Clinical presentation of a neuropsychiatric lupus patient with symmetrical basal ganglia lesions containing cytotoxic oedema cores surrounded by vasogenic oedema

Neuroimaging in mitochondrial disease

The anatomic complexity of the brain in combination with its high energy demands makes this organ specifically vulnerable to defects of mitochondrial oxidative phosphorylation. Therefore, neurodegeneration is a hallmark of mitochondrial diseases. The nervous system of affected individuals typically shows selective regional vulnerability leading to distinct patterns of tissue damage. A classic example is Leigh syndrome, which causes symmetric alterations of basal ganglia and brain stem. Leigh syndrome can be caused by different genetic defects (>75 known disease genes) with variable disease onset ranging from infancy to adulthood. Other mitochondrial diseases are characterized by focal brain lesions, which is a core feature of MELAS syndrome (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes). Apart from gray matter, also white matter can be affected by mitochondrial dysfunction. White matter lesions vary depending on the underlying genetic defect and may progress into cystic cavities. In view of the recognizable patterns of brain damage in mitochondrial diseases, neuroimaging techniques play a key role in diagnostic work-up. In the clinical setting, magnetic resonance imaging (MRI) and MR spectroscopy (MRS) are the mainstay of diagnostic work-up. Apart from visualization of brain anatomy, MRS allows the detection of metabolites such as lactate, which is of specific interest in the context of mitochondrial dysfunction. However, it is important to note that findings like symmetric basal ganglia lesions on MRI or a lactate peak on MRS are not specific, and that there is a broad range of disorders that can mimic mitochondrial diseases on neuroimaging. In this chapter, we will review the spectrum of neuroimaging findings in mitochondrial diseases and discuss important differential diagnoses. Moreover, we will give an outlook on novel biomedical imaging tools that may provide interesting insights into mitochondrial disease pathophysiology.

Bilateral striopallidal calcinosis secondary to systemic lupus erythematosus

Bilateral symmetric striatopallidal calcinosis with or without deposits in dentate nucleus, thalamus, and white matter is reported in patients ranging from asymptomatic, metabolic, toxic, and genetic autosomal dominant, familial or sporadic forms. Of the connective tissue diseases, it has been reported in very few cases in patients with systemic lupus erythematosus, many incorrectly labeled as Fahr syndrome without even having hypoparathyroidism. Here we describe a 30-year-old female patient with neuropsychiatric systemic lupus erythematosus manifested at diagnosis with mood disorders and anxiety, and 1-year later develops Lupus headache; Incidentally, an aneurism of the right middle cerebral artery and bilateral and symmetric calcifications of the caudate and lenticular nuclei were noted; this finding is a rarely reported manifestation of neuropsychiatric systemic lupus erythematosus.

A review of the literature based on this case was carried out in electronic databases. There are approximately 29 patients reported in the literature, with calcifications in the basal ganglia associated with systemic lupus erythematosus occurs almost exclusively in young women (96.5%) with a mean age of 33.36 years (2 months-76 years), with a race predilection for Asians (65.5%). Regarding the neuropsychiatric syndromes defined by the American College of Rheumatology, the most frequently associated are movement disorders; followed by cognitive dysfunction, seizure disorders, mood disorders, cerebrovascular disease, psychosis, and acute confusional state, transverse myelitis, and demyelinating syndrome. The mean duration time of the SLE to detection of the basal ganglia calcification is 7.62 years (3 days-31 years).