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Etemadifar M, Mehri A, Sedaghat N, Salari M, Tavassoli Naini P. Multiple sclerosis in sarcoidosis patients: Two case reports. Clin Case Rep 2022; 10:e6332. [PMID: 36172327 PMCID: PMC9468654 DOI: 10.1002/ccr3.6332] [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] [Received: 02/26/2022] [Revised: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
Abstract
Two cases of sarcoidosis referred to our clinic with neurological symptoms. They were diagnosed with multiple sclerosis using non‐invasive studies. The first patient refused treatment and died of myocardial infarction 6 months after visiting our clinic. The second received interferon‐beta and methotrexate with a favorable outcome after 3 years. Since the possible similar presentation of the two conditions could appear indistinct for certain diagnosis, accurate evaluation of symptoms and paraclinical data can provide the best approach to each condition.
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Affiliation(s)
- Masoud Etemadifar
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Armin Mehri
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Nahad Sedaghat
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
| | - Mehri Salari
- Functional Neurosurgery Research Center Shohada Tajrish Comprehensive Neurosurgical Center of Excellence Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Parsa Tavassoli Naini
- Neurosurgery Research Department Alzahra University Hospital Isfahan University of Medical Sciences Isfahan Iran
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2
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Goel J, Anadure R, Gupta S, Wilson V, Saxena R, Sahu S, Mutreja D. A Study of the Clinical Profile, Radiologic Features, and Therapeutic Outcomes in Neurosarcoidosis from Two Tertiary Care Centers in Southern India. Neurol India 2021; 68:609-616. [PMID: 32643673 DOI: 10.4103/0028-3886.288976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Sarcoidosis is an inflammatory granulomatous disease affecting multiple organ systems. Neurological manifestations are rare and seen in approximately 5% cases of sarcoidosis. They may commonly precede the diagnosis of sarcoidosis. Since there is paucity of Indian literature on this subject, we decided to review the clinical and radiological profile, laboratory abnormalities, treatment and long-term outcomes in our patients with neurosarcoidosis (NS). Methods The study was done by retrospective review of medical records for all cases diagnosed as NS during the period Jan 2014-Jan 2018. These cases were classified as definite, probable, and possible NS, on the basis of established diagnostic parameters (Zajicek criteria). The follow-up record in these cases ranged from 6 months to 3 years, with special emphasis on monitoring the response to treatment and long-term disability. Results The cases showed varied clinical abnormalities and imaging findings. Cranial neuropathies and myelopathy were the most common clinical presentations. Optic neuritis was most common cranial neuropathy, followed by facial nerve palsy and lower cranial nerve palsies. Most common magnetic resonance imaging findings were T2 hyperintense parenchymal lesions and meningeal enhancement. There was strong correlation between baseline clinico radiological parameters and long-term outcomes, as evidenced by relatively poor prognosis seen in cases with bilateral optic neuritis, myelopathy and imaging evidence of hydrocephalus, or leptomeningitis. Conclusion The diagnosis of NS requires a high degree of suspicion, coupled with exclusion of alternate diagnosis. It commonly precedes the onset of systemic sarcoidosis. Central nervous system involvement in sarcoidosis is associated with poor clinical outcomes.
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Affiliation(s)
- Jitesh Goel
- Department of Neurology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Ravi Anadure
- Department of Medicine, Agram Post, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Salil Gupta
- Department of Neurology, Army Hospital R and R, New Delhi, India
| | - Vinny Wilson
- Department of Neurology, INHS Asvini, Mumbai, India
| | - Rajeev Saxena
- Department of Neurology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Samaresh Sahu
- Department of Radiology, Command Hospital Air Force, Bengaluru, Karnataka, India
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3
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Voortman M, Stern BJ, Saketkoo LA, Drent M. The Burden of Neurosarcoidosis: Essential Approaches to Early Diagnosis and Treatment. Semin Respir Crit Care Med 2020; 41:641-651. [PMID: 32777849 DOI: 10.1055/s-0040-1710576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neurosarcoidosis (NS) is an often severe, destructive manifestation with a likely under-reported prevalence of 5 to 15% of sarcoidosis cases, and in its active phase demands timely treatment intervention. Clinical signs and symptoms of NS are variable and wide-ranging, depending on anatomical involvement. Cranial nerve dysfunction, cerebrospinal parenchymal disease, aseptic meningitis, and leptomeningeal disease are the most commonly recognized manifestations. However, non-organ-specific potentially neurologically driven symptoms, such as fatigue, cognitive dysfunction, and small fiber neuropathy, appear frequently.Heterogeneous clinical presentations and absence of any single conclusive test or biomarker render NS, and sarcoidosis itself, a challenging definitive diagnosis. Clinical suspicion of NS warrants a thorough systemic and neurologic evaluation hopefully resulting in supportive extraneural physical exam and/or tissue findings. Treatment targets the severity of the manifestation, with careful discernment of whether NS reflects active potentially reversible inflammatory granulomatous disease versus inactive postinflammatory damage whereby functional impairment is unlikely to be pharmacologically responsive. Non-organ-specific symptoms are poorly understood, challenging in deciphering reversibility and often identified too late to respond to conventional immunosuppressive/pharmacological treatment. Physical therapy, coping strategies, and stress reduction may benefit patients with all disease activity levels of NS.This publication provides an approach to screening, diagnosis, disease activity discernment, and pharmacological as well as nonpharmacological treatment interventions to reduce disability and protect health-related quality of life in NS.
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Affiliation(s)
- Mareye Voortman
- Division of Heart and Lungs, Department of Pulmonology, University Medical Centre Utrecht, The Netherlands.,ILD Care Foundation Research Team, Ede, The Netherlands
| | - Barney J Stern
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, Louisiana.,Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, University Medical Center, New Orleans, Louisiana.,Louisiana State University and Tulane University Schools of Medicine, New Orleans, Louisiana
| | - Marjolein Drent
- ILD Care Foundation Research Team, Ede, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands.,Department of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands
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4
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Arun T, Pattison L, Palace J. Distinguishing neurosarcoidosis from multiple sclerosis based on CSF analysis: A retrospective study. Neurology 2020; 94:e2545-e2554. [PMID: 32354749 DOI: 10.1212/wnl.0000000000009491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To characterize a cohort of patients with neurosarcoidosis with particular focus on CSF analysis and to investigate whether CSF values could help in distinguishing it from multiple sclerosis (MS). METHODS This retrospective cohort study enrolled 85 patients with a diagnosis of neurosarcoidosis (possible, probable, or definite). CSF total protein, white cell count, and angiotensin-converting enzyme levels were measured. CSF and serum oligoclonal immunoglobulin G (IgG) patterns were analyzed with the use of odds ratios and binary logistic regression. RESULTS Eighty patients had a probable (nonneural positive histology) or definite (neural positive histology) diagnosis of neurosarcoidosis. Most frequent findings on MRI were leptomeningeal enhancement (35%) and white matter and spinal cord involvement (30% and 23%). PET scan showed avid areas in 74% of cases. CSF analysis frequently showed lymphocytosis (63%) and elevated protein (62%), but CSF-selective oligoclonal bands were rare (3%). Serum ACE levels were elevated in 51% of patients but in only 14% of those with isolated neurosarcoidosis. Elevated CSF ACE was not found in any patient. CONCLUSIONS Large elevations in total protein, white cell count, and serum ACE occur in neurosarcoidosis but are rare in MS. The diagnostic use of these tests is, however, limited because minimal changes may occur in both. MS clinical mimics in neurosarcoidosis are not common, and intrathecal synthesis of oligoclonal IgG is a powerful discriminator because it is rare in neurosarcoidosis but occurs in 95% to 98% cases of MS. We suggest caution in making a diagnosis of neurosarcoidosis when intrathecal oligoclonal IgG synthesis is found.
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Affiliation(s)
- Tarunya Arun
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK.
| | - Laura Pattison
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
| | - Jacqueline Palace
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
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5
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Berlit P, Krämer M. Cerebral involvement in systemic vasculitides: Extracts from the guideline of the German neurological society. Neurol Res Pract 2019; 1:13. [PMID: 33324879 PMCID: PMC7650123 DOI: 10.1186/s42466-019-0016-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/22/2019] [Indexed: 01/09/2023] Open
Abstract
Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of cerebral manifestations of systemic vasculitides and rheumatic diseases. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies. This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y.
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Affiliation(s)
- Peter Berlit
- Deutsche Gesellschaft für Neurologie, Reinhardtstr. 27 C, 10117 Berlin, Germany
| | - Markus Krämer
- Neurologie, Alfried-Krupp-Krankenhaus Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
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6
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Berlit P, Krämer M. Primary angiitis of the CNS (PACNS) and Behçet disease. Neurol Res Pract 2019; 1:10. [PMID: 33324876 PMCID: PMC7650140 DOI: 10.1186/s42466-019-0014-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/28/2019] [Indexed: 11/15/2022] Open
Abstract
Cerebral vasculitis is a rare disorder but plays a major role in the differential diagnosis of stroke, encephalopathy and headache. This guideline was developed in order to support clinicians in the diagnosis and treatment of primary angiitis of the CNS (PACNS) and Neuro-Behçet. It is based on a medline research and was developed in a modified Delphi process and approved by the involved societies. This article is an abridged and translated version of the guideline published in DGNeurologie: Berlit, P. & Krämer, M. DGNeurologie (2018) 1: 17. 10.1007/s42451-018-0001-y
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Affiliation(s)
- Peter Berlit
- Deutsche Gesellschaft für Neurologie, Reinhardtstr. 27 C, 10117 Berlin, Germany
| | - Markus Krämer
- Neurologie, Alfried-Krupp-Krankenhaus Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
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7
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Chalah MA, Ayache SS. Psychiatric event in multiple sclerosis: could it be the tip of the iceberg? ACTA ACUST UNITED AC 2017; 39:365-368. [PMID: 28355344 PMCID: PMC7111399 DOI: 10.1590/1516-4446-2016-2105] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 11/23/2016] [Indexed: 01/10/2023]
Abstract
Multiple sclerosis (MS) is a chronic progressive inflammatory disease of the central nervous system. Psychiatric comorbidities are highly prevalent in patients with MS, and can have drastic impact on quality of life and interpersonal relationships. Despite this high prevalence, whether psychiatric manifestations may represent the first signs of MS is still debatable. This constitutes an important issue, since early diagnosis of "psychiatric-onset MS" would result in prompt management, which usually ameliorates long-term prognosis. Here, we discuss clinical and radiological hints that suggest a diagnosis of psychiatric-onset MS. Briefly, this entity should be considered in healthy patients presenting with late-onset psychiatric symptoms, with or without cognitive decline, and with negative family history of psychiatric diseases. A thorough neurological exam is crucial to detect any subtle neurological signs. Brain magnetic resonance imaging is recommended to rule out frontotemporal lesions that might explain the clinical picture. Poor response to standard psychiatric treatments provides additional evidence for the diagnosis of an organic disease (e.g., MS). Combining psychopharmaceuticals with intravenous corticosteroids would result in good outcomes, but patients should be monitored carefully for possible psychiatric exacerbation, a common side effect of steroids.
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Affiliation(s)
- Moussa A Chalah
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France.,Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Samar S Ayache
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France.,Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France.,Neurology Division, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
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8
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MacLean HJ, Abdoli M. Neurosarcoidosis as an MS Mimic: The trials and tribulations of making a diagnosis. Mult Scler Relat Disord 2015; 4:414-429. [PMID: 26346790 DOI: 10.1016/j.msard.2015.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 05/28/2015] [Accepted: 06/17/2015] [Indexed: 12/14/2022]
Abstract
The clinical presentation of neurosarcoidosis is varied as multiple levels of the neuraxis may be affected. When central nervous system involvement occurs, making an accurate diagnosis of the condition can be challenging, especially given the current definition for definite neurosarcoidosis requires histologic confirmation of the affected tissue (brain biopsy). This article will review our current knowledge and manifestations of neurosarcoidosis, discuss the current diagnostic approach as well as the challenges associated with a condition requiring histologic confirmation, discuss the current treatment approach, and highlight the challenges of this diagnosis with a few real-life clinical cases. We also highlight the selected differential diagnosis of neurosarcoidosis as well as multiple sclerosis which could mimic each other.
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Affiliation(s)
- Heather J MacLean
- Ottawa Hospital, General Campus, Canada; University of Ottawa, Undergraduate Medical Education, Canada.
| | - Mohammad Abdoli
- University of Ottawa, Ottawa MS Clinic, 501 Smyth Rd., Canada K1H 8L6.
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9
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Bridel C, Courvoisier DS, Vuilleumier N, Lalive PH. Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of neurosarcoidosis. J Neuroimmunol 2015. [PMID: 26198911 DOI: 10.1016/j.jneuroim.2015.05.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neurosarcoidosis (NS) is a rare condition that may mimic central nervous system (CNS) infection, neoplasia and other inflammatory disorders of the CNS such as multiple sclerosis, encephalitis and vasculitis. Diagnosis is challenging in cases with minimal or absent systemic involvement. Cerebrospinal fluid (CSF) angiotensin-converting enzyme (c-ACE) has been claimed as a valuable diagnostic tool for NS. However, there is little data evaluating its performance in routine clinical practice. FINDINGS We performed a monocentric, retrospective, chart-based study including all patients investigated with a lumbar puncture and c-ACE dosage for suspected NS between 01/01/2006 and 31/12/2012 at the Geneva University Hospital. Receiver-operating characteristic (ROC) curve and area under the curve (AUC) were performed to calculate the optimal cut-off value of c-ACE and to determine the discriminative ability of c-ACE. Of the 440 patients included in the study, 9 were diagnosed with NS on the basis of tissue biopsy. Mean c-ACE was not significantly different between NS and non-NS patients. With a cut-off value of 2 (0-2 vs ≥3), sensitivity and specificity of c-ACE were 66.7% and 67.3%, respectively. CONCLUSIONS In our clinical setting, the sensitivity and specificity of c-ACE for NS diagnosis were relatively poor and of little clinical utility.
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Affiliation(s)
- Claire Bridel
- Department of Clinical Neurosciences, Division of Neurology, Unit of Neuroimmunology and Multiple Sclerosis, University Hospital of Geneva, Switzerland.
| | | | - Nicolas Vuilleumier
- Department of Genetics and Laboratory Medicine, Laboratory Medicine Service, University Hospital of Geneva, Switzerland.
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Division of Neurology, Unit of Neuroimmunology and Multiple Sclerosis, University Hospital of Geneva, Switzerland; Department of Genetics and Laboratory Medicine, Laboratory Medicine Service, University Hospital of Geneva, Switzerland.
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10
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11
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Tana C, Wegener S, Borys E, Pambuccian S, Tchernev G, Tana M, Giamberardino MA, Silingardi M. Challenges in the diagnosis and treatment of neurosarcoidosis. Ann Med 2015; 47:576-91. [PMID: 26469296 DOI: 10.3109/07853890.2015.1093164] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The diagnosis and treatment of neurosarcoidosis can be very challenging for several reasons. It affects clinically 5%-10% of sarcoidosis patients, but can be found in up to 25% of autopsies. These data reveal that a high percentage of asymptomatic or misdiagnosed cases can be missed at an initial diagnostic approach. Clinical and imaging findings are often non-specific since they can be found in a large number of neurological disorders. Histopathology can also be confounding if not performed by an expert pathologist and not placed in an appropriate clinical context. In this review, we discuss clinical features, laboratory findings, imaging, and histology of neurosarcoidosis, and we report current evidence regarding drug therapy. We conclude that a correct diagnostic approach should include a multidisciplinary evaluation involving clinicians, radiologists, and pathologists and that future studies should evaluate the genetic signature of neurosarcoidosis as they could be helpful in the assessment of this uncommon disease. With head-to-head comparisons of medical treatment for neurosarcoidosis still lacking due to the rarity of the disease and an increasing number of immunomodulating therapies at hand, novel therapeutic approaches are to be expected within the next few years.
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Affiliation(s)
- Claudio Tana
- a Internal Medicine Unit , Guastalla Hospital, AUSL Reggio Emilia , Reggio Emilia , Italy
| | - Susanne Wegener
- b Department of Neurology , University Hospital Zurich and University of Zurich , Zurich , Switzerland
| | - Ewa Borys
- c Department of Pathology , Loyola University Medical Center and Stritch School of Medicine, Loyola University Chicago , Maywood , Illinois , USA
| | - Stefan Pambuccian
- c Department of Pathology , Loyola University Medical Center and Stritch School of Medicine, Loyola University Chicago , Maywood , Illinois , USA
| | - Georgi Tchernev
- d Polyclinic for Dermatology and Venereology and Medical Faculty , University Hospital Lozenetz and Sofia University , Sofia , Bulgaria
| | - Marco Tana
- e Department of Medicine and Science of Aging , "G. d'Annunzio" University , Chieti , Italy
| | | | - Mauro Silingardi
- a Internal Medicine Unit , Guastalla Hospital, AUSL Reggio Emilia , Reggio Emilia , Italy
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12
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Wegener S, Linnebank M, Martin R, Valavanis A, Weller M. Clinically Isolated Neurosarcoidosis: A Recommended Diagnostic Path. Eur Neurol 2014; 73:71-7. [DOI: 10.1159/000366199] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/29/2014] [Indexed: 11/19/2022]
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13
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Rounds WH, Ligocki AJ, Levin MK, Greenberg BM, Bigwood DW, Eastman EM, Cowell LG, Monson NL. The antibody genetics of multiple sclerosis: comparing next-generation sequencing to sanger sequencing. Front Neurol 2014; 5:166. [PMID: 25278930 PMCID: PMC4165282 DOI: 10.3389/fneur.2014.00166] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 08/19/2014] [Indexed: 11/29/2022] Open
Abstract
We previously identified a distinct mutation pattern in the antibody genes of B cells isolated from cerebrospinal fluid (CSF) that can identify patients who have relapsing-remitting multiple sclerosis (RRMS) and patients with clinically isolated syndromes who will convert to RRMS. This antibody gene signature (AGS) was developed using Sanger sequencing of single B cells. While potentially helpful to patients, Sanger sequencing is not an assay that can be practically deployed in clinical settings. In order to provide AGS evaluations to patients as part of their diagnostic workup, we developed protocols to generate AGS scores using next-generation DNA sequencing (NGS) on CSF-derived cell pellets without the need to isolate single cells. This approach has the potential to increase the coverage of the B-cell population being analyzed, reduce the time needed to generate AGS scores, and may improve the overall performance of the AGS approach as a diagnostic test in the future. However, no investigations have focused on whether NGS-based repertoires will properly reflect antibody gene frequencies and somatic hypermutation patterns defined by Sanger sequencing. To address this issue, we isolated paired CSF samples from eight patients who either had MS or were at risk to develop MS. Here, we present data that antibody gene frequencies and somatic hypermutation patterns are similar in Sanger and NGS-based antibody repertoires from these paired CSF samples. In addition, AGS scores derived from the NGS database correctly identified the patients who initially had or subsequently converted to RRMS, with precision similar to that of the Sanger sequencing approach. Further investigation of the utility of the AGS in predicting conversion to MS using NGS-derived antibody repertoires in a larger cohort of patients is warranted.
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Affiliation(s)
- William H Rounds
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Ann J Ligocki
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Mikhail K Levin
- Department of Clinical Sciences, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Benjamin M Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | | | | | - Lindsay G Cowell
- Department of Clinical Sciences, University of Texas Southwestern Medical Center , Dallas, TX , USA
| | - Nancy L Monson
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center , Dallas, TX , USA ; Department of Immunology, University of Texas Southwestern Medical Center , Dallas, TX , USA
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14
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Overview of neurosarcoidosis: recent advances. J Neurol 2014; 262:258-67. [PMID: 25194844 PMCID: PMC4330460 DOI: 10.1007/s00415-014-7482-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 01/10/2023]
Abstract
Sarcoidosis (SA) is a granulomatous, multisystem disease of unknown etiology. Most often the disease affects lungs and mediastinal lymph nodes, but it may occur in other organs. Neurosarcoidosis (NS) more commonly occurs with other sarcoidosis forms, in 1 % of cases it involves only nervous system. Symptomatic NS occurs but on autopsy study up to 25 % of cases are confirmed. NS can affect central nervous system: the brain, spinal cord and peripheral nerves, and muscles. The diagnosis of neurosarcoidosis facilitates diagnostic criteria: histopathological, imaging and cerebrospinal fluid examination, and clinical symptoms. At present, there are no set standards for treatment of patients suffering from NS. Early therapy of symptomatic patients is recommended. Corticosteroids still are the first line of treatment for NS patients. In cases of steroids resistance, lack of their effectiveness or existence of contraindication to their use, immunosuppressant treatment is recommended. The latest NS algorithm with immunosuppressive treatment is discussed.
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15
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Diagnosis and management of Neuro-Behçet's disease: international consensus recommendations. J Neurol 2013; 261:1662-76. [PMID: 24366648 PMCID: PMC4155170 DOI: 10.1007/s00415-013-7209-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/04/2013] [Indexed: 11/16/2022]
Abstract
Neuro-Behçet’s disease (NBD) is one of the more serious manifestations of Behçet’s disease (BD), which is a relapsing inflammatory multisystem disease with an interesting epidemiology. Though NBD is relatively uncommon, being potentially treatable, neurologists need to consider it in the differential diagnosis of inflammatory, infective, or demyelinating CNS disorders. Evidence-based information on key issues of NBD diagnosis and management is scarce, and planning for such studies is challenging. We therefore initiated this project to develop expert consensus recommendations that might be helpful to neurologists and other clinicians, created through an extensive literature review and wide consultations with an international advisory panel, followed by a Delphi exercise. We agreed on consensus criteria for the diagnosis of NBD with two levels of certainty in addition to recommendations on when to consider NBD in a neurological patient, and on the use of various paraclinical tests. The management recommendations included treatment of the parenchymal NBD and cerebral venous thrombosis, the use of disease modifying therapies, prognostic factors, outcome measures, and headache in BD. Future studies are needed to validate the proposed criteria and provide evidence-based treatments.
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Abstract
PURPOSE OF REVIEW The aims of this article are to discuss the epidemiology, pathophysiology and clinical phenomenology of neurosarcoidosis, as well as current approaches to diagnosis and treatment. This review focuses on central nervous system (CNS) complications of sarcoidosis. RECENT FINDINGS Neurosarcoidosis is a rare disorder with diverse clinical manifestations and outcomes. It is often difficult to diagnose and even more difficult to treat. New diagnostic approaches include the use of [¹⁸F]-fluorodeoxyglucose PET to identify potential biopsy sites. Success has been reported in the treatment of steroid refractory cases with disease-modifying therapies that were originally designed to manage other chronic inflammatory conditions by neutralizing key cytokines or depleting leukocyte subsets. SUMMARY The diagnosis and management of neurosarcoidosis can be challenging. Currently, the disorder is treated with corticosteroids in combination with global immunosuppressant agents and/or immunomodulatory monoclonal antibodies, such as infliximab. The development of novel CNS penetrant drugs that are particularly effective at inhibiting granuloma formation would represent a significant therapeutic advance. Future progress will be informed by a deeper understanding of the pathways underlying the granulomatous inflammation characteristic of sarcoidosis and by an increased appreciation of how sarcoid lesions evolve in the CNS microenvironment.
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Wengert O, Rothenfusser-Korber E, Vollrath B, Bohner G, Scheibe F, Otto C, Hofmann J, Angstwurm K, Ruprecht K. Neurosarcoidosis: Correlation of cerebrospinal fluid findings with diffuse leptomeningeal gadolinium enhancement on MRI and clinical disease activity. J Neurol Sci 2013; 335:124-30. [DOI: 10.1016/j.jns.2013.09.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 12/19/2022]
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18
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Honigberg MC, Papavassiliou E, Cohen YZ. Primary leptomeningeal melanocytosis presenting as chronic meningitis. J Clin Neurosci 2013; 21:1056-8. [PMID: 24355206 DOI: 10.1016/j.jocn.2013.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/18/2013] [Indexed: 11/19/2022]
Abstract
We report a patient with primary leptomeningeal melanocytosis presenting as chronic meningitis. A previously healthy 27-year-old man presented with 2 months of severe headaches and photophobia. A lumbar puncture was notable for a highly elevated cerebrospinal fluid (CSF) protein level without pleocytosis. Imaging at the time of admission suggested only meningitis without the presence of parenchymal lesions. On the basis of the CSF findings, early meningeal biopsy was performed, leading to the diagnosis of a meningeal melanocytic neoplasm. Early meningeal biopsy should be considered in patients with meningitis when the CSF profile suggests the possibility of a central nervous system neoplasm.
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Affiliation(s)
- Michael C Honigberg
- Tosteson Medical Education Center, Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115, USA.
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Tosteson Medical Education Center, Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115, USA
| | - Yehuda Z Cohen
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Tosteson Medical Education Center, Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115, USA
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Kim SS, Richman DP, Johnson WO, Hald JK, Agius MA. Limited utility of current MRI criteria for distinguishing multiple sclerosis from common mimickers: primary and secondary CNS vasculitis, lupus and Sjogren's syndrome. Mult Scler 2013; 20:57-63. [PMID: 23736535 DOI: 10.1177/1352458513491329] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) criteria play an important role in making an earlier diagnosis of multiple sclerosis (MS) in patients presenting with clinically isolated syndrome. OBJECTIVE The objective of this paper is to determine whether MRI criteria may be used to distinguish MS from primary and secondary central nervous system (CNS) vasculitis, lupus, and Sjogren's syndrome. METHODS MRI criteria were applied retrospectively to images for patients with clinically definite MS (CDMS), primary CNS vasculitis, secondary CNS vasculitis, and autoimmune disorders including systemic lupus erythematosus (SLE) and Sjogren's syndrome. Classical statistics and Bayesian analyses were performed. RESULTS Overall modified Barkhof's MRI criteria were statistically significant in distinguishing CDMS (60%) from SLE/Sjogren's syndrome (17%, p = 0.0173) but not in distinguishing CDMS from primary CNS vasculitis (50%, p = 0.7376) or secondary CNS vasculitis (58%, p = 1.0000). Four of the five other MRI criteria tested were demonstrated to be superior to modified Barkhof's criteria in predicting MS: nine or more T2 lesions (a component of Barkhof's criteria), one or more ovoid periventricular T2 lesions, one or more perpendicular periventricular T2 lesions, and one or more T2 lesions larger than 6 mm. CONCLUSIONS MRI criteria, including the modified Barkhof's criteria, were unsuccessful in distinguishing MS from primary CNS vasculitis or secondary CNS vasculitis and mildly successful in distinguishing MS from SLE/Sjogren's syndrome.
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Affiliation(s)
- Susan S Kim
- Neurology Service, VANCHCS, Sacramento VA Medical Center, Department of Veterans Affairs, USA
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Lefèvre G, Zéphir H, Michelin E, Semah F, Warembourg F, Pruvo JP, Hachulla E, Lenfant P, Dubucquoi S, Vermersch P, Hatron PY, Prin L, Launay D. Neurolupus (2e partie). Description des outils diagnostiques et thérapeutiques devant une manifestation psychiatrique ou neurologique centrale au cours du lupus érythémateux systémique. Rev Med Interne 2012; 33:503-13. [DOI: 10.1016/j.revmed.2012.03.354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 01/02/2012] [Accepted: 03/31/2012] [Indexed: 12/23/2022]
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Pelidou SH, Giannopoulos S, Tzavidi S, Lagos G, Kyritsis AP. Multiple sclerosis presented as clinically isolated syndrome: the need for early diagnosis and treatment. Ther Clin Risk Manag 2011; 4:627-30. [PMID: 18827858 PMCID: PMC2500255 DOI: 10.2147/tcrm.s2515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To aid in the timely diagnosis of patients who present with clinically isolated syndrome (CIS). Patients and methods We studied 25 patients (18 women, 7 men), originally presented in our clinic with a CIS suggestive of multiple sclerosis (MS). All patients underwent the full investigation procedure including routine tests, serology, cerebrospinal fluid (CSF) examinations, evoked potentials (EPs), and magnetic resonance imaging (MRI) of brain and cervical spinal cord. Patients were imaged at baseline, and every three months thereafter up to a year. Results The CIS was consisted of optic neuritis in 12 cases, incomplete transverse myelitis (ITM) in 7 cases, Lhermitte sign in 2 cases, internuclear ophthalmoplegia (INO) in 2 cases, mild brainstem syndrome in 1 case, and tonic-clonic seizures in 1 case. Using the baseline and three-month scans 18/25 (72%) patients developed definite MS in one year of follow up while 7 (28%) had no further findings during this observation period. Immunomodulatory treatments were applied to all definite MS patients. Conclusion In light of new treatments available, MRIs at 3 month intervals are helpful to obtain the definite diagnosis of MS as early as possible.
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Martin M, Gil H, Hafsaoui C, Meaux-Ruault N, Magy-Bertrand N. Responsabilité de la ciclosporine dans la survenue d’un neuro-Behçet ? Rev Med Interne 2010; 31:e7-8. [DOI: 10.1016/j.revmed.2010.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 12/22/2009] [Accepted: 02/27/2010] [Indexed: 10/19/2022]
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23
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Gama PDD, Machado LDR, Livramento JA, Gomes HR, Adoni T, Lino AMM, Marchiori PE, Morales RDR, Lana-Peixoto MA, Callegaro D. Study of oligoclonal bands restricted to the cerebrospinal fluid in multiple sclerosis patients in the city of São Paulo. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 67:1017-22. [PMID: 20069212 DOI: 10.1590/s0004-282x2009000600011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2009] [Accepted: 08/07/2009] [Indexed: 11/21/2022]
Abstract
The frequency of oligoclonal bands (OCB) restricted to the cerebrospinal fluid (CSF) from patients with multiple sclerosis (MS) varies widely in different populations. The objective of this study was to determine the frequency of these OCB in a group of MS patients in the city of São Paulo. Techniques used to detect OCB consisted of isoelectric focusing followed by immunoblotting. Oligoclonal bands were found in 49 (54.4%) out of 90 patients with clinically definite MS; in (31.2%) of the 16 patients with clinically isolated syndrome; in 7 (17.9%) of 39 patients with inflammatory disorders of the central nervous system (IDCNS), and in none of the individuals with no neurological condition (control group). The specificity of the method was 100% when compared to the control group and 82.1% when compared to the IDCNS group. These results suggest that the frequency of CSF OCB is much lower in Brazilian MS patients from São Paulo city than that reported in MS series from Caucasian populations.
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Affiliation(s)
- Paulo Diniz da Gama
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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A pragmatic approach to diagnosing and treating neurosarcoidosis in the 21st century. Curr Opin Pulm Med 2010; 16:472-9. [DOI: 10.1097/mcp.0b013e32833c86df] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Granger N, Smith PM, Jeffery ND. Clinical findings and treatment of non-infectious meningoencephalomyelitis in dogs: a systematic review of 457 published cases from 1962 to 2008. Vet J 2010; 184:290-7. [PMID: 19410487 DOI: 10.1016/j.tvjl.2009.03.031] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 03/25/2009] [Accepted: 03/27/2009] [Indexed: 11/22/2022]
Abstract
Non-infectious meningoencephalomyelitis (NIME) presents clinicians with diagnostic problems because specific diagnosis requires histopathological examination of central nervous system (CNS) tissue. In the absence of a precise diagnosis, clinicians refer instead to 'meningoencephalomyelitis of unknown origin' (MUO). This article compares published data on histopathologically diagnosed disease (granulomatous meningoencephalomyelitis and necrotising encephalitis) with information available on the clinically-defined category of MUO. Small, middle-aged female dogs are most commonly affected by all types of NIME, but there is considerable overlap in diagnostic parameters of these diseases. Future clinical trials must aim to compare prospectively two or more randomly allocated treatments and to include pre-trial power calculations. This article provides the necessary background information to permit rational patient selection on clinical presentation alone, rather than requiring CNS biopsy, thus maximising patient recruitment whilst minimising heterogeneity.
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Affiliation(s)
- Nicolas Granger
- Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge, CB3 0ES, UK
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Afección del sistema nervioso central en el síndrome de Sjögren primario. Med Clin (Barc) 2009; 133:349-59. [PMID: 19376547 DOI: 10.1016/j.medcli.2008.12.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 12/10/2008] [Indexed: 11/23/2022]
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Abstract
Although neurosarcoidosis seems to occur in only 5% to 10% of patients who have sarcoidosis, it may lead to significant complications. The diagnosis of neurosarcoidosis usually relies on indirect information from imaging and spinal fluid examination. Although MR imaging remains the most sensitive technique for detecting neurologic disease, other tests, including positron emission tomography scanning and cerebral spinal fluid examination, can provide important information. The role of immunosuppressive agents such as methotrexate, cyclophosphamide, and azathioprine has been expanded, and these agents should be considered for the treatment of some manifestations of neurosarcoidosis. Reports of the antitumor necrosis factor agent infliximab suggest that this drug can be helpful for patients who have neurosarcoidosis.
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Affiliation(s)
- Elyse E Lower
- Interstitial Lung Disease and Sarcoidosis Center, University of Cincinnati Medical Center, 3235 Eden Avenue, Cincinnati, OH 45267, USA.
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Pelidou SH, Giannopoulos S, Tzavidi S, Tsifetaki N, Kitsos G, Stefanou D, Kostadima V, Drosos AA, Kyritsis AP. Neurological manifestations of connective tissue diseases mimicking multiple sclerosis. Rheumatol Int 2007; 28:15-20. [PMID: 17571265 DOI: 10.1007/s00296-007-0384-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 05/22/2007] [Indexed: 11/24/2022]
Abstract
The objective of the study was to analyze retrospectively the clinical, laboratory and imaging findings of multiple sclerosis (MS), such as the manifestations in a cohort of 132 patients referred to the neurology in and outpatient clinic. The proposed clinical and laboratory diagnostic criteria for MS and connective tissue disorders were systematically assessed in 132 consecutive patients. Cerebrospinal fluid serology and brain or spinal cord MRI were studied in all cases. In patients suspected for connective tissue disorder, schirmer test, rose bengal staining and biopsy of minor salivary glands were performed. A total of 115 (87%) patients were diagnosed to have definite MS, while 17 (13%) were diagnosed to have connective tissue disorder. Positive neurological and MRI findings were observed in both groups. The majority of patients with connective tissue disorder demonstrated extra-neurological manifestations like Raynaud's phenomenon, arthritis, livedo reticularis, purpura and presence of multiple autoantibodies in their sera. All patients with MS should be screened systematically for connective tissue disorder. In the absence of pathognomonic clinical and laboratory findings, the diagnosis of MS is a diagnosis of exclusion.
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Affiliation(s)
- Sigliti-Henrietta Pelidou
- Department of Neurology, University of Ioannina School of Medicine, University Campus, Ioannina 45110, Greece
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Li B, Dong H, Zhang J, Song X, Guo L. Cerebrospinal fluid IgG profiles and oligoclonal bands in Chinese patients with multiple sclerosis. Acta Neurol Scand 2007; 115:319-24. [PMID: 17489942 DOI: 10.1111/j.1600-0404.2006.00753.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate the significance of oligoclonal bands (OCBs) and intrathecal IgG fractions (IgGIF) for the diagnosis of multiple sclerosis (MS) in northern China. MATERIALS AND METHODS OCBs in cerebrospinal fluid from 30 patients with MS, 34 with other inflammatory neurological diseases (IND) and 22 with non-inflammatory neurological diseases (NIND) were detected using isoelectric focusing. IgGIF was calculated based on corresponding formula. RESULTS There was no significant difference in the frequencies of positive OCBs and elevated IgGIF between the MS group and the IND group. Compared with NIND, the MS and IND groups had a significantly higher incidence of OCBs and elevated IgGIF. The sensitivity, specificity and positive result likelihood ratio of OCBs for the diagnosis of MS were 63.3%, 74.2% and 2.5 respectively; those of IgGIF were 36.7%, 84.5% and 2.4. CONCLUSIONS The two parameters, OCBs and IgGIF are of less diagnostic value for MS in China.
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Affiliation(s)
- B Li
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Tsai JH, Sukavatcharin S, Rao NA. Utility of lumbar puncture in diagnosis of Vogt-Koyanagi-Harada disease. Int Ophthalmol 2007; 27:189-94. [PMID: 17340216 DOI: 10.1007/s10792-007-9044-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 01/13/2007] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the significance of lumbar puncture in diagnosis of Vogt-Koyanagi-Harada disease (VKH). METHOD A retrospective analysis was conducted on 116 consecutive patients diagnosed with VKH. Two additional patients who presented with acute VKH were included in the analysis. Demographic characteristics, including gender, age, and ethnicity, were extracted from the medical record. The stage of disease at presentation was documented. Pertinent laboratory results and diagnostic procedures such as lumbar puncture, fluorescein angiography, and echography that contributed to the diagnosis of VKH were collected. RESULTS Lumbar puncture results for 10 patients were available. Eight of these patients presented with pleocytosis consistent with a diagnosis of VKH. Clinical features and fluorescein angiography confirmed the diagnosis in these patients. Both of the patients who did not exhibit cerebrospinal fluid (CSF) pleocytosis presented with headache, vision loss, and bilateral uveitis. Fluorescein angiography disclosed multiple foci of leakage at the retinal pigment epithelium level with accumulation of dye under the retina and disc leakage, confirming diagnosis of VKH. CONCLUSION The utility of lumbar puncture as a diagnostic criterion for VKH should be re-evaluated given that clinical features and fluorescein angiography alone often support the diagnosis. The inherent risks and complications associated with the procedure must prompt the clinician to reserve this evaluation for atypical presentations.
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Affiliation(s)
- Julie H Tsai
- Doheny Eye Institute, Department of Ophthalmology, Keck School of Medicine of the University of Southern California, 1355 San Pablo Street DVRC211, Los Angeles, CA, USA
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Fadil H, Kelley RE, Gonzalez-Toledo E. Differential Diagnosis of Multiple Sclerosis. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2007; 79:393-422. [PMID: 17531852 DOI: 10.1016/s0074-7742(07)79018-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
There are a number of illnesses that can mimic multiple sclerosis (MS). This pretty much includes any pathological process that can reflect injury to the central nervous system either in a transient or progressive basis. Typically, MS presents itself in individuals in their teens up to their late 30s. On occasion, however, one can see MS present in patients in their 60s. However, in retrospect, many of these patients might have had subtle manifestations of MS in their younger years. Visual obscuration or visual loss can be a manifestation of retinal ischemia, retinal migraine, or optic neuritis which might or might not evolve into a clinical picture compatible with MS. Cranial neuropathy, long tract signs, sensory disturbance, and/or gait ataxia can be related to a number of different processes such as illicit drug use, neurosarcoidosis, neuro-Behcet's disease, neuroborreliosis, HIV-related disease, neurosyphilis, vascular occlusive disease including vasculitis, connective tissue disorders, acute disseminated encephalomyelitis (ADEM), idiopathic transverse myelitis, neuromyelitis optica (NMO), or tropical spastic paraparesis. In addition, a constellation of symptoms, with questionable objective findings, along with normal MRI imaging, normal CSF results, and normal evoked response testing, when indicated, might identify a conversion disorder or possibly malingering. There are now established criteria for the diagnosis of MS, but initial presentations can be less than "textbook" in nature. With the advent of immunomodulating therapy, it has become more important to diagnose MS more effectively earlier on in the course of the illness. Prior to specific therapy for MS, astute clinicians did not necessarily move with alacrity to establish the diagnosis in patients with subtle or transient manifestations. This was in recognition of the fact that little could be offered to alter the course of the illness and a number of patients might never experience further problems if they were lucky enough to have their illness go into permanent remission after one minor exacerbation.
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Affiliation(s)
- Halim Fadil
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana 71103, USA
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Kapfhammer I, Armbruster C, Armbruster C. Neurosarcoidosis--a diagnostic pitfall with consequences. Wien Klin Wochenschr 2006; 118:554-7. [PMID: 17009069 DOI: 10.1007/s00508-006-0662-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 06/28/2006] [Indexed: 10/24/2022]
Abstract
Neurosarcoidosis is often a diagnostic dilemma, especially in the absence of other organ involvement. We report a 64-year-old patient who had suffered from paraplegia due to an intramedullar process since 1995. The presumptive diagnosis based on computed tomography was spinal cord infarction. Six years later, he complained about increasing paresthesia. Magnetic resonance imaging of the spinal cord showed nodular meningeal enhancement. Computed tomography of the thorax revealed mediastinal and hilar lymphadenopathy. Bronchoscopy under generalized anesthesia was performed. The differential cell count in bronchoalveolar lavage fluid showed 39% lymphocytes and a CD4(+)/CD8(+) ratio of 17.7. Histological examination of biopsy specimens from the hilar lymph nodes revealed non-necrotizing granulomas with epitheloid cells and Langerhans-type giant cells, consistent with the diagnosis of sarcoidosis. As a result of these findings, lumbar puncture was undertaken and a raised protein concentration and pleocytosis were found in the cerebrospinal fluid. The number of lymphocytes (9,250 lymphocytes/l) and a CD4(+)/CD8(+) ratio of 10.78 led to the diagnosis of neurosarcoidosis. Paralysis might have been prevented if the correct diagnosis of neurosarcoidosis had been established earlier in this patient.
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Abstract
Behçet's syndrome (BS) is a multisystem disease of unknown etiology, characterized by chronic relapsing cardinal symptoms of orogenital ulcers, uveitis, and different skin lesions. Its major pathologic feature is vasculitis. Neuro-Behçet's syndrome (NBS) is defined as a constellation of neurologic manifestations with characteristic neuropathologic findings, usually confirmed by ancillary investigations, in patients who meet the diagnostic criteria for BS. Neurologic manifestations of the syndrome are more common in male patients and have been reported to occur in anywhere from 5% to 50% of BS patients, depending on their geographical region. NBS primarily affects the central nervous system and includes parenchymal and nonparenchymal involvement. Peripheral neuropathy and myopathy are rare. Immunosuppression is widely used for treatment.
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Affiliation(s)
- Erdal Diri
- Rheumatology, Trinity Hospital, Minot, ND 58701, USA.
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