Acute Monocular Visual Loss in Carcinomatous Hypertrophic Pachymeningitis Mimicking Giant Cell Arteritis

Cranial giant cell arteritis mimickers: A masquerade to unveil

Giant cell arteritis (GCA) is a large-vessel vasculitis that affects cranial and extra-cranial arteries. Extra-cranial GCA presents mainly with non-specific symptoms and the differential diagnosis is very broad, while the cranial form has more typical clinical picture and physicians have a lower threshold for diagnosis and treatment. Although temporal artery biopsy (TAB) has an established role, ultrasound (US) is being increasingly used as the first-line imaging modality in suspected GCA. Vasculitides (especially ANCA-associated), hematological disorders (mainly amyloidosis), neoplasms, infections, atherosclerosis and local disorders can affect the temporal arteries or might mimic the symptoms of cranial GCA and produce US and TAB findings that resemble those of temporal vasculitis. Given that prompt diagnosis is essential and proper treatment varies significantly among these diseases, in this review we aimed to collectively present disorders that can masquerade cranial GCA.

Idiopathic Hypertrophic Pachymeningitis Mimicking Meningioma with Occlusion of Superior Sagittal Sinus: Case Report and Review of Literature

BACKGROUND

Idiopathic hypertrophic pachymeningitis is a rare inflammatory condition with diffuse thickening of the dura mater, which may cause a compressive effect or vascular compromise.

CASE DESCRIPTION

A 40-year-old Chinese man presented with persistent headache for 6 months and a sudden epileptic seizure 2 days ago. Magnetic resonance imaging demonstrated a large (71 × 34 × 27 mm) extra-axial mass at the right frontal convexity with severe edema mimicking meningioma. The lesion and peripheral dura mater showed contrast enhancement. Additionally, the skull near the lesion was eroded. Meningioma was diagnosed, and the patient underwent surgery. During the operation, we found the lesion texture was very tough, and the superior sagittal sinus was occluded. Histopathologic findings revealed a large number of infiltrated lymphocytes with fibrosis and microabscess formation; intracranial idiopathic hypertrophic pachymeningitis was diagnosed. Follow-up magnetic resonance imaging performed 3 months after surgery demonstrated the enhancement was notably alleviated.

CONCLUSIONS

Idiopathic hypertrophic pachymeningitis should be part of the differential diagnosis of some cases of meningioma.

A case of suspected MPO-ANCA-related hypertrophic pachymeningitis with atypical presentation

A 66‐year‐old man presented to our emergency department with acute consciousness disorder, headache, and fever. Initial laboratory data indicated a high level of inflammatory reaction. Enhanced magnetic resonance imaging revealed a thickening of the right cranial dura mater on T1‐weighted images. We presumed the patient was diagnosed as having myeloperoxidase antineutrophil cytoplasmic antibody (MPO‐ANCA)‐related hypertrophic pachymeningitis (HP). Acute impaired consciousness without focal signs is an unusual presentation of HP. This treatable disease should be considered as a differential diagnosis when a patient presents with drowsiness and headache.

Multifocal Fibrosclerosis with Hypertrophic Pachymeningitis and a Soft Tissue Mass around the Thoracic Vertebral Bodies: A Case Report with Review of the Literature

Multifocal fibrosclerosis is the term used to represent a combination of similar fibrous lesions occurring at different anatomical sites. We herein report a hypertrophic pachymeningitis patient with a soft tissue mass around the thoracic vertebral bodies. A histopathological analysis of the biopsied tissues from both lesions showed dense fibrosis and a marked infiltration of lymphocytes and plasma cells, which lead to the diagnosis of multifocal fibrosclerosis. This pathological condition closely resembles that of IgG4-related disease and is a very rare combination of manifestations. Our case suggests that hypertrophic pachymeningitis patients need to also undergo a whole body examination.

Bilateral Vision Loss Secondary to Pachymeningitis in a Patient with IgG4-Related Disease

IgG4-related disease (IgG4-RD) is a recently recognized fibroinflammatory condition associated with disease in nearly every organ, including the meninges. A proportion of idiopathic hypertrophic pachymeningitis cases may involve a component of meningeal IgG4-RD. We present a patient with severe bilateral vision loss found to have thickening of the dura mater on MRI, and subsequently diagnosed with IgG4-RD after dural biopsy.

Optic neuropathy caused by Propionibacterium acnes pachymeningitis

We describe a patient with vision loss from an optic neuropathy caused by Propionibacterium acnes pachymeningitis. The patient's optic neuropathy was stabilized with appropriate antibiotic therapy.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

[Skull metastase masquerading as temporal arteritis: report of two cases]

INTRODUCTION

Temporal arteritis is the most common systemic vasculitis of the elderly. A definitive diagnosis is obtained on temporal artery biopsy examination (TAB). However, 30% of TAB yields false negative results. In such cases, diagnosis relies on clinical presentation and exclusion of alternative diagnosis. Conversely, false positive TAB are uncommon.

CASE REPORTS

We report two patients who presented with headache, scalp tenderness and increased acute phase reactants, suggesting temporal arteritis, but which turned out to reveal a skull metastase. Temporal artery biopsy performed in one case demonstrated arterial wall inflammation.

CONCLUSION

Clinicians must be aware that a skull lesion can mimick temporal arteritis.