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Koncz R, Say MJ, Gleason A, Hardy TA. The neurocognitive and neuropsychiatric manifestations of Susac syndrome: a brief review of the literature and future directions. Neurol Sci 2024; 45:5181-5187. [PMID: 38954275 PMCID: PMC11470906 DOI: 10.1007/s10072-024-07672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/20/2024] [Indexed: 07/04/2024]
Abstract
Encephalopathy is part of the clinical triad of Susac syndrome, but a detailed understanding of the neurocognitive and neuropsychiatric profile of this condition is lacking. Existing literature indicates that cognitive deficits range in severity from subtle to profound. Executive function and short-term recall are affected frequently. Psychiatric manifestations may be absent or may include anxiety, mood disorders or psychosis. If psychiatric phenomena develop during the disease course, it can be hard to disentangle whether symptoms directly relate to the pathology of Susac syndrome or are secondary to treatment-related side effects. In this article, we review what is known about the cognitive and psychiatric morbidity of Susac syndrome and identify areas where knowledge is deficient. Importantly, we also provide a framework for future research, arguing that better phenotyping, understanding of pathophysiology, evaluation of treatments on cognitive and psychiatric outcomes, and longitudinal data capture are vital to improving patient outcomes.
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Affiliation(s)
- Rebecca Koncz
- The University of Sydney Specialty of Psychiatry, Concord, NSW, Australia.
- Department of Psychiatry, Concord Repatriation General Hospital, Concord, NSW, Australia.
| | - Miranda J Say
- Department of Psychology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Andrew Gleason
- Department of Consultation-Liaison Psychiatry, Concord Repatriation General Hospital, Concord, NSW, Australia
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Todd A Hardy
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia
- Brain and Mind Centre, University of Sydney, Camperdown, NSW, Australia
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Kachaner A, Mageau A, Goulenok T, François C, Delory N, Chauveheid MP, Louenan C, Doan S, Halimi C, Klein I, Papo T, Sacré K. Immunosuppressive agents or intravenous immunoglobulin in addition to glucocorticoids in the treatment of Susac syndrome: a French national cohort study. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00220-0. [PMID: 39305913 DOI: 10.1016/s2665-9913(24)00220-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 07/05/2024] [Accepted: 07/17/2024] [Indexed: 10/20/2024]
Abstract
BACKGROUND Susac syndrome is a rare disease affecting mainly young women and is characterised by an occlusive microvessel disease limited to the brain, retina, and inner ear. No randomised controlled trial has been published or declared as ongoing to investigate treatments for Susac syndrome. We aimed to compare the effect of glucocorticoids given alone or in combination with immunosuppressive agents or intravenous immunoglobulin for the prevention of relapse in patients with Susac syndrome. METHODS The Phenotypic and Etiological Characterization of Susac Syndrome-National Clinical Research Hospital Program study is a prospective national cohort study that started enrolling on Nov 29, 2011, and included all consecutive patients aged 18 years or older with Susac syndrome who were referred to the French reference centre (Department of Internal Medicine, Bichat-Claude Bernard Hospital, Paris). Susac syndrome was defined by either the triad of encephalopathy with typical brain MRI abnormalities, cochleo-vestibular damage, and multiple occlusions of retinal central artery branches, or at least two of the three criteria without any alternative diagnosis. Collected data included fundoscopy, retinal angiography, audiometry, cerebrospinal fluid, brain MRI, and treatment received at diagnosis; months 1, 3, 6, and 12 after diagnosis; and then annually for 5 years or in the case of a relapse. The primary outcome was defined as the first relapse occurring within a 36-month follow-up period from the first day of treatment, characterised by new clinical symptoms or signs, and new abnormalities observed on retinal angiography, audiometry, or brain MRI, necessitating treatment intensification. There was no involvement of people with lived experience at any stage. The study is registered at ClinicalTrials.gov, NCT01481662. FINDINGS Between Nov 29, 2011, and Dec 2, 2022, 64 patients were included in the study, with a mean age at diagnosis of 35 years (SD 11); 41 (64%) were women and 23 (36%) were men. At diagnosis, 60 patients received glucocorticoids; 40 (63%) of 64 patients received glucocorticoids alone as a first-line therapy while 20 (31%) received glucocorticoids in combination with immunosuppressive agents or intravenous immunoglobulin. Overall, 46 (72%) of 64 patients had a first relapse with a median relapse-free survival time of 3·96 months (95% CI 2·24-16·07). Comparison of relapse-free survival showed no significant difference between the two treatment strategies (hazard ratio [HR] 1·11 [95% CI 0·56-2·17], p=0·76), compared with glucocorticoids alone as the reference group. In patients who first relapsed while treated with glucocorticoids alone, there was no significant difference in second relapse-free survival between those who did or did not receive immunosuppressive agents or intravenous immunoglobulin as a second-line therapy (HR 2·66 [95% CI 0·63-11·18], p=0·18). INTERPRETATION The combination of glucocorticoids with immunosuppressive agents or intravenous immunoglobulin did not appear to reduce the risk of Susac syndrome relapse compared with glucocorticoids alone. Our findings did not support the systematic use of immunosuppressive agents in Susac syndrome. FUNDING French Ministry of Health.
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Affiliation(s)
- Alexandra Kachaner
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Arthur Mageau
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Tiphaine Goulenok
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Chrystelle François
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Nicole Delory
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Marie-Paule Chauveheid
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Cedric Louenan
- Department of Epidemiology, Biostatistics and Clinical Research, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Serge Doan
- Department of Ophthalmology, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Caroline Halimi
- Department of Otolaryngology, Head and Neck Surgery, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Isabelle Klein
- Department of Radiology, Clinique Alleray-Labrouste, Paris, France
| | - Thomas Papo
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Karim Sacré
- Department of Internal Medicine, Hôpital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France; Centre de Recherche sur l'Inflammation, INSERM UMR1149, CNRS ERL8252, Faculté de Médecine site Bichat, Laboratoire d'Excellence Inflamex, Paris, France.
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Piura Y, Bregman N, Kavé G, Karni A, Kolb H, Vigiser I, Day GS, Lopez-Chiriboga S, Shiner T, Regev K. Long-term cognitive outcomes in Susac syndrome: A case series. J Neuroimmunol 2024; 393:578396. [PMID: 38908330 DOI: 10.1016/j.jneuroim.2024.578396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/17/2024] [Accepted: 06/19/2024] [Indexed: 06/24/2024]
Abstract
Susac syndrome (SuS) presents with encephalopathy, visual disturbances, and hearing loss from immune-mediated microvascular occlusion. While acute SuS is well-described, long-term cognitive outcomes with current treatments are underknown. We assessed ten SuS patients treated in accordance with evidence-based guidelines using immunotherapies targeting humoral and cell-mediated pathways. Patients were followed for a median 3.6 years. Initially, cognition inversely correlated with corpus callosum lesions on MRI. All reported cognitive improvement; 5/10 patients had residual deficits in visual attention and executive function. Early, aggressive treatment was associated with good outcomes; extensive early corpus callosum lesions may identify patients at-risk of persistent cognitive deficits.
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Affiliation(s)
- Yoav Piura
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Cognitive Neurology Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; The Neuroimmunology and Multiple Sclerosis Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel.
| | - Noa Bregman
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Cognitive Neurology Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Gitit Kavé
- Department of Education and Psychology, The Open University of Israel, Ra'anana, Israel; Cognitive Neurology Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; The Neuroimmunology and Multiple Sclerosis Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Hadar Kolb
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; The Neuroimmunology and Multiple Sclerosis Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ifat Vigiser
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel; The Neuroimmunology and Multiple Sclerosis Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Gregory S Day
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | | | - Tamara Shiner
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Cognitive Neurology Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Keren Regev
- Department of Neurology, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel; The Neuroimmunology and Multiple Sclerosis Unit, Neurological Institute, Tel Aviv Medical Center, Tel Aviv, Israel
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Basagni B, Abbruzzese L, Radicchi G, Damora A, Salti G, Malentacchi GM, Caputo N, Zoccolotti P, Scarselli C, Mancuso M. Cognitive profile in a young woman with Susac syndrome: a case report. Neurocase 2024; 30:83-90. [PMID: 38869248 DOI: 10.1080/13554794.2024.2366457] [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: 08/09/2023] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
Susac syndrome is a rare immune-mediated endotheliopathy affecting the microvasculature. It presents three main symptoms: encephalopathy, branch retinal artery occlusions, and hearing loss . Here we present a new case report focusing on the evolution of the cognitive profile. The patient underwent two neuropsychological examinations. The first, one month after the onset of the symptomatology, highlighted a prevalent involvement of verbal executive functions. The second, conducted six months later, revealed a global improvement in most previously deficient areas, although with the persistence of a difficulty in cognitive estimation. . This case illustrates the importance of a comprehensive analysis of patients with Susac syndrome to appreciate the whole range of cognitive deficits and reliably evaluate symptom evolution.
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Affiliation(s)
| | | | | | | | - Giulia Salti
- Tuscany Rehabilitation Clinic, Montevarchi, Italy
| | | | | | - Pierluigi Zoccolotti
- Tuscany Rehabilitation Clinic, Montevarchi, Italy
- Sapienza University, Rome, Italy
| | | | - Mauro Mancuso
- Physical and Rehabilitative Medicine Unit, NHS ASL-Toscana Sud-Est, Grosseto, Italy
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Maleki A, Saigal K, Kera J. Susac syndrome in a patient with chronic myelocytic leukemia: Consequence or coincidence? Am J Ophthalmol Case Rep 2024; 33:101996. [PMID: 38318442 PMCID: PMC10839863 DOI: 10.1016/j.ajoc.2024.101996] [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] [Received: 09/29/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
Purpose In this study, we report a patient who presented with both chronic myelocytic leukemia (CML) and Susac syndrome (SS). Observations A 45-year-old male diagnosed with CML in the blast phase sought consultation due to a deterioration in vision in his right eye. He also had hearing loss and severe migraneous headaches. Best corrected visual acuity was light perception and 20/20 in the right and left eyes, respectively. The slit lamp examination and intraocular pressure were within normal ranges for both eyes. Upon dilated fundoscopy, organized vitreous hemorrhage was observed in the right eye, while the left eye exhibited extensive sclerotic vessels with retinal neovascularization in the periphery. Ultrasound of the right eye showed tractional retinal detachment. Optical coherence tomography of the left retina showed thinning of the retina in temporal macula. Fluorescein angiography revealed a substantial nonperfused region in the peripheral left retina, accompanied by arterioarterial and arteriovenous collaterals, along with microaneurysms. MRI showed scattered foci of hyperintensity within the supratentorial white matter, mostly subcortical on T2-weighted and fluid-attenuated inversion-recovery. The patient received a diagnosis of SS and was subsequently referred to the neurology service for further assessment and potential treatment. Conclusion and importance SS may manifest as a presentation of CML. It is advisable to conduct investigations for SS in CML patients experiencing neurological, ophthalmological, or otological symptoms.
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Affiliation(s)
- Arash Maleki
- Department of Ophthalmology, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32608, USA
- The Ocular Immunology and Uveitis Foundation, 1440 Main Street #201, Waltham, MA, 02451, USA
| | - Khushi Saigal
- College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - Jeslin Kera
- Department of Ophthalmology, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32608, USA
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Cviková M, Štefela J, Všianský V, Dufek M, Doležalová I, Vinklárek J, Herzig R, Zemanová M, Červeňák V, Brichta J, Bárková V, Kouřil D, Aulický P, Filip P, Weiss V. Case report: Susac syndrome-two ends of the spectrum, single center case reports and review of the literature. Front Neurol 2024; 15:1339438. [PMID: 38434197 PMCID: PMC10904644 DOI: 10.3389/fneur.2024.1339438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Susac syndrome is a rare and enigmatic complex neurological disorder primarily affecting small blood vessels in the brain, retina, and inner ear. Diagnosing Susac syndrome may be extremely challenging not only due to its rarity, but also due to the variability of its clinical presentation. This paper describes two vastly different cases-one with mild symptoms and good response to therapy, the other with severe, complicated course, relapses and long-term sequelae despite multiple therapeutic interventions. Building upon the available guidelines, we highlight the utility of black blood MRI in this disease and provide a comprehensive review of available clinical experience in clinical presentation, diagnosis and therapy of this disease. Despite its rarity, the awareness of Susac syndrome may be of uttermost importance since it ultimately is a treatable condition. If diagnosed in a timely manner, early intervention can substantially improve the outcomes of our patients.
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Affiliation(s)
- Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jakub Štefela
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vít Všianský
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Michal Dufek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Irena Doležalová
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Jan Vinklárek
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital, Hradec Králové, Czechia
| | - Markéta Zemanová
- Department of Ophthalmology and Optometry, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Vladimír Červeňák
- Department of Medical Imaging, St. Anne’s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jaroslav Brichta
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
| | - Veronika Bárková
- Department of Clinical Pharmacology, St. Anne's University Hospital, Brno, Czechia
| | - David Kouřil
- Department of Neurology, Blansko Hospital, Blansko, Czechia
| | - Petr Aulický
- Department of Anesthesiology, Hospital of the Brothers of Charity Brno, Brno, Czechia
| | - Pavel Filip
- Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czechia
- Center for Magnetic Resonance Research (CMRR), University of Minnesota, Minneapolis, MN, United States
| | - Viktor Weiss
- Department of Neurology, St. Anne’s University Hospital in Brno and Faculty of Medicine at Masaryk University, Brno, Czechia
- Department of Neurology, Charles University Faculty of Medicine, Hradec Králové, Czechia
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7
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Stinissen R, Tukanov E, Wyckmans M, Kerstens J, Willekens B. Clinical characteristics and treatment approaches in patients with Susac syndrome: a scoping review of cases. J Neurol 2023; 270:5719-5730. [PMID: 37668702 DOI: 10.1007/s00415-023-11936-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Susac syndrome (SuS) is a rare disease characterized by encephalopathy, hearing impairment and visual disturbances. Immunosuppressive treatments are used based on the hypothesis that an autoimmune endotheliopathy drives the disease. However, a solid evidence-based treatment approach is lacking. The aim of this review is to provide an overview of patient characteristics, disease course and treatment patterns related to successful outcome that have been reported in literature since 2013. METHODS Three reviewers conducted a systematic literature search in February 2022. The primary outcome was treatment used, derived from cases classified as probable or definite SuS, describing successful treatment outcome (i.e. no signs of disease activity for ≥ 1 month). Secondary outcomes were time-to-relapse and follow-up time. Published case reports and case series were included. Various clinical characteristics and treatment(s) were extracted and categorized into different phases of treatment. RESULTS A total of 810 records was identified. 120 articles met inclusion criteria and 161 cases were extracted. Of these, 151 cases were classified as probable or definite SuS and included in the final analysis. Number of combinations of treatments used per treatment phase were: 6 empirically, 35 after confirmed diagnosis, 43 for maintenance treatment, 22 after relapse, 18 during maintenance post-relapse. Median follow-up time was 12.3 months (0.5; 120) and median time to relapse was 4 months (1; 120). CONCLUSION This scoping review summarizes treatment approaches in patients with SuS, highlighting variability. International efforts to collect clinical, imaging and treatment data from patients with SuS in registries are needed, in order to provide less biased and long-term follow-up information on treatment response, predictors of relapse and patient outcomes. This may lead to more evidence-based therapeutic approaches.
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Affiliation(s)
- Robin Stinissen
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Eldar Tukanov
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Martin Wyckmans
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Jeroen Kerstens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
- Laboratory of Experimental Hematology, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.
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Bullock DR, Spencer RT, Vehe RK, Srivastava S, Rennebohm RM. Use of disease assessment tools to increase the value of case reports on Susac syndrome: two case reports. J Med Case Rep 2023; 17:158. [PMID: 37046335 PMCID: PMC10097450 DOI: 10.1186/s13256-023-03838-9] [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: 01/17/2020] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Susac syndrome is an immune-mediated, ischemia-producing, occlusive microvascular endotheliopathy that threatens the brain, retina, and inner ear. There is a need for disease assessment tools that can help clinicians and patients to more easily, accurately, and uniformly track the clinical course and outcome of Susac syndrome. Ideally, such tools should simultaneously facilitate the clinical care and study of Susac syndrome and improve the value of future case reports. To meet this need, two novel clinical assessment tools were developed: the Susac Symptoms Form and the Susac Disease Damage Score. The former is a comprehensive self-report form that is completed by patients/families to serially document the clinical status of a patient. The latter documents the extent of damage perceived by individual patients/families and their physicians. Both forms were initially trialed with two particularly representative and instructive patients. The results of this trial are shared in this report. CASE PRESENTATION Patient 1 is a 21-year-old Caucasian female who presented with an acute onset of headache, paresthesias, cognitive dysfunction, and emotional lability. Patient 2 is a 14-year-old Caucasian female who presented with an acute onset of headache, cognitive dysfunction, urinary incontinence, ataxia, and personality change. Both patients fulfilled criteria for a definite diagnosis of Susac syndrome: both eventually developed brain, retinal, and inner ear involvement, and both had typical "snowball lesions" on magnetic resonance imaging. The Susac Symptoms Form documented initial improvement in both patients, was sufficiently sensitive in detecting a subsequent relapse in the second patient, and succinctly documented the long-term clinical course in both patients. The Disease Damage Score documented minimal disease damage in the first patient and more significant damage in the second. CONCLUSIONS The Susac Symptoms Form and the Disease Damage Score are useful disease assessment tools, both for clinical care and research purposes. Their use could enhance the value of future case reports on Susac syndrome and could improve opportunities to learn from a series of such reports.
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Affiliation(s)
- Danielle R Bullock
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, East Bldg Rm M668, 2450 Riverside Ave, Minneapolis, MN, 55454, USA
| | - Robert T Spencer
- Colorado Arthritis Center, Rheumatology, 401 E Hampden Ave, Suite 410, Englewood, CO, 80113, USA
| | - Richard K Vehe
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, East Bldg Rm M668, 2450 Riverside Ave, Minneapolis, MN, 55454, USA
| | - Sunil Srivastava
- Ophthalmology Department, Cole Eye Institute, Cleveland Clinic, 2022 E 105th St, Cleveland, OH, 44106, USA
| | - Robert M Rennebohm
- Division of Pediatric Rheumatology, Institute of Pediatrics, Formerly at the Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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9
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Masjuan M, Ivanovski T, Sarasibar Ezcurra H, Rigo Oliver E. Behavioral Impairment and Amnesia at the Onset of Susac Syndrome. Cureus 2023; 15:e38089. [PMID: 37252530 PMCID: PMC10209653 DOI: 10.7759/cureus.38089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Susac syndrome (SS) is an autoimmune microangiopathy that affects the brain, retina, and inner ear, causing a wide range of clinical manifestations. The triad of encephalopathy, visual disturbances, and hearing loss constitute the classic disease presentation. We describe an original clinical case of a young male with a definitive diagnosis of SS, who presented with disordered behavior and amnesia, initially manifested as a dissociative or anxiety disorder but with a fulminant evolution toward severe encephalopathy associated with retinal infarcts and sensorineural hearing loss. After the diagnosis of SS, aggressive immunosuppressive treatment was started with significant neurological improvement and favorable evolution during the follow-up period. SS is a rare but potentially devastating disease that can cause great disability if not properly diagnosed and treated. The onset of SS with behavioral or psychiatric manifestation can be misleading, causing a diagnostic delay.
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Affiliation(s)
- Marc Masjuan
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | - Trajche Ivanovski
- Neurology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
| | | | - Elena Rigo Oliver
- Ophthalmology, Hospital Universitario Son Llatzer, Palma de Mallorca, ESP
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Dekeyser C, Vanhoorne A, Hemelsoet D, Van Hijfte L, De Zaeytijd J, Van Driessche V, Van Hoecke H, Miatton M, Van Vrekhem T, Maes L, Laureys G. Atypical clinical and novel radiological findings in Susac syndrome: Experience from a large monocentric cohort. J Neuroimmunol 2023; 376:578032. [PMID: 36736020 DOI: 10.1016/j.jneuroim.2023.578032] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/03/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
Susac syndrome (SuS) is a rare immune-mediated endotheliopathy that affects the brain, retina and inner ear and is characterised by the variable clinical triad of encephalopathy, visual and vestibulocochlear dysfunction. Here, we present clinical and paraclinical data of 19 SuS patients followed at Ghent University Hospital and highlight some atypical clinical and novel radiological findings. Our findings suggest that spinal involvement expands the clinical phenotype of SuS. We further introduce dark blood sequences as a more sensitive technique to detect radiological disease activity in SuS. Our data add to the current understanding of the diagnosis, monitoring and treatment of SuS.
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Affiliation(s)
- Cathérine Dekeyser
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Alexander Vanhoorne
- Department of Neurology, AZ Groeninge, President Kennedylaan 4, Kortrijk, Belgium.
| | - Dimitri Hemelsoet
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Liesbeth Van Hijfte
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Julie De Zaeytijd
- Department of Ophthalmology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Veroniek Van Driessche
- Department of Radiology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Helen Van Hoecke
- Department of Otorhinolaryngology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Marijke Miatton
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Tineke Van Vrekhem
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Leen Maes
- Department of Otorhinolaryngology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium; Department of Rehabilitation Sciences, Ghent University, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Guy Laureys
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
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11
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Fisher L, David P, Sobeh T, Liberman RB, Amital H. Susac syndrome following COVID-19 vaccination: a case-based review. Clin Rheumatol 2023; 42:1713-1717. [PMID: 36877303 PMCID: PMC9986653 DOI: 10.1007/s10067-023-06564-1] [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: 10/23/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
COVID-19 vaccine circulation approval was a turning point for the coronavirus pandemic. The current approved COVID-19 vaccines, including messenger ribonucleic acid (mRNA)-based and adenovirus vector-based vaccines, were shown to significantly reduce the disease mortality and severity, and its adverse reactions are mainly mild ones. However, few cases of autoimmune conditions, both flare-ups and new-onset, were described in association with these vaccines. Susac vasculitis (SaS) is a rare autoimmune disease characterized by the clinical triad of encephalopathy, visual disturbances, and sensorineural hearing loss. Its pathogenesis is still not fully understood but is believed to be related to autoimmune processes, including autoantibodies to anti-endothelial cells and cellular immune processes that lead to microvascular damage and, consequently, micro-occlusions of the cerebral, inner ear, and retinal vessels. It has been previously described following vaccination and, most recently, few cases following coronavirus vaccines. We here describe a case of a previously healthy 49-year-old man diagnosed with SaS 5 days following the first dose of the BNT162b2 COVID-19 vaccine.
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Affiliation(s)
- Lior Fisher
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Paula David
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamer Sobeh
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Israel
| | - Roberta Bisker Liberman
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Pontifical Catholic University of São Paulo, São Paulo, Brazil
| | - Howard Amital
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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12
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Wu G, Jiang W, Li Z, Huang D, Wu L. Misdiagnosis of Susac syndrome as demyelinating disease and primary angiitis of the central nervous system: A case report. Front Neurol 2022; 13:1055038. [PMID: 36570458 PMCID: PMC9772262 DOI: 10.3389/fneur.2022.1055038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Susac syndrome (SuS) is a rare neuroinflammatory disease that manifests with a triad of hearing loss, branch retinal artery occlusions, and encephalopathy. Patients with SuS are frequently misdiagnosed because the clinical trial is incompletely present at disease onset. In this report, we present a case of a 29-year-old man manifesting sleepiness, epilepsy, urinary dysfunction, and hemiparesis at the initial stage. Magnetic resonance imaging (MRI) revealed multiple abnormal signals located in the lateral paraventricular, corpus callosal, and pons. In addition, the patient had sustained elevation of CSF pressure and protein. ADEM was considered according to the clinical and radiographic findings. However, symptoms were not significantly improved after methylprednisolone therapy. He showed a vision decline in the third month after the disease onset. It was considered from intracranial hypertension or optic neuritis, and therefore retinal arteriolar impairment was ignored. As the disease progresses, cognitive decline was presented. Brain MRI exhibits multiple significant hyperintensities on the DWI sequence with speck-like gadolinium enhancement. Thus, PACNS was diagnosed. The SuS was not made until the presence of hearing decline in the 4 months after the disease onset. The case will be helpful for clinicians to better recognize the atypical initial manifestation of SuS.
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Affiliation(s)
- Gang Wu
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,Department of Neurology, No 984 Hospital of PLA, Beijing, China
| | - Wei Jiang
- Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences, Amsterdam, Netherlands
| | - Zunbo Li
- Department of Neurology, Xi'an Gao Xin Hospital, Xi'an, China
| | - Dehui Huang
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,*Correspondence: Dehui Huang
| | - Lei Wu
- Department of Neurology, The First Medical Centre of Chinese PLA General Hospital, Beijing, China,Lei Wu
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13
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Ahmed S, Khan TA, Liaqat T, Ijaz U, Sarfaraz H. A young soldier with Susac syndrome: a case report. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Susac syndrome is a rare disease with multisystem manifestations. While the exact pathogenesis is not known, it has been proposed to be an autoimmune endotheliopathy affecting the microvasculature of the brain, retina, and inner ear. The disease is characterized by a triad of encephalopathy, vision loss, and hearing loss. However, patients may not have the triad at initial presentation and present with only a single finding.
Case presentation
A 25-year-old male resident of Panu Akil presented to Combined Military Hospital Lahore with complaints of dizziness and vertigo associated with severe migraine like headaches. He experienced sudden painless loss of vision in his right eye and was admitted to the medical intensive care unit. On examination, he had right-beating nystagmus and diplopia along with scintillating scotoma. After his admission, contrast-enhanced magnetic resonance imaging (MRI) was done which showed numerous enhancing bilateral white matter internal capsule micro-infarcts indicating typical “string of pearls” sign and a snowball lesion on the corpus callosum. His fundus fluorescein angiography (FFA) did not exhibit any branched retinal artery occlusions (BRAO). Fundoscopy showed the presence of drusen spots. His pure tone audiometry was unremarkable. Based on the highly characteristic findings present on the MRI, a diagnosis of Susac syndrome was made. He was started on injection methylprednisolone 1 gm IV in 500 ml normal saline over 1 h once a day for 5 days and then once a week for 8 weeks. He was also started on tablet mycophenolate mofetil 500 mg once daily for 7 days. Patient showed marked clinical improvement afterwards.
Conclusions
Susac syndrome is a rare multisystem illness with an often insidious presentation. Patients can be misdiagnosed due to the nonspecific nature of the early complaints present in the disease. High index of suspicion is required for timely diagnosis and adequate management. Although no specific guidelines exist, management consists mainly of immunosuppressants.
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14
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Bugallo González I, García Fernández M, Rodríguez Villa S, Scalcione C. Susac syndrome: The importance of an early diagnosis. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:290-294. [PMID: 35526953 DOI: 10.1016/j.oftale.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/18/2021] [Indexed: 06/14/2023]
Abstract
A 38-year-old man who attended the emergency department with headache, accompanied by vomiting, bradypsychia and gait instability, for which he was admitted to Neurology for study. During his admission, he began to present bilateral hearing loss and blurred vision in the left eye, with areas of arterial occlusion and hyperfluorescence of the arterial wall being observed in the ophthalmological examination. As a result, he was diagnosed with Susac syndrome. He was treated with systemic corticosteroids, as well as with rituximab and subsequently, with intravenous immunoglobulins and mycophenolate mofetil. The patient managed to preserve visual acuity, with gait instability and bilateral hearing loss as sequelae. Early diagnosis of Susac syndrome is important, because a delay in the start of treatment can lead to irreversible sequelae such as deafness, blindness or neurological involvement.
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Affiliation(s)
- I Bugallo González
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
| | - M García Fernández
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - S Rodríguez Villa
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - C Scalcione
- Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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15
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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16
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Triplett JD, Qiu J, O'Brien B, Gopinath S, Trewin B, Spring PJ, Shaffi M, Ip J, Chan F, Chen L, Wilson I, Muller C, Beadnall HN, Boggild M, Van der Walt A, Roxburgh R, Seery N, Kalincik T, Barnett MH, Parratt JDE, Reddel SW, Tsang B, Hardy TA. Diagnosis, differential diagnosis and misdiagnosis of Susac syndrome. Eur J Neurol 2022; 29:1771-1781. [PMID: 35262238 PMCID: PMC9314104 DOI: 10.1111/ene.15317] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 11/28/2022]
Abstract
Background and purpose Susac syndrome (SuS) is an inflammatory condition of the brain, eye and ear. Diagnosis can be challenging, and misdiagnosis is common. Methods This is a retrospective review of the medical records of 32 adult patients from an Australasian cohort of SuS patients. Results An alternative diagnosis prior to SuS was made in 30 patients (94%) with seven patients receiving two or more diagnoses. The median time to diagnosis of SuS was 3 months (range 0.5–100 months). The commonest misdiagnoses were migraine in 10 patients (31%), cerebral vasculitis in six (19%), multiple sclerosis in five (16%) and stroke in five (16%). Twenty‐two patients were treated for alternative diagnoses, 10 of whom had further clinical manifestations prior to SuS diagnosis. At presentation seven patients (22%) met criteria for definite SuS, 19 (59%) for probable SuS and six (19%) for possible SuS. Six patients (19%) presented with brain–eye–ear involvement, 14 with brain–ear (44%), six with brain–eye (19%) and six (19%) with only brain involvement. In patients with the complete triad of symptoms the median delay to diagnosis was 3 months (range 1–9 months) compared to 5.25 months (range 0.5–100 months) for patients with encephalopathy and ocular symptoms at presentation. Conclusions Susac syndrome patients are frequently misdiagnosed at initial presentation, despite many having symptoms or radiological features that are red flags for the diagnosis. Delayed diagnosis can lead to patient morbidity. The varied ways in which SuS can present, and clinician failure to consider or recognize SuS, appear to be the main factors leading to misdiagnosis.
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Affiliation(s)
- James D Triplett
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Jessica Qiu
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Sumana Gopinath
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Benjamin Trewin
- Department of Neurology, Campbelltown Hospital, Sydney, NSW, Australia
| | - Penelope J Spring
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | | | - Jerome Ip
- Section of Neurology, Sydney Adventist Hospital, Sydney, NSW, Australia
| | - Fiona Chan
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Luke Chen
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Ian Wilson
- Department of Neurology, Cairns Hospital, Cairns, Qld, Australia
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Heidi N Beadnall
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mike Boggild
- Department of Neurology, Townsville Hospital, Townsville, Qld, Australia
| | - Anneke Van der Walt
- Department of Neurology, The Alfred Hospital, Monash University, Melbourne, Vic, Australia
| | - Richard Roxburgh
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Nabil Seery
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
| | - Tomas Kalincik
- MS Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michael H Barnett
- Brain & Mind Centre, University of Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John D E Parratt
- Department of Neurology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Stephen W Reddel
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia
| | - Benjamin Tsang
- Department of Neurology, Sunshine Coast Hospital, Sunshine Coast, Qld, Australia
| | - Todd A Hardy
- Department of Neurology, Concord Hospital, University of Sydney, NSW, Australia.,Brain & Mind Centre, University of Sydney, NSW, Australia
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17
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Susac Syndrome Following COVID-19 Vaccination: A Case Report. Vaccines (Basel) 2022; 10:vaccines10030363. [PMID: 35334994 PMCID: PMC8954499 DOI: 10.3390/vaccines10030363] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the COVID-19 pandemic, numerous vaccines have been developed for the disease. However, with large-scale vaccination has come the gradual emergence of immunological phenomena caused by these new vaccines. Herein, we report a 48-year-old female with a sudden onset of inferior visual field defects in the left eye following her first dose of the ChAdOx1 vaccine. Dilated fundus examination combined with optical coherence tomography and fluorescein angiography confirmed the diagnosis of branch retinal artery occlusion. Within 4 weeks following vaccination, symptoms associated with hearing impairment developed, and magnetic resonance imaging revealed leptomeningeal enhancement. The diagnosis of Susac syndrome (SS) was confirmed. The development of SS may be caused by endotheliopathy resulting from the molecular mimicry of the ChAdOx1 vaccine. Clinicians should be aware of the symptoms of SS, which may develop after COVID-19 vaccination. Further experimental surveillance and case–control studies are required to confirm this relationship.
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18
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Wang A, Hu K, Yang Y, Yang B, Liu J, Chen X, Liu Y, Si Z. Susac syndrome with the typical clinical triad: A case report and literature review. J Neuroimmunol 2022; 367:577822. [DOI: 10.1016/j.jneuroim.2022.577822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/31/2021] [Accepted: 01/29/2022] [Indexed: 11/25/2022]
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19
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Wang H, Hu P, Li Q, Fan H. A case of nasopharyngeal carcinoma presenting as Susac syndrome. Br J Hosp Med (Lond) 2021; 82:1-3. [PMID: 34983223 DOI: 10.12968/hmed.2021.0406] [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]
Affiliation(s)
- Heng Wang
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Peng Hu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Qingyun Li
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Hongbin Fan
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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20
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Manifestation of Susac syndrome during interferon beta-1a and glatiramer acetate treatment for misdiagnosed multiple sclerosis: a case report. BMC Ophthalmol 2021; 21:352. [PMID: 34592956 PMCID: PMC8481314 DOI: 10.1186/s12886-021-02101-3] [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: 03/31/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Susac syndrome (SS) is characterized by the triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. However, the diagnosis of SS remains difficult because the clinical triad rarely occurs at disease onset, and symptom severity varies. SS symptoms often suggest other diseases, in particular multiple sclerosis (MS), which is more common. Misdiagnosing SS as MS may cause serious complications because MS drugs, such as interferon beta-1a, can worsen the course of SS. This case report confirms previous reports that the use of interferon beta-1a in the course of misdiagnosed MS may lead to exacerbation of SS. Moreover, our case report shows that glatiramer acetate may also exacerbate the course of SS. To the best of our knowledge, this is the first reported case of exacerbation of SS by glatiramer acetate. Case presentation We present a case report of a patient with a primary diagnosis of MS who developed symptoms of SS during interferon beta-1a treatment for MS; these symptoms were resolved after the discontinuation of the treatment. Upon initiation of glatiramer acetate treatment, the patient developed the full clinical triad of SS. The diagnosis of MS was excluded, and glatiramer acetate therapy was discontinued. The patient’s neurological state improved only after the use of a combination of corticosteroids, intravenous immunoglobulins, and azathioprine. Conclusions The coincidence of SS signs and symptoms with treatment for MS, first with interferon beta-1a and then with glatiramer acetate, suggests that these drugs may influence the course of SS. This case report indicates that treatment with glatiramer acetate may modulate or even exacerbate the course of SS.
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21
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Scheifer C, Henry Feugeas MC, Roriz M, Cohen Aubart F, Doan S, Jouvent E, Klein I, Machado C, Rouzaud D, Papo T, Sacré K. Brain magnetic resonance imaging lesion load at diagnosis, severity at onset and outcomes in Susac syndrome: A prospective cohort study. Eur J Neurol 2021; 29:121-129. [PMID: 34382290 DOI: 10.1111/ene.15062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Susac syndrome (SuS) is a rare occlusive microvessel disease of the brain, retina and inner ear. We aimed to determine whether brain lesion load at the acute phase predicts poor outcomes in SuS. METHODS A prospective national cohort study was conducted from December 2012 to December 2019 in 20 centres in France. Patients included at the principal investigator's center with available brain magnetic resonance imaging (MRI) at diagnosis were analyzed. MRI was reviewed by an experienced neuroradiologist blinded to clinical status. The size, topography and number of hyperintense lesions on diffusion-weighted imaging (DWI-HL) were analyzed at diagnosis and during follow-up. Outcomes involved descriptive characteristics of patients at onset and last follow-up. RESULTS Twenty-three patients (38.1 [18.8-56.5] years, 16 females) were prospectively studied. The triad (i.e., brain, eye and ear involvement) was complete at onset in 17 patients. Brain MRI was performed 1.1 (0.1-3.4) months after the first symptom. All patients had DWI-HL at the acute phase. Patients were separated into two groups according to the number of DWI-HL on first MRI: a first group of patients (n=15) displaying low brain lesion load (<50 DWI-HL per patient) and a second group of patients (n=8) displaying high brain lesion load (≥100 DWI-HL). The median follow-up was 57.9 (9.7-98) months. Clinical features, treatment, relapse rate, time to disappearance of DWI-HL, disabilities and professional outcome did not differ according to brain lesion load. CONCLUSION Brain lesion load assessed by DWI at the acute phase is not associated with risks of disability in SuS.
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Affiliation(s)
- Carole Scheifer
- Department of Internal Medecine, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Marie-Cécile Henry Feugeas
- Department of Radiology, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Mélanie Roriz
- Department of Internal Medecine, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Fleur Cohen Aubart
- Department of Internal Medecine, Hospital Pitié-Salpétrière, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Serge Doan
- Department of Ophthalmology, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Eric Jouvent
- Department of Neurology, Hospital Lariboisière, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Isabelle Klein
- Department of Radiology, Clinique Alleray-Labrouste, Université de Paris, Paris, France
| | - Carla Machado
- Department of Neurology, Hospital Lariboisière, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Diane Rouzaud
- Department of Internal Medecine, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Thomas Papo
- Department of Internal Medecine, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France.,INSERM UMR1149, Paris, France
| | - Karim Sacré
- Department of Internal Medecine, Hospital Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France.,INSERM UMR1149, Paris, France
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22
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Wiendl H, Gross CC, Bauer J, Merkler D, Prat A, Liblau R. Fundamental mechanistic insights from rare but paradigmatic neuroimmunological diseases. Nat Rev Neurol 2021; 17:433-447. [PMID: 34050331 DOI: 10.1038/s41582-021-00496-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 02/04/2023]
Abstract
The pathophysiology of complex neuroimmunological diseases, such as multiple sclerosis and autoimmune encephalitis, remains puzzling - various mechanisms that are difficult to dissect seem to contribute, hampering the understanding of the processes involved. Some rare neuroimmunological diseases are easier to study because their presentation and pathogenesis are more homogeneous. The investigation of these diseases can provide fundamental insights into neuroimmunological pathomechanisms that can in turn be applied to more complex diseases. In this Review, we summarize key mechanistic insights into three such rare but paradigmatic neuroimmunological diseases - Susac syndrome, Rasmussen encephalitis and narcolepsy type 1 - and consider the implications of these insights for the study of other neuroimmunological diseases. In these diseases, the combination of findings in humans, different modalities of investigation and animal models has enabled the triangulation of evidence to validate and consolidate the pathomechanistic features and to develop diagnostic and therapeutic strategies; this approach has provided insights that are directly relevant to other neuroimmunological diseases and applicable in other contexts. We also outline how next-generation technologies and refined animal models can further improve our understanding of pathomechanisms, including cell-specific and antigen-specific CNS immune responses, thereby paving the way for the development of targeted therapeutic approaches.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany.
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Doron Merkler
- Department of Pathology and Immunology, Division of Clinical Pathology, University and University Hospitals of Geneva, Geneva, Switzerland
| | - Alexandre Prat
- Department of Neuroscience, University of Montreal, Montreal, Canada
| | - Roland Liblau
- Infinity, Université Toulouse, CNRS, Inserm, Toulouse, France.,CHU Toulouse, Hôpital Purpan, Immunology Department, Toulouse, France
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23
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Abstract
PURPOSE To present the clinical manifestations and results of key diagnostic investigations in patients with Susac syndrome, with special emphasis on the principal role of fluorescein angiography (FA) of the peripheral retina. METHODS A retrospective analysis of medical records (collected 2000-2019) of 20 patients (15 women and five men), aged 20 to 51 years (mean age: 31.6 years) with complete or incomplete Susac syndrome diagnosed by an ophthalmic examination and widefield fluorescein angiography (WF-FA) by Spectralis and Optos Tx200. RESULTS Fluorescein angiography abnormalities included vascular changes in the posterior pole in 64.7% and in the peripheral retina in 82.4%. Widefield FA abnormalities in the peripheral retina alone were seen in 35.3% and in the posterior pole, but without peripheral vascular involvement, in 17.6%. Secondary leakage from veins was noted in 58.8%. CONCLUSION Widefield FA of the peripheral retina has a key role in cases of suspected Susac syndrome as it confirms the diagnosis and assesses disease activity. In addition to the characteristic findings, late-phase FA revealed leakage from veins which is not a typical sign. Patients experiencing migraine headaches may benefit from increasing awareness of neurologists and otologists who more promptly referred patients with suspected Susac syndrome for ophthalmologic evaluation and WF-FA of the peripheral retina.
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24
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Yang J, Ma X, Li R, Ma X, Chen J, Zhang X. Reversible splenial lesion syndrome in sisters with sensorineural deafness as the first manifestation. Heliyon 2021; 7:e07057. [PMID: 34113728 PMCID: PMC8170165 DOI: 10.1016/j.heliyon.2021.e07057] [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] [Received: 08/17/2020] [Revised: 12/29/2020] [Accepted: 05/10/2021] [Indexed: 11/17/2022] Open
Abstract
Reversible splenial lesion syndrome (RESLES) is a rare clinico-radiological disorder syndrome with unclear pathophysiology. Here, two sisters with sensorineural deafness as the chief complaint diagnosed with RESLES was reported. Although the sisters had the disease successively, they were divided into two types on imaging by isolated lesions of splenium of the corpus callosum (SCC) and extensive lesions of the corpus callosum. The clinical manifestations and lesions on MRI disappeared after 6 months. The sensorineural deafness of the sisters in this article may be caused by transcallosal auditory pathway (TCAP) injury. Auditory handicap has been found in previous RESLES cases, indicating that we know little about the connection between the SCC and the auditory pathway, and further research is needed.
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Affiliation(s)
- Jinbo Yang
- Department of Neurology, Ninth Hospital of Xingtai City, Xingtai, Hebei, 055250, China
| | - Xiaodan Ma
- Department of Neurology, Ninth Hospital of Xingtai City, Xingtai, Hebei, 055250, China
| | - Rujuan Li
- Department of Neurology, Ninth Hospital of Xingtai City, Xingtai, Hebei, 055250, China
| | - Xiaohui Ma
- Department of Neurology, Ninth Hospital of Xingtai City, Xingtai, Hebei, 055250, China
| | - Junmin Chen
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China
| | - Xiangjian Zhang
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China
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David C, Sacré K, Papo T. [Update on Susac syndrome]. Rev Med Interne 2021; 43:26-30. [PMID: 34119343 DOI: 10.1016/j.revmed.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
Susac syndrome is a rare disease affecting mainly young women, characterized by a microangiopathy limited to the cerebral, retinal, and cochlear vessels. Although the pathophysiology of Susac syndrome is not yet fully elucidated, recent advances favour a primitive vasculitis affecting the cerebral, retinal and cochlear small vessels. Susac syndrome must be recognized in the presence of the pathognomonic clinical triad associating: 1/subacute encephalopathy with unusual headache and pseudopsychiatric features associated with diffuse white matter, grey matter nuclei and specifically corpus callosum lesions on brain MRI; 2/eye involvement that may be pauci-symptomatic, with occlusions of the branches of the central artery of the retina at fundoscopy and arterial wall hyperfluorescence on fluorescein angiography; and 3/cochleo-vestibular damage with hearing loss predominating at low frequencies on the audiogram. Relapses are frequent during an active period lasting approximately 2 years. Eventually, the disease resolves but isolated retinal arterial wall hyperfluorescence without new occlusions may recur, which should not lead to treatment intensification. First-line treatment consists of a combination of anti-aggregants and high dose corticosteroids. In refractory patients or in case of relapse, immunomodulatory molecules such as intravenous immunoglobulins or immunosuppressive drugs such as mycophenolate mofetil, cyclophosphamide or rituximab should be started. Unfortunately, sequelae-mostly hearing loss- remain frequent in these young patients.
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Affiliation(s)
- C David
- Service de médecine interne, Hôpital Bichat, Paris, France
| | - K Sacré
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - T Papo
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
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Abstract
PURPOSE OF REVIEW Provide an overview of the current diagnosis, pathophysiology, and treatment of Susac's syndrome (SuS), with special emphasis on summarizing what is currently known about headache as a symptom of disease activity. RECENT FINDINGS The most recent literature in SuS has focused on furthering the understanding of the underlying pathology and efficacy of treatments for SuS. The importance of early recognition to facilitate timely treatment and avoid long-term disability has been highlighted. Headache, the most common symptom experienced by patients with SuS, can occur up to 6 months in advance of other symptoms, and exacerbations of headache can herald increased disease activity. Susac's syndrome (SuS) is a rare disorder classically characterized by triad of encephalopathy, branch retinal artery occlusion (BRAO), and sensory neuronal hearing loss (SNHL). The full triad is uncommon at initial presentation, which can confound efforts to make timely diagnosis and treatment decisions. Headache is the most common symptom in SuS, is often an early feature, and can help separate SuS from other diagnoses in the differential. However, the features and management of the headache associated with SuS have not been systematically defined in the literature.
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Affiliation(s)
- Jessica A Dawe
- Department of Medicine,Division of Neurology, Dalhousie University,Halifax Infirmary, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - A Laine Green
- Department of Neurology, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, 03766, USA.
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27
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Susac Syndrome and Pregnancy. Case Rep Neurol Med 2020; 2020:6049126. [PMID: 33425410 PMCID: PMC7775175 DOI: 10.1155/2020/6049126] [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: 10/14/2019] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
Susac syndrome (SuS) is a rare poorly characterised disorder that affects the brain, retina, and cochlea. Here, we present a case of a 31-year-old pregnant female with a new diagnosis of SuS that was successfully managed to 36 weeks of gestation with minimal disease burden to both the mother and newborn. She was treated initially using intravenous methylprednisolone followed by oral prednisone, and intravenous immunoglobulin (IVIg). We stress the importance of a multidisciplinary approach, involving both neurology and maternal-fetal medicine, and provide guidance in navigating the various options for immunosuppressive therapy during pregnancy.
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Wilf-Yarkoni A, Elkayam O, Aizenstein O, Oron Y, Furer V, Zur D, Goldstein M, Barequet D, Hallevi H, Karni A, Habot-Wilner Z, Regev K. Increased incidence of Susac syndrome: a case series study. BMC Neurol 2020; 20:332. [PMID: 32878610 PMCID: PMC7465403 DOI: 10.1186/s12883-020-01892-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines. METHODS This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study. RESULTS Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability. CONCLUSIONS We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.
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Affiliation(s)
- A Wilf-Yarkoni
- Neuro-Immunology Service and Department of Neurology Rabin Medical Center, 4941492, Petach Tikva, Israel.
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Neuroradiology unit, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Y Oron
- Department of ENT, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Barequet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Hallevi
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Karni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience Tel Aviv University, Tel Aviv, Israel
| | - Z Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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The Successful Use of Infliximab in a Relapsing Case of Susac's Syndrome. Case Rep Neurol Med 2020; 2020:9317232. [PMID: 32566335 PMCID: PMC7303758 DOI: 10.1155/2020/9317232] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/22/2020] [Accepted: 05/22/2020] [Indexed: 12/31/2022] Open
Abstract
Susac's syndrome is a rare and debilitating disease characterized by the triad of encephalopathy, branch retinal artery occlusions, and sensorineural hearing loss. All manifestations may not be clinically apparent at presentation resulting in delayed diagnosis. Early recognition of the syndrome may prevent disease sequelae such as permanent cognitive, visual, and hearing loss. We present such a case of Susac's syndrome that was also refractory to conventionally prescribed combination of immunosuppressive treatments including high-dose potent corticosteroids, intravenous cyclophosphamide, methotrexate, plasma exchange, rituximab, and mycophenolate. His disease was stabilized with infliximab in combination with a tapering course of low-dose prednisone. After 2 years of remission with TNF treatment, consideration is being given to ceasing therapy. He has the sequelae of bilateral sensorineural hearing loss but no visual impairment or cognitive deficits on follow-up with neuropsychometric testing. This is the first case report to our knowledge of the successful use of infliximab for a patient with Susac's syndrome that was necessary following treatment with cyclophosphamide and then rituximab.
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Affiliation(s)
- Mario Kofler
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Triplett JD, Buzzard KA, Lubomski M, Riminton DS, Barnett MH, Welgampola MS, Halmagyi GM, Nguyen M, Landau K, Lee AG, Plant GT, Fraser CL, Reddel SW, Hardy TA. Immune-mediated conditions affecting the brain, eye and ear (BEE syndromes). J Neurol Neurosurg Psychiatry 2019; 90:882-894. [PMID: 30852493 DOI: 10.1136/jnnp-2018-319002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 12/19/2022]
Abstract
The triad of central nervous system symptoms, visual disturbance and hearing impairment is an oft-encountered clinical scenario. A number of immune-mediated diseases should be considered among the differential diagnoses including: Susac syndrome, Cogan syndrome or Vogt-Koyanagi-Harada disease; demyelinating conditions such as multiple sclerosis or neuromyelitis optica spectrum disorder; systemic diseases such as systemic lupus erythematosus, Sjögren syndrome or Behcet disease and granulomatous diseases such as sarcoidosis. In this article, we coin the term 'BEE syndromes' to draw attention to the various immune-mediated diseases that affect the brain, eye and ear. We present common disease manifestations and identify key clinical and investigation features.
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Affiliation(s)
- James D Triplett
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Katherine A Buzzard
- Department of Neurosciences, Eastern Health, Monash University, Clayton, Victoria, Australia
| | - Michal Lubomski
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - D Sean Riminton
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Michael H Barnett
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Miriam S Welgampola
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - G Michael Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - MaiAnh Nguyen
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Klara Landau
- Department of Ophthalmology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital in Houston, Houston, Texas, USA.,Weill Cornell Medical College, Cornell University, New York City, New York, USA.,University of Texas Medical Branch (UTMB), Baylor College of Medicine, The UT MD Anderson Cancer Center, Texas A and M College of Medicine (AGL), Houston, Texas, USA
| | - Gordon T Plant
- National Hospital for Neurology and Neurosurgery and Moorfield's Eye Hospital, University College London, London, UK
| | - Clare L Fraser
- Brain and Mind Centre, University of Sydney, Syndey, New South Wales, Australia
| | - Stephen W Reddel
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Todd A Hardy
- Neuroimmunology Clinic, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
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Heng LZ, Bailey C, Lee R, Dick A, Ross A. A review and update on the ophthalmic implications of Susac syndrome. Surv Ophthalmol 2019; 64:477-485. [DOI: 10.1016/j.survophthal.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/26/2022]
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Coulette S, Lecler A, Saragoussi E, Zuber K, Savatovsky J, Deschamps R, Gout O, Sabben C, Aboab J, Affortit A, Charbonneau F, Obadia M. Diagnosis and Prediction of Relapses in Susac Syndrome: A New Use for MR Postcontrast FLAIR Leptomeningeal Enhancement. AJNR Am J Neuroradiol 2019; 40:1184-1190. [PMID: 31248864 DOI: 10.3174/ajnr.a6103] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 05/13/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Leptomeningeal enhancement can be found in a variety of neurologic diseases such as Susac Syndrome. Our aim was to assess its prevalence and significance of leptomeningeal enhancement in Susac syndrome using 3T postcontrast fluid-attenuated inversion recovery MR imaging. MATERIALS AND METHODS From January 2011 to December 2017, nine consecutive patients with Susac syndrome and a control group of 73 patients with multiple sclerosis or clinically isolated syndrome were included. Two neuroradiologists blinded to the clinical and ophthalmologic data independently reviewed MRIs and assessed leptomeningeal enhancement and parenchymal abnormalities. Follow-up MRIs (5.9 MRIs is the mean number per patient over a median period of 46 months) of patients with Susac syndrome were reviewed and compared with clinical and retinal fluorescein angiographic data evaluated by an independent ophthalmologist. Fisher tests were used to compare the 2 groups, and mixed-effects logistic models were used for analysis of clinical and imaging follow-up of patients with Susac syndrome. RESULTS Patients with Susac syndrome were significantly more likely to present with leptomeningeal enhancement: 5/9 (56%) versus 6/73 (8%) in the control group (P = .002). They had a significantly higher leptomeningeal enhancement burden with ≥3 lesions in 5/9 patients versus 0/73 (P < .001). Regions of leptomeningeal enhancement were significantly more likely to be located in the posterior fossa: 5/9 versus 0/73 (P < .001). Interobserver agreement for leptomeningeal enhancement was good (κ = 0.79). There was a significant association between clinical relapses and increase of both leptomeningeal enhancement and parenchymal lesion load: OR = 6.15 (P = .01) and OR = 5 (P = .02), respectively. CONCLUSIONS Leptomeningeal enhancement occurs frequently in Susac syndrome and could be helpful for diagnosis and in predicting clinical relapse.
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Affiliation(s)
- S Coulette
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - A Lecler
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - E Saragoussi
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - K Zuber
- Clinical Research Unit (K.Z.)
| | - J Savatovsky
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - R Deschamps
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - O Gout
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - C Sabben
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - J Aboab
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - A Affortit
- Ophthalmology Department (A.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | | | - M Obadia
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
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