Ulcerative colitis and giant cell arteritis associated with sensorineural deafness

Giant Cell Arteritis: A Case-Based Narrative Review of the Literature

Purpose of Review

Giant cell arteritis (GCA) is a chronic, inflammatory condition, primarily affecting the medium and larger arteries. The purpose of this narrative review is to describe GCA in the context of headache and facial pain, based on a case and the available current literature. Understanding the etiology, pathophysiology, the associated conditions, and the differential diagnoses is important in managing GCA.

Recent Findings

In a patient presenting with unilateral facial/head pain with disturbances of vision, GCA should be considered in the differential diagnosis. There is an association of GCA with several comorbid conditions, and infections including coronavirus-19 (COVID-19) infection. Management of GCA primarily depends upon the identification of the affected artery and prompt treatment. Permanent visual loss and other serious complications are associated with GCA.

Summary

GCA is characterized by robust inflammation of large- and medium-sized arteries and marked elevation of systemic mediators of inflammation. An interdisciplinary approach of management involving the pertinent specialties is strongly recommended.

Neurology of inflammatory bowel disease

Inflammatory bowel diseases (IBD) are chronic inflammatory conditions affecting the digestive system, comprising two main distinctive entities, ulcerative colitis (UC) and Crohn's disease (CD). Besides gastrointestinal manifestations, IBD causes extraintestinal manifestations in the central and peripheral nervous system. The incidence of neurological complications in IBD ranges from 0.25% to 47.5%. The pathophysiology of neurological manifestations of IBD is mostly immune mediated, but dysfunction of the brain-gut axis, arterial and venous thromboembolism, infections, nutritional deficiencies and side-effects of medications (steroids, metronidazole, sulfasalazine, anti-TNF-α, anti-integrin antibodies) are other contributory mechanisms. Patients with IBD have an increased risk of arterial and venous stroke, mainly during periods of exacerbations. Vasculitis is extremely rare. There is a bidirectional association between multiple sclerosis and IBD, with a relative risk for comorbidity of 1.54, being 1.53 for the risk of multiple sclerosis in IBD and 1.55 for the risk of IBD in multiple sclerosis patients. Anti-TNF-α therapy is contraindicated in the treatment of patients who have both IBD and multiple sclerosis. Demyelinating disorders can also be a rare complication of anti-TNF-α therapy. Optic neuritis, transverse myelitis, progressive myelopathy, central nervous system infections, epilepsy and encephalopathy are among other uncommon neurological complications. Peripheral nervous system manifestations include peripheral neuropathy, either demyelination and axonal, myasthenia gravis and polymyositis/dermatomyositis and localized forms of myositis.

Giant cell arteritis associated with inflammatory bowel disease: a case-series and review of the literature

To describe the clinical characteristics, management, and outcome of a series of patients with giant cell arteritis (GCA) and inflammatory bowel disease (IBD). Patients with both GCA and IBD evaluated between 1/1/1996 and 12/30/2018 were retrospectively identified. Clinical characteristics, laboratory parameters, radiologic features, histopathology, management and outcomes were abstracted. A systematic literature review identifying patients with IBD and GCA was performed via a Medline and EMBASE search from inception through December 31 2019. Six patients were identified with GCA and IBD (66% male). Five (83%) had ulcerative colitis (UC) and one had Crohn's disease (CD). Diagnosis of IBD preceded GCA in four patients with an average interval of 30 years (range 14-42). Average time to IBD diagnosis in those with prior GCA diagnosis was 1.5 years. During mean follow-up of 4.3 years, GCA relapse was infrequent with only one patient with relapse observed. Systematic literature review identified six additional patients with confirmed coexistence of GCA and IBD. Similar to the current series, male sex was more common and ulcerative colitis was the predominant IBD phenotype. The current study reports findings from the largest single-institution case-series of co-existent GCA and IBD. In contrast to Takayasu arteritis with co-existent IBD, which displays a predilection for female sex and Crohn's disease phenotype, both the current study and review of literature demonstrate a stronger association of GCA with male sex and ulcerative colitis. Further studies addressing a potential pathophysiologic connection between GCA and IBD are suggested.

Temporal Arteritis Presenting as an Isolated Bilateral Abducens Nerve Palsy: A Rare Case of a 65-year-old Male

Giant cell arteritis (GCA) or temporal arteritis (TA) is a granulomatous inflammation of medium to large-sized arteries. It may have a diverse presentation. The most common presenting symptoms of GCA are fever, malaise, unilateral headache, jaw claudication, polymyalgia rheumatica (PMR) and ophthalmoplegia. Most severe sequelae of GCA could be blindness. We report a case of a 65-year-old Caucasian male who presented for the third time with recurrent episodes of diplopia. Neurologic exam showed bilateral cranial nerve (CN) VI palsy, slightly worse on the right than the left side. Other focal neurological deficits were absent. GCA was considered and biopsy of the temporal artery was performed which showed necrotizing pan-arteritis, consistent with GCA. The patient was empirically treated with intravenous (IV) methylprednisolone while awaiting the biopsy results which resulted in the resolution of the symptoms. As far as we know, this is the second case in the literature about the bilateral sixth CN involvement in the background of GCA.

Hearing loss in autoimmune disorders: Prevalence and therapeutic options

The objective of this study was to review our current knowledge relative to the correlation between sensorineural hearing loss (SNHL) and autoimmune diseases, focusing on the prevalence of hearing loss in different pathologies and possible therapeutic approaches. A review of the literature on hearing loss in different forms of autoimmune disease has been carried out, with emphasis on incidence and prevalence of SNHL. Therapeutic protocols have been assessed including both conservative medical and rehabilitative methods. Cochlear implant outcomes have been investigated. The prevalence of hearing loss in autoimmune and immune-mediated inner ear diseases, as referred by case reports or single-center statistics, is widely variable. More difficult is the evaluation of severe/profound SNHL, usually reported in relation to cochlear implantation. Though these patients represent ideal candidates for cochlear implantation, as they become deaf after years of hearing; the associated systemic disease, the specific damage on inner ear structures and the medication taken may influence the result of cochlear implantation. The main problem is the cochlear fibrosis or ossification that has been found to affect 50% of implanted ears in patients suffering from autoimmune and immune-mediated SNHL. Hence, in the presence of severe/profound SNHL earlier implantation may be indicated before post-inflammatory obliterative changes to the cochlea.

Hearing Loss in Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) has many characteristics of autoimmune diseases. Sensorineural hearing loss has been reported in many autoimmune diseases. Little is known about hearing loss in patients with IBD.

METHODS

A prospective blinded comparative study was conducted over a 3-year period. IBD patients and controls underwent a complete otorhinolaryngeal examination and eudiometry test.

RESULTS

Altogether 105 participants (76 patients and 29 controls) took part in this study. Mean age was 36, 51 % were males, and 40 % of the patients were presently hospitalized due to IBD exacerbation. Audiometric examination revealed that any hearing loss (mild to severe) was found in 29 (38 %) of the IBD population, compared to 4 (14 %) of the control group (p = 0.02). Extraintestinal manifestation (EIM) was present in 33/76 (43 %) of IBD patients. Any hearing loss and moderate to severe hearing loss were found in 17/33 (52 %) and 7/33 (21 %) in the EIM-positive group compared to 12/43 (28 %) and 4/43 (9 %) in the EIM-negative group (p = 0.036 and p = 0.14, respectively). Out of patients over the age of 40 with other EIMs, all 11/11 (100 %) of patients had any hearing loss compared to 8/12 (66 %) of patients over the age of 40 without other EIMs, p = 0.035.

CONCLUSIONS

Hearing loss may be another EIM of IBD. It is found in 38 % of IBD patients and in up to 52 % of patients with other EIMs and increases over the age of 40. Early hearing evaluation should be recommended to these high-risk IBD patients.

Sudden hearing loss and Crohn disease: when Cogan syndrome must be suspected

Cogan's syndrome is a rare systemic vasculitis of unknown origin. It is characterized by the presence of worsening audiovestibular and ocular symptoms that may manifest simultaneously or sequentially. No specific diagnostic laboratory tests or imaging studies exist. The diagnosis is clinical and should be established as early as possible so as to initiate prompt treatment with steroids and prevent rapid progression to deafness or blindness and potentially fatal systemic involvement. We report a case of association between Cogan's syndrome and ileal Crohn's disease which we believe deserves attention since, after an accurate review of the literature, we have found approximately 250 reports of patients with Cogan's syndrome, only 13 of whom with concurrent chronic inflammatory bowel disease; of these 13 cases, none experienced improvement after therapy. In the light of the good outcome obtained in our case, we proposed a valid treatment option with boluses of steroids, combined with early systemic immunosuppression and intra-tympanic steroid injections.

Multiple cranial nerve palsies in giant cell arteritis and response to cyclophosphamide: a case report and review of the literature

Giant cell arteritis (GCA) has been previously associated with cranial mononeuritis (usually optic neuritis). We hereby describe a 68-year-old man who presented due to fever and diplopia of acute onset. Physical examination revealed left abducens nerve palsy and a hearing defect in the right ear. Brain imaging and cerebrospinal fluid analysis were not diagnostic. GCA was suspected, and treatment with high-dose methylprednisolone was initiated, leading to marked improvement. Temporal artery biopsy confirmed the presence of GCA. While considering corticosteroid tapering, the patient experienced hoarseness due to right laryngeal nerve palsy. Addition of cyclophosphamide to the treatment resulted in full response. GCA mainly affects large vessels, but one or more cranial nerve palsies may also occur. Following a review of the literature, this is the first report of three cranial nerve palsies in the setting of histologically proven GCA. The role of cyclophosphamide in this entity is also discussed.

Neurologic manifestations of inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic, relapsing and remitting inflammatory conditions affecting the digestive system, comprising two main distinctive diseases, ulcerative colitis (UC) and Crohn's disease (CD). Besides the classic gastrointestinal manifestations, a variable number of IBD patients present with extraintestinal manifestations, including central and peripheral nervous system involvement. Peripheral neuropathy is one of the most common complications. An inflammatory myopathy has also been found. Cranial neuropathies include the Melkersson-Rosenthal syndrome, optic neuritis, and sensorineural hearing loss. Patients with IBD have a remarkable thromboembolic tendency and are at increased risk of both venous and arterial thrombotic complications. The prothrombotic state in IBD has multiple contributors. Ischemic stroke occurs through several mechanisms, including large artery disease, small vessel disease, paradoxical embolism, endocarditis, vasculitis, and associated with anti-TNF-α therapy. Thrombosis of the dural sinus and cerebral veins are at least as frequent as arterial stroke in IBD. Multiple sclerosis has been repeatedly associated with IBD. Up to 50% of IBD present asymptomatic white matter lesions. Other central nervous system complications include a slowly progressive myelopathy, epidural and subdural spinal empyema secondary to fistulous extension from the rectum, seizures, and encephalopathy.

Interstitial Keratitis, Vertigo, and Vasculitis: Typical Cogan's Syndrome

Cogan's syndrome (CS) is a chronic inflammatory disorder of unknown etiology that most commonly affects young adults. Clinical hallmarks are bilateral interstitial keratitis and vestibuloauditory dysfunction. Association between CS and systemic vasculitis as well as aortitis also exists. The diagnosis of CS is based upon presence of characteristic inflammatory eye disease and vestibuloauditory dysfunction. We describe classic Cogan's syndrome in a 47-year-old female from Ardabil. The patient was admitted with headache, vertigo, nausea, vomiting, right leg claudication, musculoskeletal pains, bilateral hearing loss, and blindness for the past two months. Ophthalmologic examination revealed that visual acuity was 0.1 bilaterally. Conjunctival hyperemia, bilateral cataract, and interstitial keratitis were detected with a slit lamp examination. Pure tone audiogram (PTA) and auditory brain stem response (ABR) showed bilateral sensorineural hearing loss. The other differential diagnosis of CS was studied and ruled out. Pulse i.v. methylprednisolone and cyclophosphamide were given and were followed by oral prednisolone and cyclophosphamide. Clinical follow-up showed partial improvement.

Bone marrow transplantation as a strategy for the treatment of autoimmune hearing loss in MRL/Mp-lpr/lpr mice

Sensorineural hearing loss (SNHL) has been reported to develop as a main part of or in combination with systemic and organ-specific autoimmune diseases. The aim of the current study is to treat autoimmune SNHL in MRL/Mp-lpr/lpr (MRL/lpr) mice, a murine model of systemic autoimmune disease, using allogeneic bone marrow transplantation (BMT), which replaces recipient bone marrow cells with bone marrow cells from a non-autoimmune-prone donor. The results indicate that BMT can be used to treat SNHL; cochlear pathology, serum autoantibodies and lupus nephritis are ameliorated. Therefore, it is conceivable that the autoimmune SNHL in the MRL/lpr mice results not from defects in the cochlea, including the stria vascularis, but from defects in the bone marrow, and BMT would therefore provide a curative effect on inner ear autoimmune dysfunction associated with systemic autoimmune diseases.

Sensorineural hearing loss in patients with inflammatory bowel disease: a subclinical extraintestinal manifestation

Isolated case reports in which symptomatic hearing loss develops suddenly during the course of inflammatory bowel disease (IBD) have been reported, but the presence of subclinical sensorineural hearing loss (SNHL) associated with IBD has been investigated in only two preliminary studies. In order to research this further, we aimed to investigate the presence of subclinical SNHL in IBD by comparison with a control group and to examine possible relations between the bowel disease parameters and hearing loss.Otoscopy, tympanometry, and pure tone audiometry were carried out in 39 patients with IBD (21 Crohn's disease [CD], 18 ulcerative colitis [UC]) and 25 healthy age- and sex-matched controls. All patients and control subjects had normal otoscopy findings and tympanometry was unremarkable, excluding middle ear disease and conductive hearing loss. Analysis of each frequency examined showed that the average hearing thresholds were increased significantly in the study group compared to those of the control group at higher frequencies (2, 4, and 8 kHz). When these parameters were compared with the control group according to subgroups of IBD, a significant difference was determined for the UC group at frequencies of 2, 4, and 8 kHz and for the CD group only at the frequency of 4 kHz. Although there was a trend of increment in SNHL as the age of the patient and duration and extent of UC increased, no significant correlation was observed between SNHL and these parameters or sex, activity, involvement site, medication history of IBD, and coexistence of other extraintestinal manifestations. In conclusion, it was demonstrated that a subclinical SNHL may be associated with UC and somewhat with CD, affecting mainly the high frequencies. In light of this finding, it may be advisable to investigate labyrinth functions as well as other extraintestinal manifestations in patients with IBD.

Hipoacusia asociada a colitis ulcerosa

OBJECTIVE

To value the eventual immunomediation in sensorineural hearing loss (SHL) on patients bearing of ulcerative colitis (UC).

MATERIAL AND METHODS

In a group of forty-nine cases with a mean age of 41.6+/-9.3 years old we studied the hearing loss level, the disease activity index, the peripheral blood inflammation markers and the anticochlear antibodies by mean of Western-blot technique (WB).

RESULTS

The 26.5% knew about their deafness, although SHL was detected in 59.1% of cases. The mean age of onset was 40.3+/-9.8 years. 48.9% showed a positive WB, always in 68-70 kDa molecular weight blots. Moreover, patients with positive WB showed more severe deafness, higher disease activity and more altered parameters, especially erythrosedimentation rate.

CONCLUSIONS

Audiologic and peripheral blood findings observed allow us to establish a reasonable suspicion of an autoimmune or immunomediated pathway of hearing loss on UC.

Cauda Equina Syndrome as a Clinical Presentation of Primary Angiitis of the Central Nervous System (PACNS)

Primary angiitis of the central nervous system (PACNS) is a form of vasculitis affecting the central nervous system (CNS) that is not associated with systemic disease or vasculitis outside the CNS. It is a rare disease with significant morbidity and mortality. Delay in diagnosis and treatment is common due to its nonspecific clinical symptoms and lack of efficient noninvasive diagnostic tests. The finding of vasculitis in the leptomeningeal and cortical biopsy sample has remained the gold standard for making the diagnosis of PACNS. We describe a patient whose clinical symptoms of cauda equina syndrome led to a nerve root biopsy that was consistent with PACNS despite prior extensive investigations including a brain biopsy. This report highlights the cauda equina syndrome as a clinical presentation of PACNS and emphasizes the need for awareness of this rare condition.

Ulcerative colitis presenting as sensorineural deafness, brainstem encephalopathy, and white matter lesions

BACKGROUND

Several rare neurologic complications of ulcerative colitis have been reported.

REVIEW SUMMARY

We report a 69-year-old Japanese woman who developed bilateral sensorineural deafness, 2 attacks of bilateral ophthalmoplegia, and bilateral facial nerve palsy in association with ulcerative colitis. Laboratory data showed elevated cerebrospinal fluid (CSF) protein without pleocytosis, abnormal auditory brainstem evoked potentials, and multiple high signal lesions on magnetic resonance imaging of the brainstem and cerebral deep white matter. Her symptoms improved with corticosteroid therapy except for sensorineural deafness and an exacerbation of cerebral deep white matter lesions without any new clinical signs.

CONCLUSION

Immunologic mechanisms may have led to her central and peripheral nervous system findings in addition to her colon disorder.

Prevention of autoimmune hearing loss in MRL/lpr mice by bone marrow transplantation

We examined the effects of bone marrow transplantation (BMT) on immune-mediated inner ear diseases in MRL/Mp-lpr/lpr (MRL/lpr) mice, which manifest not only lupus nephritis but also sensorineural hearing loss (SNHL) at the age of 20 weeks. These mice were treated with cyclophosphamide (CY) and irradiation (5 Gy x 2), followed by the transplantation of bones plus bone marrow cells from allogeneic normal C57BL/6 mice at the age of 12 weeks. Hematolymphoid cells were reconstituted with donor-derived cells 3 months after BMT. Thus-treated MRL/lpr mice showed neither lupus nephritis nor SNHL even 24 weeks after BMT. No pathological findings were observed in either glomeruli or cochleae. These findings suggest that BMT can be used to prevent the development of autoimmune SNHL in MRL/lpr mice.

Sensorineural hearing loss in ulcerative colitis

Sensorineural hearing loss has been described in a small number of patients with ulcerative colitis. At present, it is not known whether this is a rare and sporadic association, or whether these reports represent an under recognised extra-intestinal manifestation of ulcerative colitis. The aim of this study was to determine the prevalence of hearing loss in patients with ulcerative colitis. Twenty patients with active ulcerative colitis (mean age 45 years) were recruited prospectively along with 20 healthy age- and sex-matched controls. Otoscopy, tympanometry and pure tone audiometry were performed. The activity of the disease was scored according to a 12-month cumulative disease activity index. No patients complained of auditory symptoms. Otoscopy and tympanometry were normal in all patients and controls. Pure tone audiometry showed significant sensorineural hearing loss over all frequencies in patients with ulcerative colitis compared with controls. This preliminary study indicates that subclinical sensorineural hearing loss is associated with ulcerative colitis. Further study is warranted to determine the nature of the relationship and its pathological basis.

Cogan's syndrome

Work originating in the 1940s led to the characterization of a rare, chronic inflammatory disorder with a unique predilection for the cornea and vestibuloauditory apparatus, now called Cogan's syndrome (CS) after the ophthalmologist who first described it. CS occurs primarily in young adults and typically presents with interstitial keratitis (IK) and Ménière's-like episodes developing within several months of each other. The inflammatory process may target other ocular sites, and the disease itself may be accompanied by aortitis or a Takayasu's-like or medium-sized vessel vasculitis. Morbidity in CS results from deafness and complications from cardiovascular disease. Most evidence suggests that the ocular and vestibuloauditory manifestations are not a consequence of vasculitis but rather mediated by other immunologic mechanisms, possibly organ-specific autoimmunity. The cornerstone of treatment in CS is corticosteroids, topically for IK and systemically for inner ear dysfunction. Early corticosteroid therapy appears to be critical for reversing hearing loss. Cochlear implants can partially restore auditory function and have been a salvation for patients who suffer from deafness as a result of permanent cochlear damage.

Progressive sensorineural hearing impairment in systemic vasculitides

OBJECTIVES

A large series of patients with various forms of systemic vasculitis were evaluated to analyze the prevalence of progressive sensorineural hearing loss (PSNHL), its characteristics and evolution, and the effects of different therapies.

METHODS

A total of 673 patients were questioned about the presence of subjective audiovestibular disturbances. Of those, 80 subjects complained of subjective audiological disturbances and underwent oto-rhino-laryngological and audiovestibular evaluation. Those patients with progressive hearing impairment were selected and studied carefully.

RESULTS

A PSNHL was observed in 14 patients. The hearing loss was bilateral and asymmetrical in most subjects. It was usually sensorineural, with a cochlear lesion. Unsteadiness was the most frequent vestibular symptom and canal paresis or palsy was noted in most patients. Systemic corticosteroids and cyclophosphamide were useful treatments; in unresponsive patients, satisfactory results were obtained with methotrexate and plasma exchange.

CONCLUSIONS

PSNHL is a rare complication of systemic vasculitis, but occasionally is one of the presenting symptoms. Its clinical evolution is variable, but timely clinical assessment and treatment can positively affect prognosis.

Sensorineural hearing loss and ulcerative colitis

The association of sensorineural hearing loss and ulcerative colitis is well documented and it is speculated that this is autoimmune in origin. A case in a 12-year-old boy is described, that initially responded to steroid therapy, but four years later resulted in bilateral, profound sensorineural hearing loss in spite of good control of his bowel disease. Immunological tests may provide a clue as to the aetiology of suspected cases of autoimmune inner ear disease. Immediate treatment with steroids with or without immunosuppressive therapy is essential as delay may lead to irreversible hearing loss.

The possible association of pyoderma gangrenosum and progressive sensorineural deafness

Deafness is known to be associated with certain autoimmune disorders. This article describes a hitherto unreported possible association between pyoderma gangrenosum and progressive bilateral sensorineural deafness.