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Desbois AC, Shor N, Chapelon C, Maillart E, Touitou V, Cacoub P, Saadoun D. [Neurological involvement of sarcoidosis: current diagnostic and therapeutic strategies]. Rev Med Interne 2023; 44:123-132. [PMID: 36804049 DOI: 10.1016/j.revmed.2023.01.013] [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: 07/21/2022] [Revised: 01/15/2023] [Accepted: 01/20/2023] [Indexed: 02/18/2023]
Abstract
Neurosarcoidosis (NS) is a rare but severe form of sarcoidosis. NS is associated with significant morbidity and mortality. Mortality is about 10% at 10 years with more than 30% of patients who have a significant disability. The most frequent features are cranial neuropathy (the facial and optic nerve most commonly affected), cranial parenchymal lesions, meningitis, spinal corn abnormalities (20-30%) and more rarely peripheral neuropathy (approximately 10-15%). The challenge of diagnosis is to eliminate other diagnoses. Atypical presentations should make to discuss the need for cerebral biopsy in order to highlight the presence of granulomatous lesions while eliminating alternative diagnosis. Therapeutic management is based on corticosteroid therapy and immunomodulators. There are no comparative prospective study to allow us to define the first-line immunosuppressive treatment and the therapeutic strategy in refractory patients. Conventional immunosuppressants such as methotrexate, mycophenolate mofetil and cyclophosphamide are commonly used. Data on the efficacy of anti-TNFα (including infliximab) in refractory and/or severe forms are increasing during the last ten years. Additional data is necessary to assess their interest in first line in patients with severe involvement and a significant risk of relapse.
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Affiliation(s)
- A C Desbois
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France.
| | - N Shor
- AP-HP, groupe hospitalier Pitié-Salpêtrière, service de neuroradiologie, France
| | - C Chapelon
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
| | - E Maillart
- AP-HP, Groupe hospitalier Pitié-Salpétrière, service d'ophtalmologie, France
| | - V Touitou
- AP-HP, groupe hospitalier Pitié-Salpêtrière, service de neurologie, France
| | - P Cacoub
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
| | - D Saadoun
- Sorbonne universités, AP-HP, groupe hospitalier Pitié-Salpêtrière, département de médecine interne et immunologie clinique, 75013 Paris, France; Centre national de référence maladies auto-immunes et systémiques rares, centre national de référence maladies auto inflammatoires rares et amylose inflammatoire, Inserm, UMR S 959, Immunology-Immunopathology- Immunotherapy (I3), 75005 Paris, France
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Topiwala K, Rath S, Daniel A, Prasad A. Cauda Equina Syndrome in Neurosarcoidosis. Cureus 2020; 12:e10069. [PMID: 33005501 PMCID: PMC7522054 DOI: 10.7759/cureus.10069] [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] [Indexed: 11/30/2022] Open
Abstract
Neurosarcoidosis (NS) is a mimicker of many infectious, neoplastic, and inflammatory diseases. It most commonly involves the cranial nerves followed by meninges, ventricles, hypothalamic-pituitary axis, spinal cord, and brainstem/cerebellum. While NS myelopathy has been increasingly recognized, pathophysiological/prognostic and management principles in NS-mediated cauda equina (CE) and conus medullaris (CM) syndromes, which constitute a small and rare minority of this subset, remain elusive. We present the case of a 49 -year-old Hispanic man who developed a peripheral facial palsy and primary hypogonadism within a span of 12 months and eventually got diagnosed with NS after he presented with CE syndrome. We also performed an extensive literature review, with a discussion on the underlying pathophysiology and current management recommendations for NS-mediated CE/CM syndrome. CE/CM syndromes in a middle-aged man should prompt the consideration of NS as a possible differential diagnosis. While steroid responsive, the majority of NS-CE/CM patients are left with residual neurodeficits with quick relapses when steroids are tapered, making the case for early institution of immunosuppressive therapies.
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Affiliation(s)
| | - Subhendu Rath
- Neurology, University of Michigan School of Medicine, Ann Arbor, USA
| | | | - Avinash Prasad
- Neurology, University of Connecticut School of Medicine, Hartford Hospital, Hartford, USA
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Abstract
Background:Intravascular large cell lymphoma (ILCL) is a diagnostic challenge, with neurological, cutaneous and constitutional symptoms. The natural history is usually an evolution to a comatose state. As invasive procedures are usually required for diagnosis, recognizing the typical clinical pattern is critical since an effective treatment is available.Method:After an extensive literature review of the subject, we report a case of ILCL, analyzing clinical, laboratory, radiological and pathological data. We will also give a special attention to the clinical picture of a conus medullaris (CM) lesion with subsequent encephalopathy in the same patient.Results:We report here a 61-year-old woman with a paraplegia caused by a CM lesion, evolving about one year latter to encephalopathy and eventual coma, with the diagnosis of ILCL confirmed by autopsy. The present case is similar to eight other cases in literature who had CM lesion associated with ILCL, knowing that 80-90% of these patients will eventually evolve to encephalopathy without treatment. Conclusions: ILCL is a recognized but rare cause of coma. Diagnosing it is tremendously important since it is fatal if left untreated. We propose that this specific picture (conus medullaris lesion, eventually evolving to encephalopathy) is quite characteristic and will directly result in better outcome if recognized.
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Conley RN, Longmuir GA. Brain and Spinal Cord. Clin Imaging 2014. [DOI: 10.1016/b978-0-323-08495-6.00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Reda HM, Taylor SW, Klein CJ, Boes CJ. A case of sensory ataxia as the presenting manifestation of neurosarcoidosis. Muscle Nerve 2011; 43:900-5. [PMID: 21607973 DOI: 10.1002/mus.22045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sarcoidosis rarely selectively affects the cauda equina with characteristic motor and sensory impairments.Using imaging, we report a case of cauda equina polyradiculopathy presenting with progressive sensory ataxia without clinical or electrophysiological evidence of motor involvement. Neurosarcoidosis was diagnosed pathologically by proximal dorsal root biopsy after systemic investigations for inflammatory, infectious, and neoplastic etiologies were found to be negative. There was clinical and radiographic improvement with corticosteroids. In addition, we review previously reported cases of cauda equina sarcoidosis.
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Affiliation(s)
- Haatem M Reda
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
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Abstract
Although neurosarcoidosis seems to occur in only 5% to 10% of patients who have sarcoidosis, it may lead to significant complications. The diagnosis of neurosarcoidosis usually relies on indirect information from imaging and spinal fluid examination. Although MR imaging remains the most sensitive technique for detecting neurologic disease, other tests, including positron emission tomography scanning and cerebral spinal fluid examination, can provide important information. The role of immunosuppressive agents such as methotrexate, cyclophosphamide, and azathioprine has been expanded, and these agents should be considered for the treatment of some manifestations of neurosarcoidosis. Reports of the antitumor necrosis factor agent infliximab suggest that this drug can be helpful for patients who have neurosarcoidosis.
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Affiliation(s)
- Elyse E Lower
- Interstitial Lung Disease and Sarcoidosis Center, University of Cincinnati Medical Center, 3235 Eden Avenue, Cincinnati, OH 45267, USA.
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Boulaajaj FZ, Rafai MA, El Otmani H, El Moutawakkil B, Hakim K, Fadel H, Slassi I. [Subacute myelopathy revealing systemic sarcoidosis]. Rev Neurol (Paris) 2007; 163:1049-53. [PMID: 18033043 DOI: 10.1016/s0035-3787(07)74177-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The spinal localization is rare for neurosarcoidosis (0.43 percent of cases) but can be the inaugural manifestation of the disease. We report two cases of spinal neurosarcoidosis in a 57-year-old man and a 43-year*old woman with uneventful past medical histories. Both presented progressive myelopathic features. METHODS Magnetic resonance imaging (MRI) of the spine demonstrated intramedullary lesions, dorsal in the first case, and cervical in the second case. Serum angiotensin converting enzyme was elevated. Radiographs of the chest revealed bilateral symmetric hilar mediastinal lymphadenopathy in the first patient, and bronchial biopsy demonstrated non caseating granulomas. In the second patient the diagnosis was made on pathological examination of a minor salivary gland biopsy. RESULTS The patients received corticosteroid therapy with good response in the second patient. CONCLUSION The diagnosis of intramedullary sarcoidosis is difficult without a previous diagnosis of systemic sarcoidosis or other apparent symptom(s). Extraneurologic biopsies may be suggestive. We reviewed the literature on the diagnosis and treatment of intramedullary sarcoidosis.
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Affiliation(s)
- F Z Boulaajaj
- Service de Neurologie--Explorations Fonctionnelles, CHU Ibn Rochd, Quartier des Hôpitaux, Casablanca, Maroc.
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Abstract
The origins of neurosarcoidosis, a multisystemic granulomatous disease, remain unknown. Nervous system localizations remain rare, but severe. Lymphocytic meningitis, psychiatric disorders, diabetes insipidus and cranial nerve palsy are the most frequent signs. Cerebral fluid test and cervical medullar and cerebral MRI with gadolinium have to be performed first. In some cases, histological evidence of granuloma have to be obtained with neuromuscular, meningeal or cerebral biopsies. Functional impairment and life-threatening conditions require early corticosteroid therapy. In worsening cases or in the event of no therapeutic response or poor tolerance to corticosteroids, other immunosuppressive agents should be associated. Maintenance therapy and most often life long maintenance therapy allow a continuous success while avoiding relapse.
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Tanasescu R, Kremer S, Taillandier L, Lacour JC, Bracard S, Picard L. [What is your diagnosis?]. J Neuroradiol 2005; 31:397-8. [PMID: 15687959 DOI: 10.1016/s0150-9861(04)97023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Sarcoidosis is an inflammatory multisystem disorder of unknown cause. Practically no organ is immune to sarcoidosis; most commonly, in up to 90% of patients, it affects the lungs. The nervous system is involved in 5-15% of patients. Neurosarcoidosis is a serious and commonly devastating complication of sarcoidosis. Clinical diagnosis of neurosarcoidosis depends on the finding of neurological disease in multisystem sarcoidosis. As the disease can present in many different ways without biopsy evidence, solitary nervous-system sarcoidosis is difficult to diagnose. Corticosteroids are the drug of first choice. In addition, several cytotoxic drugs, including methotrexate, have been used to treat sarcoidosis. The value of new drugs such as anti-tumour necrosis factor alpha will be assessed. In this review we describe the clinical manifestations of neurosarcoidosis, diagnostic dilemmas and considerations, and therapy.
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Affiliation(s)
- Elske Hoitsma
- Department of Neurology, Sarcoidosis Management Center, University Hospital Maastricht, Netherlands.
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Abstract
PURPOSE OF REVIEW The neurological manifestations of sarcoidosis, which occur in 5% of patients with the condition, present in a variety of ways that can be assigned to several broad categories. A comprehensive approach to the diagnosis and management of neurosarcoidosis involves an appreciation of the strategies to confirm a diagnosis of sarcoidosis and neurosarcoidosis and the available therapeutic options. RECENT FINDINGS In addition to traditional approaches to the diagnosis of sarcoidosis, positron emission tomography can be used to identify otherwise occult sites of systemic inflammation which can be targeted for biopsy. Although corticosteroids remain the mainstay of treatment, other immunosuppressive and immunomodulatory agents can be used in the multi-modality therapy of sarcoidosis. SUMMARY Neurosarcoidosis can be 'staged' with the use of neurodiagnostic testing and diagnosed with varying degrees of certainty. Treatment should be approached within the context of the anticipated clinical course of the patient, avoidance of adverse drug effects, and, as necessary, from the perspective of the comprehensive management of a chronic disease.
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Affiliation(s)
- Barney J Stern
- Department of Neurology, Emory University, Atlanta, Georgia, USA.
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