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Rare presentation of multiple thromboses in Erdheim-Chester disease: a case-based review. Int J Hematol 2022; 116:798-806. [PMID: 35687294 DOI: 10.1007/s12185-022-03393-x] [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: 01/16/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND ECD is a rare non-Langerhans cell histiocytosis with diverse and heterogeneous clinical manifestations, ranging from single-lesion forms to multi-system involvement, including slowly progressing unifocal forms to rapidly evolving life-threatening disease. CASE PRESENTATION A female patient presented with a 2-month history of fever. Imaging revealed multiple thromboses, bone destruction, an abnormal pituitary stalk, and clinical manifestations of diabetes insipidus. Excisional biopsy of a tibial lesion was sent for microscopic examination, and subsequent immunohistochemical testing was positive for expression of CD68 and CD163, and negative for expression of the immune markers CD1a, S100, and langerin. This confirmed the diagnosis of ECD. Treatment with methylprednisolone to inhibit the immune inflammatory response along with anti-cytokine therapy with an interleukin-6 antagonist resulted in satisfactory disease control. CONCLUSION We report a rare case of multiple thromboses, embolism, and multiple organ involvement as the main presentation of ECD, suggesting that ECD should be considered in patients presenting with multiple thromboses associated with multisystem damage. We successfully treated our patient with glucocorticoids and interleukin-6 antagonist. This patient's response to treatment suggests that hormone therapy and cytokine/chemokine therapy may be a potential novel treatment for patients with ECD without gene mutations.
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Trevisan AC, Alexandre-Santos L, Assad RL, Itikawa EN, Pitella FA, Kato M, Silvah JH, Santos AC, Louzada-Junior P, Wichert-Ana L. Temporal and spatial changes in cerebral blood flow in neuropsychiatric systemic lupus erythematosus: a subtraction brain spect study. Eur J Hybrid Imaging 2021; 5:19. [PMID: 34734310 PMCID: PMC8566625 DOI: 10.1186/s41824-021-00112-3] [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: 07/01/2021] [Accepted: 09/13/2021] [Indexed: 11/16/2022] Open
Abstract
This study was addressed to evaluate the temporal and spatial changes in regional cerebral blood flow (rCBF) of patients with neuropsychiatric systemic lupus erythematosus (NPSLE). Our objective was to correlate the subtracted SPECT coregistered to MRI features (SISCOM) with demographic, clinical and laboratory findings to shed light upon the pathophysiological evolution of the NPSLE. Twenty-six NPSLE patients with MRI and pre- and post-treatment brain SPECT with [99mTc]Tc-ECD. SISCOM features were categorized as improvement, worsening, activation and/or deactivation of rCBF findings. Patients mean age of 43.19 years and 65.38% white were evaluated. The patients mean age at onset of SLE was 26.05 and 42.29 for NPSLE. The mean time between the onset of SLE and first NPSLE symptoms was 05.57 years. The disease has already been initiated as NPSLE in 4 patients. The SLEDAI average score was 31.69 and the SLICC/ACR-DI score was 06.96. The patients underwent an average of 09.23 cyclophosphamide. The SISCOM findings showed functional and pathological states on different brain regions. The rCBF changes were not associated with index scores. There was, however, a trend towards an association between lower SLEDAI scores with improvement and higher SLEDAI with worsening in SISCOM, Also a trend of association between lower SLICC score with improvement, and higher SLICC with worsening. The female gender was predictive of activation and worsening, separately, and deactivation and worsening in a set. Non-white patients were predictive of worsening. The seizure was predictive of deactivation separately, and deactivation and worsening in a set. Finally, normal C3 was a predictor of improvement. The present study showed dynamic brain changes in NPSLE patients. SISCOM technique showed improved rCBF in some brain areas, and worsening, activation and deactivation in others. There were associations between rCBF changes and gender, skin colour and complement C3 and association trends with SLEDAI and SLICC scores.
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Affiliation(s)
- Ana Carolina Trevisan
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil. .,Inter-units Bioengineering Postgraduate Program, University of São Paulo, São Carlos School of Engineering / USP, São Carlos, SP, Brazil.
| | - Leonardo Alexandre-Santos
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil.,Inter-units Bioengineering Postgraduate Program, University of São Paulo, São Carlos School of Engineering / USP, São Carlos, SP, Brazil
| | - Rodrigo Luppino Assad
- Division of Rheumatology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Felipe Arriva Pitella
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Mery Kato
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - José Henrique Silvah
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Antonio Carlos Santos
- Magnetic Resonance Laboratory, Department of Medical Imaging, Hematology, and Clinical Oncology Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Paulo Louzada-Junior
- Division of Rheumatology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lauro Wichert-Ana
- Nuclear Medicine and PET/CT Laboratory. Ribeirão Preto Medical School, Post Graduate Program in Internal Medicine, University of São Paulo, Ribeirão Preto, Brazil.,Inter-units Bioengineering Postgraduate Program, University of São Paulo, São Carlos School of Engineering / USP, São Carlos, SP, Brazil
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Sebök M, van Niftrik CH, Piccirelli M, Bozinov O, Wegener S, Esposito G, Pangalu A, Valavanis A, Buck A, Luft AR, Regli L, Fierstra J. BOLD cerebrovascular reactivity as a novel marker for crossed cerebellar diaschisis. Neurology 2018; 91:e1328-e1337. [DOI: 10.1212/wnl.0000000000006287] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/02/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo study blood oxygen level–dependent cerebrovascular reactivity (BOLD-CVR) as a surrogate imaging marker for crossed cerebellar diaschisis (CCD).MethodsTwenty-five participants with symptomatic unilateral cerebrovascular steno-occlusive disease underwent a BOLD-CVR and an acetazolamide challenged (15O)-H2O-PET study. CCD and cerebellar asymmetry index were determined from PET and compared to BOLD-CVR quantitative values. Neurologic status at admission and outcome after 3 months were determined with NIH Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores.ResultsFor both the BOLD-CVR and PET examination, a significant cerebellar asymmetry index was found for participants exhibiting CCD (CCD+ vs CCD−: for BOLD-CVR 13.11 ± 9.46 vs 1.52 ± 4.97, p < 0.001; and for PET 7.31 ± 2.75 vs 1.68 ± 2.98, p < 0.001). The area under the curve for BOLD-CVR was 0.89 (95% confidence interval: 0.75–1.0) with 0.91 sensitivity and 0.81 specificity to detect CCD. Participants exhibiting CCD were in poorer clinical condition at baseline (CCD+ vs CCD−: NIHSS 7 vs 1, p = 0.003; mRS 3 vs 1, p = 0.001) and after 3-month follow-up (NIHSS 2 vs 0, p = 0.02; mRS 1 vs 0, p = 0.04). Worse performance on both scores showed an agreement with a larger BOLD-CVR cerebellar asymmetry index. This was not found for PET.ConclusionsBOLD-CVR demonstrates similar sensitivity to detect CCD as compared to (15O)-H2O-PET in patients with symptomatic unilateral cerebrovascular steno-occlusive disease. Furthermore, participants exhibiting CCD had a poorer baseline neurologic performance and neurologic outcome at 3 months.Classification of evidenceThis study provides Class II evidence that BOLD-CVR identifies CCD in patients with symptomatic unilateral cerebrovascular steno-occlusive disease.
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Sato S, Kojima D, Shimada Y, Yoshida J, Fujimato K, Fujiwara S, Kobayashi M, Kubo Y, Yoshida K, Terasaki K, Tsutsui S, Miyoshi K, Ogasawara K. Preoperatively reduced cerebrovascular contractile reactivity to hypocapnia by hyperventilation is associated with cerebral hyperperfusion syndrome after arterial bypass surgery for adult patients with cerebral misery perfusion due to ischemic moyamoya disease. J Cereb Blood Flow Metab 2018; 38:1021-1031. [PMID: 29383984 PMCID: PMC5999000 DOI: 10.1177/0271678x18757621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The present study examined whether preoperatively reduced cerebrovascular contractile reactivity to hypocapnia by hyperventilation is associated with development of cerebral hyperperfusion syndrome after arterial bypass surgery for adult patients with cerebral misery perfusion due to ischemic moyamoya disease. Among 65 adult patients with ischemic moyamoya disease, 19 had misery perfusion in the precentral region on preoperative 15O positron emission tomography and underwent arterial bypass surgery for that region. Brain technetium-99 m-labeled ethyl cysteinate dimer single-photon emission computed tomography (SPECT) was preoperatively performed with and without hyperventilation challenge and relative cerebrovascular contractile reactivity to hypocapnia (RCVCRhypocap) (%/mmHg) was calculated in the precentral region. Development of cerebral hyperperfusion syndrome was determined using perioperative changes of symptoms and brain N-isopropyl-p-[123I]-iodoamphetamine SPECT performed after surgery. RCVCRhypocap was significantly lower in the 6 patients with cerebral hyperperfusion syndrome (-2.85 ± 1.10%/mmHg) than in the 13 patients without cerebral hyperperfusion syndrome (0.18 ± 1.97%/mmHg; p = 0.0050). Multivariate analysis demonstrated low RCVCRhypocap as an independent predictor of cerebral hyperperfusion syndrome (95% confidence interval, 0.04-0.96; p = 0.0433). Preoperatively reduced cerebrovascular contractile reactivity to hypocapnia by hyperventilation is associated with development of cerebral hyperperfusion syndrome after arterial bypass surgery for adult patients with cerebral misery perfusion due to ischemic moyamoya disease.
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Affiliation(s)
- Shinpei Sato
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Daigo Kojima
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan.,2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yasuyoshi Shimada
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan.,2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Jun Yoshida
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan.,2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kentaro Fujimato
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shunrou Fujiwara
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan.,2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kazunori Terasaki
- 2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shouta Tsutsui
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenya Miyoshi
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- 1 Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan.,2 Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
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Acker G, Lange C, Schatka I, Pfeifer A, Czabanka MA, Vajkoczy P, Buchert R. Brain Perfusion Imaging Under Acetazolamide Challenge for Detection of Impaired Cerebrovascular Reserve Capacity: Positive Findings with 15O-Water PET in Patients with Negative 99mTc-HMPAO SPECT Findings. J Nucl Med 2017; 59:294-298. [PMID: 28729429 DOI: 10.2967/jnumed.117.195818] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/27/2017] [Indexed: 11/16/2022] Open
Abstract
Cerebrovascular reserve capacity (CVRC) is an important parameter for treatment decisions in chronic cerebrovascular diseases. It can be assessed by measuring the acetazolamide-induced change in regional cerebral blood flow using SPECT with 99mTc-labeled hexamethylpropyleneamine oxime (99mTc-HMPAO) or PET with 15O-water. Methods: Our database was searched for patients with moyamoya vasculopathy or atherosclerotic cerebrovascular disease who had undergone 15O-water PET after normal 99mTc-HMPAO SPECT results with respect to CVRC. 15O-water PET was analyzed visually and quantitatively. Quantitative analysis was based on parametric CVRC maps generated by voxelwise image subtraction. Results: The search identified 18 patients (43 ± 15 y, 12 moyamoya vasculopathy). PET revealed impaired CVRC in 8 patients (44%). Quantitative analysis confirmed the positive visual findings in 15O-water PET and the negative findings in 99mTc-HMPAO SPECT. Conclusion:15O-water PET enables detection of impaired CVRC in a considerable fraction of symptomatic patients with stenoocclusion and negative 99mTc-HMPAO SPECT.
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Affiliation(s)
- Güliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany; and
| | - Catharina Lange
- Department of Nuclear Medicine, Charité-Universitätsmedizin, Berlin, Germany
| | - Imke Schatka
- Department of Nuclear Medicine, Charité-Universitätsmedizin, Berlin, Germany
| | - Andreas Pfeifer
- Department of Nuclear Medicine, Charité-Universitätsmedizin, Berlin, Germany
| | - Marcus A Czabanka
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany.,Center for Stroke Research, Berlin, Germany
| | - Ralph Buchert
- Department of Nuclear Medicine, Charité-Universitätsmedizin, Berlin, Germany
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