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de Amorim JC, Torricelli AK, Frittoli RB, Lapa AT, Dertkigil SSJ, Reis F, Costallat LT, França Junior MC, Appenzeller S. Mimickers of neuropsychiatric manifestations in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2019; 32:623-639. [PMID: 31203921 DOI: 10.1016/j.berh.2019.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Systemic lupus erythematosus (SLE), presenting with new onset or worsening neuropsychiatric (NP) symptoms, is a challenge in clinical practice. Mimickers such as infections, drug-induced side effects, metabolic abnormalities, malignancies, and alcohol-related disorders have to be excluded, before attributing the manifestations to disease activity. Proper diagnosis is essential to guide adequate management and reduce morbidity and mortality. In this review article, we will highlight clinical, laboratorial, and neuroradiological features that are helpful to assist in the differential diagnosis.
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Affiliation(s)
- Jaqueline Cristina de Amorim
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil; Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil
| | | | - Renan Bazuco Frittoli
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil; Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Brazil
| | - Aline Tamires Lapa
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil; Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil
| | | | - Fabiano Reis
- Department of Radiology, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tl Costallat
- Rheumatology Unit, Department of Medicine, School of Medical Science, University of Campinas, Brazil
| | | | - Simone Appenzeller
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Brazil; Rheumatology Unit, Department of Medicine, School of Medical Science, University of Campinas, Brazil.
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Su L, Ding M, Chen L, Li C, Lao M. Primary central nervous system lymphoma in a patient with systemic lupus erythematosus mimicking high-grade glioma: A case report and review of literature. Medicine (Baltimore) 2018; 97:e11072. [PMID: 29879076 PMCID: PMC5999485 DOI: 10.1097/md.0000000000011072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Primary central nervous system lymphoma (PCNSL) is a rare disease. Studies of PCNSL in patients with rheumatic diseases are lacking. Neither clinical symptoms nor radiographic manifestation is specific to PCNSL. Therefore, it could be misdiagnosed with other diseases such as brain tumors. Chemotherapy is the primary treatment for PCNSL, while the role of surgery remains controversial. PATIENT CONCERNS We reported a 39-year-old woman with systemic lupus erythematosus (SLE) developed PCNSL after 15-year treatment with multiple immunosuppressants. DIAGNOSES Cranial magnetic resonance imaging (MRI) showed multi-focal lesions with ring-like enhancement post-contrast in the right hemisphere, which mimicked glioma radiographically. Owing to the severe symptoms of intracranial hypertension, gross tumor resection was performed. Pathological exam showed perivascular infiltration of atypical lymphoid cells with CD20 and Epstein-Barr virus (EBV) -encoded RNA (EREB) positive. The patient was diagnosed with diffuse large B-cell lymphoma (DLBCL). INTERVENTIONS The patient received six cycles of chemotherapy and autologous stem cell transplantation (ASCT) subsequently. OUTCOMES The patient remained complete remission until this article was written. LESSONS PCNSL in immunocompromised hosts may present heterogeneous contrast enhancement, which should be differentiated from other diseases especially high-grade glioma.
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Affiliation(s)
| | | | | | | | - Minxi Lao
- Department of Geriatrics
- Department of Rheumatology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Abstract
Lymphoproliferative disorders are known to complicate immunosuppressive therapy and two cases of primary lymphoma of CNS (PCNSL) have previously been described in association with mycophenolate mofetil (MMF) treatment. We report the third case of PCNSL in a patient with lupus nephropathy while on MMF treatment. PCNSL may be seen more frequently considering the increased use of MMF in immunosuppressant responsive conditions.
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Affiliation(s)
- P F Finelli
- Department of Neurology, Hartford Hospital and University of Connecticut School of Medicine, Hartford, CT 06102-5037, USA.
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Alobaid A, Torlakovic E, Kongkham P. Primary Central Nervous System Immunomodulatory Therapy-Induced Lymphoproliferative Disorder in a Patient with Ulcerative Colitis: A Case Report and Review of the Literature. World Neurosurg 2015; 84:2074.e15-9. [DOI: 10.1016/j.wneu.2015.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 01/26/2023]
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Allen PB, Laing G, Connolly A, O'Neill C. EBV-associated colonic B-cell lymphoma following treatment with infliximab for IBD: a new problem? BMJ Case Rep 2013; 2013:bcr-2013-200423. [PMID: 24081592 DOI: 10.1136/bcr-2013-200423] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients with inflammatory bowel disease who do not respond to steroid therapy often require treatment with immunomodulators in an attempt to achieve a response and maintain remission. However, a major concern and controversy is whether these treatments are putting the patients at a significantly increased risk of developing lymphomas. This case reports a patient with severe ulcerative colitis who had been previously treated with azathioprine and infliximab, and subsequently developed diffuse large B-cell colonic lymphoma.
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Affiliation(s)
- Patrick B Allen
- Department of Gastroenterology, Ulster Hospital, Belfast, UK
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Théophile H, Schaeverbeke T, Miremont-Salamé G, Abouelfath A, Kahn V, Haramburu F, Bégaud B. Sources of information on lymphoma associated with anti-tumour necrosis factor agents: comparison of published case reports and cases reported to the French pharmacovigilance system. Drug Saf 2011; 34:577-85. [PMID: 21663333 DOI: 10.2165/11590200-000000000-00000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor (TNF) agents, through their intense immunoregulatory effect, have been suspected to increase the risk of malignant lymphoma. However, the classical epidemiological approaches conducted over about the last 10 years have not totally succeeded in addressing the question of a causal or artifactual association. Therefore, the analysis of a substantial set of case reports, although usually considered as poorly generalizable to the general population, could be particularly informative. Two main sources of case reports in postmarketing settings are available; publications in medical journals and reports to pharmacovigilance systems. OBJECTIVE The aim of the study was to compare the characteristics of case reports from both these sources in order to understand whether they provided the same information for the investigation of the causal link between lymphoma and anti-TNF agents. METHODS All case reports of malignant lymphoma in patients treated with an anti-TNF agent published in MEDLINE and all reports to the French pharmacovigilance system up to 1 February 2010 were identified. Cases of malignant lymphoma identified in postmarketing surveillance from both sources were compared regarding the following variables: age, sex, anti-TNF agent involved, indication for use, type of lymphoma, prior or concomitant immunosuppressive drugs and time to onset of lymphoma. RESULTS A total of 81 published case reports and 61 cases reported to the French pharmacovigilance system were compared. In published reports, patients were younger (p = 0.03) and more frequently receiving a first anti-TNF treatment (p = 0.03), particularly infliximab (p = 0.03). Conversely, in the pharmacovigilance system reports, a succession of different anti-TNFs (p = 0.03) and adalimumab (p < 0.0001) were more frequently reported. Lymphomas in patients treated with anti-TNF agents for Crohn's disease were more prevalent in published cases than in pharmacovigilance reports (p < 0.0001), and in particular involved hepatosplenic T-cell lymphoma. Conversely, rheumatoid arthritis was the main indication for anti-TNF agents in pharmacovigilance reports (p = 0.01). Time to onset was markedly shorter in published cases (median 12 months) than in pharmacovigilance reports (median 30 months; p = 0.0001). CONCLUSIONS Characteristics of published cases and those reported to the French pharmacovigilance system differed markedly for all characteristics tested, except sex and the use of prior or concomitant immunosuppressive drugs. Published case reports favoured convincing arguments for drug causation whereas cases reported to the pharmacovigilance system were more disparate but could describe more accurately the reality of lymphoma occurrence in this particular population. These results argue for the use of the pharmacovigilance reports when case reports are used to investigate the causal link between lymphoma and anti-TNF agents at the population level. Data from cases notified to the French pharmacovigilance system did not indicate an increased risk of lymphoma during the early phase of anti-TNF treatment. To confirm this hypothesis, a study combining pharmacovigilance reports from several countries, or, if feasible, a cohort study both with a large sample size and a long duration of follow-up would be required.
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González-Darder JM, Vera-Román JM, Pesudo-Martínez JV, Cerdá-Nicolás M, Ochoa E. Tumoral presentation of primary central nervous system lymphomatoid granulomatosis. Acta Neurochir (Wien) 2011; 153:1963-70. [PMID: 21792698 DOI: 10.1007/s00701-011-1088-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 07/12/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Lymphomatoid granulomatosis (LYG) is an angiocentric Epstein-Barr virus (EBV) related B-cell proliferation associated with a reactive T-cell component with an uncertain malignant potential. LYG present at diagnosis as a mass lesion in the central nervous system (CNS) is rare, and only a few cases have been reported. In this article we present four cases of tumoral CNS-LYG and propose some guidelines for its management. METHODS Clinical, pathological, imaging and laboratory information of four immunocompetent patients, all of them treated surgically, with a final diagnosis of LYG and presenting with an isolated intracranial tumoral mass is reviewed. RESULTS Two parenchymal lesions were located in the cerebellum and temporal lobe, and the other two involved the cavernous sinus. At surgery they were avascular, hard, lard-like, necrotic and plastic well-defined lesions, with invasion of the leptomeninges and thrombosis of the small leptomeningeal arteries and veins. Intraoperative pathology excluded any tumor. Pathological studies showed a polymorphic and polyclonal infiltration around, in the wall and into the lumen of medium-sized cortical and leptomeningeal vessels causing their obstruction and tissular necrosis. EBV-infected cells were present. CONCLUSIONS Making a preoperative diagnosis of CNS-LYG appearing initially as a tumoral mass is difficult because of the lack of pathognomonic clinical symptoms or imaging signs. Surgical management with radical resection of the mass is almost always followed by the long-term local control of the lesion, although the disease may have a disseminated, systemic or malignant evolution.
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Miehsler W, Novacek G, Wenzl H, Vogelsang H, Knoflach P, Kaser A, Dejaco C, Petritsch W, Kapitan M, Maier H, Graninger W, Tilg H, Reinisch W. A decade of infliximab: The Austrian evidence based consensus on the safe use of infliximab in inflammatory bowel disease. J Crohns Colitis 2010; 4:221-56. [PMID: 21122513 DOI: 10.1016/j.crohns.2009.12.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 12/01/2009] [Indexed: 12/15/2022]
Abstract
Infliximab (IFX) has tremendously enriched the therapy of inflammatory bowel diseases (IBD) and other immune mediated diseases. Although the efficacy of IFX was undoubtedly proven during the last decade numerous publications have also caused various safety concerns. To summarize the immense information concerning adverse events and safety issues the Austrian Society of Gastroenterology and Hepatology launched this evidence based consensus on the safe use of IFX which covers the following topics: infusion reactions and immunogenicity, skin reactions, opportunistic infections (including tuberculosis), non-opportunistic infections (bacterial and viral), vaccination, neurological complications, hepatotoxicity, congestive heart failure, haematological side effects, intestinal strictures, stenosis and bowel obstruction (SSO), concomitant medication, malignancy and lymphoma, IFX in the elderly and the young, mortality, fertility, pregnancy and breast feeding. To make the vast amount of information practicable for routine application the consensus was finally condensed into a checklist for a safe use of IFX which consists of two parts: issues to be addressed prior to anti-TNF therapy and issues to be addressed during maintenance. Both parts are further divided into obligatory and facultative items.
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Affiliation(s)
- W Miehsler
- Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria.
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Biasiotta A, Frati A, Salvati M, Raco A, Fazi M, D'Elia A, Cruccu G. Primary hypothalamic lymphoma in a patient with systemic lupus erythematosus: case report and review of the literature. Neurol Sci 2010; 31:647-52. [PMID: 20585820 DOI: 10.1007/s10072-010-0338-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 05/22/2010] [Indexed: 11/25/2022]
Abstract
A 67-year-old female was admitted to our department with difficulty in speech, disorientation, memory loss and seizures. Blood laboratory tests revealed diabetes insipidus. This patient had been treated with steroids for systemic lupus erythematosus (SLE) for 30 years. Due to this treatment neurological symptoms had been understated causing a long delay in performing ulterior researches. A brain MRI revealed a mass lesion in the hypothalamic area. A biopsy was performed and histopathological diagnosis was malignant large B cell lymphoma. Subsequently, she received methotrexate therapy but died of pneumonia during the second cycle. Primary central nervous system lymphoma in association with SLE is a rare occurrence but it should be considered in the diagnostic process when neurological symptoms occur. A brain MRI must be performed and corticosteroids should be interrupted. A biopsy of the cerebral mass lesion permits diagnosis and appropriate therapy may be administered.
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Affiliation(s)
- Antonella Biasiotta
- Department of Neurological Sciences - Neurology, University of Rome Sapienza, Rome, Italy
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Abstract
The recent development of inhibitors of key immune response proteins has revolutionized the therapy of autoimmune diseases; these immunomodulator agents include monoclonal antibodies and receptor antagonists. However, as with all therapies, these new agents are not without side effects and complications. In particular, anti-tumor necrosis factor alpha (TNFalpha) agents have been reported to be associated with an increased incidence of lymphoproliferative disorders, infections, and vasculitis. We evaluated the clinicopathological features of 18 cases of immunomodulator agent-related lymphoproliferative disorders (IAR-LPD) from several institutions. These included 6 cases of B-cell lymphoma, 2 cases of T-cell lymphoma, 3 cases of classical Hodgkin lymphoma, and 7 atypical lymphoid proliferations that did not fulfill diagnostic criteria for lymphoma; two of the latter regressed after discontinuation of the immunomodulator agent therapy. All eight lymphoma patients with available information had also received prior chemotherapy (methotrexate or 6-mercaptopurine). EBV was strongly associated with the B-cell and classical Hodgkin lymphomas. This case series illustrates that a broad range of lymphoid proliferations can occur after immunomodulator agent therapy and that these immunomodulator agent-related lymphoproliferative disorders have considerable overlap with other well-defined lymphoproliferative diseases associated with iatrogenic immunosuppression. Further study is warranted to evaluate how these therapies interact with other immunosuppressive agents and the underlying abnormal immune system to enhance the development of lymphomas and atypical lymphoid proliferations.
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Schmidt LA, Lim MS. T cell lymphoproliferative disorders associated with anti-tumor necrosis factor alpha antibody therapy for ulcerative colitis: literature summary. J Hematop 2009; 2:121-6. [PMID: 19669196 PMCID: PMC2725290 DOI: 10.1007/s12308-009-0029-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 02/09/2009] [Indexed: 12/19/2022] Open
Abstract
The enhanced risk of development of lymphoproliferative disorders in patients with inflammatory bowel disease has been attributed to immunosuppressive/immunomodulatory therapies. Infliximab is a chimeric monoclonal immunoglobulin G1 antibody directed against tumor necrosis factor alpha (TNF-α) that was approved by the Food and Drug Administration (FDA) in 1998 as an effective therapeutic agent against inflammatory bowel disease. Malignant lymphomas of both B and T cell lineage have been described in patients undergoing therapy involving TNF-α blockade. To date, eight cases of Epstein–Barr virus (EBV)-negative hepatosplenic T cell lymphoma associated with infliximab have been reported to the FDA’s Adverse Event Reporting System, as well as several other T cell lymphoproliferative disorders with aggressive clinical outcomes. We present the histologic, immunophenotypic, and molecular features of a T cell lymphoproliferative disorder involving the axillary lymph node of a 33-year-old male following infliximab treatment for ulcerative colitis. These EBV-negative lymphomas suggest that lymphoproliferative disorders following infliximab treatment for inflammatory bowel disease may involve EBV-independent immune dysregulation. The spectrum of lymphoproliferative disorders associated with infliximab and the potential mechanisms by which they occur are discussed.
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Affiliation(s)
- Lindsay A Schmidt
- Department of Pathology, M5240 Medical Science I, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109-0602 USA
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Biancone L, Calabrese E, Petruzziello C, Pallone F. Treatment with biologic therapies and the risk of cancer in patients with IBD. ACTA ACUST UNITED AC 2007; 4:78-91. [PMID: 17268543 DOI: 10.1038/ncpgasthep0695] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 10/30/2006] [Indexed: 12/18/2022]
Abstract
The proven involvement of cytokines in the pathophysiology of IBD has led to the development of powerful, selective, anticytokine drugs--so-called biologics--as a therapy for IBD. Although the efficacy of infliximab, a chimeric monoclonal IgG1 antibody directed against tumor necrosis factor, is proven and the use of biologic agents is growing worldwide, there is concern about their long-term safety, which includes the risk of developing cancer. An increased risk of malignancies, particularly lymphoma, has been reported in some studies of infliximab-treated patients with IBD; however, the increased risk could be caused by the underlying chronic disease, severity of the disease, concomitant medications (e.g. conventional immunomodulators), infliximab itself, or all of these variables. At present, the data do not provide clear evidence for a causal association between infliximab and the increased cancer risk. In appropriately selected patients with severe, refractory Crohn's disease, the benefits of biologic therapy seem to outweigh the cancer risk. Multicenter, case-control studies in large populations, with a long-term follow-up are needed to define the outcome of patients with IBD treated with biologic therapies.
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Cha JHJ, Furie K, Kay J, Walensky RP, Mullins ME, Hedley-Whyte ET. Case records of the Massachusetts General Hospital. Case 39-2006. A 24-year-old woman with systemic lupus erythematosus, seizures, and right arm weakness. N Engl J Med 2006; 355:2678-89. [PMID: 17182994 DOI: 10.1056/nejmcpc069030] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jang-Ho J Cha
- Department of Neurology, Massachusetts General Hospital, USA
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Moritz ML, Ayus JC. Case 8-2006: a woman with Crohn's disease and altered mental status. N Engl J Med 2006; 354:2833-4; author reply 2834. [PMID: 16807427 DOI: 10.1056/nejmc061008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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