Aseptic meningitis and cranial nerve palsy revealing adult-onset Still's disease

Case report: Wallerian degeneration: The innate-immune response to adult-onset Still's disease peripheral nerve injury

Peripheral nerve injury is one of the rare complications of adult-onset Still's disease (AOSD). We report a 20-year-old woman diagnosed with AOSD combined with severe sensory neuropathy. She presented with a sore throat, joint pain, rash, and lymphadenopathy. After receiving glucocorticoid therapy, her fever, rash, and inflammatory markers improved. Unexpectedly, 3 weeks after the onset, she experienced sudden paresthesia in her extremities, decreased muscle strength, and diminished tendon reflexes. The electrophysiological examination and peripheral nerve biopsy confirmed immune-mediated severe sensory neuropathy. For the first time, we report typical Wallerian degeneration in AOSD patients with sensory neuropathy by nerve biopsy. Compared with other common symptoms, the delayed aggravation of neurological symptoms may be an important characteristic of sensory neuropathy secondary to AOSD. We emphasize that intensive attention to neurological symptoms after general symptoms control, administration of adequate and appropriate prolonged immunosuppressive therapy, and long-term follow-up are essential for these patients.

Adult-onset Still's disease with neurological involvement: a single-centre report

OBJECTIVES

Adult-onset Still's disease (AOSD) is a multifactorial systemic autoinflammatory disease. Neurological damage has been rarely reported in AOSD. We aimed to characterize the clinical features of AOSD patients with neurological involvement.

METHODS

A total of 187 AOSD patients were admitted to Peking Union Medical College Hospital from January 2015 to August 2019. The complete medical records were reviewed in this retrospective study. Clinical features of 14 AOSD patients with neurological involvement were collected and compared with those without.

RESULTS

The prevalence of neurological involvement in AOSD inpatients was 7.5%. The median disease duration was 4.5 months, with a range of 1-15 months. The frequent symptoms were fever [14 (100%)], rash [13 (92.9%)], liver dysfunction [11 (78.6%)], arthralgia/arthritis [10 (71.4%)] and lymphadenopathy [10 (71.4%)]. Four (28.6%) patients had macrophage activation syndrome (MAS). Aseptic meningitis was the most common presentation (64.3%) when the nervous system was involved. Other rare manifestations included cranial nerve palsy, encephalitis and cerebral infarction. The rate of MAS, serum levels of lactate dehydrogenase and ferritin were significantly higher in AOSD patients with neurological involvement than in those without. All patients received high-dose corticosteroid therapy and immunosuppressive agents and two were given tocilizumab. Clinical remission was achieved in all 14 AOSD patients with neurological involvement.

CONCLUSION

Neurological involvement, particularly aseptic meningitis, is not a rare complication of AOSD. It is frequently complicated by MAS. There may be a potential relationship between the neurological damage of AOSD and MAS.

[Antagonists of interleukin-6 (tocilizumab), in adult refractory still disease]

INTRODUCTION

The pathogenesis of Still's disease is best elucidated for the better recognition of the involvement of Many pro-inflammatory cytokines in the genesis of this condition. Publications have reported the contribution beneficial for certain biotherapeutics, such as anti-TNFa, the anti-CD20 or antagonists of interleukine1 (IL-1) tested successfully in the treatment of systemic Juvenile idiopathic arthritis (Still's disease the child), the tocilizumab is a humanized monoclonal antibody directed against the receptor for interleukin-6 and is beginning to be reported as effective in some refractory cases of Still's disease in adults.

PATIENTS

We report two young patients with Still's disease in adults with refractory early and prolonged remission after the first infusion tocilizumab.

CONCLUSION

The tocilizumab can be used in patients MSA with refractory after failure or intolerance conventional treatments.

Miller Fisher syndrome in adult onset Still's disease: case report and review of the literature of other neurological manifestations

Adult-onset Still's disease (AOSD) is a multi-system inflammatory disorder characterized by high spiking fevers, evanescent salmon-coloured rash, arthralgias or arthritis, hepatosplenomegaly, lymphadenopathy and sore throat. There is no specific test or combination of tests that can establish the diagnosis of AOSD and patients may present with other systemic involvement including neurological manifestations in 7-12% of cases. We present a complex case of a patient with AOSD who developed the Miller-Fisher variant of Guillain-Barré syndrome. This immunological disorder of the nervous system has not been described in association with AOSD before. We also review the literature on other neurological manifestations in AOSD. AOSD mimics different disease processes and its multi-system manifestations may complicate the picture further.