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Yun SY, Choi YJ, Chung SR, Suh CH, Kim SC, Lee JH, Baek JH. Image findings of anti-neutrophil cytoplasmic antibody-associated vasculitis involving the skull base. Clin Radiol 2023; 78:e568-e573. [PMID: 37164808 DOI: 10.1016/j.crad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/02/2023] [Accepted: 04/05/2023] [Indexed: 05/12/2023]
Abstract
AIM To investigate computed tomography (CT) and magnetic resonance imaging (MRI) features of skull bases involving anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). MATERIALS AND METHODS A retrospective review was undertaken to identify an institutional historical cohort of 17 patients with confirmed AAV who underwent CT or MRI and had skull base involvement between 2002 and 2021. Two radiologists reviewed the extent and features of the lesions, bone changes, and other MRI findings. RESULTS A total of 17 patients (12 men; mean age ± standard deviation, 46.5 ± 17.1 years) were selected. AAV presented as infiltrative lesions with involvement at various sites. Most cases involved the paranasal sinuses (PNS; 88%, 15/17), nasopharynx (88%, 15/17), pterygopalatine fossa (82%, 14/17), and parapharyngeal space (82%, 14/17), frequently accompanied by mucosal irregularity of the PNS and nasopharynx (71%, 12/17). Central skull base and temporal bone involvement were seen in 53% (9/17) and 38% (6/16) of cases, respectively. On T1-weighted imaging (WI) and T2WI MRI, all lesions (15/15) showed predominant signal iso-intensity to grey matter. CONCLUSIONS Although radiological findings of AAV are non-specific and skull base involvement is less common, AAV may be considered if infiltrative lesions predominantly involving the PNS, nasopharynx, pterygopalatine fossa, and parapharyngeal space with combined bone changes of skull base are seen.
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Affiliation(s)
- S Y Yun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; Department of Radiology, Inje University Busan Paik Hospital, Busan, Republic of Korea
| | - Y J Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - S R Chung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - C H Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - S C Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J H Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - J H Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Bonek K, Brożek-Mądry E, Wroński J, Płaza M, Zielińska A, Helon K, Wójcik K, Wisłowska M. Combination Treatment of Locoregionally Aggressive Granulomatosis with Polyangiitis and Cranial Base Infiltration. Brain Sci 2023; 13:1140. [PMID: 37626497 PMCID: PMC10452321 DOI: 10.3390/brainsci13081140] [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: 06/16/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVES To present a personalized approach in three cases of treatment-resistant, locoregionally aggressive forms of cANCA-positive granulomatosis with polyangiitis (GPA) and skull base involvement. METHODS Three patients with GPA and skull base involvement were described alongside a critical review of the current literature. RESULTS All presented patients suffered from GPA with an inflammatory tumor at the skull base, alongside cerebellopontine angle involvement, cranial nerve palsies, cerebellar disorders, concomitant hearing loss, and severe otalgia. Symptoms were associated with progressive granulomatous destruction of the temporal bone, laryngopharynx, and central nervous system infiltration. Treatment with cyclophosphamide and high doses of glucocorticoid steroids were ineffective but subsequent therapy with rituximab was successful in the presented cases. The literature review showed that the course of the disease with skull base involvement is associated with poorer clinical and radiological responses to standard pharmacotherapies. CONCLUSION Granulomatous inflammation localized in the skull base is associated with a more aggressive disease progression and is less likely to respond to pharmacotherapy. Standard induction therapy with cyclophosphamide and glucocorticoid steroids may be ineffective. A better response may be achieved by using rituximab and concomitant local treatment with glucocorticoid steroid injections.
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Affiliation(s)
- Krzysztof Bonek
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Eliza Brożek-Mądry
- Department of Otorhinolaryngology, National Institute of Medicine of the Ministry of Interior and Administration, 02-507 Warsaw, Poland
| | - Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Mateusz Płaza
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Agnieszka Zielińska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Katarzyna Helon
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Krzysztof Wójcik
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, 31-007 Krakow, Poland
- POLVAS Consortium, Jagiellonian University Medical College, 31-007 Krakow, Poland
| | - Małgorzata Wisłowska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
- POLVAS Consortium, Jagiellonian University Medical College, 31-007 Krakow, Poland
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Huang JH, Hagiwara M. Skull Base Tumor Mimics. Neuroimaging Clin N Am 2022; 32:327-344. [DOI: 10.1016/j.nic.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Radiologic Differentiation between Granulomatosis with Polyangiitis and Its Mimics Involving the Skull Base in Humans Using High-Resolution Magnetic Resonance Imaging. Diagnostics (Basel) 2021; 11:diagnostics11112162. [PMID: 34829509 PMCID: PMC8618208 DOI: 10.3390/diagnostics11112162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/16/2021] [Accepted: 11/20/2021] [Indexed: 12/20/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) can involve the skull base or the Eustachian tubes. GPA is diagnosed on the basis of clinical manifestations and serological tests, although it is challenging to discriminate GPA from infectious processes driving skull base osteomyelitis (SBO) and malignant processes such as nasopharyngeal carcinoma (NPC). Moreover, current serological tests have a low sensitivity and cannot distinguish GPA from these other conditions. We hypothesized that certain MRI characteristics would differ significantly among conditions and aimed to evaluate whether the features could differentiate between GPA, SBO, and NPC involving the skull base. We retrospectively evaluated the MRI findings of patients with GPA, SBO, and NPC. We performed univariable logistic regression analyses to identify the predictive variables for differentiating between conditions and evaluated their diagnostic values. We showed, for the first time, that certain MRI findings significantly differed between patients with GPA and those with SBO or NPC, including the lesion morphology and extent, the apparent diffusion coefficient (ADC) values, the contrast enhancement patterns, the presence or absence of necrosis, and retropharyngeal lymphadenopathy. In conclusion, utilizing certain MRI features can improve the diagnostic performance of MRI by differentiating GPA with skull base involvement from other conditions with similar radiologic findings, including SBO and NPC, facilitating treatment plans and, thus, improving patient outcomes.
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Nakazawa M, Suzuki K, Yasuoka H, Yamaoka K, Takeuchi T. Successful rituximab treatment of granulomatosis with polyangiitis with cranial neuropathies. Inflamm Regen 2018; 38:20. [PMID: 30473736 PMCID: PMC6240939 DOI: 10.1186/s41232-018-0079-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background In granulomatosis with polyangiitis (GPA), peripheral nerve involvement is common but central nervous system (CNS) involvement is extremely rare and treatment strategy has not been established. We report a case of intravenous cyclophosphamide (IVCY)-resistant GPA with associated cranial neuropathies that was successfully treated with rituximab (RTX). Case presentation A 37-year-old man with intractable sinusitis had several months of headache, hoarseness, and dysphagia; a month of right-sided deafness and nasal bleeding; and a week of dysarthria, steppage gait, and numbness in the right L5 distribution. A magnetic resonance imaging (MRI) examination of the head showed an infiltrative lesion in the right skull base encasing the carotid sheath. Computed tomography (CT) scan of the chest revealed a 23 mm nodule in the left upper lobe. Histology was inconclusive. Therefore, the patient was diagnosed as GPA. He was treated with glucocorticoids (GC) and IVCY. Three months later, he was readmitted for recurrence of headache and new left-sided hearing loss. He was treated with GC and RTX, and a 1-year remission followed. The molecular mechanism of RTX is not fully understood. In this case, RTX was more effective at rapidly and strongly suppressing B cells than CY. Since the B cell count was proportional to the patient's clinical manifestations, B cells might represent a suitable target for the treatment of GPA with cranial neuropathies. Conclusions GPA with cranial neuropathies might be useful with RTX as induction therapy.
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Affiliation(s)
- Maho Nakazawa
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Kunihiro Yamaoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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Malachovsky I, Janickova M, Stasko J, Kasaj M, Sadlonova V, Novakova E, Gengelova P, Smatanová M, Statelová D. Pseudomonas Infection of the Temporomandibular Joint (TMJ) Health and Public Health Issues. ACTA MEDICA MARTINIANA 2017. [DOI: 10.1515/acm-2017-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The authors describe a case of a rare infectious disease of intra-articular tissues of the temporomandibular joint caused mainly by Pseudomonas aeruginosa. In scientific literature, under the heading invasive (malignant) external otitis, we can find cases of an infectious disease of the external acoustic meatus caused by a microbial agent of Pseudomonas aeruginosa which can subsequently penetrate into structures. However, a primary affliction of the abovementioned structures has not been described. Localisation and severity of the infection requires long-term and massive treatment with antibiotics.
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Affiliation(s)
- I. Malachovsky
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - M. Janickova
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - J. Stasko
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - M. Kasaj
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - V. Sadlonova
- Institute of Microbiology, Comeniu University, Jessenius Faculty of Medicine, Martin , Slovakia
| | - E. Novakova
- Institute of Microbiology, Comeniu University, Jessenius Faculty of Medicine, Martin , Slovakia
| | - P. Gengelova
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - M. Smatanová
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Martin , Slovakia
| | - D. Statelová
- Clinic of Stomatology and Maxillofacial Surgery, Comenius University, Jessenius Faculty of Medicine and University Hospital Martin, Kollarova Str.N. 2,036 59, Martin , Slovak Republic
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Can computed tomography and magnetic resonance imaging differentiate between malignant pathology and osteomyelitis in the central skull base? The Journal of Laryngology & Otology 2016; 129:852-9. [PMID: 26314320 DOI: 10.1017/s0022215115001991] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Central skull base osteomyelitis is clinically difficult to distinguish from malignancy. METHOD The computed tomography and magnetic resonance imaging scans of six patients with central skull base osteomyelitis were compared with scans from patients with a range of skull base conditions. RESULTS AND CONCLUSION Computed tomography scans of central skull base osteomyelitis show much less bony destruction relative to the magnetic resonance imaging changes, whereas malignancy cases were associated with similar bony destruction on computed tomography and magnetic resonance imaging. In magnetic resonance imaging scans, it was possible to confirm previous findings of clival hypointensity on T1-weighted images relative to normal fatty marrow. In addition, there were signs of pre- and para-clival soft tissue infiltration, with the obliteration of normal fat planes and frank soft tissue masses in all six central skull base osteomyelitis patients. Signal intensity on T2-weighted images of the clivus was high in five central skull base osteomyelitis patients. With intravenous contrast, fascial plane anatomy appeared restored in central skull base osteomyelitis cases, almost in keeping with that of non-involved areas. This was not a feature in any of the malignant conditions.
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Iannella G, Greco A, Granata G, Manno A, Pasquariello B, Angeletti D, Didona D, Magliulo G. Granulomatosis with polyangiitis and facial palsy: Literature review and insight in the autoimmune pathogenesis. Autoimmun Rev 2016; 15:621-31. [PMID: 26851550 DOI: 10.1016/j.autrev.2016.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/01/2016] [Indexed: 01/28/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is an autoimmune systemic necrotizing small-vessel vasculitis associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). Oto-neurological manifestations of ANCA-associated vasculitis according to PR3-ANCA positivity and MPO-ANCA positivity are usually reported. Facial nerve palsy is usually reported during the clinical course of the disease but it might appear as the presenting sign of GPA. Necrotizing vasculitis of the facial nerve 'vasa nervorum' is nowadays the most widely accepted etiopathogenetic theory to explain facial damage in GPA patients. A central role for PR3-ANCA in the pathophysiology of vasculitis in GPA patients with oto-neurological manifestation is reported. GPA requires prompt, effective management of the acute and chronic manifestations. Once the diagnosis of GPA has been established, clinicians should devise an appropriate treatment strategy for each individual patient, based on current clinical evidence, treatment guidelines and recommendations.
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Affiliation(s)
- Giannicola Iannella
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Antonio Greco
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Guido Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37-00161 Rome, Italy.
| | - Alessandra Manno
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Benedetta Pasquariello
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Diletta Angeletti
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
| | - Dario Didona
- First Dermatology Division, Institute Dermopatico dell'Immacolata-IRCCS, Via Monti di Creta, 104-00167 Rome, Italy.
| | - Giuseppe Magliulo
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico,151-00161, Rome, Italy.
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The Many Faces of Granulomatosis With Polyangiitis: A Review of the Head and Neck Imaging Manifestations. AJR Am J Roentgenol 2015; 205:W619-29. [DOI: 10.2214/ajr.14.13864] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Söderström A, Revaz S, Dudler J. Cranial neuropathies in granulomatosis with polyangiitis (Wegener's): a case-based review. Clin Rheumatol 2013; 34:591-6. [PMID: 24352751 DOI: 10.1007/s10067-013-2420-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/18/2013] [Indexed: 12/19/2022]
Abstract
The purpose of this case-based review is to highlight cranial nerve involvement in granulomatosis with polyangiitis (Wegener's). In this disease, cranial nerve involvement may be less frequent than other neurological manifestations, but often goes unrecognized by physicians as a sign of the disease, and its prevalence and importance is likely underestimated. Awareness of this aspect of the disease is necessary to make the proper diagnosis rapidly, as it can be a major feature of a patient's presentation. We also briefly discuss the known pathogenic mechanisms, which could be important when selecting the best therapeutic option.
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Affiliation(s)
- Ana Söderström
- Service de Rhumatologie, Médecine Physique et Réhabilitation, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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MacDonald AS, Santa Maria PL. Wegener's Granulomatosis Presenting with Bilateral Facial Nerve Palsy and Limited to the Head and Neck. ACTA ACUST UNITED AC 2013. [DOI: 10.4303/jcrm/235697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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