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Fu X, Zhan Q, Zhang L, Tian X. Case report: Shingles-associated probable Bickerstaff brainstem encephalitis with IgM anti-sulfatide positivity. Front Immunol 2024; 15:1358886. [PMID: 38660303 PMCID: PMC11041370 DOI: 10.3389/fimmu.2024.1358886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Background Bickerstaff brainstem encephalitis (BBE) is a rare disease considered caused by acute demyelination of the brainstem, most often resulting from secondary autoimmune responses. To our knowledge, this is the first probable case report of shingles-associated BBE with anti-sulfatide IgM positivity. Case presentation We report the case of an 83-year-old woman with symptoms of progressive limb weakness, difficulty swallowing food, and disturbed consciousness that occurred 4 weeks following herpes zoster infection. Autoimmune anti-sulfatide antibodies were positive and fluid-attenuated inversion recovery (FLAIR) sequences revealed clear high signal intensity in pons and bilateral thalamus. Our patient's condition improved markedly with glucocorticoid treatment. After 2 months of treatment, our patient was fully recovered. We considered that for her case, BBE is the most appropriate diagnosis. Conclusions We emphasize the importance of a careful medical history and assessment of clinical symptoms, performing MRI, testing autoimmune antibodies for rapid diagnosis, and ruling out differential diagnoses. Further studies involving more patients with BBE with IgM anti-sulfatide autoantibodies will increase the understanding of the clinical characteristics and advance the diagnosis and treatment of this syndrome. Meanwhile, it is crucial for dermatologists to know about this severe neurological complication following shingles.
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Affiliation(s)
- Xiaoxue Fu
- Baoding First Central Hospital, Baoding, Hebei, China
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Caliskan E, Sager SG, Yukselmis U, Kilic AK, Gunbey HP. Coexistence of longitudinally extensive transverse myelitis and diffuse midline glioma in the brainstem in an adolescent boy with acute flaccid paralysis. Childs Nerv Syst 2024; 40:227-232. [PMID: 37737897 DOI: 10.1007/s00381-023-06163-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
We present the case of a previously healthy 13-year-old boy who was admitted to the emergency department with acute flaccid paralysis. Magnetic resonance imaging revealed radiological evidence of longitudinally extensive transverse myelitis. Additionally, homogeneous T2 signal increase was observed in the pons and medulla oblongata, initially indicating brainstem encephalitis. Subsequent evaluations confirmed a coexistence of diffuse midline glioma (DMG) in the brain stem alongside acute transverse myelitis (ATM). Children with ATM generally have a more favorable prognosis than adults. However, despite the implementation of advanced treatment methods, the patient's quadriplegia did not improve and resulted in spinal cord sequela atrophy. DMG exhibits an aggressive growth pattern and lacks a known curative treatment. This case represents an exceedingly rare synchronous occurrence of aggressive conditions, underscoring the importance of raising awareness among physicians. Furthermore, we aim to discuss the radiologic differential diagnosis, as this is the first documented instance in the literature.
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Affiliation(s)
- Emine Caliskan
- Department of Pediatric Radiology, Kartal Dr. Lutfi Kirdar City Hospital, University of Health Sciences, D-100 Güney Yanyol, Cevizli Mevkii, No:47, 34865, Kartal, Istanbul, Turkey.
| | - Safiye Gunes Sager
- Department of Pediatric Neurology, Kartal Dr. Lutfi Kirdar City Hospital, University of Health Sciences, D-100 Güney Yanyol, Cevizli Mevkii, No:47, 34865, Kartal, Istanbul, Turkey
| | - Ufuk Yukselmis
- Department of Pediatric Intensive Care, Kartal Dr. Lutfi Kirdar City Hospital, University of Health Sciences, D-100 Güney Yanyol, Cevizli Mevkii, No:47, 34865, Kartal, Istanbul, Turkey
| | - Ahmet Kasim Kilic
- Department of Neurology, Kartal Dr. Lutfi Kirdar City Hospital, University of Health Sciences, D-100 Güney Yanyol, Cevizli Mevkii, No:47, 34865, Kartal, Istanbul, Turkey
| | - Hediye Pınar Gunbey
- Department Radiology, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, D-100 Güney Yanyol, Cevizli Mevkii, No:47, 34865, Kartal Istanbul, Turkey
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García de Andoin Sojo C, Gómez Muga J, Aza Martínez I, Antón Méndez L, Fornell Pérez R. Lesiones inflamatorias del troncoencéfalo: claves diagnósticas en RM. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Wahed LA, Cho TA. Imaging of Central Nervous System Autoimmune, Paraneoplastic, and Neuro-rheumatologic Disorders. Continuum (Minneap Minn) 2023; 29:255-291. [PMID: 36795880 DOI: 10.1212/con.0000000000001244] [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: 02/18/2023]
Abstract
OBJECTIVE This article provides an overview of the imaging modalities used in the evaluation of central nervous system (CNS) autoimmune, paraneoplastic, and neuro-rheumatologic disorders. An approach is outlined for interpreting imaging findings in this context, synthesizing a differential diagnosis based on certain imaging patterns, and choosing further imaging for specific diseases. LATEST DEVELOPMENTS The rapid discovery of new neuronal and glial autoantibodies has revolutionized the autoimmune neurology field and has elucidated imaging patterns characteristic of certain antibody-associated diseases. Many CNS inflammatory diseases, however, lack a definitive biomarker. Clinicians should recognize neuroimaging patterns suggestive of inflammatory disorders, as well as the limitations of imaging. CT, MRI, and positron emission tomography (PET) modalities all play a role in diagnosing autoimmune, paraneoplastic, and neuro-rheumatologic disorders. Additional imaging modalities such as conventional angiography and ultrasonography can be helpful for further evaluation in select situations. ESSENTIAL POINTS Knowledge of imaging modalities, both structural and functional, is critical in identifying CNS inflammatory diseases quickly and can help avoid invasive testing such as brain biopsy in certain clinical scenarios. Recognizing imaging patterns suggestive of CNS inflammatory diseases can also facilitate the early initiation of appropriate treatments to diminish morbidity and future disability.
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MOG antibody associated disease (MOGAD) presenting with extensive brain stem encephalitis: A case report. eNeurologicalSci 2022; 29:100432. [DOI: 10.1016/j.ensci.2022.100432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
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Bhatia SS, Canepa C, Notarianni A. Bickerstaff’s brainstem encephalitis mimicking herpetic encephalomyelitis in a liver transplant patient with anti-GQ1b antibodies. BMJ Case Rep 2022; 15:15/12/e251784. [DOI: 10.1136/bcr-2022-251784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A woman in her late 70s with a history of liver transplant presented with ophthalmoplegia, ataxia, areflexia, positive Babinski’s sign and reduced consciousness. This followed an antecedent illness in the form of a herpes zoster infection. MRI of the brain/spinal cord, cerebrospinal fluid analysis with viral PCR and routine blood tests were normal, and tacrolimus neurotoxicity was ruled out. Serum anti-GQ1b antibodies were positive. A diagnosis of Bickerstaff’s brainstem encephalitis was made, forming part of the continuum that involves Miller-Fisher syndrome, entitled the ‘anti-GQ1b syndrome’. Complete recovery ensued without intravenous immunoglobulins or plasma exchange. The role of monitoring anti-ganglioside pattern change to predict or confirm disease recurrence and disease severity is further discussed.
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Thy M, Gaudemer A, Vellieux G, Sonneville R. Critical care management of meningitis and encephalitis: an update. Curr Opin Crit Care 2022; 28:486-494. [PMID: 35975963 DOI: 10.1097/mcc.0000000000000980] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW Meningitis and encephalitis represent severe neurological syndromes associated with encephalopathy, seizures, focal deficits, and neurological sequelae in survivors. We update on the critical care management of adult patients with severe meningitis and encephalitis. RECENT FINDINGS Large multicenter studies conducted in the adult population improved current knowledge on the epidemiology and outcomes of patients with severe meningitis and encephalitis. An early multimodal diagnostic workup (including CSF analysis, brain MRI, EEG, and serum studies) is mandatory for diagnosis and prognostication in those patients.New diagnostic methods, including multiplex PCR and next-generation sequencing techniques, allow for a faster differential diagnosis of infectious causes that may require specific antimicrobial therapy. Autoimmune causes of encephalitis, which may require urgent immunotherapy, are also increasingly recognized in the ICU setting. Although observational data suggest that early combined immunotherapy is associated with better neurological outcomes in patients with autoimmune encephalitis, randomized clinical trials have yet to be performed. SUMMARY Our review highlights the importance of an early multimodal approach for diagnosing severe meningitis and encephalitis. Randomized clinical trials are needed to identify pharmacological interventions that may improve patients' outcomes.
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Affiliation(s)
- Michael Thy
- Department of Intensive Care Medicine, AP-HP, Hôpital Bichat - Claude Bernard
- Department of Infectious and Tropical Diseases, AP-HP, Bichat Hospital
- EA 7323 - Pharmacology and Therapeutic Evaluation in Children and Pregnant Women
| | - Augustin Gaudemer
- Department of Radiology, AP-HP, Bichat Hospital, Université de Paris Cité
| | - Geoffroy Vellieux
- Paris Brain Institute, ICM, Inserm, CNRS, Sorbonne Université
- Clinical Neurophysiology Department, Pitié-Salpêtrière Hospital
| | - Romain Sonneville
- Department of Intensive Care Medicine, AP-HP, Hôpital Bichat - Claude Bernard
- INSERM UMR1137, IAME, Université Paris Cité, Paris, France
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Orozco E, Guo Y, Chen JJ, Dubey D, Howell B, Moutvic M, St Louis EK, McKeon A. Clinical Reasoning: A 43-Year-Old Man With Subacute Onset of Vision Disturbances, Jaw Spasms, Balance, and Sleep Difficulties. Neurology 2022; 99:387-392. [PMID: 35794020 PMCID: PMC9502740 DOI: 10.1212/wnl.0000000000200950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022] Open
Abstract
A brainstem syndrome is recognizable in patients presenting with a combination of visual disturbances, incoordination, gait problems, speech and swallowing difficulties, and new-onset sleep symptomatology. Brainstem disorders of subacute onset (onset and progression with accumulation of disabling deficits in 6–12 weeks) are generally of autoimmune, infectious, inflammatory, or infiltrative neoplastic cause. An autoimmune or infectious brainstem disorder may be referred to as brainstem encephalitis or rhombencephalitis. We describe a patient with paraneoplastic autoimmune rhombencephalitis, in whom diagnostic clues included the following: diverse visual and sleep symptoms, trismus, and choking in the history; see-saw nystagmus, opsoclonus, dysarthria, jaw dystonia, and episodic laryngospasm on examination; subtle but longitudinal and nonenhancing T2 MRI abnormalities in the brainstem and upper cervical cord; and oligoclonal bands in the CSF. His movement disorder–specific neural IgG profile revealed ANNA-2 (anti-Ri) and KLHL-11-IgG. Both are biomarkers of paraneoplastic brainstem encephalitis. KLCHL-11-IgG has been reported to accompany germ cell tumors, which was found in a solitary metastasis to the left inguinal lymph node in our patient, along with an atrophic left testis. Multidisciplinary treatment (autoimmune neurology, sleep medicine, ophthalmology, and physiatry) led to significant clinical improvements. This case provides a framework for the evaluation of patients with subacute-onset brainstem syndromes and the investigation and management of those with paraneoplastic and other autoimmune diseases.
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Affiliation(s)
- Emma Orozco
- Department of Laboratory Medicine and Pathology
| | | | | | | | - Bradley Howell
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan
| | | | | | - Andrew McKeon
- Department of Laboratory Medicine and Pathology .,Neurology
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Corrêa DG, Hygino da Cruz LC, Freddi TDAL. The oculomotor nerve: Anatomy and Pathology. Semin Ultrasound CT MR 2022; 43:389-399. [DOI: 10.1053/j.sult.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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