10.3390/diagnostics14090927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND To describe high-resolution brain vessel wall MRI (VW-MRI) patterns and morphological brain findings in central nervous system (CNS) vasculitis patients. METHODS Fourteen patients with confirmed CNS Vasculitis from two tertiary centers underwent VW-MRI using a 3T scanner. The images were reviewed by two neuroradiologists to assess vessel wall enhancement characteristics and locations. RESULTS Fourteen patients were included (six females; average age 48 ± 19 years). Diagnoses included primary CNS vasculitis (PCNSV) in six patients and secondary CNS vasculitis (SCNSV) in eight, half of which were infection-related. Thirteen patients showed vessel wall enhancement, which was intense in eleven patients (84.6%) and concentric in twelve (92.3%), affecting the anterior circulation in nine patients (69.2%), posterior in two patients (15.4%), and both circulations in two patients (15.4%). The enhancement patterns were similar across different CNS vasculitis types. DWI changes corresponded with areas of vessel wall enhancement in 77% of patients. Conclusions: CNS vasculitis is often associated with intense, concentric vessel wall enhancement in VW-MRI, especially in the anterior circulation. The consistent presence of DWI alterations in affected territories suggests a possible link to microembolization or hypoperfusion. These imaging findings complement parenchymal brain MRI and MRA/DSA data, potentially increasing the possibility of a clinical diagnosis of CNS vasculitis.
Collapse
Affiliation(s)
- Serena D’Aniello
- Department of Advanced Biomedical Science, University of Napoli “Federico II”, 80125 Naples, Italy
| | - Arianna Rustici
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Laura Ludovica Gramegna
- Vall d’Hebron Research Institute, Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Servicio de Radiología, Unidad de Neuroradiología, Hospital del Mar, 08003 Barcelona, Spain
| | - Claudia Godi
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Neuroradiology Unit, Sant’Antonio Abate Hospital, ASST Valle Olona, 21013 Gallarate, Italy
| | - Laura Piccolo
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Mauro Gentile
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Alessandro Carrozzi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
| | - Massimo Dall’Olio
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, 40139 Bologna, Italy
| | - Luigi Simonetti
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Maggiore, 40133 Bologna, Italy
| | - Raffaella Chieffo
- Experimental Neurophysiology Unit, IRCCS San Raffaele, Institute of Experimental Neurology (INSPE), 20132 Milan, Italy
| | - Nicoletta Anzalone
- Neuroradiology Unit and CERMAC, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Luigi Cirillo
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40138 Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40123 Bologna, Italy
- Neuroradiology Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, 40139 Bologna, Italy
| |
Collapse
|
4
|
Sherri A, Mortada MM, Makowska J, Lewandowska-Polak A. Primary angiitis of the CNS and ANCA-associated vasculitis: from pathology to treatment. Rheumatol Int 2024; 44:211-222. [PMID: 37777632 PMCID: PMC10796583 DOI: 10.1007/s00296-023-05461-9] [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: 07/26/2023] [Accepted: 09/03/2023] [Indexed: 10/02/2023]
Abstract
Vasculitis of the central nervous system can be a localized process, such as primary angiitis of the central nervous system (PACNS), or systemic vasculitis, such as ANCA-associated vasculitis (AAV). Since both conditions share neurological manifestations, the following review will discuss the neurological aspects of both. This review aims to provide a comprehensive comparison of the pathogenesis, clinical manifestation and assessment, diagnostic workup, and treatment protocol for both PACNS and AAV with central nervous system involvement. To provide a comprehensive comparison and update, a literature review was conducted using PubMed and Ovid databases (Embase and Medline). Then, the references were retrieved, screened, and selected according to the inclusion and exclusion criteria. PACNS and AAV share similarities in clinical presentation and neurological symptoms, especially in terms of headache, focal deficits, and cognitive impairment. Additionally, both conditions may exhibit similarities in laboratory and radiological findings, making brain biopsy the gold standard for differentiation between the two conditions. Moreover, the treatment protocols for PACNS and AAV are nearly identical. Comparing PACNS and AAV with CNS involvement highlights the similarities in clinical presentation, radiological findings, and treatment protocols between the two conditions. Further research should focus on establishing a practical diagnostic protocol.
Collapse
Affiliation(s)
- Alaa Sherri
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland.
| | | | - Joanna Makowska
- Department of Rheumatology, Medical University of Lodz, Łódź, Poland
| | | |
Collapse
|
5
|
Yoshikawa S, Ueda T. The visualization of hypertrophic pachymeningitis in antineutrophil cytoplasmic antibody-associated granulomatosis with polyangiitis on contrast-enhanced FLAIR. Radiol Case Rep 2024; 19:418-423. [PMID: 38028296 PMCID: PMC10679861 DOI: 10.1016/j.radcr.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Hypertrophic pachymeningitis is a rare inflammatory condition that leads to the thickening of the dura mater, either due to unknown or identifiable secondary causes. Granulomatosis with polyangiitis is a notable causative agent, and hypertrophic pachymeningitis is the initial presentation in certain cases. The diagnosis of hypertrophic pachymeningitis is aided by contrast-enhanced MRI, although distinguishing between normal and abnormal dural enhancement can be challenging using contrast-enhanced T1WI. This study highlights the case of an 80-year-old woman diagnosed with hypertrophic pachymeningitis secondary to antineutrophil cytoplasmic antibody-associated granulomatosis with polyangiitis, where contrast-enhanced FLAIR played a crucial role in distinctly identifying abnormal dural enhancement and differentiating it from normal dura. In conclusion, although contrast-enhanced T1WI remains indispensable, contrast-enhanced FLAIR can serve as a valuable complementary tool in MRI study sequences for the diagnosis of hypertrophic pachymeningitis.
Collapse
Affiliation(s)
- Satoshi Yoshikawa
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, 9-7 Jurakumawari-Matsushita-cho, Nakagyo-ku, Kyoto 604-8401, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, 9-7 Jurakumawari-Matsushita-cho, Nakagyo-ku, Kyoto 604-8401, Japan
| |
Collapse
|
6
|
Houben E, de Groot PF, Vegting Y, Vos JMI, Nur E, Hilhorst ML, Hak AE(L, Kwakernaak AJ. Not Everything Is as It Seems: A Case Series and Overview of Diseases Mimicking Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. J Clin Med 2023; 12:6144. [PMID: 37834788 PMCID: PMC10573599 DOI: 10.3390/jcm12196144] [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: 09/03/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare heterogeneous disease in which treatment must be initiated early to prevent irreversible organ damage and death. There are several diseases that can mimic AAV, even in the presence of positive ANCA serology and/or histological evidence of vasculitis, as demonstrated in this case series. We reflect on the diagnostic approach of patients with AAV and provide an overview of AAV-mimicking diseases that can be considered in patients with atypical disease presentation or course.
Collapse
Affiliation(s)
- Eline Houben
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Pieter F. de Groot
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
| | - Yosta Vegting
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Josephine M. I. Vos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marc L. Hilhorst
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - A. E. (Liesbeth) Hak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Arjan J. Kwakernaak
- Department of Medicine, Division of Clinical Immunology and Allergy, Vasculitis Center of Expertise, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (E.H.)
- Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medicine, Division of Nephrology, Amsterdam University Medical Center, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
7
|
Zhang X, Zhao GB, Li LK, Wang WD, Lin HL, Yang N. Myeloperoxidase-antineutrophil cytoplasmic antibody-associated vasculitis with headache and kidney involvement at presentation and with arthralgia at relapse: A case report. World J Clin Cases 2023; 11:5167-5172. [PMID: 37583854 PMCID: PMC10424013 DOI: 10.12998/wjcc.v11.i21.5167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/12/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Patients with proteinase 3-antineutrophil cytoplasmic antibody associated vasculitis (AAV) experience different manifestations at the initial onset and relapse. However, such cases of different initial and relapse manifestations have not been reported in myeloperoxidase (MPO)-AAV patients. CASE SUMMARY A 52-year-old woman was admitted to our hospital because of headache. Laboratory findings indicated nephrotic range proteinuria and microscopic hematuria, serum creatinine of 243 μmol/L, anti-MPO antibody titer of > 400 RU/mL, and positive perinuclearantineutrophil cytoplasmic antibody. Renal biopsy showed pauci-immune crescentic glomerulonephritis. The cerebrospinal fluid examination and brain magnetic resonance imaging did not show any abnormality. Therefore, MPO-AAV was diagnosed. Corticosteroids, plasmapheresis, and cyclophosphamide as induction therapy and mycophenolate mofetil (MMF) as maintenance therapy were administered. The patient's headache disappeared; serum creatinine returned to normal; complete remission of microscopic hematuria and proteinuria was observed. Anti-MPO antibody titer reached normal limits after immunosuppressive treatment. Twenty-five months after stopping the immunosuppressive treatment, the patient relapsed with arthralgia, without neurological or renal involvement. The patient's arthralgia improved after treatment with prednisone and MMF. CONCLUSION We have reported a rare case of MPO-AAV who initially presented with headache and kidney involvement. However, relapse presented with only arthralgia, which was completely different from the initial manifestations. This case suggests that AAV relapse should be highly suspected in MPO-AAV patients after remission, when clinical manifestations at relapse are different from those at onset. Prednisone and MMF may provide a good choice for refractory arthralgia during relapse in MPO-AAV patients.
Collapse
Affiliation(s)
- Xue Zhang
- Graduate School, Dalian Medical University, Dalian 116011, Liaoning Province, China
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Guang-Ben Zhao
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Long-Kai Li
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Wei-Dong Wang
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Hong-Li Lin
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| | - Ning Yang
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian 116011, Liaoning Province, China
| |
Collapse
|
8
|
Yuan D, Ji Q, Xia JH, Wang JJ, Liang N. Granulomatous polyangiitis involving the fourth ventricle: Report of a rare case and a literature review. Open Life Sci 2023; 18:20220654. [PMID: 37483427 PMCID: PMC10358746 DOI: 10.1515/biol-2022-0654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/05/2023] [Accepted: 06/10/2023] [Indexed: 07/25/2023] Open
Abstract
Granulomatous polyangiitis (GPA) is a rare systemic autoimmune vasculitis disease that is highly correlated with anti-neutrophil cytoplasmic antibodies (ANCAs). It was formerly called as "Wegener's granulomatosis." The clinical manifestations are diverse, mainly involving the upper respiratory tract, lungs, and kidneys, and this disease can involve the brain parenchyma as an isolated solid mass. Only one case has been reported thus far. To provide further information on this rare case, we report a case of GPA involving the fourth ventricle and review the relevant literature. A 32-year-old Chinese female developed fever, cough, and shortness of breath for 20 days. An 80 mm × 80 mm skin ulcer was seen on the right lower limb. CT showed multiple large patches of increased density in both lungs. The patient's serological ANCA was positive. Later, the patient developed dizziness and headache. Magnetic resonance imaging of the head showed a mass of approximately 21 mm × 24 mm in the fourth ventricle. The patient had a craniotomy for mass resection, and macroscopically, the mass was gray-red and measured 25 mm × 20 mm × 20 mm, was soft, had local hemorrhage and necrosis, and had no capsule. The main microscopic features included necrotizing granulomatous vasculitis, the patient's immunohistochemistry was positive for CD68 and negative for glial fibrillary acidic protein, and the acid-fast staining and hexaamine silver staining were negative. Combined with the clinical history, serology, and imaging, the pathological diagnosis was GPA in the fourth ventricle. The patient was switched to rituximab combined with steroid therapy because she did not tolerate cyclophosphamide. After 5 months of follow-up, the patient's lung lesions and skin ulcers had completely improved, but the brain lesions had further progressed. When a patient has multiple system diseases, abnormal clinical manifestations, and positive serological ANCAs, a diagnosis of GPA should be carefully considered, and biopsies of easy-to-access sites should be performed. If the patient's histopathological manifestations include vasculitis, granuloma, and necrosis, a diagnosis of GPA is more likely. If a patient subsequently develops an intraventricular mass, the clinicians should consider a diagnosis of GPA, which can rarely involve the cerebral ventricle to avoid an unnecessary biopsy or surgical treatment of intracranial lesions. When a patient is intolerant to the traditional treatment drug cyclophosphamide and needs to be switched to rituximab, the treatment effect of intracerebral lesions is not ideal; therefore, the treatment of lesions involving GPA in the ventricle is worthy of further exploration.
Collapse
Affiliation(s)
- Dan Yuan
- Department of Pathology the Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Qing Ji
- Department of Pathology the Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Jin-Hua Xia
- Department of Pathology the Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Jin-Jing Wang
- Department of Pathology the Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Na Liang
- Department of Histology and Embryology, Zunyi Medical University, Zunyi, Guizhou 563000, China
| |
Collapse
|
9
|
Toledano M. Neurologic Manifestations of Rheumatologic Disease. Continuum (Minneap Minn) 2023; 29:734-762. [PMID: 37341329 DOI: 10.1212/con.0000000000001263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article describes the neurologic manifestations of systemic rheumatologic disorders. LATEST DEVELOPMENTS Although most have historically been classified as autoimmune disorders, rheumatologic diseases are increasingly conceptualized as distributed along a spectrum with various contributions of autoimmune (adaptive immune dysregulation) and autoinflammatory (innate immune dysregulation) mechanisms. Our evolving understanding of systemic immune-mediated disorders has been accompanied by an expansion in our differential diagnoses and therapeutic options. ESSENTIAL POINTS Rheumatologic disease involves both autoimmune and autoinflammatory mechanisms. Neurologic symptoms can be the first manifestation of these disorders, and familiarity with the systemic manifestations of specific diseases is essential to establish the correct diagnosis. Conversely, knowledge of the neurologic syndromes that are most likely to be associated with specific systemic disorders can help narrow the differential and increase confidence when attributing a neuropsychiatric symptom to an underlying systemic disorder.
Collapse
|
10
|
Shimojima Y, Sekijima Y. Hypertrophic pachymeningitis in ANCA-associated vasculitis: Clinical and immunopathological features and insights. Autoimmun Rev 2023; 22:103338. [PMID: 37062439 DOI: 10.1016/j.autrev.2023.103338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
Hypertrophic pachymeningitis (HP) is an inflammatory disorder characterized by intracranial and spinal thickened dura mater, leading to several neurological manifestations including headaches, cranial neuropathies, seizures, and sensorimotor disorders. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a crucial disease that is implicated in the development of immune-mediated HP. HP is observed throughout the clinical course of AAV, and 3%-4% of patients with AAV experience HP as the initial clinical episode. However, patients with ANCA-related HP are unclassifiable in the classification criteria of AAV when HP is the only manifestation, suggesting that ANCA-related HP can be identified as a central nervous system-limited type of AAV. Among patients with AAV, those who develop HP have predominantly been classified as having granulomatosis with polyangiitis (GPA). Myeloperoxidase-ANCA positivity has been more frequently demonstrated than proteinase 3-ANCA positivity in patients with ANCA-related HP. The ear, nose, and throat manifestations, such as otitis media, sinusitis, and mastoiditis, as well as mucous membranes/eyes manifestations including sudden visual loss, are robustly associated with HP in AAV. The histology of thickened dura mater tissues includes fibrotic changes and infiltration of several immunocompetent cells, but the typical findings of GPA, such as granulomatous inflammation with necrotizing vasculitis, are not observed in all patients with ANCA-related HP. Corticosteroids are the first-line therapy for ANCA-related HP, while the concomitant use of immunosuppressive agents including cyclophosphamide, methotrexate, and mycophenolate mofetil, is an ideal strategy for achieving remission. Rituximab is a useful agent in refractory ANCA-related HP.
Collapse
Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| |
Collapse
|
11
|
Ungprasert P, Wijarnpreecha K, Dejhansathit S, Cheungpasitporn W. Antineutrophil Cytoplasmic Autoantibodies-Associated Vasculitides and Risk of Stroke: A Systematic Review and Meta-analysis. Neurol India 2022; 70:1868-1873. [PMID: 36352580 DOI: 10.4103/0028-3886.359250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Increased incidence of cardiovascular disease, including stroke, has been consistently observed in patients with chronic inflammatory diseases, although data on antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides (AAV) are still limited due to the relative rarity of the disease. METHODS Two investigators independently searched published studies indexed in MEDLINE and EMBASE database from inception to June 2019 using the search terms related to AAV and stroke. The eligible study must be cohort study that consisted of cohort of patients with AAV and cohort of patients without AAV. The study must follow the participants for incident stroke. The magnitude of difference in the incidence of stoke between the cohorts must be reported. Pooled effect estimates were calculated by combining the effect estimate of each eligible study using generic inverse variance method. Statistical heterogeneity was assessed using the Cochran's Q test and I2 statistics. All analyses were conducted using RevMan 5.3 software from the Cochrane Collaboration. RESULTS A total of six cohort studies fulfilled the eligibility criteria and were included into the meta-analysis. Patients with AAV had a higher risk of developing incident stroke than individuals without AAV with the a pooled risk ratio of 2.02 (95% CI, 1.02-4.00; I2 of 89%). Funnel revealed no suggestive evidence of publication bias. CONCLUSION A significantly higher risk of incident stroke among patients with AAV than individuals without AAV was demonstrated by this meta-analysis.
Collapse
Affiliation(s)
- Patompong Ungprasert
- Department of Research and Development, Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Siroj Dejhansathit
- Department of Internal Medicine, Texas Tech University Health Science Center, Lubbock, Texas, USA
| | - Wisit Cheungpasitporn
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
12
|
Shimojima Y, Kishida D, Ichikawa T, Kida T, Yajima N, Omura S, Nakagomi D, Abe Y, Kadoya M, Takizawa N, Nomura A, Kukida Y, Kondo N, Yamano Y, Yanagida T, Endo K, Hirata S, Matsui K, Takeuchi T, Ichinose K, Kato M, Yanai R, Matsuo Y, Nishioka R, Okazaki R, Takata T, Ito T, Moriyama M, Takatani A, Miyawaki Y, Ito-Ihara T, Kawaguchi T, Kawahito Y, Sekijima Y. Hypertrophic pachymeningitis in ANCA-associated vasculitis: a cross-sectional and multi-institutional study in Japan (J-CANVAS). Arthritis Res Ther 2022; 24:204. [PMID: 35999568 PMCID: PMC9396769 DOI: 10.1186/s13075-022-02898-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study investigated the characteristics of hypertrophic pachymeningitis (HP) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), using information from a multicenter study in Japan. METHODS We analyzed the clinical information of 663 Asian patients with AAV (total AAV), including 558 patients with newly diagnosed AAV and 105 with relapsed AAV. Clinical findings were compared between patients with and without HP. To elucidate the relevant manifestations for HP development, multivariable logistic regression analyses were additionally performed. RESULTS Of the patients with AAV (mean age, 70.2 ± 13.5 years), HP was noted in 30 (4.52%), including 20 (3.58%) with newly diagnosed AAV and 10 (9.52%) with relapsed AAV. Granulomatosis with polyangiitis (GPA) was classified in 50% of patients with HP. A higher prevalence of GPA was significantly observed in patients with HP than in those without HP in total AAV and newly diagnosed AAV (p < 0.001). In newly diagnosed AAV, serum proteinase 3 (PR3)-ANCA positivity was significantly higher in patients with HP than in those without HP (p = 0.030). Patients with HP significantly had ear, nose, and throat (ENT) (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.03-2.14, p = 0.033) and mucous membrane/eye manifestations (OR 5.99, 95% CI 2.59-13.86, p < 0.0001) in total AAV. Moreover, they significantly had conductive hearing loss (OR 11.6, 95% CI 4.51-29.57, p < 0.0001) and sudden visual loss (OR 20.9, 95% CI 5.24-85.03, p < 0.0001). CONCLUSION GPA was predominantly observed in patients with HP. Furthermore, in newly diagnosed AAV, patients with HP showed significantly higher PR3-ANCA positivity than those without HP. The ear and eye manifestations may be implicated in HP development.
Collapse
Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Takashi Kida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Omura
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University, Tokyo, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Naoya Kondo
- Department of Nephrology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Takuya Yanagida
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoshi Matsui
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo Medical University School of Medicine, Nishinomiya, Hyogo, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Matsuo
- Department of Rheumatology, Tokyo Kyosai Hospital, Tokyo, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University, Yonago, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Hospital, Izumo, Shimane, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Ayuko Takatani
- Rheumatic Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| |
Collapse
|
13
|
Asakawa S, Arai S, Kawagoe M, Ohata C, Ono W, Murata H, Tamura Y, Uchida S, Shibata S, Fujigaki Y. A Young Patient with Microscopic Polyangiitis Requiring Hemodialysis with Complications of Repeated Episodes of Posterior Reversible Encephalopathy Syndrome Probably Due to Different Etiologies. Intern Med 2022; 61:1423-1431. [PMID: 34645762 PMCID: PMC9152853 DOI: 10.2169/internalmedicine.7941-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
A young woman with microscopic polyangiitis (MPA) requiring hemodialysis showed repeated posterior reversible encephalopathy syndrome (PRES) with spatiotemporal multiple lesions over a period of two months. The first PRES episode with confusion and the second PRES episode with vertigo and nausea were caused by MPA, hypertension and renal failure. These symptoms were improved by the reinforcement of MPA treatment and blood pressure management. The third PRES episode with nausea, headache, seizure and visual changes was induced by rituximab infusion and hypertension. The PRES was improved with blood pressure and convulsant management. These conditions are challenging to diagnose and treat.
Collapse
Affiliation(s)
- Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Mika Kawagoe
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Chiaki Ohata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Wataru Ono
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Hiroshi Murata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| |
Collapse
|
14
|
Koritala T, Mene-Afejuku TO, Schaefer M, Dondapati L, Pleshkova Y, Yasmin F, Mushtaq HA, Khedr A, Adhikari R, Al Mutair A, Alhumaid S, Rabaan AA, Al-Tawfiq JA, Jain NK, Khan SA, Kashyap R, Surani S. Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature. Cureus 2021; 13:e19814. [PMID: 34963834 PMCID: PMC8695666 DOI: 10.7759/cureus.19814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), formerly named Wegner’s granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.
Collapse
Affiliation(s)
| | | | | | - Lavanya Dondapati
- Internal Medicine, Dr. N.T.R University of Health Sciences, Vijayawada, IND
| | | | - Farah Yasmin
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | | | - Anwar Khedr
- Critical Care Medicine, Mayo Clinic, Mankato, USA.,Medicine, Tanta University Faculty of Medicine, Tanta, EGY
| | - Ramesh Adhikari
- Hospital Medicine, Franciscan Health, Lafayette, USA.,Geriatrics, Brown University, Providence, USA
| | - Abbas Al Mutair
- Emergency Medicine, Almoosa Specialist Hospital, Al-Ahsa, SAU
| | - Saad Alhumaid
- Pharmaceutical Care, Al-Ahsa Health Cluster, Al-Ahsa, SAU
| | - Ali A Rabaan
- Molecular Microbiology, Johns Hopkins Aramco Healthcare, Dhahran, SAU
| | | | | | | | - Rahul Kashyap
- Anesthesiology and Critical Care, Mayo Clinic, Rochester, USA
| | - Salim Surani
- Anesthesiology, Mayo Clinic, Rochester, USA.,Medicine, Texas A&M University, College Station, USA.,Medicine, University of North Texas Dallas, Dallas, USA.,Internal Medicine, Pulmonary Associates of Corpus Christi, Corpus Christi, USA.,Clinical Medicine, University of Houston, Houston, USA
| |
Collapse
|
15
|
Taylor K, Muscal E, Van Mater H. The Role of Pediatric Rheumatologists in Autoimmune Brain Disease. Rheum Dis Clin North Am 2021; 48:343-369. [PMID: 34798957 DOI: 10.1016/j.rdc.2021.09.002] [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: 10/19/2022]
Abstract
The spectrum of autoimmune and inflammatory brain diseases continues to evolve with medical advances facilitating both the detection of inflammation of the central nervous system and the discovery of novel disease mechanisms. The clinical overlap of these disorders with primary rheumatic diseases and the efficacy of immunotherapy have led to strong partnerships between pediatric rheumatologists, neurologists, psychiatrists, and other providers in the care of children with these conditions. Early diagnosis and initiation of targeted therapy improve clinical outcomes, highlighting the importance of interdisciplinary collaborative care.
Collapse
Affiliation(s)
- Kathryn Taylor
- Pediatrics, Division of Neurology, Duke University, Durham, NC, USA.
| | - Eyal Muscal
- Division of Rheumatology and Co-appointment in Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Heather Van Mater
- Pediatrics, Division of Rheumatology, Duke University, Durham, NC, USA
| |
Collapse
|
16
|
Vasculitis Presenting as Autonomic Failure. Neurologist 2021; 26:117-121. [PMID: 34190203 DOI: 10.1097/nrl.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Granulomatosis with polyangiitis (GPA) is a vasculitic process that can cause neurological dysfunction in addition to characteristic sinus and pulmonary manifestations. This case report highlights the spectrum of nervous system manifestations and includes rarely reported autonomic and pituitary involvement. CASE REPORT A 62-year-old woman presented with orthostatic intolerance, tachycardia, dry mouth, and temperature sensitivity; subsequent autonomic reflex study demonstrated widespread postganglionic sympathetic sudomotor, cardiovagal, and cardiovascular adrenergic impairment reflective of autonomic neuropathy and overall autonomic failure. Additional progressive symptoms included dysarthria, dysphagia, bilateral hearing loss, voice hoarseness, and right-sided facial numbness with multiple cranial neuropathies identified on neurological examination. The diagnosis of central diabetes insipidus was also confirmed. Pachymeningitis was present on brain magnetic resonance imaging. Pathologic review of the dural biopsy specimen revealed necrotizing granulomatous vasculitis consistent with GPA. She was treated with intravenous methylprednisolone and rituximab. Over the next 2 months, she had near-complete resolution of her symptoms with normalization on repeat autonomic testing. CONCLUSIONS This is a unique GPA case presenting with autonomic failure and pituitary dysfunction with conclusive objective findings of autonomic dysfunction. Autonomic dysfunction and other disease manifestations were responsive to immunosuppressive therapy.
Collapse
|
17
|
Araújo T, Maia R, Massano J, Mendonça L, Guimarães J. From Kidney to Brain: An Uncommon Severe Relapse of Myeloperoxidase Anti-Neutrophil Cytoplasmic Antibody (MPO-ANCA) Vasculitis. Cureus 2021; 13:e14205. [PMID: 33936909 PMCID: PMC8086049 DOI: 10.7759/cureus.14205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/06/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of rare autoimmune diseases that affect medium and small blood vessels, with uncommon, variable central nervous system (CNS) involvement. It poses diagnosis challenges due to the limited accuracy of conventional imaging and vast differential diagnosis. We describe the case of a 76-year-old man with a previously diagnosed myeloperoxidase (MPO)-positive AAV with exclusive renal involvement. The patient presented to our emergency department (ED) with sudden-onset weakness of the right side of the body, difficulty speaking, fever, and a history of progressive cognitive impairment in the previous three months (loss of memory, time and space disorientation, acalculia). Brain imaging showed multiple acute and subacute ischemic lesions, suggesting CNS vasculitic involvement. The patient was treated with methylprednisolone pulses, followed by rituximab, with motor and cognitive improvement. Timely diagnosis and adequate treatment of AAV as a cause for new-onset neurological symptoms are crucial to improve outcomes. Otherwise, a higher risk of relapse remains, and extensive neurological deficits may become permanent. Evidence regarding the best treatment options in these patients is scarce and case reports provide further data on this topic.
Collapse
Affiliation(s)
- Tiago Araújo
- Department of Internal Medicine, Unidade Local de Saúde do Litoral Alentejano, Santiago do Cacém, PRT
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Rúben Maia
- Department of Neuroradiology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - João Massano
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, PRT
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina da Universidade do Porto, Porto, PRT
| | - Luis Mendonça
- Department of Nephrology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Joana Guimarães
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, PRT
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina da Universidade do Porto, Porto, PRT
| |
Collapse
|
18
|
Krishna R, De Giacomi F, Kumar N, Kalina P, Specks U, Baqir M. Rituximab Versus Cyclophosphamide for Central Nervous System Involvement of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Series. J Clin Rheumatol 2021; 27:64-72. [PMID: 31567753 DOI: 10.1097/rhu.0000000000001169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the effectiveness of rituximab (RTX) with cyclophosphamide (CYC) in patients who have central nervous system (CNS) involvement in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS A computer-assisted search was conducted to identify all adults who received a diagnosis of AAV with CNS involvement from January 1, 1997, through July 1, 2017, at our institution. RESULTS Of the 17 patients identified, 11 had received RTX, and 6 had received CYC. Age at diagnosis of CNS involvement was similar in both groups. In the RTX group, 91% of the patients were women; in the CYC group, 33% were women (p = 0.03). At the time of CNS presentation, orbital involvement had occurred in 6 patients in the RTX group and in none of the patients in the CYC group. Initial remission of induction was achieved in all patients (100%) in the CYC group and in 10 patients (91%) in the RTX group. Two patients had no response to RTX: 1 patient when RTX was used for remission induction at the time of diagnosis and the second patient when RTX was used for remission induction after relapse. The median follow-up was 38 months (range, 9-127 months). Central nervous system relapse occurred in 4 patients in the RTX group and in 1 patient in the CYC group. Of the 4 patients in the RTX group with relapse, 3 had marked ocular involvement. Both nonresponder patients in the RTX group had ocular involvement. CONCLUSION Rituximab is as effective as CYC in remission induction in patients with CNS involvement in AAV.
Collapse
Affiliation(s)
- Rachana Krishna
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Federica De Giacomi
- Cardio-Thoracic-Vascular Department, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | | | | | - Ulrich Specks
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
19
|
Yang Z, Cai D, Sun Y, Zhong D, Zhou H, Zhang D, Zhang W. Intramedullary lesion resection as an effective treatment of spinal cord microscopic polyangiitis: a case report. Neurol Sci 2021; 42:3943-3946. [PMID: 33608757 DOI: 10.1007/s10072-021-05103-7] [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: 09/03/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Microscopic polyangiitis (MPA), an autoimmune disease, is a subtype of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The lungs and kidneys are the most common targets, whereas spinal cord involvement is rare. METHODS We reported the clinical manifestations, diagnosis, and management of a patient with spinal cord MPA. RESULTS The patient showed spinal compression symptoms and was diagnosed with MPA following magnetic resonance imaging (MRI) and histological examination. Spinal compression symptoms were completely relieved after intramedullary lesion resection and postoperative treatment with methylprednisolone. CONCLUSION The diagnosis of MPA without typical manifestations can be challenging. MRI and histological examination are of great importance in spinal cord MPA diagnosis. Intramedullary lesion resection is an effective treatment for spinal cord MPA. Methylprednisolone is also recommended for postoperative treatment.
Collapse
Affiliation(s)
- Zhiqian Yang
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Research Center of Stem Cell Therapy for Pituitary Disease, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Critical Disease Stem Cell Therapy Innovation Team, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Dongpeng Cai
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Research Center of Stem Cell Therapy for Pituitary Disease, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Yesheng Sun
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Research Center of Stem Cell Therapy for Pituitary Disease, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Dequan Zhong
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Hui Zhou
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Deyuan Zhang
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Guangdong Provincial Engineering and Technology Research Center of Stem Cell Therapy for Pituitary Disease, No. 19 Nonglinxia Road, Guangzhou, 510080, China.,Critical Disease Stem Cell Therapy Innovation Team, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China
| | - Wei Zhang
- Department of Neurosurgery, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China. .,Guangdong Provincial Engineering and Technology Research Center of Stem Cell Therapy for Pituitary Disease, No. 19 Nonglinxia Road, Guangzhou, 510080, China. .,Critical Disease Stem Cell Therapy Innovation Team, First Affiliated Hospital of Guangdong Pharmaceutics University, No. 19 Nonglinxia Road, Guangzhou, 510080, China.
| |
Collapse
|
20
|
Triano MJ, Haberstroh WD, Lenka A, Whelton SA. Relapsed granulomatosis with polyangiitis with panhypopituitarism. BMJ Case Rep 2021; 14:14/1/e237774. [PMID: 33509867 PMCID: PMC7845712 DOI: 10.1136/bcr-2020-237774] [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: 01/30/2023] Open
Abstract
A man in his early 60s with a medical history of granulomatosis with polyangiitis (GPA) in remission for two decades without maintenance therapy presented with non-specific complaints of profound fatigue and 40-pound weight loss. He was seronegative for antinuclear antibodies and cytoplasmic antineutrophilic antibodies, but erythrocyte sedimentation rate and C reactive protein levels were elevated. Endocrinological testing revealed adrenal insufficiency, hypogonadism, hypothyroidism and diabetes insipidus. An MRI of the head revealed extensive sinonasal inflammation eroding through the floor of the sella turcica and into the pituitary gland and stalk. Biopsy of the sinonasal tissues was inconclusive. On review of his case, a multidisciplinary team diagnosed him with panhypopituitarism secondary to a recurrence of GPA. He responded well to glucocorticoids and methotrexate with marked reduction of pituitary enhancement on imaging and resolution of diabetes insipidus. He will require lifelong testosterone, levothyroxine and glucocorticoids for hormone replacement therapy.
Collapse
Affiliation(s)
- Matthew J Triano
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA
| | - William D Haberstroh
- Division of General Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Abhishek Lenka
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean A Whelton
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA,Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA
| |
Collapse
|
21
|
Wu M, Ren J, Luo Y. Hypertrophic spinal pachymeningitis caused by ANCA-associated vasculitis revealed by 18F-FDG PET/CT: A case report. Medicine (Baltimore) 2021; 100:e24388. [PMID: 33546079 PMCID: PMC7837913 DOI: 10.1097/md.0000000000024388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) can involve the central nervous system in estimatedly 15% of patients. Hypertrophic pachymeningitis causes inflammatory hypertrophy of the cranial or spinal dura mater and patients present with various neurological deficits. ANCA-associated hypertrophic spinal pachymeningitis has rarely been reported in literature. We report a case of AAV presenting with hypertrophic spinal pachymeningitis detected by 18F-FDG PET/CT. PATIENT CONCERNS A 66-year-old woman diagnosed with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis developed back pain, bilateral lower limb weakness, dysuria, and dysporia 1 month ago. DIAGNOSIS Contrast-enhanced MRI showed thickening and enhancement of the dura mater in the thoracic cord. Intraspinal hypermetabolism in the corresponding region was observed on 18F-FDG PET/CT. The patient was finally diagnosed with ANCA-associated hypertrophic spinal pachymeningitis. INTERVENTIONS The patient was treated with a higher dose of prednisone and cyclophosphamide. OUTCOMES After 2-week treatment, the patient's neurological symptoms improved rapidly and laboratory findings were ameliorated. A repeated contrast-enhanced MRI showed partial improvement of the disease in the thoracic cord. LESSONS 18F-FDG PET/CT and contrast-enhanced MRI can aid in the clinical diagnosis and surveillance in AAV-associated hypertrophic spinal pachymeningitis and potentially facilitate early recognition and intervention to prevent irreversible neurological impairment.
Collapse
Affiliation(s)
- Meiqi Wu
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine; Beijing, PR China
| | - Jingyun Ren
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine; Beijing, PR China
| | - Yaping Luo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine; Beijing, PR China
| |
Collapse
|
22
|
Abrantes FF, Moraes MPMD, Rezende Filho FM, Pedroso JL, Barsottini OGP. A clinical approach to hypertrophic pachymeningitis. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:797-804. [PMID: 33295420 DOI: 10.1590/0004-282x20200073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms. OBSERVATIONS HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor. CONCLUSION HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.
Collapse
Affiliation(s)
- Fabiano Ferreira Abrantes
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Flávio Moura Rezende Filho
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | - José Luiz Pedroso
- Universidade Federal de São Paulo, Divisão de Neurologia Geral, Departamento de Neurologia, São Paulo SP, Brazil
| | | |
Collapse
|
23
|
Xiao X, Fu D, Feng L. Hypertrophic Pachymeningitis in a Southern Chinese Population: A Retrospective Study. Front Neurol 2020; 11:565088. [PMID: 33281701 PMCID: PMC7705170 DOI: 10.3389/fneur.2020.565088] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/07/2020] [Indexed: 11/13/2022] Open
Abstract
Aims: To investigate the causes, clinical characteristics, imaging features, and therapeutic implications of hypertrophic pachymeningitis (HP) in a southern Chinese population. Methods: We retrospectively analyzed 48 patients with HP with different causes from 1 January 2006 to 31 December 2018. Clinical manifestation, laboratory findings, and neuroimaging results were evaluated in all HP patients. Results: The mean age at onset was 50 ± 12 years. The most common diagnosis was idiopathic HP (67%), followed by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (15%), tuberculous meningitis (8%), viral meningitis (6%), and bacterial meningitis (4%). Headache was the most common symptom. The most frequently changed laboratory finding was elevated erythrocyte sedimentation rate (ESR). Imaging was characterized by cerebral or spinal dura mater enhancement in MRI scan with contrast. Enhancements were mainly located in the posterior fossa for idiopathic HP; frontal, parietal, and occipital lobes for ANCA-related HP; and posterior fossa for tuberculous-associated HP. Diffuse enhancement was found in most cases, except for tuberculous-associated HP. Glucocorticoid or immunosuppressive treatment was applied in most cases. Conclusions: The etiology of HP varied among patients, with idiopathic HP being the most common. MRI showed enhancement of the dura mater, which differed according to different etiologies. Glucocorticoid or immunosuppressive agents were the primary drugs for treatment.
Collapse
Affiliation(s)
- Xuewen Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Dongni Fu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, China
| | - Li Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
24
|
Gul M, Azari Jafari A, Shah M, Mirmoeeni S, Haider SU, Moinuddin S, Chaudhry A. Molecular Biomarkers in Multiple Sclerosis and Its Related Disorders: A Critical Review. Int J Mol Sci 2020; 21:E6020. [PMID: 32825639 PMCID: PMC7547375 DOI: 10.3390/ijms21176020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/17/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system (CNS) which can lead to severe disability. Several diseases can mimic the clinical manifestations of MS. This can often lead to a prolonged period that involves numerous tests and investigations before a definitive diagnosis is reached. As well as the possibility of misdiagnosis. Molecular biomarkers can play a unique role in this regard. Molecular biomarkers offer a unique view into the CNS disorders. They help us understand the pathophysiology of disease as well as guiding our diagnostic, therapeutic, and prognostic approaches in CNS disorders. This review highlights the most prominent molecular biomarkers found in the literature with respect to MS and its related disorders. Based on numerous recent clinical and experimental studies, we demonstrate that several molecular biomarkers could very well aid us in differentiating MS from its related disorders. The implications of this work will hopefully serve clinicians and researchers alike, who regularly deal with MS and its related disorders.
Collapse
Affiliation(s)
- Maryam Gul
- Precision Rheumatology INC, 2050 South Euclid Street, Anaheim, CA 92802, USA
| | - Amirhossein Azari Jafari
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud 3614773947, Iran; (A.A.J.); (S.M.)
| | - Muffaqam Shah
- Deccan College of Medical Sciences, P.O. Kanchanbagh, DMRL ‘X’ Road, Santhosh Nagar, Hyderabad 500058, Telangana State, India;
| | - Seyyedmohammadsadeq Mirmoeeni
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud 3614773947, Iran; (A.A.J.); (S.M.)
| | - Safee Ullah Haider
- Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Lahore 54000, Pakistan;
| | - Sadia Moinuddin
- Department of Internal Medicine, San Antonio Regional Medical Center, 999 San Bernardino Rd, Upland, CA 91786, USA;
| | - Ammar Chaudhry
- Department of Radiology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA;
| |
Collapse
|
25
|
Sloane KL, Anand P. Inflammatory Vasculitides of the Central Nervous System. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00817-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
26
|
Li C, Zou Y, Lu X, Wang G, Shu X. Pituitary dysfunction in patients with ANCA associated vasculitis: prevalence, presentation, and outcomes. Ther Adv Chronic Dis 2020; 11:2040622320930636. [PMID: 32566116 PMCID: PMC7285954 DOI: 10.1177/2040622320930636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/22/2020] [Indexed: 11/23/2022] Open
Abstract
Background: The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are rare multisystem autoimmune diseases characterized by inflammatory cell infiltration causing necrosis of small blood vessels. Pituitary involvement in AAV is poorly described. This study aimed to describe the prevalence, clinical characteristics, and outcomes of pituitary involvement in patients with AAV. Methods: A total of 150 patients diagnosed with AAV and hospitalized in the China–Japan Friendship Hospital between 2009 and 2019 were enrolled in this retrospective study. Patients diagnosed with pituitary involvement in AAV were selected for inclusion. Results: Three patients (2%) were identified with pituitary involvement. Two patients had positive ANCA titers, one with proteinase 3 positive and one with myeloperoxidase positive antibodies. Pituitary dysfunction presented as an initial symptom in one patient and developed over the course of the diseases in the other two patients. All three patients had abnormal hormones. Among them, two patients had an enlarged pituitary, shown by magnetic resonance images (MRIs), and one patient had a normal sized pituitary, shown by MRI, but presented with increased linear radioactivity uptake in the pituitary fossa by positron emission tomography-computed tomography. All patients were treated with corticosteroid and immunosuppressive therapy. Both pituitary dysfunction and vasculitis were in remission. Conclusion: Pituitary involvement is uncommon in AAV and it can occur at any point during AAV. The main clinical manifestations are central diabetes insipidus and panhypopituitarism. Immunosuppressive therapy could significantly alleviate clinical symptoms as well as pituitary imaging.
Collapse
Affiliation(s)
- Chunjia Li
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Yu Zou
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoming Shu
- Department of Rheumatology, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, Beijing, 100029, China
| |
Collapse
|
27
|
Wildner P, Stasiołek M, Matysiak M. Differential diagnosis of multiple sclerosis and other inflammatory CNS diseases. Mult Scler Relat Disord 2020; 37:101452. [DOI: 10.1016/j.msard.2019.101452] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/12/2022]
|
28
|
Soun JE, Song JW, Romero JM, Schaefer PW. Central Nervous System Vasculopathies. Radiol Clin North Am 2019; 57:1117-1131. [DOI: 10.1016/j.rcl.2019.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
29
|
Sattui SE, Spiera RF. Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Is There Still a Role for Cyclophosphamide? Rheum Dis Clin North Am 2019; 45:379-398. [PMID: 31277751 DOI: 10.1016/j.rdc.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of systemic necrotizing vasculitides that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Treatment of these conditions has improved during the past 2 decades with better understanding of these conditions and availability of newer agents. Cyclophosphamide (CYC) was the first drug demonstrated to afford successful treatment and improvement in AAV. With the emergence of newer agents with more favorable safety profiles, CYC is no longer the cornerstone of management of AAV. This article reviews existing data for treatment and the current role of CYC in the management of AAV.
Collapse
Affiliation(s)
- Sebastian E Sattui
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Robert F Spiera
- Division of Rheumatology, Department of Medicine, Weill Cornell Medical College, Scleroderma, Vasculitis & Myositis Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| |
Collapse
|
30
|
Zhang S, Yuan D, Tan G. Neurological Involvement in Primary Systemic Vasculitis. Front Neurol 2019; 10:430. [PMID: 31105641 PMCID: PMC6498988 DOI: 10.3389/fneur.2019.00430] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/09/2019] [Indexed: 11/16/2022] Open
Abstract
Primary systemic vasculitis can affect every structure in both the central and peripheral nervous system, causing varied neurological manifestations of neurological dysfunction. Early recognition of the underlying causes of the neurological symptoms can facilitate timely treatment and improve the prognosis. This review highlights the clinical manifestations of primary systemic vasculitis in the nervous system.
Collapse
Affiliation(s)
- Shanshan Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongli Yuan
- The Institute of Medical Information, Chongqing Medical University, Chongqing, China
| | - Ge Tan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
31
|
Abstract
"Vasculitides are a heterogeneous group of inflammatory diseases of blood vessels in which genetic variation plays an important role in their susceptibility and clinical spectrum. Because of the use of novel technologies and the increase of the sample size of the study cohorts, the knowledge of the genetic background of vasculitides has considerably expanded during the last years. However, few insights have been obtained regarding the genetics underlying severe clinical phenotypes, such as those related to the nervous system. In this review the authors provide an updated overview of the genetic landscape behind vasculitis predisposition and development of neurologic manifestations."
Collapse
|
32
|
Zheng Y, Zhang Y, Cai M, Lai N, Chen Z, Ding M. Central Nervous System Involvement in ANCA-Associated Vasculitis: What Neurologists Need to Know. Front Neurol 2019; 9:1166. [PMID: 30687221 PMCID: PMC6335277 DOI: 10.3389/fneur.2018.01166] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective: To provide a comprehensive review of the central nervous system (CNS) involvement in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), including the pathogenesis, clinical manifestations, ancillary investigations, differential diagnosis, and treatment. Particular emphasis is placed on the clinical spectrum and diagnostic testing of AAV. Recent Findings: AAV is a pauci-immune small-vessel vasculitis characterized by neutrophil-mediated vasculitis and granulomatousis. Hypertrophic pachymeninges is the most frequent CNS presentation. Cerebrovascular events, hypophysitis, posterior reversible encephalopathy syndrome (PRES) or isolated mass lesions may occur as well. Spinal cord is rarely involved. In addition, ear, nose and throat (ENT), kidney and lung involvement often accompany or precede the CNS manifestations. Positive ANCA testing is highly suggestive of the diagnosis, with each ANCA serotype representing different groups of AAV patients. Pathological evidence is the gold standard but not necessary. Once diagnosed, prompt initiation of induction therapy, including steroid and other immunosuppressants, can greatly mitigate the disease progression. Conclusions and Relevance: Early recognition of AAV as the underlying cause for various CNS disorders is important for neurologists. Ancillary investigations especially the ANCA testing can provide useful information for diagnosis. Future studies are needed to better delineate the clinical spectrum of CNS involvement in AAV and the utility of ANCA serotype to classify those patients. Evidence Review: We searched Pubmed for relevant case reports, case series, original research and reviews in English published between Sep 1st, 2001 and Sep 1st, 2018. The following search terms were used alone or in various combinations: “ANCA,” “proteinase 3/PR3-ANCA,” “myeloperoxidase/MPO-ANCA,” “ANCA-associated vasculitis,” “Wegener's granulomatosis,” “microscopic polyangiitis,” “Central nervous system,” “brain” and “spinal cord”. All articles identified were full-text papers.
Collapse
Affiliation(s)
- Yang Zheng
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yinxi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mengting Cai
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Nanxi Lai
- Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhong Chen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Pharmacology, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, College of Pharmaceutical Sciences, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meiping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
33
|
Hypertrophic pachymeningitis as an important neurological complication of granulomatosis with polyangiitis. Reumatologia 2018; 56:399-405. [PMID: 30647488 PMCID: PMC6330683 DOI: 10.5114/reum.2018.80719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022] Open
Abstract
Headache is a common symptom in patients with granulomatosis with polyangiitis (GPA) mainly due to chronic sinusitis or orbital disease. Meningeal involvement may thus remain unrecognized for a long time. This can lead to a significant delay in accurate diagnosis, serious local damage of the central nervous system and high relapse rates. New diagnostic techniques such as contrast MRI allow one to identify inflammation of the dura mater in the course of GPA more frequently. The objective of this article is to characterize hypertrophic pachymeningitis (HP) in patients with GPA and report diagnostic difficulties associated with this complication.
Collapse
|