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Li C, Wang Y, Lin Y, Gong Q, Wu B, Zheng W, Tian Y, Chen Y, Tian M. Intrathecal injection of methotrexate and dexamethasone for vasculitis granuloma of the fourth ventricle: a case report and literature review. Clin Rheumatol 2024; 43:1217-1226. [PMID: 37914837 DOI: 10.1007/s10067-023-06777-4] [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: 07/17/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023]
Abstract
Granulomatosis with polyangiitis (GPA) is a pauci-immune small vessel vasculitis characterised by neutrophil-mediated vasculitis and granuloma. The presence of intracranial parenchymal space-occupying lesions is rarely seen in GPA patients. In this manuscript, we report a case of GPA with granuloma of the fourth ventricle accompanied by obstructive hydrocephalus. Treatment with glucocorticoids (GCs) and multiple immunosuppressants cyclophosphamide (CYC), mycophenolate mofetil (MMF), and rituximab (RTX) showed poor efficacy in this case. After removal of the granuloma by craniotomy, GPA relapsed within 3 months. Under the premise of GC and MMF treatment combined with intrathecal injection of dexamethasone (DXM) and methotrexate (MTX), the intracranial granuloma gradually shrank, and the patient's general condition was alleviated, showing that this is an effective treatment method. Key Points • To date, there are few reports of granulomatous vasculitis combined with granuloma of the fourth ventricle, and our case is the second. • In this case, multiple immunosuppressants and rituximab were ineffective treatments, and the intracranial granuloma was effectively controlled by intrathecal injection of dexamethasone (DXM) and methotrexate (MTX). • Based on this report, it can be suggested that intrathecal injection is effective in treating patients with GPA and central nervous system involvement, but large-scale sample studies are needed.
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Affiliation(s)
- Chunyan Li
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Yu Wang
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Yupei Lin
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Qianla Gong
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Bangcui Wu
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Wendan Zheng
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Yingying Tian
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Yong Chen
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China
| | - Mei Tian
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China.
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Triano MJ, Haberstroh WD, Lenka A, Whelton SA. Relapsed granulomatosis with polyangiitis with panhypopituitarism. BMJ Case Rep 2021; 14:14/1/e237774. [PMID: 33509867 PMCID: PMC7845712 DOI: 10.1136/bcr-2020-237774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
A man in his early 60s with a medical history of granulomatosis with polyangiitis (GPA) in remission for two decades without maintenance therapy presented with non-specific complaints of profound fatigue and 40-pound weight loss. He was seronegative for antinuclear antibodies and cytoplasmic antineutrophilic antibodies, but erythrocyte sedimentation rate and C reactive protein levels were elevated. Endocrinological testing revealed adrenal insufficiency, hypogonadism, hypothyroidism and diabetes insipidus. An MRI of the head revealed extensive sinonasal inflammation eroding through the floor of the sella turcica and into the pituitary gland and stalk. Biopsy of the sinonasal tissues was inconclusive. On review of his case, a multidisciplinary team diagnosed him with panhypopituitarism secondary to a recurrence of GPA. He responded well to glucocorticoids and methotrexate with marked reduction of pituitary enhancement on imaging and resolution of diabetes insipidus. He will require lifelong testosterone, levothyroxine and glucocorticoids for hormone replacement therapy.
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Affiliation(s)
- Matthew J Triano
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA
| | - William D Haberstroh
- Division of General Internal Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Abhishek Lenka
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean A Whelton
- Department of Neurosurgery, Georgetown University School of Medicine, Washington, DC, USA,Division of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, USA
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Abushamat LA, Kerr JM, Lopes MBS, Kleinschmidt-DeMasters BK. Very Unusual Sellar/Suprasellar Region Masses: A Review. J Neuropathol Exp Neurol 2019; 78:673-684. [PMID: 31233145 DOI: 10.1093/jnen/nlz044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/15/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022] Open
Abstract
The cause of sellar region masses in large retrospective series is overwhelmingly pituitary adenomas (84.6%), followed by craniopharyngiomas (3.2%), cystic nonneoplastic lesions (2.8%), inflammatory lesions (1.1%), meningiomas (0.94%), metastases (0.6%), and chordomas (0.5%) (1). While other rare lesions were also identified (collectively 6.0%), single unusual entities in the above-cited series numbered <1-2 examples each out of the 4122 cases, underscoring their rarity. We searched our joint files for rare, often singular, sellar/suprasellar masses that we had encountered over the past several decades in our own specialty, tertiary care specialty pituitary center practices. Cases for this review were subjectively selected for their challenging clinical and/or histological features as well as teaching value based on the senior authors' (MBSL, BKD) collective experience with over 7000 examples. We excluded entities deemed to be already well-appreciated by neuropathologists such as mixed adenoma-gangliocytoma, posterior pituitary tumors, metastases, and hypophysitis. We identified examples that, in our judgment, were sufficiently unusual enough to warrant further reporting. Herein, we present 3 diffuse large cell B cell pituitary lymphomas confined to the sellar region with first presentation at that site, 2 sarcomas primary to sella in nonirradiated patients, and 1 case each of granulomatosis with polyangiitis and neurosarcoidosis with first presentations as a sellar/suprasellar mass. Other cases included 1 of chronic lymphocytic leukemia within a gonadotroph adenoma and 1 of ectopic nerve fascicles embedded within a somatotroph adenoma, neither of which impacted patient care. Our objective was to share these examples and review the relevant literature.
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Affiliation(s)
- Layla A Abushamat
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Janice M Kerr
- Department of Endocrinology, University of Colorado Health Sciences Center, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - M Beatriz S Lopes
- Department of Pathology (Neuropathology) and Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Bette K Kleinschmidt-DeMasters
- Department of Pathology
- Department of Neurology
- Department of Neurosurgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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