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Nikolaidou A, Beis I, Dragoumi P, Zafeiriou D. Neuropsychiatric manifestations associated with Juvenile Systemic Lupus Erythematosus: An overview focusing on early diagnosis. Brain Dev 2024; 46:125-134. [PMID: 38061949 DOI: 10.1016/j.braindev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024]
Abstract
Juvenile systemic lupus erythematosus (jSLE) is a chronic multisystem inflammatory disease that manifests before the age of 16 years, following a remitting - relapsing course. The clinical presentation in children is multifaceted, most commonly including constitutional, hematological, cutaneous, renal, and neuropsychiatric symptoms. Neuropsychiatric manifestations range widely, affecting approximately 14-95 % of jSLE patients. They are associated with high morbidity and mortality, particularly at a younger age. Headaches, seizures, cognitive dysfunction, and mood disorders are the most frequent neuropsychiatric manifestations. The pathophysiological mechanism is quite complex and has not yet been fully investigated, with autoantibodies being the focus of research. The diagnosis of neuropsychiatric jSLE remains challenging and exclusionary. In this article we review the clinical neuropsychiatric manifestations associated with jSLE with the aim that early diagnosis and prompt treatment is achieved in children and adolescents with the disease.
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Affiliation(s)
- Anna Nikolaidou
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Beis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
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2
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Alzahrani Y. Pediatric Posterior Reversible Encephalopathy Syndrome: A Review With Emphasis on Neuroimaging Characteristics. Cureus 2023; 15:e51216. [PMID: 38283439 PMCID: PMC10821201 DOI: 10.7759/cureus.51216] [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] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by the sudden onset of seizures, headaches, and visual disturbances. Its exact cause is unknown, but several triggers and associated conditions are identified, including high blood pressure, kidney dysfunction, and various medications. Magnetic resonance imaging (MRI) plays a crucial role in diagnosis due to its high sensitivity and specificity for detecting characteristic features. Pediatric PRES exhibit age-dependent differences in triggers, radiological findings, and clinical course. The lesions typically involve the posterior cortical and subcortical white matter, but atypical locations and features are also observed. While generally reversible with appropriate treatment, PRES carries a risk of permanent neurological damage. Despite increasing cases, the current literature on pediatric PRES remains limited. This review highlights the need for further research to understand the mechanisms, delineate distinct clinical and radiological features, and develop precise diagnostic and management strategies for pediatric patients.
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3
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Hwang J, Cho WH, Cha SH, Ko JK. Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm: A case report. World J Clin Cases 2023; 11:4723-4728. [PMID: 37469736 PMCID: PMC10353519 DOI: 10.12998/wjcc.v11.i19.4723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized mainly by occipital and parietal lobe involvement, which can be reversible within a few days. Herein, we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm (UIA).
CASE SUMMARY A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery. Clipping surgery was performed uneventfully, and he regained consciousness quickly immediately after the surgery. At the 4th hour after surgery, he developed a disorder of consciousness and aphasia. Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal, occipital, and frontal lobes ipsilaterally, without restricted diffusion, consistent with unilateral PRES. With conservative treatment, his symptoms and radiological findings almost completely disappeared within weeks. In our case, the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion.
CONCLUSION Our unique case highlights that, to our knowledge, this is the second report of PRES developing after craniotomy for the treatment of UIA. Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.
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Affiliation(s)
- Joseph Hwang
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Won-Ho Cho
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Seung-Heon Cha
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
| | - Jun-Kyueng Ko
- Department of Neurosurgery, Biomedical Research Institute, Pusan National University Hospital, School of Medicine, Pusan National University, Busan 49241, South Korea
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4
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Li Y, Song J, Huq AM, Timilsina S, Gershwin ME. Posterior reversible encephalopathy syndrome and autoimmunity. Autoimmun Rev 2023; 22:103239. [PMID: 36464226 DOI: 10.1016/j.autrev.2022.103239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by acute or subacute onset of neurological symptoms (e.g., headache, seizure, confusion, vomiting, and diminished eyesight) and impaired endothelial barrier function of the cerebral circulation that leads to bilateral subcortical vasogenic edema, while exhibiting a "reversible" feature in most cases. Clinically, various predisposing or precipitating conditions have been identified, such as hypertension, autoimmune diseases, renal dysfunction/failure, preeclampsia/eclampsia, post-transplantation conditions, and certain therapeutic agents. Among several putative mechanisms, the immune activation hypothesis prevails, as up to 50% of patients with PRES harbor abnormalities related to autoimmunity, such as concurrent systemic lupus erythematosus. In this Review, we summarize the clinical and laboratory evidence that places PRES in the context of autoimmunity.
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Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Ahm M Huq
- Department of Pediatrics, Central Michigan University, Detroit, MI 48201, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
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5
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de Castro JTDS, Appenzeller S, Colella MP, Yamaguti-Hayakawa G, Paula EVD, Annichinno-Bizzachi J, Cendes F, Fabiano R, Orsi FA. Neurological manifestations in thrombotic microangiopathy: Imaging features, risk factors and clinical course. PLoS One 2022; 17:e0272290. [PMID: 36129939 PMCID: PMC9491546 DOI: 10.1371/journal.pone.0272290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Thrombotic microangiopathy (TMA) is a group of microvascular occlusive disorders that presents with neurological involvement in up to 87% of the cases. Although the central nervous system (CNS) is an important target organ in TMA, the role of neurological manifestations in the disease clinical course is not well established. In this study, we described the neurological manifestations and CNS radiological aspects in patients with a first, acute TMA event. We also examined the association between severe neurological involvement and adverse clinical outcomes in TMA. Methods A cohort of patients diagnosed with a first TMA event between 1995 and 2016 was included, their medical charts and imaging tests were retrospectively evaluated. Results A total of 49 patients were included, 85.7% were women and the mean age was 36.5 years-old (SD 13.0). Neurological manifestations were described in 85.7% of the patients, most of them (88%) were considered severe and consisted of confusion, compromised sensorimotor function, stupor, seizures, and personality change. Imaging tests were performed in 62% of the patients with neurological manifestations and detected acute CNS lesions, such as posterior reversible encephalopathy syndrome, hemorrhagic and ischemic stroke were observed, in 7 (27%) of them. While the need for intensive care unit admission was greater and longer among patients with severe neurological manifestations, the number of plasma exchange sessions, the total duration of hospitalization and in-hospital death were similar between groups. Conclusions Severe neurological manifestations are common in first TMA events and are responsible for a worse disease presentation at admission. While the effect of neurological manifestations on acute TMA clinical course seems to be modest, these manifestations may have an important impact on the development of chronic cognitive impairment, which highlights the need for proper diagnosis and treatment.
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Affiliation(s)
- José Thiago de Souza de Castro
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- * E-mail:
| | - Simone Appenzeller
- Rheumatology Unit, School of Medical Science, University of Campinas, Campinas, São Paulo, Brazil
| | - Marina Pereira Colella
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Gabriela Yamaguti-Hayakawa
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Erich Vinícius De Paula
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Joyce Annichinno-Bizzachi
- Thrombosis and Hemostasis Unit, Hematology and Hemotherapy Center, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Discipline of Hematology and Hemotherapy, Department of Internal Medicine, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernando Cendes
- Department of Neurology, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Reis Fabiano
- School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
- Department of Radiology, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
| | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, (UNICAMP), Campinas, São Paulo, Brazil
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6
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Appenzeller S, Pereira DR, Julio PR, Reis F, Rittner L, Marini R. Neuropsychiatric manifestations in childhood-onset systemic lupus erythematosus. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:571-581. [PMID: 35841921 DOI: 10.1016/s2352-4642(22)00157-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Neuropsychiatric manifestations occur frequently and are challenging to diagnose in childhood-onset systemic lupus erythematosus (SLE). Most patients with childhood-onset SLE have neuropsychiatric events in the first 2 years of disease. 30-70% of patients present with more than one neuropsychiatric event during their disease course, with an average of 2-3 events per person. These symptoms are associated with disability and mortality. Serum, cerebrospinal fluid, and neuroimaging findings have been described in childhood-onset SLE; however, only a few have been validated as biomarkers for diagnosis, monitoring response to treatment, or prognosis. The aim of this Review is to describe the genetic risk, clinical and neuroimaging characteristics, and current treatment strategies of neuropsychiatric manifestations in childhood-onset SLE.
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Affiliation(s)
- Simone Appenzeller
- Department of Orthopedics, Rheumatology, and Traumatology, University of Campinas, Campinas, Brazil; Rheumatology Laboratory, University of Campinas, Campinas, Brazil.
| | - Danilo Rodrigues Pereira
- Rheumatology Laboratory, University of Campinas, Campinas, Brazil; Medical Physiopathology Graduate Program, University of Campinas, Campinas, Brazil
| | - Paulo Rogério Julio
- Rheumatology Laboratory, University of Campinas, Campinas, Brazil; Child and Adolescent Health Graduate Program, University of Campinas, Campinas, Brazil
| | - Fabiano Reis
- Department of Radiology, University of Campinas, Campinas, Brazil
| | - Leticia Rittner
- School of Medical Science; School of Electrical and Computer Engineering, University of Campinas, Campinas, Brazil
| | - Roberto Marini
- Pediatric Rheumatology Unit, Department of Pediatrics, University of Campinas, Campinas, Brazil
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7
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Mergen S, Long B, Matlock A. Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians. J Emerg Med 2021; 61:666-673. [PMID: 34696929 DOI: 10.1016/j.jemermed.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension. OBJECTIVE This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES. DISCUSSION PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger. CONCLUSION PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.
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Affiliation(s)
- Stephanie Mergen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Aaron Matlock
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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8
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Buonanno P, Vargas M, Marra A, Iacovazzo C, Servillo G. Lupus and posterior reversible encephalopathy syndrome. Lupus 2020; 29:1146-1147. [DOI: 10.1177/0961203320935182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Annachiara Marra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
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9
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Sheikh-Bahaei N, Acharya J, Rajamohan A, Kim PE. Advanced Imaging Techniques in Diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES). Front Neurol 2020; 11:165. [PMID: 32218764 PMCID: PMC7078242 DOI: 10.3389/fneur.2020.00165] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/21/2020] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES) in some circumstances can be challenging and structural imaging may not be sufficient to distinguish it from other differential diagnostic considerations. Advanced imaging techniques, such as MR spectroscopy or positron emission tomography (PET) can provide additional information to determine the diagnosis. Other techniques, such as susceptibility weighted imaging (SWI) improves detection of hemorrhage which has prognostic role. CT or MR Perfusion as well as Single-Photon Emission Computed Tomography (SPECT) are more useful to understand the underlying vasculopathic changes in PRES and may answer some of the unresolved controversies in pathophysiology of this complex disease. In this review we summarized the findings of previous studies using these advanced methods and their utilities in diagnosis or prognosis of PRES.
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Affiliation(s)
- Nasim Sheikh-Bahaei
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jay Acharya
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Anandh Rajamohan
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Paul E Kim
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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10
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020; 8:585. [PMID: 33042923 PMCID: PMC7518237 DOI: 10.3389/fped.2020.00585] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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11
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020. [PMID: 33042923 DOI: 10.3389/fped.2020.0058534(8):494-500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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12
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Vaysman T, Xu P, Vartanian T, Michalak P, Pike K, Liu A. "Highlighting" red nuclei by atypical posterior reversible encephalopathy syndrome in a patient with systemic lupus erythematosus. Clin Case Rep 2019; 7:1404-1408. [PMID: 31360498 PMCID: PMC6637357 DOI: 10.1002/ccr3.2245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/26/2019] [Accepted: 05/10/2019] [Indexed: 11/07/2022] Open
Abstract
This is a case report in which a patient with SLE had a brainstem variant of PRES, and MRI demonstrated atypical distribution of FLAIR hyperintensity in the thalami and the midbrain sparing the red nuclei bilaterally (Figure 1). This impressive lesion pattern may reveal the disease mechanisms of PRES in patients with SLE.
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Affiliation(s)
- Tetyana Vaysman
- Department of Internal MedicineUniversity of MarylandCheverlyMaryland
| | - Prissilla Xu
- Department of PharmacyAdventist Health White MemorialLos AngelesCalifornia
| | - Tara Vartanian
- Department of NeurologyAdventist Health White MemorialLos AngelesCalifornia
| | | | - Kesley Pike
- Ross University School of MedicineNorth BrunswickNew Jersey
| | - Antonio Liu
- Department of NeurologyAdventist Health White MemorialLos AngelesCalifornia
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13
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de Amorim JC, Frittoli RB, Pereira D, Postal M, Dertkigil SSJ, Reis F, Costallat LTL, Appenzeller S. Epidemiology, characterization, and diagnosis of neuropsychiatric events in systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:407-416. [DOI: 10.1080/1744666x.2019.1564040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jaqueline Cristina de Amorim
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Campinas, Brazil
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Renan Bazuco Frittoli
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Danilo Pereira
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Mariana Postal
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | | | - Fabiano Reis
- Departament of Radiology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Lilian TL Costallat
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
| | - Simone Appenzeller
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
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14
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Racchiusa S, Mormina E, Ax A, Musumeci O, Longo M, Granata F. Posterior reversible encephalopathy syndrome (PRES) and infection: a systematic review of the literature. Neurol Sci 2019; 40:915-922. [PMID: 30604335 DOI: 10.1007/s10072-018-3651-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 11/16/2018] [Indexed: 11/24/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy characterized by a rapid onset of symptoms including headache, seizures, confusion, blurred vision, and nausea associated with a typical magnetic resonance imaging appearance of reversible subcortical vasogenic edema prominent and not exclusive of parieto-occipital lobes. Vasogenic edema is caused by a blood-brain barrier leak induced by endothelial damage or a severe arterial hypertension exceeding the limits of cerebral blood flow autoregulation. Although the exact pathophysiological mechanism is still unclear, frequent conditions that may induce PRES include severe hypertension, eclampsia/pre-eclampsia, acute kidney diseases and failure, immunosuppressive therapy, solid organ, or bone marrow transplantation. Conversely to other conditions, which may induce PRES, the link between severe infection or sepsis and PRES, often associated with gram-positive bacteria, is still poorly understood and less well known. Clinicians from multiple disciplines, such as neurologists and internists, may encounter during their profession patients with severe infection or sepsis and should consider the possible association between PRES and these conditions. We systematically reviewed the literature about this association in order to provide a helpful clinical insight of such complex pathophysiological mechanism, highlighting the importance of recognizing PRES in such a complex clinical scenario.
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Affiliation(s)
- Sergio Racchiusa
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Enricomaria Mormina
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy.,Department of Clinical and experimental Medicine, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Antonietta Ax
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Olimpia Musumeci
- Department of Clinical and experimental Medicine, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Marcello Longo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
| | - Francesca Granata
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico "G. Martino" Via Consolare Valeria 1, 98100, Messina, Italy
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Merayo-Chalico J, Barrera-Vargas A, Juárez-Vega G, Alcocer-Varela J, Arauz A, Gómez-Martín D. Differential serum cytokine profile in patients with systemic lupus erythematosus and posterior reversible encephalopathy syndrome. Clin Exp Immunol 2018; 192:165-170. [PMID: 29271478 DOI: 10.1111/cei.13095] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/15/2017] [Accepted: 12/16/2017] [Indexed: 11/29/2022] Open
Abstract
Systemic lupus erythematosus (SLE) patients are susceptible to the development of posterior reversible encephalopathy syndrome (PRES). The main theory concerning the physiopathology of PRES suggests that there is brain-blood barrier damage, which is associated with endothelial dysfunction, and characterized by vasogenic oedema. However, current evidence regarding its physiopathogenic mechanisms is quite scant. The aim of this study was to analyse the expression of different serum cytokines, as well as vascular endothelial growth factor (VEGF) and soluble CD40 ligand (sCD40L), in patients with PRES/systemic lupus erythematosus (SLE) and to compare them with levels in SLE patients without PRES and in healthy controls. We performed a transversal study in a tertiary care centre in México City. We included 32 subjects (healthy controls, n = 6; remission SLE, n = 6; active SLE, n = 6 and PRES/SLE patients, n = 14). PRES was defined as reversible neurological manifestations (seizures, visual abnormalities, acute confusional state), associated with compatible changes by magnetic resonance imaging (MRI). Serum samples were obtained during the first 36 h after the PRES episode and were analysed by cytometric bead array, Luminex multiplex assay or enzyme-linked immunosorbent assay (ELISA). Interleukin (IL)-6 and IL-10 levels were significantly higher in PRES/SLE patients (P = 0·013 and 0·025, respectively) when compared to the other groups. Furthermore, IL-6 and IL-10 levels displayed a positive correlation (r = 0·686, P = 0·007). There were no differences among groups regarding other cytokines, sCD40L or VEGF levels. A differential serum cytokine profile was found in PRES/SLE patients, with increased IL-6 and IL-10 levels. Our findings, which are similar to those described in other neurological manifestations of SLE, support the fact that PRES should be considered among the SLE-associated neuropsychiatric syndromes.
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Affiliation(s)
- J Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - A Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - G Juárez-Vega
- Red de Apoyo a la Investigación, CIC- UNAM, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - A Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco, Mexico City, Mexico
| | - D Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.,Red de Apoyo a la Investigación, CIC- UNAM, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Geschwind MD, Murray K. Differential diagnosis with other rapid progressive dementias in human prion diseases. HANDBOOK OF CLINICAL NEUROLOGY 2018; 153:371-397. [PMID: 29887146 DOI: 10.1016/b978-0-444-63945-5.00020-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prion diseases are unique in medicine as in humans they occur in sporadic, genetic, and acquired forms. The most common human prion disease is sporadic Creutzfeldt-Jakob disease (CJD), which commonly presents as a rapidly progressive dementia (RPD) with behavioral, cerebellar, extrapyramidal, and some pyramidal features, with the median survival from symptom onset to death of just a few months. Because human prion diseases, as well as other RPDs, are relatively rare, they can be difficult to diagnose, as most clinicians have seen few, if any, cases. Not only can prion diseases mimic many other conditions that present as RPD, but some of those conditions can present similarly to prion disease. In this article, the authors discuss the different etiologic categories of conditions that often present as RPD and also present RPDs that had been misdiagnosed clinically as CJD. Etiologic categories of conditions are presented in order of the mnemonic used for remembering the various categories of RPDs: VITAMINS-D, for vascular, infectious, toxic-metabolic, autoimmune, mitochondrial/metastases, iatrogenic, neurodegenerative, system/seizures/sarcoid, and demyelinating. When relevant, clinical, imaging, or other features of an RPD that overlap with those of CJD are presented.
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Affiliation(s)
- Michael D Geschwind
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, United States.
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
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Damrongpipatkul U, Oranratanachai K, Kasitanon N, Wuttiplakorn S, Louthrenoo W. Clinical features, outcome, and associated factors for posterior reversible encephalopathy in Thai patients with systemic lupus erythematosus: a case-control study. Clin Rheumatol 2017; 37:691-702. [DOI: 10.1007/s10067-017-3892-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
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Jafri K, Patterson SL, Lanata C. Central Nervous System Manifestations of Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2017; 43:531-545. [DOI: 10.1016/j.rdc.2017.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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19
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A comparison of TAFRO syndrome between Japanese and non-Japanese cases: a case report and literature review. Ann Hematol 2017; 97:401-407. [DOI: 10.1007/s00277-017-3138-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/18/2017] [Indexed: 12/14/2022]
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20
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Miller-Hodges E, Dominiczak AF, Jennings GLR, Oparil S, Batlle DC, Elijovich F, Basile JN, Laffer CL, Oliveras A, Dhaun N. Hypertension and Its Complications in a Young Man With Autoimmune Disease. Hypertension 2017; 69:536-544. [PMID: 28242716 DOI: 10.1161/hypertensionaha.117.09036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eve Miller-Hodges
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Anna F Dominiczak
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Garry L R Jennings
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Suzanne Oparil
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Daniel C Batlle
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Fernando Elijovich
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Jan N Basile
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Cheryl L Laffer
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Anna Oliveras
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.)
| | - Neeraj Dhaun
- From the University/British Heart Foundation Centre of Research Excellence, University of Edinburgh, United Kingdom (E.M.-H., N.D.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham (S.O.); Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL (D.C.B.); Division of Clinical Pharmacology, Department of Medicine (F.E.) and Department of Medicine (C.L.L.), Vanderbilt University School of Medicine, Nashville, TN; Medical University of South Carolina, Charleston (J.N.B.); and Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Spain (A.O.).
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21
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The diagnosis and clinical management of the neuropsychiatric manifestations of lupus. J Autoimmun 2016; 74:41-72. [PMID: 27427403 DOI: 10.1016/j.jaut.2016.06.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 06/21/2016] [Indexed: 01/03/2023]
Abstract
Neuropsychiatric (NP) involvement in Systemic Lupus Erythematosus (SLE), can be a severe and troubling manifestation of the disease that heavily impacts patient's health, quality of life and disease outcome. It is one of the most complex expressions of SLE which can affect central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms, including genetic factors, vasculopathy, vascular occlusion, neuroendocrine-immune imbalance, tissue and neuronal damage mediated by autoantibodies, inflammatory mediators, blood brain barrier dysfunction and direct neuronal cell death can be all involved. About NPSLE a number of issues are still matter of debate: from classification and burden of NPSLE to attribution and diagnosis. The role of neuroimaging and new methods of investigation still remain pivotal and rapidly evolving as well as is the increasing knowledge in the pathogenesis. Overall, two main pathogenetic pathways have been recognized yielding different clinical phenotypes: a predominant ischemic-vascular one involving large and small blood vessels, mediated by aPL, immune complexes and leuko-agglutination which it is manifested with more frequent focal NP clinical pictures and a predominantly inflammatory-neurotoxic one mediated by complement activation, increased permeability of the BBB, intrathecal migration of autoantibodies, local production of immune complexes and pro-inflammatory cytokines and other inflammatory mediators usually appearing as diffuse NP manifestations. In the attempt to depict a journey throughout NPSLE from diagnosis to a reasoned therapeutic approach, classification, epidemiology, attribution, risk factors, diagnostic challenges, neuroimaging techniques and pathogenesis will be considered in this narrative review based on the most relevant and recent published data.
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