1
|
Berntsson SG, Elmgren A, Gudjonsson O, Grabowska A, Landtblom AM, Moraes-Fontes MF. A comprehensive diagnostic approach in suspected neurosarcoidosis. Sci Rep 2023; 13:6539. [PMID: 37085608 PMCID: PMC10121682 DOI: 10.1038/s41598-023-33631-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 04/16/2023] [Indexed: 04/23/2023] Open
Abstract
Neurosarcoidosis presents a diagnostic challenge in clinical settings, as it has no pathognomonic symptoms or signs and a wide range of differential diagnoses. The aim of this report is to present the pathological features of our group of patients, obtained through a systematic diagnostic approach. This retrospective cohort study enrolled all adult patients primarily diagnosed with neurosarcoidosis at the neurology department of a tertiary center in Sweden over a period of 30 years, from 1990 to 2021. We identified 90 patients, 54 with possible neurosarcoidosis and 36 with probable neurosarcoidosis. CNS biopsy revealed an alternative diagnosis for 24 patients, who were then excluded. The collected data from medical records included demographic and clinical characteristics, systemic and/or neurological isolated involvement, various laboratory tests, including cerebrospinal fluid (CSF), serum analysis, imaging studies (MRI, FDG-PET/CT, and HRCT), nerve conduction studies, electromyography, and pathology reports of central nervous system (CNS), and extra-neural tissue biopsies. Sixty-six patients were included in our cohort. The median age at onset of symptoms was 49 years, with a similar sex distribution. Cranial neuropathies (38%), motor deficit (32%), headache (16%), and pituitary dysfunction (12%) were the most common presenting features. CSF studies were abnormal in 77% of the patients, who showed lymphocytosis (57%), elevated protein (44%), oligoclonal bands (40%), elevated ACE (28%), and raised T lymphocyte CD4+/CD8+ ratios (13%). Strikingly, MRI showed that 17% of the patients presented with isolated pituitary gland lesions. FDG-PET/CT was performed in 22 patients (33%) and confirmed systemic sarcoidosis in 11. Despite our extensive workup, the final classification for our patients only allowed for a definite diagnosis in 14 patients; the remainder were classified as probable (32) or possible (20) neurosarcoidosis. Since 2007, the employment of a structured laboratory and imaging approach and the increasing number of CNS biopsies have facilitated and improved the process of correct attribution in patients with presumptive neurosarcoidosis, especially in patients with isolated neurological lesions. We highlight a higher frequency of pituitary lesions due to neurosarcoidosis than has been classically described. A detailed laboratory diagnostic workup is included.
Collapse
Affiliation(s)
| | - Andreas Elmgren
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
| | - Olafur Gudjonsson
- Department of Medical Sciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anna Grabowska
- Department of Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Anne-Marie Landtblom
- Department of Medical Sciences, Neurology, Uppsala University, 751 85, Uppsala, Sweden
| | | |
Collapse
|
2
|
Shenoy A, Marwaha PK, Worku DA. CD8 Encephalitis in HIV: A Review of This Emerging Entity. J Clin Med 2023; 12:jcm12030770. [PMID: 36769419 PMCID: PMC9917721 DOI: 10.3390/jcm12030770] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Encephalitis is a life-threatening neurological condition with multiple causes in the setting of Human Immunodeficiency Virus (HIV). CD8 Encephalitis (CD8E) is a newly recognised condition which can present in an acute manner, with pertinent features including classical radiological findings with an intense brain parenchymal infiltration of CD8+ T cells. This review attempted to clarify the symptomatology, distribution and determinants of this condition, as well as to examine its vast unknowns. METHODS A literature review was undertaken in July 2022, utilising the PubMed and Google Scholar databases. Papers published between 2006-2022 were reviewed. Eighteen papers, totalling 57 patients, were found and analysed. Statistical analysis was undertaken using Chi-squared and Wilcoxon rank-sum tests as appropriate, with p < 0.05 deemed significant. RESULTS In this review, 57 patients were identified, with a female (61%, 34/56) and Black African (70%, 40/57) preponderance. Females were more likely to present with headache (p = 0.006), and headache was more likely to be present in those who died (p = 0.02). There was no statistically significant association between baseline CD4 count (p = 0.079) and viral load (p = 0.72) with disease outcome. Overall, 77% (41/53) of patients had classical imaging findings, including bilateral gadolinium-enhancing punctate and perivascular white matter lesions. However, many patients (23/57) required a brain biopsy as part of their diagnostic workup. Corticosteroid treatment was commonly prescribed in patients (64%, 35/55) and had a mortality benefit, with an overall survival in this group of 71% (p = 0.0008). In those who died, median survival was 5.5 months. In rare instances, recurrence of the disease was noted, which responded poorly to treatment. DISCUSSION CD8E represents a new and complex condition with few risk factors identified for its occurrence. The presenting symptoms are broad, but headache appears to be more common in females and more significantly associated with death. Though rare, CD8E is likely under-diagnosed, possibly due to overlapping features with other illnesses and lack of physician experience in its recognition and management. Corticosteroids demonstrate a clear mortality benefit, but more studies are required to determine their optimal dosing and duration, as well as the use of steroid-sparing agents. Further reviews should help to better determine the risk factors for the condition, as well as non-invasive biomarkers, to aid in diagnosis and help to predict poor prognosis and disease recurrence.
Collapse
Affiliation(s)
- Aniruddh Shenoy
- Haematology, Christie Hospital, Manchester M20 4BX, UK
- Correspondence: (A.S.); (D.A.W.)
| | - Pavan Kaur Marwaha
- Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK
| | - Dominic Adam Worku
- Infectious Diseases, Morriston Hospital, Swansea SA6 6NL, UK
- Public Health Wales, Cardiff CF10 4BZ, UK
- Correspondence: (A.S.); (D.A.W.)
| |
Collapse
|
3
|
Vlad B, Neidhart S, Hilty M, Ziegler M, Jelcic I. Differentiating neurosarcoidosis from multiple sclerosis using combined analysis of basic CSF parameters and MRZ reaction. Front Neurol 2023; 14:1135392. [PMID: 37034091 PMCID: PMC10080049 DOI: 10.3389/fneur.2023.1135392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Background Neurosarcodosis is one of the most frequent differential diagnoses of multiple sclerosis (MS) and requires central nervous system (CNS) biopsy to establish definite diagnosis according to the latest consensus diagnostic criteria. We here analyzed diagnostic values of basic cerebrospinal fluid (CSF) parameters to distinguish neurosarcoidosis from MS without CNS biopsy. Methods We retrospectively assessed clinical, radiological and laboratory data of 27 patients with neurosarcoidosis treated at our center and compared following CSF parameters with those of 138 patients with relapsing-remitting MS: CSF white cell count (WCC), CSF/serum albumin quotient (Qalb), intrathecal production of immunoglobulins including oligoclonal bands (OCB), MRZ reaction, defined as a polyspecific intrathecal production of IgG reactive against ≥2 of 3 the viruses measles (M), rubella (R), and zoster (Z) virus, and CSF lactate levels. Additional inflammatory biomarkers in serum and/or CSF such as neopterin, soluble interleukin-2 receptor (sIL-2R) and C-reactive protein (CRP) were assessed. Results There was no significant difference in the frequency of CSF pleocytosis, but a CSF WCC > 30/μl was more frequent in patients with neurosarcoidosis. Compared to MS, patients with neurosarcoidosis showed more frequently an increased Qalb and CSF lactate levels as well as increased serum and CSF levels of sIL-2R, but a lower frequency of intrathecal IgG synthesis and positive MRZ reaction. Positive likelihood ratio (PLR) of single CSF parameters indicating neurosarcoidosis was highest, if (a) CSF WCC was >30/μl (PLR 7.2), (b) Qalb was >10 × 10-3 (PLR 66.4), (c) CSF-specific OCB were absent (PLR 11.5), (d) CSF lactate was elevated (PLR 23.0) or (e) sIL-2R was elevated (PLR>8.0). The combination of (a) one of three following basic CSF parameters, i.e., (a.1.) CSF WCC >30/ul, or (a.2.) QAlb >10 × 10-3, or (a.3.) absence of CSF-specific OCB, and (b) absence of positive MRZ reaction showed the best diagnostic accuracy (sensitivity and specificity each >92%; PLR 12.8 and NLR 0.08). Conclusion Combined evaluation of basic CSF parameters and MRZ reaction is powerful in differentiating neurosarcoidosis from MS, with moderate to severe pleocytosis and QAlb elevation and absence of intrathecal IgG synthesis as useful rule-in parameters and positive MRZ reaction as a rule-out parameter for neurosarcoidosis.
Collapse
Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Stephan Neidhart
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marc Hilty
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Mario Ziegler
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ilijas Jelcic
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neuroimmunology and Multiple Sclerosis Research Section, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- *Correspondence: Ilijas Jelcic
| |
Collapse
|
4
|
Alakhras H, Goodman BD, Zimmer M, Aguinaga S. Confusion, Hallucinations, and Primary Polydipsia: A Rare Presentation of Neurosarcoidosis. Cureus 2022; 14:e21687. [PMID: 35237482 PMCID: PMC8882310 DOI: 10.7759/cureus.21687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 11/05/2022] Open
Abstract
Neurosarcoidosis is a rare manifestation of sarcoidosis that can exhibit a variety of neuropsychiatric symptoms and can present independently of pulmonary or other systemic symptoms. This is the case of a 51-year-old African American male who presented with recurrent episodes of auditory and visual hallucinations, confusion, seizures that did not respond to antiepileptics, and recent-onset primary polydipsia. In the emergency department, he did not have meningeal signs, focal neurologic deficits, or a fever. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse meningeal enhancement. The patient underwent a lumbar puncture (LP), with cerebrospinal fluid (CSF) analysis notably revealing an elevated angiotensin-converting enzyme (ACE), an elevated CD4:CD8 ratio, and a negative infectious panel, while computed tomography (CT) imaging showed bilateral hilar lymphadenopathy. He also had an endobronchial ultrasound (EBUS) with biopsy which did not reveal granulomas. Although sarcoidosis requires granulomas for a definite diagnosis, studies and symptoms were consistent with neurosarcoidosis, and this can suggest that the disease was isolated to the central nervous system (CNS). This case highlights the need for further understanding of psychiatric symptoms as a sign of isolated neurosarcoidosis.
Collapse
|
5
|
Otto F, Harrer C, Pilz G, Wipfler P, Harrer A. Role and Relevance of Cerebrospinal Fluid Cells in Diagnostics and Research: State-of-the-Art and Underutilized Opportunities. Diagnostics (Basel) 2021; 12:diagnostics12010079. [PMID: 35054246 PMCID: PMC8774636 DOI: 10.3390/diagnostics12010079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 01/15/2023] Open
Abstract
Cerebrospinal fluid (CSF) has recently experienced a revival in diagnostics and research. However, little progress has been made regarding CSF cell analysis. For almost a century, CSF cell count and cytomorphological examination have been central diagnostic parameters, with CSF pleocytosis as a hallmark finding of neuroinflammation and cytology offering valuable clues regarding infectious, autoimmune, and malignant aetiologies. A great deal of information, however, remains unattended as modern immune phenotyping technologies have not yet been broadly incorporated into routine CSF analysis. This is a serious deficit considering the central role of CSF cells as effectors in central nervous system (CNS) immune defence and autoimmune CNS processes, and the diagnostic challenges posed by clinically overlapping infectious and immune-mediated CNS diseases. Here, we summarize historical, specimen-intrinsic, methodological, and technical issues determining the state-of-the-art diagnostics of CSF cells and outline future perspectives for this underutilized window into meningeal and CNS immunity.
Collapse
Affiliation(s)
- Ferdinand Otto
- Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, 5020 Salzburg, Austria; (F.O.); (C.H.); (G.P.); (P.W.)
| | - Christine Harrer
- Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, 5020 Salzburg, Austria; (F.O.); (C.H.); (G.P.); (P.W.)
| | - Georg Pilz
- Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, 5020 Salzburg, Austria; (F.O.); (C.H.); (G.P.); (P.W.)
| | - Peter Wipfler
- Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, 5020 Salzburg, Austria; (F.O.); (C.H.); (G.P.); (P.W.)
| | - Andrea Harrer
- Department of Neurology, Paracelsus Medical University, Christian-Doppler-Klinik, 5020 Salzburg, Austria; (F.O.); (C.H.); (G.P.); (P.W.)
- Department of Dermatology and Allergology, Paracelsus Medical University, Landeskrankenhaus, 5020 Salzburg, Austria
- Correspondence:
| |
Collapse
|
6
|
Abkur T, Saeed M. Transverse myelitis: a diagnostic challenge. Clin Med (Lond) 2021; 21:e682. [PMID: 34862236 DOI: 10.7861/clinmed.let.21.6.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Tarig Abkur
- Senior specialist registrar in neurology, Southmead Hospital, Bristol, UK
| | - Mamoun Saeed
- Senior specialist registrar in neurology, Chelsea and Westminster Hospital, London, UK
| |
Collapse
|