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Li S, Gao Y, He Y, Zhang Z. A case report of AQP4-IgG-seropositive refractory neuromyelitis optica spectrum disorder patient with Sjögren's syndrome and pancytopenia treated with inebilizumab. Front Neurol 2024; 15:1371515. [PMID: 38899058 PMCID: PMC11185937 DOI: 10.3389/fneur.2024.1371515] [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: 01/16/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Patients with neuromyelitis optica spectrum disorder (NMOSD) coexisting with both Sjögren's syndrome (SS) and pancytopenia are exceptionally rare. There is no study on the treatment of such patients. We presented a case of AQP4-IgG seropositive refractory NMOSD patient combined with SS and pancytopenia with significant response to inebilizumab. In 2017 the 49-year-old female patient was diagnosed with SS and pancytopenia without any treatment. In August 2022, she had a sudden onset of lower limbs weakness, manifested as inability to walk, accompanied by urinary incontinence. After receiving methylprednisolone and cyclophosphamide, she regained the ability to walk. In February 2023, she suffered from weakness of both lower limbs again and paralyzed in bed, accompanied by retention of urine and stool, and loss of vision in both eyes. After receiving methylprednisolone and three plasmapheresis, the condition did not further worsen, but there was no remission. In March 2023, the patient was admitted to our hospital and was formally diagnosed with AQP4-IgG seropositive NMOSD combined with SS and pancytopenia. After receiving two 300 mg injections of inebilizumab, not only the symptoms of NMOSD improved significantly, but also the symptoms of concurrent SS and pancytopenia. In the cases of AQP4-IgG seropositive NMOSD who have recurrent episodes and are comorbid with other autoimmune disorders, inebilizumab may be a good choice.
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Affiliation(s)
- Shasha Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yuting Gao
- Department of Neurology, Peking University People’s Hospital, Beijing, China
| | - Yang He
- Department of Neurology, Peking University People’s Hospital, Beijing, China
| | - Zhaoxu Zhang
- Department of Neurology, Peking University People’s Hospital, Beijing, China
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Tamanini JVG, Sabino JV, Cordeiro RA, Mizubuti V, Villarinho LDL, Duarte JÁ, Pereira FV, Appenzeller S, Damasceno A, Reis F. The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies. Semin Ultrasound CT MR 2023; 44:469-488. [PMID: 37555683 DOI: 10.1053/j.sult.2023.03.017] [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: 04/09/2023]
Abstract
Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.
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Affiliation(s)
| | - João Vitor Sabino
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Sao Paulo University, SP, Brazil
| | - Vanessa Mizubuti
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Juliana Ávila Duarte
- Department of Radiology and Diagnostic Imaging, HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda Veloso Pereira
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Alfredo Damasceno
- Department of Neurology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fabiano Reis
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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Kim JY, Lee YH, Kim JY, Lee HH, Kim YH. Intrathecal drug delivery to treat intractable neuropathic pain following Sjögren's syndrome-induced transverse myelitis: A case report. Medicine (Baltimore) 2021; 100:e26141. [PMID: 34087868 PMCID: PMC8183848 DOI: 10.1097/md.0000000000026141] [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] [Received: 03/17/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Transverse myelitis (TM) is a spinal cord inflammatory myelopathy that causes motor/sensory loss and urinary retention below the level of the affected spinal cord. Although a few case reports have described the control of neuropathic pain in patients with TM via spinal cord stimulation, no documented case regarding the control of severe allodynia following TM via intrathecal pump has been described. PATIENT CONCERNS A 37-year-old woman was referred to a pain clinic for severe intractable pain below the T5 level followed by Sjögren's syndrome-induced TM. DIAGNOSES A neurological examination revealed paresthesia and allodynia below the T5 level. The sensory evaluation was limited by extreme pain and jerking movements. The muscle strength of both lower limbs was grade 3. INTERVENTIONS Intrathecal pump was inserted into the left lower abdomen. Catheter tip was placed at the midline of the T8 level. OUTCOMES The numeric rating scale (NRS) for pain score decreased from 10 to 5. Functional Independence Measure score increased from 67 before implantation to 92 at the time of discharge, while the patient's Barthel score increased from 31 to 46. LESSONS Neuropathic pain due to Sjögren's syndrome-related TM could be controlled effectively using the intrathecal morphine pump.
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Affiliation(s)
- Ji Yeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul
| | - Yong Ho Lee
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Hospital, Daegu
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Hwa Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Hoon Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Gallo A, Martellucci S, Fusconi M, Pagliuca G, Greco A, De Virgilio A, De Vincentiis M. Sialendoscopic management of autoimmune sialadenitis: a review of literature. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:148-154. [PMID: 28516978 PMCID: PMC5463523 DOI: 10.14639/0392-100x-1605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/12/2016] [Indexed: 12/24/2022]
Abstract
Autoimmune diseases of major salivary glands include Sjögren's syndrome and a complex of disorders classified as immunoglobulin G4-related diseases. These pathologies are characterised by an autoimmune reaction mediated by T-helper lymphocytes that targets the ducts of exocrine glands in Sjögren's syndrome and glandular parenchyma in immunoglobulin G4-related diseases. Immunoglobulin G4-related diseases represent recently introduced multi-organ diseases that also involve the salivary glands. However, the morbid conditions once known as Mikulicz's disease and Kuttner's tumour were recently considered as two variants of immunoglobulin G4-related diseases affecting the major salivary glands ( immunoglobulin G4-related sialadenitis). This review briefly summarises the pathogenesis and clinical features of autoimmune diseases of the major salivary glands, focusing on the diagnostic and therapeutic role of sialendoscopy.
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Affiliation(s)
- A Gallo
- Department of Surgical Biotechnologies and Science, ENT Section "Sapienza" University of Rome, Italy
| | - S Martellucci
- Department of Surgical Biotechnologies and Science, ENT Section "Sapienza" University of Rome, Italy
| | - M Fusconi
- Department of Sensorial Organs, ENT Section "Sapienza" University of Rome, Italy
| | - G Pagliuca
- Department of Surgical Biotechnologies and Science, ENT Section "Sapienza" University of Rome, Italy
| | - A Greco
- Department of Sensorial Organs, ENT Section "Sapienza" University of Rome, Italy
| | - A De Virgilio
- Department of Sensorial Organs, ENT Section "Sapienza" University of Rome, Italy
| | - M De Vincentiis
- Department of Sensorial Organs, ENT Section "Sapienza" University of Rome, Italy
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Berkowitz AL, Samuels MA. The neurology of Sjögren's syndrome and the rheumatology of peripheral neuropathy and myelitis. Pract Neurol 2013; 14:14-22. [DOI: 10.1136/practneurol-2013-000651] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Stanifer JW, George R, Keenan RT, Massey EW. What started this? Debilitating longitudinally-extensive myelitis. Am J Med 2012; 125:1071-3. [PMID: 23098863 DOI: 10.1016/j.amjmed.2012.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 07/23/2012] [Accepted: 07/25/2012] [Indexed: 11/19/2022]
Affiliation(s)
- John W Stanifer
- Department of Medicine, Duke University Hospital, Durham, NC 27710, USA.
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Abstract
This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome. Sjögren's syndrome is a chronic inflammatory disorder of the exocrine glands with multiple nonexocrine features. It is found predominantly in middle-aged women but exists throughout the population. The diagnosis of Sjögren's syndrome can be challenging because the cardinal sicca symptoms may be subclinical or attributed to other causes, such as medications or aging. Differential diagnosis of Sjögren's syndrome can be confounded by the multiple exocrine manifestations in the mouth, eyes, ears, nose, skin, vagina, and respiratory and gastrointestinal tracts, as well as seemingly unrelated nonexocrine involvement in the thyroid, liver, kidneys and the musculoskeletal, vascular and nervous systems. This article concludes that early diagnosis of Sjögren's syndrome is crucial to prevent and/or minimize potentially life-threatening complications. Periodic follow-up of patients' status and collaboration between the primary-care physician and the rheumatologist, dentist, ophthalmologist and other specialists are indispensable.
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Affiliation(s)
- Ibtisam Al-Hashimi
- Baylor College of Dentistry, Salivary Dysfunction Clinic, Department of Periodontics, 3302 Gaston Avenue, Dallas, TX 75246, USA and University of Texas Southwestern Medical Centre, Faculty of Surgery, Division of Oral Surgery, Dallas, TX, USA.
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Semiquantitative measurement of aquaporin-4 antibodies as a possible surrogate marker of neuromyelitis optica spectrum disorders with systemic autoimmune diseases. Mod Rheumatol 2011; 22:676-84. [PMID: 22183613 DOI: 10.1007/s10165-011-0572-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 11/21/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES To assess the association between serum aquaporin-4 (AQP4) autoantibodies and neuromyelitis optica spectrum disorders (NMOSDs) associated with systemic autoimmune diseases. METHODS We retrospectively studied 626 hospitalized patients with systemic lupus erythematosus (SLE) or Sjögren's syndrome (SS). We collected serum samples from those patients with suspected NMOSDs (i.e., myelitis or optic neuritis) at the time of onset and thereafter. AQP4 antibodies were measured by a cell-based indirect immunofluorescence assay using AQP4-transfected HEK-293 cells in a semi-quantitative manner. RESULTS Sera from 6 patients with suspected NMOSDs and SLE (n = 3) or SS (n = 3) were evaluated. Among these, 2 patients' sera samples, i.e., 1 with SLE and 1 with SS, were positive for AQP4 antibodies. There was an inverse relationship between disease amelioration and antibody titer in one NMOSD patient, whereas the antibody titer remained high in the other NMOSD patient, whose clinical manifestations of NMOSDs did not improve despite intensive immunosuppressive treatments. CONCLUSIONS These results indicate that serum AQP4 antibodies are present in some SLE/SS patients with myelitis/optic neuritis and might be associated with clinical outcomes. The semi-quantitative measurement of the AQP4 antibody might be a possible surrogate marker in patients with NMOSDs associated with systemic autoimmune diseases.
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Kahlenberg JM. Neuromyelitis Optica Spectrum Disorder as an Initial Presentation of Primary Sjögren's Syndrome. Semin Arthritis Rheum 2011; 40:343-8. [DOI: 10.1016/j.semarthrit.2010.05.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/09/2010] [Accepted: 05/10/2010] [Indexed: 11/25/2022]
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Wandinger KP, Stangel M, Witte T, Venables P, Charles P, Jarius S, Wildemann B, Probst C, Iking-Konert C, Schneider M. Autoantibodies against aquaporin-4 in patients with neuropsychiatric systemic lupus erythematosus and primary Sjögren's syndrome. ACTA ACUST UNITED AC 2010; 62:1198-200. [PMID: 20131265 DOI: 10.1002/art.27337] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Klaus-Peter Wandinger
- University Medical Center Eppendorf, Hamburg, Germany, and Euroimmun, Lübeck, Germany
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Abstract
Transverse myelitis is a neurological disorder causing acute spinal cord injury as a result of acute inflammation, often associated with para infectious processes and autoimmune disease. The purpose of this article is to review the literature on the geoepidemiology of transverse myelitis and assess its environmental associations. Articles from 1981 to 2009 were reviewed in Pub Med along with potential causes such as autoimmune disease (focusing on systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), and Sjogren's), infection, vaccination, and intoxication.
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Affiliation(s)
- Anupama Bhat
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA 95616, USA
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Quartuccio L, Ferraccioli GF, De Vita S. Transverse myelitis in primary Sjögren's syndrome: usefulness of low‐dose oral cyclophosphamide rather than pulse therapy. Scand J Rheumatol 2009; 35:409-10. [PMID: 17062445 DOI: 10.1080/03009740600588301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sjogren's syndrome-associated meningoencephalomyelitis: cerebrospinal fluid cytokine levels and therapeutic utility of tacrolimus. J Neurol Sci 2007; 267:182-6. [PMID: 17996906 DOI: 10.1016/j.jns.2007.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 10/05/2007] [Accepted: 10/08/2007] [Indexed: 11/22/2022]
Abstract
Serial changes in the circulating and cerebrospinal fluid (CSF) cytokine levels were assessed in a patient with Sjogren's syndrome (SS)-associated meningoencephalomyelitis. A 16-yr-old girl diagnosed as having primary SS at 8 yr of age presented headache and vomiting. CSF studies revealed lymphocyte-dominant pleocytosis and high IgM index, but no evidence of infection. Disturbed consciousness and diffuse slow waves on electroencephalogram led to the diagnosis of SS-meningoencephalitis. The clinical condition subsided after a cycle of dexamethasone therapy, however, 2 months later urinary retention and paresthesia of the lower body developed. Craniospinal magnetic resonance imaging (MRI) showed extensive intraparenchymal lesions with high T2-weighted signal intensity adjacent to the posterior left horn of lateral ventricle of the brain and the longitudinal lesion from C5 to T10 of the spinal cord. High-dose methyl-prednisolone and subsequent tacrolimus therapy has effectively controlled the activity of SS-meningoencephalomyelitis. Monitoring of systemic and CSF cytokine levels during the course of illness revealed that CSF interleukin-6, but not interferon-gamma or tumor necrosis factor-alpha levels were the sensitive indicator of disease activity. The unique cytokine profile, differing from those of infectious meningitis may be useful for predicting the central nervous system involvement in autoimmune disease.
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Abstract
Sjogren's syndrome is an autoimmune exocrinopathy that predominantly affects salivary and lachrymal glands, leading to dry eyes and mouth. The most common clinical problems faced by the rheumatologist are those of dry eyes and mouth, parotid swelling, fatigue and extraglandular manifestations. The first stage in management is to make an accurate diagnosis based on the American/European consensus criteria. The most frequent differential diagnoses are dry eyes and mouth symptoms, a variant of chronic fatigue syndrome and fibromyalgia, and sialosis, which causes a non-inflammatory enlargement of the parotid glands. The mainstay of treatment for the sicca symptoms is local therapy, and that for the milder systemic symptoms is hydroxychloroquine. Steroids and immunosuppressive drugs are reserved for more severe extraglandular disease. In spite of intensive research in other systemic treatments including biologic therapies, there is limited evidence to support their use in routine clinical practice.
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Affiliation(s)
- P J Venables
- Kennedy Institute Division, Imperial College, London, UK.
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Theodoridou A, Settas L. Demyelination in rheumatic diseases. J Neurol Neurosurg Psychiatry 2006; 77:290-5. [PMID: 16484634 PMCID: PMC2077679 DOI: 10.1136/jnnp.2005.075861] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2005] [Revised: 10/10/2005] [Accepted: 10/17/2005] [Indexed: 11/03/2022]
Abstract
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system (CNS) characterised by multifocal areas of demyelination in the white matter of the brain and spinal cord. Autoantibodies, for example antinuclear antibodies, can also be present. MS and other demyelinating processes, such as transverse myelitis and optic neuritis (which may be clinically isolated cases or be part of the clinical spectrum of MS), are sometimes difficult to differentiate from CNS involvement in systemic autoimmune diseases like systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), Sjoegren's syndrome (SS), and Adamantiades-Behcet disease (BD). An acute isolated neurological syndrome presents the biggest diagnostic problem, since it is common in MS, but can also be the only feature or first manifestation in SLE, APS, SS, and BD. Indeed, the clinical presentation and lesions evidenced by magnetic resonance imaging may be similar.
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Affiliation(s)
- A Theodoridou
- Rheumatology Unit of the 1st Internal Medicine department, AHEPA University Hospital, 54006 Thessaloniki, Greece.
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Abstract
PURPOSE OF REVIEW To summarize the current literature on central nervous system manifestations of vasculitides and connective tissue diseases. RECENT FINDINGS There have been advances in understanding the mechanisms behind the initiation and perpetuation of inflammatory processes in vasculitic neuropathy. Clinically relevant data have been obtained on the predictive criteria for a positive biopsy result in giant cell arteritis, the imaging characteristics of primary angiitis of the central nervous system, and Behçet disease, and the clinical and radiologic features of neuro-Behçet disease. There is more clarity about the central nervous system syndromes attributable to systemic lupus erythematosus and new insights into the central mechanisms involved in the manifestations of Sjögren syndrome and rheumatoid arthritis. Novel immunomodulatory agents, such as infliximab, have shown some benefit in rheumatoid vasculitis and Sjögren syndrome. SUMMARY A better understanding of the clinical, radiographic, and serologic characteristics of various central nervous system complications of rheumatologic diseases has been gained in the past year. Recent advances in understanding the pathophysiology of peripheral nervous system complications and their treatment may affect the management of the central nervous system complications.
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Affiliation(s)
- Russell L Chin
- Peripheral Neuropathy Center, Department of Neurology, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, New York 10022, USA.
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Abstract
The incidence, aetiology and optimal treatment of CNS Sjögren's syndrome, including myelopathy associated with Sjögren's syndrome, are unknown at the present time. CNS Sjögren's syndrome is thought to be the result of an autoimmune vasculitis, but other mechanisms may be important. Spinal cord involvement in CNS Sjögren's syndrome may present as acute transverse myelitis, progressive myelitis, Brown-Séquard syndrome, neurogenic bladder or lower motor neurone disease. Optic nerve pathology frequently accompanies spinal cord involvement. Acute transverse myelitis has a high mortality and appears to be the most frequent form of spinal cord involvement in CNS Sjögren's syndrome, occurring in about 1% of all patients with Sjögren's syndrome. The patient's symptomatology and clinical course dictate current treatment of myelopathy. First-line treatment appears to be corticosteroid therapy. However, when the patient's condition fails to improve or deteriorates a nonsteroidal immunosuppressant agent should be considered. Agents used to treat myelopathy include cyclophosphamide, chlorambucil, azathioprine, ciclosporin (cyclosporin) and methotrexate in conjunction with corticosteroids. Most data exist as anecdotal reports. The agent of first choice, based on adverse effect profile and efficacy, appears to be cyclophosphamide given intravenously in pulse doses. Other nonsteroidal immunosuppressant agents should be considered, especially when lack of efficacy of, or intolerance to, cyclophosphamide exists in the patient's history. Glandular and other extraglandular symptoms may benefit concomitantly from the immunosuppressant treatment. In addition, when acute relief of symptomatology is needed, the patient may benefit from a trial of plasmapheresis or intravenous immunoglobulin. Infliximab (anti-tumour necrosis factor-alpha antibodies) has not been used as a treatment modality for myelopathy, but has shown some usefulness in the treatment of extraglandular symptoms, as well as peripheral nervous system manifestations of Sjögren's syndrome. This agent might be considered when all other treatment modalities have failed given the presumed importance of tumour necrosis factor in the pathogenesis of Sjögren's syndrome.
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Affiliation(s)
- Susan J Rogers
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas 78229-3900, USA.
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