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Yaghmaei E, Najafi A, Daneshvar Kakhki R. Longitudinal Extensive Transverse Myelitis due to Varicella-Zoster Virus Infection in an Undiagnosed HIV-Positive Patient. Case Rep Neurol Med 2024; 2024:9027198. [PMID: 39055723 PMCID: PMC11272404 DOI: 10.1155/2024/9027198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 04/21/2024] [Accepted: 06/13/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Longitudinal extensive transverse myelitis (LETM) has four main causes: inflammatory, malnutrition, vascular, and infectious causes. Among the commonly described viral causes leading to LETM are the Herpesviridae family, HIV, and HTLV-1. Case Presentation. A 43-year-old man presented with asymmetric weakness of the lower limbs (the left side was weaker), urinary retention, and flank pain. The symptoms began five days after shingle eruption and progressed over twelve days. He was diagnosed with longitudinal extensive transvers myelitis extending from T4 to T6, which corresponded to the same dermatome involved in shingles. The PCR result of cerebrospinal fluid was positive for varicella-zoster virus with a viral load of 500 copies/ml. Additionally, the initial HIV enzyme-linked immunosorbent assay (ELISA) test was positive, and his CD4 count was 72 cells/mm3. Other lab results were normal. Based on the appearance of LETM in the thoracic MRI at T4-T6, VZV myelitis was diagnosed, and treatment was initiated with acyclovir (30 mg/kg divided daily for twenty-one days), methylprednisolone (1 g/day for three days), prophylactic antibiotics (trimethoprim/sulfamethoxazole, rifampin, and isoniazid), and antiretroviral therapy (dolutegravir and Truvada). After 2-month follow-up, he was nearly free of symptoms. Conclusion Infection is one of the critical causes of transverse myelitis. When a patient presents with skin shingles along with myelopathy, varicella-zoster myelitis should be considered, and the patient should be evaluated in terms of immune system dysfunction. Treatment with acyclovir has been shown to be effective in reducing clinical symptoms in such cases.
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Affiliation(s)
- Elahe Yaghmaei
- Department of NeurologyKashan University of Medical Sciences, Kashan, Iran
| | - Ahmad Najafi
- Infectious Diseases Research CenterKashan University of Medical Sciences, Kashan, Iran
| | - Reza Daneshvar Kakhki
- Autoimmune Diseases Research CenterKashan University of Medical Sciences, Kashan, Iran
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2
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Tzanetakos D, Tzartos JS, Velonakis G, Giannopoulos S, Tsivgoulis G. Neuromyelitis optica spectrum disorder-associated myelitis mimicking intramedullary neoplasm as a diagnostic pitfall: a case report. Neurol Sci 2024:10.1007/s10072-024-07684-5. [PMID: 38985372 DOI: 10.1007/s10072-024-07684-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 07/04/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Dimitrios Tzanetakos
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - John S Tzartos
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Velonakis
- Research Unit of Radiology, Second Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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3
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Etemadifar M, Mousavi S, Salari M, Hosseinian SA, Mansouri AR. Whole spinal transverse myelitis in neuromyelitis optica spectrum disorder. Mult Scler Relat Disord 2024; 87:105666. [PMID: 38749352 DOI: 10.1016/j.msard.2024.105666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Spinal cord is one of the prominent targets of autoimmune mechanisms in Neuromyelitis Optica Spectrum Disorder (NMOSD). Rarely, NMOSD causes damage to the entire length of the spinal cord, from cervical segments to conus medullaris, which has not been characterized in the existing literature. MATERIAL AND METHOD We reviewed medical records, demographic information, and magnetic resonance imaging (MRI) sequences of 174 NMOSD patients from January 2011 to January 2023 who were admitted to Isfahan Multiple Sclerosis center to find patients with whole spinal transverse myelitis (TM). RESULTS Whole spinal TM was present in five patients (2.9 %). Three patients were seropositive for Aquaporin-4 (AQP4) antibody; Myelin Oligodendrocyte Glycoprotein antibody (MOG IgG) tested negative for all of them. Lower limb weakness was the most frequent clinical complaint. Two patients presented with optic neuritis; One patient reported having episodes of nausea and vomiting. These patients, overall, yielded a higher expanded disability status scale (EDSS) score than the other NMOSD patients. CONCLUSION Whole spinal TM is a rare finding in NMOSD, which is strongly associated with a higher severity and a worse outcome of the disease. The role of anti-AQP4 antibodies in the extent of myelitis in NMOSD has yet to be investigated.
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Affiliation(s)
- Masoud Etemadifar
- Department of Neurosurgery, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soulmaz Mousavi
- Alzahra Research Institute, 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
| | | | - Amir Reza Mansouri
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.
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4
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Rocchi C, Forcadela M, Kelly P, Linaker S, Gibbons E, Bhojak M, Jacob A, Hamid S, Huda S. The absence of antibodies in longitudinally extensive transverse myelitis may predict a more favourable prognosis. Mult Scler 2024; 30:345-356. [PMID: 38258822 DOI: 10.1177/13524585231221664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Isolated first episodes of longitudinally extensive transverse myelitis (LETM) have typically been associated with neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). However, in some cases, serological testing and screening for other aetiologies are negative, a condition referred to as double seronegative longitudinally extensive transverse myelitis (dsLETM). OBJECTIVE The objective of this study was to evaluate comparative outcomes of dsLETM, MOGAD-LETM and NMOSD-LETM. METHODS Cohort study of LETM cases seen in the UK NMOSD Highly Specialised Service between January 2008 and March 2022. RESULTS LETM = 87 cases were identified (median onset age = 46 years (15-85); median follow-up = 46 months (1-144); 47% NMOSD-LETM = 41 (aquaporin-4 antibodies (AQP4-IgG) positive = 36), 20% MOGAD-LETM = 17 and 33% dsLETM = 29). Despite similar Expanded Disability Status Scale (EDSS) at nadir, last EDSS was higher in AQP4-IgG and seronegative NMOSD-LETM (sNMOSD) (p = 0.006). Relapses were less common in dsLETM compared to AQP4-IgG NMOSD-LETM and sNMOSD-LETM (19% vs 60% vs 100%; p = 0.001). Poor prognosis could be predicted by AQP4-IgG (odds ratio (OR) = 38.86 (95% confidence interval (CI) = 1.36-1112.86); p = 0.03) and EDSS 3 months after onset (OR = 65.85 (95% CI = 3.65-1188.60); p = 0.005). CONCLUSION dsLETM remains clinically challenging and difficult to classify with existing nosological terminology. Despite a similar EDSS at nadir, patients with dsLETM relapsed less and had a better long-term prognosis than NMOSD-LETM.
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Affiliation(s)
| | | | | | | | | | | | - Anu Jacob
- The Walton Centre Foundation Trust, Liverpool, UK/Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Shahd Hamid
- The Walton Centre Foundation Trust, Liverpool, UK
| | - Saif Huda
- The Walton Centre Foundation Trust, Liverpool, UK
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5
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Pesante BD, Paro MR, Nadeem T, Bulsara KR, Choi DB. Lumbar decompression and fusion for symptomatic spinal stenosis in a patient with chronic thoracic sensory level from prior transverse myelitis: a case report. J Med Case Rep 2024; 18:42. [PMID: 38310259 PMCID: PMC10838414 DOI: 10.1186/s13256-024-04367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/05/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Many patients with transverse myelitis suffer from sensory loss below the spinal level of the lesion. This is commonly associated with chronic neuropathic pain. However, the presence of somatic pain below a complete thoracic sensory level after transverse myelitis is exceptionally rare, and it is unclear if surgical decompression is an effective form of treatment for these patients. CASE PRESENTATION In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression. CONCLUSION This is the first reported case of a patient with symptomatic lumbar stenosis after transverse myelitis whose lower back pain and quality of life improved following surgical decompression and fusion. This case provides evidence that typical lumbago is possible in patients with sensory loss from transverse myelitis, and standard lumbar decompression may provide benefit for these patients.
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Affiliation(s)
- Benjamin D Pesante
- University of Connecticut School of Medicine, UConn Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA.
| | - Mitch R Paro
- University of Connecticut School of Medicine, UConn Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, Department of Surgery, UConn Health, Farmington, CT, USA
| | - David B Choi
- Division of Neurosurgery, Department of Surgery, UConn Health, Farmington, CT, USA
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Dhakal B, Bogati K, Baniya S, Muhammad QUA, Pathak BD, Pokharel R, Adhikari S, Upadhaya Regmi B, Subedi RC, Pant P, Paudel R. Longitudinally extensive transverse myelitis, a disabling disorder with a good prognosis: a case series from Nepal. Ann Med Surg (Lond) 2024; 86:252-256. [PMID: 38222755 PMCID: PMC10783345 DOI: 10.1097/ms9.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/13/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Longitudinally extensive transverse myelitis (LETM) is a rare spinal cord disorder with variable etiologies and presentations. It can present solely or as an association with other neurological disorders. Methodology It was a series of cases of LETM in a tertiary care hospital. Clinical presentation and outcomes The initial three cases presented with bilateral lower extremity weakness and were diagnosed as transverse myelitis while, the fourth case, already diagnosed as LETM presented with seizure followed by loss of consciousness. All four cases had a good prognosis to date with continued physiotherapy. Conclusion The early diagnosis of the disease helps to guide the optimal management and decide the potential need for physiotherapy.
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Affiliation(s)
| | | | | | | | | | - Rojina Pokharel
- Manmohan Cardiothoracic and Vascular Transplant Center, Kathmandu
| | | | | | | | | | - Raju Paudel
- Shree Birendra Hospital, Nepalese Army Institute of Health Sciences
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7
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de Paiva JLR, Sabino JV, Pereira FV, Okuda PA, Villarinho LDL, Queiroz LDS, França MC, Reis F. The Role of MRI in the Diagnosis of Spinal Cord Tumors. Semin Ultrasound CT MR 2023; 44:436-451. [PMID: 37555685 DOI: 10.1053/j.sult.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Spinal cord tumors are uncommon, and its multiple representatives not always have pathognomonic characteristics, which poses a challenge for both patients and caring physicians. The radiologist performs an important role in recognizing these tumors, as well as in differentiating between neoplastic and non-neoplastic processes, supporting clinical and surgical decision-making in patients with spinal cord injury. Magnetic Resonance Imaging (MRI) assessment, paired with a deep understanding of the various patterns of cord involvement allied to detailed clinical data can provide a diagnosis or significantly limit the differential diagnosis in most cases. In this article, we aim to review the most common and noteworthy intramedullary and extramedullary spinal tumors, as well as some other tumoral mimics, with an emphasis on their MRI morphologic characteristics.
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Affiliation(s)
- Jean L R de Paiva
- Department of Anesthesiology, Oncology and Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - João V Sabino
- Department of Anesthesiology, Oncology and Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Fernanda V Pereira
- Department of Anesthesiology, Oncology and Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Paulo A Okuda
- Department of Anesthesiology, Oncology and Radiology, University of Campinas (UNICAMP), Campinas, Brazil
| | | | | | - Marcondes C França
- Department of Neurology, University of Campinas (UNICAMP), Campinas, Brazil
| | - Fabiano Reis
- Department of Anesthesiology, Oncology and Radiology, University of Campinas (UNICAMP), Campinas, Brazil.
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8
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Masuda H, Mori M, Hirano S, Uzawa A, Uchida T, Muto M, Ohtani R, Aoki R, Hirano Y, Kuwabara S. Higher longitudinal brain white matter atrophy rate in aquaporin-4 IgG-positive NMOSD compared with healthy controls. Sci Rep 2023; 13:12631. [PMID: 37537208 PMCID: PMC10400628 DOI: 10.1038/s41598-023-38893-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/17/2023] [Indexed: 08/05/2023] Open
Abstract
We aimed to compare longitudinal brain atrophy in patients with neuromyelitis optica spectrum disorder (NMOSD) with healthy controls (HCs). The atrophy rate in patients with anti-aquaporin-4 antibody-positive NMOSD (AQP4 + NMOSD) was compared with age-sex-matched HCs recruited from the Japanese Alzheimer's Disease Neuroimaging Initiative study and another study performed at Chiba University. Twenty-nine patients with AQP4 + NMOSD and 29 HCs were enrolled in the study. The time between magnetic resonance imaging (MRI) scans was longer in the AQP4 + NMOSD group compared with the HCs (median; 3.2 vs. 2.9 years, P = 0.009). The annualized normalized white matter volume (NWV) atrophy rate was higher in the AQP4 + NMOSD group compared with the HCs (median; 0.37 vs. - 0.14, P = 0.018). The maximum spinal cord lesion length negatively correlated with NWV at baseline MRI in patients with AQP4 + NMOSD (Spearman's rho = - 0.41, P = 0.027). The annualized NWV atrophy rate negatively correlated with the time between initiation of persistent prednisolone usage and baseline MRI in patients with AQP4 + NMOSD (Spearman's rho = - 0.43, P = 0.019). Patients with AQP4 + NMOSD had a greater annualized NWV atrophy rate than HCs. Suppressing disease activity may prevent brain atrophy in patients with AQP4 + NMOSD.
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Affiliation(s)
- Hiroki Masuda
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Shigeki Hirano
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Tomohiko Uchida
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Mayumi Muto
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
- Department of Neurology, Chiba Rosai Hospital, 2-16, Tatsumidai-Higashi, Ichihara, 290-0003, Japan
| | - Ryohei Ohtani
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
- Department of Neurology, Kimitsu Chuo Hospital, 1010, Sakurai, Kisarazu-Shi, Chiba, 292-8535, Japan
| | - Reiji Aoki
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Yoshiyuki Hirano
- Research Center for Child Mental Development, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260-8670, Japan
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9
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Kim KH, Baek YH, Kang YW, Yoon BA, Moon SY. A Case of Transverse Myelitis Following Treatment with Atezolizumab for Advanced Hepatocellular Carcinoma. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:35-39. [PMID: 37489081 DOI: 10.4166/kjg.2023.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
The results of the IMbrave150 study have led to widespread use of the combination therapy of atezolizumab and bevacizumab as a first-line treatment for unresectable or metastatic hepatocellular carcinoma (HCC). Compared to traditional cytotoxic chemotherapy agents, immune checkpoint inhibitors show a spectrum of side effects ranging from mild side effects such as skin rash to potentially severe systemic effects such as myocarditis. We present a case of transverse myelitis diagnosed during the treatment of HCC with atezolizumab and bevacizumab combination therapy.
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Affiliation(s)
- Kyung Han Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Yang-Hyun Baek
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Yeo Wool Kang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Byeol-A Yoon
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Sang Yi Moon
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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10
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Gonsalves DG, Raffa PEAZ, de Sousa GG, Rigueiral MEG, Estevão IA, Pacheco CC, Medeiros RTR, Franceschini PR, de Aguiar PHP. B-Cell Lymphoma Intramedullary Tumor: Case Report and Systematic Review. Asian J Neurosurg 2023; 18:231-245. [PMID: 37397032 PMCID: PMC10310451 DOI: 10.1055/s-0043-1768574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Intramedullary tumors represent the major cause of spinal cord injuries, and its symptoms include pain and weakness. Progressive weakness may concomitantly occur in the upper and lower limbs, along with lack of balance, spine tenderness, sensory loss, trophic changes of extremity, hyperreflexia, and clonus. The study protocol was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the MEDLINE electronic database was performed to identify the studies reporting the clinical features of children and adults who presented with an intramedullary lymphoma. Twenty-one studies were included, reporting 25 cases. Manuscripts were excluded if the full-text article was not available, original data were not reported (e.g., review articles), or if the main disease was not intramedullary lymphoma. A structured data extraction form was employed to standardize the identification and retrieval of data from manuscripts. To enlighten the discussion, a case is also presented. An 82-year-old woman with Fitzpatrick skin type II, diagnosed and treated for non-Hodgkin's lymphoma 7 years ago, was admitted with mental confusion and memory loss for the past 2 months-evolving with recurring falls from her own height. One day before admission, she displayed Brown-Séquard syndrome. An expansive lesion from C2 to C4 in the cervical spinal cord was found and a hypersignal spinal cord adjacent was described at the bulb medullary transition to the C6-C7 level. A primary spinal cord tumor was considered, as well as a melanoma metastasis, due to the lesion's flame pattern. The patient presented a partial recovery of symptoms and a reduction of the spinal cord edema after being empirically treated with corticosteroids, but the lesion maintained its extent. Subsequently, a large diffuse B-cell lymphoma with nongerminal center was found in open body biopsy, infiltrating neural tissue. The main objective of the present study is to report a surgical case treated for a large diffuse B-cell lymphoma, in addition to presenting the results of a systematic review of primary intramedullary spinal cord lymphoma.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paulo Henrique Pires de Aguiar
- Department of Neurosurgery, Santa Paula Hospital, São Paulo, Brazil
- Department of Research and Innovation, Laboratory of Cellular and Molecular Biology, Faculty of Medicine of ABC, Santo André, São Paulo, Brazil
- Department of Neurology, School of Medicine of Pontifical Catholic University of São Paulo, Sorocaba, São Paulo, Brazil
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11
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Jarius S, Aktas O, Ayzenberg I, Bellmann-Strobl J, Berthele A, Giglhuber K, Häußler V, Havla J, Hellwig K, Hümmert MW, Kleiter I, Klotz L, Krumbholz M, Kümpfel T, Paul F, Ringelstein M, Ruprecht K, Senel M, Stellmann JP, Bergh FT, Tumani H, Wildemann B, Trebst C. Update on the diagnosis and treatment of neuromyelits optica spectrum disorders (NMOSD) - revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part I: Diagnosis and differential diagnosis. J Neurol 2023:10.1007/s00415-023-11634-0. [PMID: 37022481 DOI: 10.1007/s00415-023-11634-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 04/07/2023]
Abstract
The term 'neuromyelitis optica spectrum disorders' (NMOSD) is used as an umbrella term that refers to aquaporin-4 immunoglobulin G (AQP4-IgG)-positive neuromyelitis optica (NMO) and its formes frustes and to a number of closely related clinical syndromes without AQP4-IgG. NMOSD were originally considered subvariants of multiple sclerosis (MS) but are now widely recognized as disorders in their own right that are distinct from MS with regard to immunopathogenesis, clinical presentation, optimum treatment, and prognosis. In part 1 of this two-part article series, which ties in with our 2014 recommendations, the neuromyelitis optica study group (NEMOS) gives updated recommendations on the diagnosis and differential diagnosis of NMOSD. A key focus is on differentiating NMOSD from MS and from myelin oligodendrocyte glycoprotein antibody-associated encephalomyelitis (MOG-EM; also termed MOG antibody-associated disease, MOGAD), which shares significant similarity with NMOSD with regard to clinical and, partly, radiological presentation, but is a pathogenetically distinct disease. In part 2, we provide updated recommendations on the treatment of NMOSD, covering all newly approved drugs as well as established treatment options.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ilya Ayzenberg
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Judith Bellmann-Strobl
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Achim Berthele
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Katrin Giglhuber
- Department of Neurology, School of Medicine, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Vivien Häußler
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Data Integration for Future Medicine (DIFUTURE) Consortium, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Martin W Hümmert
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke, Berg, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Markus Krumbholz
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Neurology and Stroke, University Hospital of Tübingen, Tübingen, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, LMU Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Friedemann Paul
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Experimental and Clinical Research Center, a Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité-Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, and Berlin Institute of Health, and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Neurology and Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Makbule Senel
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology and Institute of Neuroimmunology and MS (INIMS), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- APHM, Hopital de la Timone, CEMEREM, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | | | | | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Corinna Trebst
- Department of Neurology, Hannover Medical School, Hannover, Germany.
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12
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Fadda G, Flanagan EP, Cacciaguerra L, Jitprapaikulsan J, Solla P, Zara P, Sechi E. Myelitis features and outcomes in CNS demyelinating disorders: Comparison between multiple sclerosis, MOGAD, and AQP4-IgG-positive NMOSD. Front Neurol 2022; 13:1011579. [PMID: 36419536 PMCID: PMC9676369 DOI: 10.3389/fneur.2022.1011579] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/11/2022] [Indexed: 07/25/2023] Open
Abstract
Inflammatory myelopathies can manifest with a combination of motor, sensory and autonomic dysfunction of variable severity. Depending on the underlying etiology, the episodes of myelitis can recur, often leading to irreversible spinal cord damage and major long-term disability. Three main demyelinating disorders of the central nervous system, namely multiple sclerosis (MS), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorders (AQP4+NMOSD) and myelin oligodendrocyte glycoprotein-IgG associated disease (MOGAD), can induce spinal cord inflammation through different pathogenic mechanisms, resulting in a more or less profound disruption of spinal cord integrity. This ultimately translates into distinctive clinical-MRI features, as well as distinct patterns of disability accrual, with a step-wise worsening of neurological function in MOGAD and AQP4+NMOSD, and progressive disability accrual in MS. Early recognition of the specific etiologies of demyelinating myelitis and initiation of the appropriate treatment is crucial to improve outcome. In this review article we summarize and compare the clinical and imaging features of spinal cord involvement in these three demyelinating disorders, both during the acute phase and over time, and outline the current knowledge on the expected patterns of disability accrual and outcomes. We also discuss the potential implications of these observations for patient management and counseling.
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Affiliation(s)
- Giulia Fadda
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Eoin P. Flanagan
- Department of Neurology, Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Laura Cacciaguerra
- Department of Neurology, Center for MS and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
- Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Paolo Solla
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Pietro Zara
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Elia Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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13
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Muacevic A, Adler JR, Losada V, Lovera JF. Autoimmune Myelitis and Myocarditis in a Patient With Anti-Aquaporin-4, Antinuclear, and Antiphospholipid Autoantibodies: The Neuromyelitis Optica-Systemic Lupus Erythematosus (NMO-SLE) Overlap Syndrome. Cureus 2022; 14:e31334. [PMID: 36514583 PMCID: PMC9741486 DOI: 10.7759/cureus.31334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/12/2022] Open
Abstract
The coexistence of two or more autoimmune diseases is well-known, e.g., a person can have neuromyelitis optica (NMO) and systemic lupus erythematosus (SLE) at the same time. We report a case of NMO-SLE overlap syndrome with myelitis and myocarditis as the initial manifestations. The patient, a 64-year-old man, presented with a 15-day history of ascending sensory loss and a 10-day history of exertional dyspnea. Magnetic resonance imaging (MRI) revealed longitudinally extensive transverse myelitis (LETM) from C7 to T6. Serology showed a high anti-aquaporin-4 antibody level. We diagnosed NMO based on these findings. Echocardiography showed a hypokinetic left ventricle with a severely reduced ejection fraction. Cardiac MRI demonstrated delayed gadolinium enhancement in the myocardium consistent with active inflammation. Because the cardiac findings could not be explained on the basis of NMO, we started searching for another autoimmune disease. Serology came back positive for a variety of autoantibodies, including antinuclear, anti-dsDNA, anti-chromatin, anti-cardiolipin, anti-β2-glycoprotein-1, and lupus anticoagulant. These findings, along with leukopenia and low serum complement C4, prompted us to diagnose SLE, in addition to NMO. He was initially treated with plasmapheresis and methylprednisolone. Maintenance therapy consisted of rituximab, hydroxychloroquine, and aspirin. One year later, he only complained of mild paresthesia in the feet. Patients with NMO should always be screened for SLE especially if they have signs and symptoms that cannot be accounted for by NMO alone, e.g., our patient had myocarditis. Conversely, patients with SLE and evidence of transverse myelitis should be screened for anti-AQP4 antibodies.
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14
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Ghosh R, Mandal A, León-Ruiz M, Roy D, Das S, Dubey S, Benito-León J. Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases. Neurologia 2022:S2173-5808(22)00081-5. [PMID: 35907627 DOI: 10.1016/j.nrleng.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/09/2022] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Scrub typhus is a potentially life-threatening but curable disease that can produce multi-organ failure. Neurological manifestations in scrub typhus have gained attention recently, where the entire neural axis except the myoneural junction can be involved. Although the pathogenesis of neurological involvement has not been established, immune-mediated mechanisms are suspected. This article reports the clinicopathological features of scrub typhus cases presenting several rare neurological and neuropsychiatric manifestations. METHODS Three hundred fifty-four serologically confirmed scrub typhus cases were admitted to the Department of General Medicine of Burdwan Medical College and Hospital (West Bengal, India) between May 2018 and May 2022. There were 50 patients who had predominantly neurological manifestations. Of these 50 cases, ten patients presented with extremely rare neurological manifestations. RESULTS We report 10 cases of scrub typhus (four men and six women) who presented with complex neurological pictures (posterior reversible encephalopathy syndrome, Opalski syndrome, parkinsonism, cerebellitis, isolated opsoclonus, acute transverse myelitis, myositis, polyradiculoneuropathy with cranial neuropathy, acute transient behavioral changes, and fibromyalgia). Immune-mediated mechanisms might have mediated the pathogenesis of most cases following scrub typhus infection. CONCLUSION From a clinicopathological point of view, each case was unique in its presentation and treatment response. In any acute onset neurological disorders associated with febrile illness in the tropics or subtropics, scrub typhus infection should be included in the differential diagnosis, despite the absence of eschar and unremarkable neuroimaging findings. This otherwise curable disease may result in multi-organ dysfunction syndrome and death if the diagnosis is delayed.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Arpan Mandal
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Moisés León-Ruiz
- Section of Clinical Neurophysiology, Department of Neurology, University Hospital "La Paz", Madrid, Spain
| | - Dipayan Roy
- Indian Institute of Technology (IIT), Madras, Tamil Nadu, India; School of Humanities, Indira Gandhi National Open University, New Delhi, India
| | - Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain.
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15
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Naeem FN, Hasan SFS, Ram MD, Waseem S, Ahmed SH, Shaikh TG. The association between SARS-CoV-2 vaccines and transverse myelitis: A review. Ann Med Surg (Lond) 2022; 79:103870. [PMID: 35702684 PMCID: PMC9181565 DOI: 10.1016/j.amsu.2022.103870] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/19/2022] [Accepted: 05/22/2022] [Indexed: 12/02/2022] Open
Abstract
In late 2019, the emergence of a new viral strain, later referred to as Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) took the shape of a global pandemic, affecting millions of lives and deteriorating economies around the globe. Vaccines were developed at an exceptional rate to combat the viral desolation, all of them being rolled out once they displayed sufficient safety and efficacy. However, assorted adverse events came into attention, one of them being Transverse Myelitis (TM), an infrequent, immune-mediated, focal disease of the spinal cord. This disorder can lead to severe neurological complications including autonomic, sensory, and motor deficits. The literature aims to shed light on TM and its various etiologies, specifically in line with the vaccine, and a comprehensive treatment plan. Discussing and reducing the number of vaccines related adverse events can help succor in bringing down the vaccine hesitancy and ultimately combatting the pandemic.
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16
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Idiopathic longitudinally extensive myelitis: a brief historical excursion (review) and own clinical observation. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Idiopathic longitudinally extensive transverse myelitis is defined as a focal spinal cord lesion that involves three or more segments of the spinal cord as shown by neuroimaging, and results in a profound disability. The clinical picture of a patient with idiopathic longitudinally advanced transverse myelitis is often dramatic and may consist of paraparesis or tetraparesis, sensory disturbances, and pelvic dysfunction. Idiopathic longitudinally advanced transverse myelitis is a common manifestation of the neuromyelitis optica spectrum disorders, but can also occur in various other autoimmune and inflammatory diseases of the CNS, such as multiple sclerosis, sarcoidosis, or Sjogrens syndrome, or in infectious diseases involving the CNS. It is less likely to occur in isolation, as the only manifestation of a demyelinating disease of the nervous system of an unknown etiology (idiopathic myelitis).
Clinical case description: The clinical observation presented in the article demonstrates the difficulties of establishing a nosological diagnosis in the case of a monophasic course of TM in the absence of other autoimmune and infectious diseases of the central nervous system. The patient with idiopathic longitudinally distributed TM had no visual disturbances and no antibodies to aquaporin 4 and to myelin oligodendrocyte glycoprotein (MOG-IgG) with twice repeated tests.
Conclusion: In this regard, it is important to dynamically monitor the clinical manifestations and MRI signs in patients with an isolated lesion of a demyelinating nature in the form of longitudinally extensive transverse myelitis.
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17
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Kannan K, Karri M, Ramasamy B. An Analysis of Clinico-radiological Features and Outcome in Patients with Longitudinally Extensive Transverse Myelitis. Neurol India 2022; 70:1925-1930. [DOI: 10.4103/0028-3886.359209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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18
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Valencia-Sanchez C, Flanagan EP. Uncommon inflammatory/immune-related myelopathies. J Neuroimmunol 2021; 361:577750. [PMID: 34715593 DOI: 10.1016/j.jneuroim.2021.577750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/16/2021] [Accepted: 10/10/2021] [Indexed: 01/03/2023]
Abstract
The differential diagnosis for immune-mediated myelopathies is broad. Although clinical manifestations overlap, certain presentations are suggestive of a particular myelopathy etiology. Spine MRI lesion characteristics including the length and location, and the pattern of gadolinium enhancement, help narrow the differential diagnosis and exclude an extrinsic compressive cause. The discovery of specific antibodies that serve as biomarkers of myelitis such as aquaporin-4-IgG and myelin-oligodendrocyte -glycoprotein-IgG (MOG-IgG), has improved our understanding of myelitis pathophysiology and facilitated diagnosis. In this review we will focus on the pathophysiology, clinical presentation, imaging findings and treatment and outcomes of uncommon immune-mediated myelopathies.
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19
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Cervical longitudinally extensive myelitis after vaccination with inactivated virus-based COVID-19 vaccine. Radiol Case Rep 2021; 17:303-305. [PMID: 34849183 PMCID: PMC8614237 DOI: 10.1016/j.radcr.2021.10.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 10/21/2021] [Accepted: 10/24/2021] [Indexed: 12/03/2022] Open
Abstract
Myelitis, including longitudinally extensive transverse myelitis (LTEM), is reported in more than forty patients after coronavirus disease 2019 (COVID-19). Among COVID-19 vaccines, only Oxford-AstraZeneca COVID-19 vaccine (AZD1222) has been associated with few cases of myelitis (1 LTEM). We report the first case of myelitis/LTEM after BBIBP-CorV/Sinopharm vaccine, interestingly presented as a hemicord syndrome. A 71-year-old male presented with left-side diplegia, right-side hemihyposthesis with facial sparing and impaired position sensation in left foot after vaccination with BBIBP-CorV. MRI revealed a longitudinal signal in left cervical hemicord. This is the first reported myelitis and LTEM with COVID-19 vaccines other than AZD1222.
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20
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Lohmann L, Klotz L, Wiendl H. [Neuromyelitis Optica Spectrum Disorders - Present Insights and Recent Developments]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:516-530. [PMID: 34666391 DOI: 10.1055/a-1556-7008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The achievements of the last 15 years have essentially shaped the diagnostic methods and therapy of Neuromyelitis optica spectrum disorders (NMOSD): from discovery of aquaporin 4 antibodies and further development of diagnostic criteria the path has led to the approval of eculizumab and satralizumab as first disease modifying treatments in Europe. This article should give an overview on the present insights and future treatment options.
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21
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Barman A, Sahoo J, Viswanath A, Roy SS, Swarnakar R, Bhattacharjee S. Clinical Features, Laboratory, and Radiological Findings of Patients With Acute Inflammatory Myelopathy After COVID-19 Infection: A Narrative Review. Am J Phys Med Rehabil 2021; 100:919-939. [PMID: 34347629 PMCID: PMC8436817 DOI: 10.1097/phm.0000000000001857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT The objective of this review was to analyze the existing data on acute inflammatory myelopathies associated with coronavirus disease 2019 infection, which were reported globally in 2020. PubMed, CENTRAL, MEDLINE, and online publication databases were searched. Thirty-three acute inflammatory myelopathy cases (among them, seven cases had associated brain lesions) associated with coronavirus disease 2019 infection were reported. Demyelinating change was seen in cervical and thoracic regions (27.3% each, separately). Simultaneous involvement of both regions, cervical and thoracic, was seen in 45.4% of the patients. Most acute inflammatory myelopathy disorders reported sensory motor and bowel bladder dysfunctions. On cerebrospinal fluid analysis, pleocytosis and increased protein were reported in 56.7% and 76.7% of the patients, respectively. Cerebrospinal fluid severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction was positive in five patients. On T2-weighted imaging, longitudinally extensive transverse myelitis and short-segment demyelinating lesions were reported in 76% and 21%, respectively. Among the patients with longitudinally extensive transverse myelitis, 61% reported "moderate to significant" improvement and 26% demonstrated "no improvement" in the motor function of lower limbs. Demyelinating changes in the entire spinal cord were observed in three patients. Most of the patients with acute inflammatory myelopathy (including brain lesions) were treated with methylprednisolone (81.8%) and plasma-exchange therapy (42.4%). An early treatment, especially with intravenous methylprednisolone with or without immunoglobulin and plasma-exchange therapy, helped improve motor recovery in the patients with acute inflammatory myelopathy associated with coronavirus disease 2019.
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22
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Lin TY, Chien C, Lu A, Paul F, Zimmermann HG. Retinal optical coherence tomography and magnetic resonance imaging in neuromyelitis optica spectrum disorders and MOG-antibody associated disorders: an updated review. Expert Rev Neurother 2021; 21:1101-1123. [PMID: 34551653 DOI: 10.1080/14737175.2021.1982697] [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: 12/19/2022]
Abstract
INTRODUCTION Neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein IgG antibody-associated disorders (MOGAD) comprise two groups of rare neuroinflammatory diseases that cause attack-related damage to the central nervous system (CNS). Clinical attacks are often characterized by optic neuritis, transverse myelitis, and to a lesser extent, brainstem encephalitis/area postrema syndrome. Retinal optical coherence tomography (OCT) is a non-invasive technique that allows for in vivo thickness quantification of the retinal layers. Apart from OCT, magnetic resonance imaging (MRI) plays an increasingly important role in NMOSD and MOGAD diagnosis based on the current international diagnostic criteria. Retinal OCT and brain/spinal cord/optic nerve MRI can help to distinguish NMOSD and MOGAD from other neuroinflammatory diseases, particularly from multiple sclerosis, and to monitor disease-associated CNS-damage. AREAS COVERED This article summarizes the current status of imaging research in NMOSD and MOGAD, and reviews the clinical relevance of OCT, MRI and other relevant imaging techniques for differential diagnosis, screening and monitoring of the disease course. EXPERT OPINION Retinal OCT and MRI can visualize and quantify CNS damage in vivo, improving our understanding of NMOSD and MOGAD pathology. Further efforts on the standardization of these imaging techniques are essential for implementation into clinical practice and as outcome parameters in clinical trials.
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Affiliation(s)
- Ting-Yi Lin
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Chien
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Angelo Lu
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hanna G Zimmermann
- Experimental and Clinical Research Center, Max-Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Corporate Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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23
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Elusive tuberculous meningitis with rare neurological complication of longitudinally extensive transverse myelitis: a case report. Spinal Cord Ser Cases 2021; 7:82. [PMID: 34521808 PMCID: PMC8438549 DOI: 10.1038/s41394-021-00445-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Longitudinally extensive transverse myelitis (LETM) is inflammation of the spinal cord that spans three or more spinal segments. LETM is a rare occurrence on its own and has seldom been reported with tuberculous meningitis (TBM), the rarest and deadliest of tuberculous manifestations. TBM is usually seen in children, the immunocompromised, or those with a previous history of tuberculosis infection. CASE PRESENTATION A 24-year-old healthy male with no co-morbidities or history of tuberculosis presented with fever and headache for the past 3 months. The patient's Kernig's and Brudzinski's signs were both negative, with bilateral abnormal plantar reflexes. The neurological level of injury was T8 and the patient was classified as AIS grade A. His CSF analysis showed a lymphocytic picture. However, both GeneXpert and Ziehl-Neelsen staining came back negative for Mycobacterium tuberculosis. MRI scans of the brain and thoracic spine revealed enhancing nodules and ring lesions in the brain and spinal cord, along with the rare complication of LETM, extending from T2 to T9. DISCUSSION Although Mycobacterium tuberculosis was never isolated, the patient started recovering as soon as antituberculous therapy was initiated. Hence, more emphasis needs to be placed on radiological imaging in the management of rare medical emergencies like tuberculous meningitis, especially in areas where tuberculosis is rampant and endemic, rather than waiting for a positive culture. This case report also demonstrates the growing evidence that transverse myelitis and/or LETM is associated with TBM.
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24
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Gao JJ, Tseng HP, Lin CL, Shiu JS, Lee MH, Liu CH. Acute Transverse Myelitis Following COVID-19 Vaccination. Vaccines (Basel) 2021; 9:vaccines9091008. [PMID: 34579245 PMCID: PMC8470728 DOI: 10.3390/vaccines9091008] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022] Open
Abstract
An increasing number of people are undergoing vaccination for COVID-19 because of the ongoing pandemic. The newly developed, genetically engineered mRNA vaccines are critical for controlling the epidemic disease. However, major adverse effects, including neuroimmunological disorders, are being attributed to this vaccine. For instance, several cases of acute transverse myelitis (ATM) after COVID-19 vaccination have been reported in clinical trials. Here, we report an exceedingly rare case of longitudinally extensive transverse myelitis (LETM), a rare subtype of ATM involving three or more vertebral segments, that occurred shortly after vaccination with the Moderna COVID-19 (mRNA-1273) vaccine, with a comorbidity of vitamin B12 deficiency. The findings of subsequent investigations suggest the possibility that autoimmune responses are triggered by the reactions between anti-SARS-CoV-2 spike protein antibodies and tissue proteins, as well as the interaction between spike proteins and angiotensin-converting enzyme 2 receptors.
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Affiliation(s)
- Jhih-Jian Gao
- Department of Neurology, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan; (J.-J.G.); (H.-P.T.); (C.-L.L.)
| | - Hung-Pin Tseng
- Department of Neurology, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan; (J.-J.G.); (H.-P.T.); (C.-L.L.)
| | - Chun-Liang Lin
- Department of Neurology, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan; (J.-J.G.); (H.-P.T.); (C.-L.L.)
| | - Jr-Shiang Shiu
- Department of Emergency Medicine, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan;
| | - Ming-Hsun Lee
- Department of Radiology, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan;
| | - Ching-Hsiung Liu
- Department of Neurology, Lotung Poh-Ai Hospital, Ilan 26546, Taiwan; (J.-J.G.); (H.-P.T.); (C.-L.L.)
- Correspondence: ; Tel.: +886-3-954-3131
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25
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Acute transverse myelitis following SARS-CoV-2 vaccination: a case report and review of literature. J Neurol 2021. [PMID: 34482455 DOI: 10.1007/s00415‐021‐10785‐2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report a unique case and literature review of post COVID-19 vaccination associated transverse myelitis and with abnormal MRI findings. BACKGROUND Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only a few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2). Here, we identify a post COVID-19 vaccination patient diagnosed with acute transverse myelitis. METHOD A retrospective chart review of a patient diagnosed with post SARS-CoV-2 vaccination acute transverse myelitis, and a review of literature of all the reported cases of other post vaccination and transverse myelitis, from December 1st, 2010 till July 15th, 2021, was performed. CONCLUSION To our knowledge, this is the one of early reported case of transverse myelitis and with post SARS-CoV-2 vaccination, who responded well to plasmapheresis. Further studies would be recommended to identify the underlying correlation between COVID-19 vaccination and transverse myelitis.
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26
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Khan E, Shrestha AK, Colantonio MA, Liberio RN, Sriwastava S. Acute transverse myelitis following SARS-CoV-2 vaccination: a case report and review of literature. J Neurol 2021; 269:1121-1132. [PMID: 34482455 PMCID: PMC8418691 DOI: 10.1007/s00415-021-10785-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
Objective To report a unique case and literature review of post COVID-19 vaccination associated transverse myelitis and with abnormal MRI findings. Background Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only a few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2). Here, we identify a post COVID-19 vaccination patient diagnosed with acute transverse myelitis. Method A retrospective chart review of a patient diagnosed with post SARS-CoV-2 vaccination acute transverse myelitis, and a review of literature of all the reported cases of other post vaccination and transverse myelitis, from December 1st, 2010 till July 15th, 2021, was performed. Conclusion To our knowledge, this is the one of early reported case of transverse myelitis and with post SARS-CoV-2 vaccination, who responded well to plasmapheresis. Further studies would be recommended to identify the underlying correlation between COVID-19 vaccination and transverse myelitis.
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Affiliation(s)
- Erum Khan
- B.J. Medical College and Civil Hospital, Ahmedabad, India.,Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | - Mark A Colantonio
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Richard N Liberio
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA. .,West Virginia Clinical Transitional Science, Morgantown, WV, USA.
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Dong H, Liu Z, Duan Y, Li D, Qiu Z, Liu Y, Huang J, Wang C. Syphilitic meningomyelitis misdiagnosed as spinal cord tumor: Case and review. J Spinal Cord Med 2021; 44:789-793. [PMID: 31603731 PMCID: PMC8477965 DOI: 10.1080/10790268.2019.1658283] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Syphilitic meningomyelitis is a rare manifestation of neurosyphilis, not well described in the literature.Methods: We reported a rare case of a 29-year-old female with syphilitic meningomyelitis. Her clinical manifestations and imaging findings were discussed with the related literatures reviewed.Results: The patient presented with progressive bilateral lower extremities numbness and weakness for months. Laboratory tests revealed positive serum Treponema pallidum Hemagglutinin Test (TPHA) and rapid plasma reagin test (RPR). The cerebral spinal fluid (CSF) was positive with TPHA but negative for RPR with lymphocytic pleocytosis and elevated protein. Spinal MRI showed swelling and high-signal intensity of thoracic spinal cord except T6-7 level with associated gadolinium enhancement ("flip-flop sign") and peripheral strip-like enhancement on T1WI ("candle guttering appearance"). She was initially diagnosed as spinal cord tumor due to the chronic clinical onset and cord swelling with central enhancement found on thoracic MRI. After dramatic clinical and radiographic improvement with dexamethosone and serological tests of syphilis, she was diagnosed as probable syphilitic meningomyelitis. Till now, there are 12 cases of syphilitic myelitis reported with spinal cord MR images. Thoracic cord is the predominant involved segment (10/12), "candle guttering appearance" is the most common enhancing characteristics of the lesion (7/12), "flip-flop sign" may be seen in the stage with significant inflammation (3/12).Conclusion: Syphilitic meningomyelitis can occur at early or late stage of syphilis, the onset may be acute, subacute or chronic. The imaging findings suggested focal inflammation of the spinal cord. Prognosis is relatively good after proper treatment.
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Affiliation(s)
- Huiqing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zheng Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence to: Zheng Liu, Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing100053, People’s Republic of China; Ph: 008613910320552; 0086-10-83198899 ext 8701.
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dawei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhandong Qiu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
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Gupta V, Luthra S, Maheshwari S, Das SM. Relapsing neuromyelitis optica in an adolescent girl. BMJ Case Rep 2021; 14:e242402. [PMID: 34426420 PMCID: PMC8383875 DOI: 10.1136/bcr-2021-242402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/03/2022] Open
Abstract
Early differentiation of neuromyelitis optica spectrum disorder (NMO-SD) from multiple sclerosis (MS) is of paramount importance as NMO-SD (especially relapsing variant) has more severe morbidity than MS. We describe a case of an adolescent girl who presented with repeated episodes of optic neuritis over a period of 4 years with normal brain MRI scans. She was treated initially as relapsing remitting MS, before showing clinical evidence of transverse myelitis (TM), and eventually being diagnosed as NMO-SD. Pulse intravenous methyl prednisolone along with immunosuppressive therapy led to remission of her disease. However, delay in diagnosis as NMO-SD led to visual disability in the left eye. Therefore, in young patients with recurrent optic neuritis and normal brain MRI, it may be prudent to get spinal MRI done to look for TM, even when asymptomatic. In addition, we should keep a low threshold for requesting aquaporin-4 antibody testing in these patients.
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Affiliation(s)
- Vinita Gupta
- Ophthalmology, AIIMS Rishikesh, Rishikesh, Uttarakhand, India
| | - Saurabh Luthra
- Ophthalmology, Drishti Eye Institute, Dehradun, Uttarakhand, India
| | - Shrey Maheshwari
- Ophthalmology, Drishti Eye Institute, Dehradun, Uttarakhand, India
| | - Shrutanjoy M Das
- Ophthalmology, Drishti Eye Institute, Dehradun, Uttarakhand, India
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Pagenkopf C, Südmeyer M. A case of longitudinally extensive transverse myelitis following vaccination against Covid-19. J Neuroimmunol 2021; 358:577606. [PMID: 34182207 PMCID: PMC8223023 DOI: 10.1016/j.jneuroim.2021.577606] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 01/07/2023]
Abstract
Background Longitudinally extensive transverse myelitis (LETM) is a rare subtype of transverse myelitis (TM) that potentially results in relevant disability. Apart from association to neuromyelitis optica and other chronic demyelinating diseases of the central nervous system, many other aetiologies are known. Particularly systemic infections and vaccination are considered potential triggers for immune mediated inflammation of the spinal cord. In the course of the current Covid-19 pandemic several cases of TM following Covid-19 infection have been described. Here we present a case of LETM following vaccination against Covid-19 with AZD1222, AstraZeneca. An extensive diagnostic work up was performed to rule out alternative causes, including prior and current Covid-19 infection. Conclusion To our knowledge this is first case of LETM possibly related to Covid-19 vaccination that is published after marketing authorisation of various vaccine candidates.
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Affiliation(s)
- Claudia Pagenkopf
- Klinikum Ernst von Bergmann, Department of Neurology, Charlottenstrasse 72, 14467 Potsdam, Germany.
| | - Martin Südmeyer
- Klinikum Ernst von Bergmann, Department of Neurology, Charlottenstrasse 72, 14467 Potsdam, Germany; Department of Neurology, Medical Faculty, University Düsseldorf, Düsseldorf, Germany.
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30
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Celik H, Aksoy E, Oztoprak U, Ceylan N, Aksoy A, Yazici MU, Azapagasi E, Eksioglu AS, Yücel H, Senel S, Yuksel D. Longitudinally extensive transverse myelitis in childhood: Clinical features, treatment approaches, and long-term neurological outcomes. Clin Neurol Neurosurg 2021; 207:106764. [PMID: 34171586 DOI: 10.1016/j.clineuro.2021.106764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
AIM Longitudinally extensive transvers myelitis (LETM) is a rare and disabling condition in childhood. The aim of the present study was to share experiences from our center regarding the treatment features and clinical and radiologic course in our LETM patients in light of the literature data. MATERIAL AND METHOD The study was designed as cross-sectional and included children who followed for LETM at our pediatric neurology clinic between 2010 and 2019. ATM was diagnosed according to the diagnostic criteria report from the Transverse Myelitis Consortium Working Group. LETM was defined as the presence of spinal cord lesions spanning a length of 3 or more consecutive vertebral segments. The patients' medical records were examined in terms of demographic characteristics, presenting symptoms, history of infection prior to and during LETM, prodromal history, neurological examination, laboratory and radiological findings, clinical course, and treatment. The Barthel Index was used to assess the physical independence in activities of daily living of patients with LETM who were followed for at least one year. RESULTS A total of 15 (8 girl) patients were included in the study. The patients were between 1 and 17 years of age. Presenting symptoms included inability to walk in 12 patients, incontinence in 9 patients, low back pain in 4 patients, abdominal pain in 2 patients, and inability to use the arms in 2 patients. In Barthel Index assessment of physical independence in activities of daily living, 8 patients were evaluated as completely independent, 3 patients as moderately dependent, and 2 patients as slightly dependent. When the 4 patients with motor area impairment and moderate dependency according to the Barthel Index were examined, it was noted that all of them had been admitted 4 days after the onset of symptoms and that 2 (13.3%) had cervicothoracic involvement and 2 (13.3%) had involvement of the entire cord. CONCLUSION Shorter delay from symptom onset to initiation of immunomodulatory therapy as well as effective rehabilitation resulted in favorable outcomes, with the most noticeable improvement in the areas of motor function and incontinence.
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Affiliation(s)
- Halil Celik
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Erhan Aksoy
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ulkuhan Oztoprak
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Nesrin Ceylan
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ayse Aksoy
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Mutlu Uysal Yazici
- Department of Pediatric Intensive Care University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ebru Azapagasi
- Department of Pediatric Intensive Care University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Ayse Secil Eksioglu
- Department of Radiology University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Husniye Yücel
- Department of Pediatrics University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Saliha Senel
- Department of Pediatrics University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Deniz Yuksel
- Department of Pediatric Neurology (DY) University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
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31
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Canavero I, Ravaglia S, Valentino F, Micieli G. Guillain Barrè syndrome and myelitis associated with SARS-CoV-2 infection. Neurosci Lett 2021; 759:136040. [PMID: 34118307 PMCID: PMC8189748 DOI: 10.1016/j.neulet.2021.136040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/29/2021] [Accepted: 06/04/2021] [Indexed: 12/18/2022]
Abstract
Despite a likely underestimation due to the many obstacles of the highly infectious, intensive care setting, increasing clinical reports about COVID-19 patients developing acute paralysis for polyradiculoneuritis or myelitis determine additional impact on the disease course and outcome. Different pathogenic mechanisms have been postulated basing on clinical, laboratory and neuroimaging features, and response to treatments. Here we provide an overview with insights built on the available reports. Besides direct viral pathogenicity, a crucial role seems to be represented by immune-mediated mechanisms, supporting and further characterizing the already hypothesized neurotropic potential of SARS-CoV-2 and implying specific treatments. Proper clinical and instrumental depiction of symptomatic cases, as well as screening for their early recognition is advocated.
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Affiliation(s)
- Isabella Canavero
- Current affiliation: Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy; Emergency Neurology Unit, IRCCS Casimiro Mondino Foundation, Pavia, Italy.
| | - Sabrina Ravaglia
- Emergency Neurology Unit, IRCCS Casimiro Mondino Foundation, Pavia, Italy
| | | | - Giuseppe Micieli
- Emergency Neurology Unit, IRCCS Casimiro Mondino Foundation, Pavia, Italy
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32
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Paudel S, Nepal G, Guragain S, Shah S, Paudel BS, Ojha R, Rajbhandari R, Karn R, Gajurel BP, Paudel S. Longitudinally Extensive Transverse Myelitis: A Retrospective Study Differentiating Neuromyelitis Optica Spectrum Disorder From Other Etiologies. Cureus 2021; 13:e13968. [PMID: 33884229 PMCID: PMC8054834 DOI: 10.7759/cureus.13968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous immune-mediated inflammatory lesion of the spinal cord extending more than three vertebral segments. Neuromyelitis optica spectrum disorder (NMOSD) is the most common and important cause of LETM. This study aims to evaluate the demographic profile, clinical presentations, neuroimaging features, laboratory parameters, and etiologies of LETM and differentiates NMOSD from other etiologies of LETM. Methodology This retrospective cross-sectional study was conducted at the Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. After receiving clearance from the ethical committee, a retrospective chart review was conducted and records of all the inpatient LETM cases admitted from March 2018 to June 2020 were obtained. From the patient records, the following information was extracted: the demographic profile, clinical presentations, neuroimaging features, cerebrospinal fluid analysis, serum anti-aquaporin-4 (AQP4) immunoglobulin G status, hemogram, infectious disease profile, inflammatory markers, and auto-immune panels. Descriptive analysis of data was performed with SPSS statistics 23.0 version (IBM Corp, Armonk, NY, USA). Results In our study, the mean age of LETM patients was 36.58 years, and 12 out of 19 (63.15%) patients were young, with an age less than 40 years. A total of 13 (68.40%) patients were male, with a male-to-female ratio of 2.16. Seven (36.80%) patients had a clinical diagnosis of NMOSD with anti-AQP4 antibody-positive status, four (21.10%) had unknown etiology, three (15.8%) had post-infectious transverse myelitis, and three (15.80%) had a diagnosis of idiopathic transverse myelitis. There was a single case (5.30%) of cervical spondylotic myelopathy and leukemic transverse myelitis each. The common presenting symptoms of LETM were bladder dysfunction, paraparesis, quadriparesis, and visual impairment. Visual involvement, either unilateral or bilateral, was common in NMOSD and LETM of unknown etiology category. Similarly, brain lesion was common in patients with NMOSD and LETM of unknown etiology category. Conclusion LETM is a heterogeneous disorder with diverse etiologies and clinical presentations. NMOSD is an important cause of LETM that predominantly affects females. Optic neuritis can be seen in LETM of various etiologies, but it is more common in anti-AQP4-positive NMOSD patients. Brain lesions in LETM are common in anti-AQP4-positive NMOSD.
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Affiliation(s)
- Sunanda Paudel
- Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Gaurav Nepal
- Internal Medicine, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Sandesh Guragain
- Neurology, Nepal Medical College Teaching Hospital, Kathmandu, NPL
| | - Sangam Shah
- Neurology, Maharajgunj Medical Campus, Kathmandu, NPL
| | | | - Rajeev Ojha
- Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Reema Rajbhandari
- Neurology, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Ragesh Karn
- Neurology, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Bikram P Gajurel
- Vascular Neurology, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Sunanda Paudel
- Neurology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
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33
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Anand KA, Bhowmik KK, Sarkar A, Ghosh R, Mandal A, Swaika B, Ray BK. Tubercular longitudinally extensive transverse myelitis (LETM): An enigma for primary care physicians. J Family Med Prim Care 2021; 10:1057-1060. [PMID: 34041124 PMCID: PMC8138341 DOI: 10.4103/jfmpc.jfmpc_2101_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/02/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022] Open
Abstract
Albeit, all forms of tuberculosis (TB) are endemic in India, spinal intramedullary TB and tubercular longitudinally extensive transverse myelitis (LETM) is deemed extremely rare. With recent advances in the field of neurology, autoimmune astrocytopathy (neuromyelitis optica spectrum disorders, NMOSD), myelin-oligodendrocyte glycoprotein associated encephalomyelitis (MOG-EM), metabolic myelopathy, connective tissue diseases and viral infections have gained considerable focus in the list of differentials of LETM whereas tubercular association is often forgotten. This report presents a rare case of acute transverse myelopathy which unveiled previously undiagnosed pulmonary tuberculosis in an adult rural Indian male. The patient responded well to anti-tubercular therapy and corticosteroids. Exact pathogenesis of LETM in TB remains elusive. Association of TB with MOG-EM has been one of the recent hot-cakes. However, an ill-defined immune-inflammatory response to the infectious agent is the likely cause of tubercular LETM. Hence, the primary care physicians who are the first medical contacts of acute LETM cases and in most cases due to diagnostic dilemma there is an unavoidable delay in accurate diagnosis and initiation of therapy. Primary care doctors should nurture a high index of suspicion to diagnose this potentially lifetime-debilitating yet absolutely treatable clinical condition i.e. tubercular LETM.
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Affiliation(s)
- Kumar Abhishek Anand
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Kalyan Kumar Bhowmik
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Amit Sarkar
- Assistant Professor, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Ritwik Ghosh
- Resident, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Arpan Mandal
- Associate Professor, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Bikash Swaika
- Professor and Head of the Department, Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Biman Kanti Ray
- Professor, Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
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Jarius S, Paul F, Weinshenker BG, Levy M, Kim HJ, Wildemann B. Neuromyelitis optica. Nat Rev Dis Primers 2020; 6:85. [PMID: 33093467 DOI: 10.1038/s41572-020-0214-9] [Citation(s) in RCA: 227] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Abstract
Neuromyelitis optica (NMO; also known as Devic syndrome) is a clinical syndrome characterized by attacks of acute optic neuritis and transverse myelitis. In most patients, NMO is caused by pathogenetic serum IgG autoantibodies to aquaporin 4 (AQP4), the most abundant water-channel protein in the central nervous system. In a subset of patients negative for AQP4-IgG, pathogenetic serum IgG antibodies to myelin oligodendrocyte glycoprotein, an antigen in the outer myelin sheath of central nervous system neurons, are present. Other causes of NMO (such as paraneoplastic disorders and neurosarcoidosis) are rare. NMO was previously associated with a poor prognosis; however, treatment with steroids and plasma exchange for acute attacks and with immunosuppressants (in particular, B cell-depleting agents) for attack prevention has greatly improved the long-term outcomes. Recently, a number of randomized controlled trials have been completed and the first drugs, all therapeutic monoclonal antibodies, have been approved for the treatment of AQP4-IgG-positive NMO and its formes frustes.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany.
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Michael Levy
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
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35
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Acute and subacute myelopathy. Rev Neurol (Paris) 2020; 177:557-566. [PMID: 34024334 DOI: 10.1016/j.neurol.2020.08.003] [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: 06/17/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022]
Abstract
Myelopathy is a term referring to any pathologic process affecting the spinal cord, and encompasses a broad spectrum of etiologies. The first step is to categorize myelopathy, according to the time to reach maximum deficit. Myelopathies are commonly classified as acute, subacute or chronic, for which the etiologies are totally different. Myelopathy is considered acute when the symptoms progress to their nadir in maximum 21 days after onset. Due to heterogeneity in pathogenesis, and the overlap in the clinical and imaging presentation among etiologies, acute myelopathy is considered as a diagnostic dilemma. A simple and efficient algorithm for timely identification of the underlying cause is thus useful. In this review, we provide a simplified approach for the differential diagnosis among all causes of acute myelopathies, and describe the principal clinical and imaging features of the main etiologies in adults, including recently characterized antibody-mediated myelitis, and its mimics.
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Elnady B, Fathy SM, Elkhouly T, Ganeb S. Neuromyelitis optica spectrum standstill in rheumatic systemic autoimmune diseases. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2020. [DOI: 10.1186/s43166-020-00018-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
Neuromyelitis optica spectrum disorders (NMOSD) are considered as an autoantibody-mediated disorder that targets aquaporin-4 (AQP4); other autoantibodies could be detected in such spectrum of diseases, including anti-nuclear antibody and antibodies to extractable nuclear antigens. Systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjogren’s syndrome (SS), and other autoimmune diseases can overlap with NMOSD. We aimed in this review to address the current evidence describing the relation of NMOSD to systemic autoimmunity diseases, its controversy of being co-association or the same etiology, and its practical implications.
Main body
The current review was done using a search for related articles or case reports on PubMed until 2019. The keywords included neuromyelitis optica spectrum disorders in combination with autoimmune disease nomenclature. We described the literature background of this controversy, to summarize the evidence of NMOSD relationship to systemic autoimmune diseases.
Conclusion
NMOSD associated with systemic autoimmune diseases is more common in SLE and Sjogren’s syndrome rather than other autoimmune diseases, frequently affects females more than males; AQP4 antibodies should be tested for all NMOSD like manifestations associated with an autoimmune disorder; however, the clinical diagnosis of NMOSD regardless of the cord lesion length and the presence of positive AQP4 antibody can occur in systemic autoimmune diseases.
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Pérez CA, Patnaik A, Oommen S, Redko A, Mathis SB. Tumefactive Demyelinating Lesions in Children: A Rare Case of Conus Medullaris Involvement and Systematic Review of the Literature. J Child Neurol 2020; 35:690-699. [PMID: 32552343 DOI: 10.1177/0883073820924147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumefactive demyelinating lesions are an uncommon manifestation of demyelinating disease that mimic primary central nervous system neoplasms and can pose a diagnostic challenge in patients without a pre-existing diagnosis of multiple sclerosis. Although a biopsy may be required to distinguish TDL from neoplasms or infection, certain ancillary and radiographic findings may preclude the need for invasive diagnostic procedures. We describe the case of a 15-year-old boy with a tumefactive demyelinating lesion involving the conus medullaris. An exhaustive systematic literature search of pediatric cases of TDL yielded an additional 78 cases. This review summarizes the current knowledge and recommendations for the diagnosis and management of this condition, highlighting the clinical, demographic, and radiologic features of 79 reported cases, including our own. Furthermore, it underscores areas of the literature where evidence is still lacking. Further research is needed to optimize clinical detection and medical management of this condition.
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Affiliation(s)
- Carlos A Pérez
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Anish Patnaik
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sherwin Oommen
- Division of Child and Adolescent Neurology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alissa Redko
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Scott B Mathis
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
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38
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Kuchling J, Paul F. Visualizing the Central Nervous System: Imaging Tools for Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorders. Front Neurol 2020; 11:450. [PMID: 32625158 PMCID: PMC7311777 DOI: 10.3389/fneur.2020.00450] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/28/2020] [Indexed: 12/12/2022] Open
Abstract
Multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are autoimmune central nervous system conditions with increasing incidence and prevalence. While MS is the most frequent inflammatory CNS disorder in young adults, NMOSD is a rare disease, that is pathogenetically distinct from MS, and accounts for approximately 1% of demyelinating disorders, with the relative proportion within the demyelinating CNS diseases varying widely among different races and regions. Most immunomodulatory drugs used in MS are inefficacious or even harmful in NMOSD, emphasizing the need for a timely and accurate diagnosis and distinction from MS. Despite distinct immunopathology and differences in disease course and severity there might be considerable overlap in clinical and imaging findings, posing a diagnostic challenge for managing neurologists. Differential diagnosis is facilitated by positive serology for AQP4-antibodies (AQP4-ab) in NMOSD, but might be difficult in seronegative cases. Imaging of the brain, optic nerve, retina and spinal cord is of paramount importance when managing patients with autoimmune CNS conditions. Once a diagnosis has been established, imaging techniques are often deployed at regular intervals over the disease course as surrogate measures for disease activity and progression and to surveil treatment effects. While the application of some imaging modalities for monitoring of disease course was established decades ago in MS, the situation is unclear in NMOSD where work on longitudinal imaging findings and their association with clinical disability is scant. Moreover, as long-term disability is mostly attack-related in NMOSD and does not stem from insidious progression as in MS, regular follow-up imaging might not be useful in the absence of clinical events. However, with accumulating evidence for covert tissue alteration in NMOSD and with the advent of approved immunotherapies the role of imaging in the management of NMOSD may be reconsidered. By contrast, MS management still faces the challenge of implementing imaging techniques that are capable of monitoring progressive tissue loss in clinical trials and cohort studies into treatment algorithms for individual patients. This article reviews the current status of imaging research in MS and NMOSD with an emphasis on emerging modalities that have the potential to be implemented in clinical practice.
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Affiliation(s)
- Joseph Kuchling
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- NeuroCure Clinical Research Center, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
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Marrodan M, Gaitán MI, Correale J. Spinal Cord Involvement in MS and Other Demyelinating Diseases. Biomedicines 2020; 8:E130. [PMID: 32455910 PMCID: PMC7277673 DOI: 10.3390/biomedicines8050130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022] Open
Abstract
Diagnostic accuracy is poor in demyelinating myelopathies, and therefore a challenge for neurologists in daily practice, mainly because of the multiple underlying pathophysiologic mechanisms involved in each subtype. A systematic diagnostic approach combining data from the clinical setting and presentation with magnetic resonance imaging (MRI) lesion patterns, cerebrospinal fluid (CSF) findings, and autoantibody markers can help to better distinguish between subtypes. In this review, we describe spinal cord involvement, and summarize clinical findings, MRI and diagnostic characteristics, as well as treatment options and prognostic implications in different demyelinating disorders including: multiple sclerosis (MS), neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, anti-myelin oligodendrocyte glycoprotein antibody-associated disease, and glial fibrillary acidic protein IgG-associated disease. Thorough understanding of individual case etiology is crucial, not only to provide valuable prognostic information on whether the disorder is likely to relapse, but also to make therapeutic decision-making easier and reduce treatment failures which may lead to new relapses and long-term disability. Identifying patients with monophasic disease who may only require acute management, symptomatic treatment, and subsequent rehabilitation, rather than immunosuppression, is also important.
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Affiliation(s)
| | | | - Jorge Correale
- Neurology Department, Fleni, C1428AQK Buenos Aires, Argentina; (M.M.); (M.I.G.)
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Transverse myelitis masquerading as cauda equina syndrome, stroke and cervical myelopathy. Biomedicine (Taipei) 2020; 10:45-50. [PMID: 33854913 PMCID: PMC7608839 DOI: 10.37796/2211-8039.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022] Open
Abstract
Transverse myelitis is an uncommon but well-defined neurological syndrome. However, a high index of suspicion is needed to diagnose this condition, especially when it occurs in concomitance with preexisting spinal canal stenosis. We report our patient, a 48 year old male, who initially presented to our spine clinic with acute onset unilateral lower limb weakness associated with urinary retention, which was suspected to be cauda equina syndrome due to a prolapsed intervertebral disc. However, initial magnetic resonance (MR) imaging showed only mild spinal canal stenosis from L2-L5 and C3– C6 levels; thus, the possibility of cauda equina syndrome was ruled out. A few days later, patient developed ipsilateral upper limb weakness giving an impression of hemiparesis due to stroke. However, imaging of brain returned normal. There was still a dilemma whether symptoms could be due to cervical myelopathy as there was mild cervical cord compression with early myelomalacia changes, but the findings were subtle to come to a definite conclusion. Subsequently, patient desaturated and required ventilatory support. Repeat MR imaging of the cervical spine revealed T2 hyperintensities spanning multiple levels in the cervical cord which highlighted the possibility of transverse myelitis and the diagnosis was clinched after a CSF analysis. Despite the debilitating effects, patient responded well to corticosteroid therapy and gradually recovered. This case is reported to highlight the diagnostic dilemma and the rapid progression of transverse myelitis that demands timely medical intervention to avoid permanent disabilities.
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Krause MA, English SW, Zalewski NL. Clinical Reasoning: A 70-year-old man with rapid stepwise paraparesis and sensory loss. Neurology 2020; 94:e651-e655. [PMID: 31992685 DOI: 10.1212/wnl.0000000000008925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Monica A Krause
- From the Department of Neurology, Mayo Clinic, Rochester, MN
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Vakrakou AG, Evangelopoulos ME, Boutzios G, Tzanetakos D, Tzartos J, Velonakis G, Toulas P, Anagnostouli M, Andreadou E, Koutsis G, Stefanis L, Fragoulis GE, Kilidireas C. Recurrent myelitis and asymptomatic hypophysitis in IgG4-related disease: case-based review. Rheumatol Int 2020; 40:337-343. [PMID: 31898763 DOI: 10.1007/s00296-019-04502-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/11/2019] [Indexed: 12/24/2022]
Abstract
IgG4-related disease (IgG4-RD) is a disorder with various clinical manifestations. Central nervous system (CNS) involvement is well recognized, with hypertrophic pachymeningitis and hypophysitis being the most common manifestations. Spinal cord involvement is an extremely rare manifestation. We present the first case of an IgG4-RD patient with spinal cord parenchymal disease and concurrent hypophysitis. We review also the current literature about CNS parenchymal involvement in the context of IgG4-RD. A young female presented with clinical symptoms of myelitis. Cervical spinal cord magnetic resonance imaging (MRI) displayed features of longitudinally extensive transverse myelitis (LETM). Brain MRI showed a small number of high-intensity lesions in the deep white matter and enlargement of hypophysis with homogeneous gadolinium enhancement (asymptomatic hypophysitis). Diagnostic workup revealed elevated IgG4 serum levels (146 mg/dL). Our patient fulfilled the organ-specific diagnostic criteria of IgG4-hypophysitis. Treatment with intravenous glucocorticoids led to rapid clinical response, and to the substantial resolution of imaging findings. Azathioprine was used as a maintenance treatment. One relapse occurred 2 years after the initial diagnosis and patient was re-treated with glucocorticoids. Three years after relapse, patient is in remission with azathioprine. We present the first case of myelitis with radiological features of LETM associated with increased IgG4 serum levels and the simultaneous presence of asymptomatic IgG4-related hypophysitis.
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Affiliation(s)
- Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece.
| | - Maria-Eleptheria Evangelopoulos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Boutzios
- Endocrine Unit, Department of Pathophysiology, Laikon General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitrios Tzanetakos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - John Tzartos
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Velonakis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Panagiotis Toulas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Elissavet Andreadou
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Georgios Koutsis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
| | - George E Fragoulis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, "Laiko" General Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens, National and Kapodistrian University, Aeginition Hospital, Athens, Greece
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentation, diagnostic evaluation, and management of immune-mediated myelopathies. RECENT FINDINGS The discovery of several neural autoantibodies and their antigenic targets has revolutionized the investigation and treatment of immune-mediated myelopathies. Detection of these serologic biomarkers can support or establish a diagnosis of an autoimmune myelopathy, and, in the case of paraneoplastic syndromes, indicate the likely presence of an underlying malignancy. Distinctive lesion patterns detected on spinal cord or brain MRI narrow the differential diagnosis in patients with acute or subacute inflammatory myelopathies, including those not associated with autoantibody markers. SUMMARY Immune-mediated myelopathies usually present acutely or subacutely and have a broad differential diagnosis. A systematic diagnostic approach using data from the clinical setting and presentation, MRI lesion patterns, CSF data, and autoantibody markers can differentiate these disorders from noninflammatory myelopathies, often with precise disease classification. This, in turn, provides prognostic information, especially whether the disorder is likely to relapse, and facilitates therapeutic decision making. Diagnostic accuracy informs selection of acute immunotherapy aimed at arresting and reversing recent neurologic injury and, when necessary, selection of long-term treatment for prevention of disease progression or relapse.
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Bulut E, Shoemaker T, Karakaya J, Ray DM, Mealy MA, Levy M, Izbudak I. MRI Predictors of Recurrence and Outcome after Acute Transverse Myelitis of Unidentified Etiology. AJNR Am J Neuroradiol 2019; 40:1427-1432. [PMID: 31296526 DOI: 10.3174/ajnr.a6121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/06/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE The early prediction of recurrence after an initial event of transverse myelitis helps to guide preventive treatment and optimize outcomes. Our aim was to identify MR imaging findings predictive of relapse and poor outcome in patients with acute transverse myelitis of unidentified etiology. MATERIALS AND METHODS Spinal MRIs of 77 patients (mean age, 36.3 ± 20 years) diagnosed with acute transverse myelitis were evaluated retrospectively. Only the patients for whom an underlying cause of myelitis could not be identified within 3 months of symptom onset were included. Initial spinal MR images of patients were examined in terms of lesion extent, location and distribution, brain stem extension, cord expansion, T1 signal, contrast enhancement, and the presence of bright spotty lesions and the owl's eyes sign. The relapse rates and Kurtzke Expanded Disability Status Scale scores at least 1 year (range, 1-14 years) after a myelitis attack were also recorded. Associations of MR imaging findings with clinical variables were studied with univariate associations and binary log-linear regression. Differences were considered significant for P values < .05. RESULTS Twenty-seven patients (35.1%) eventually developed recurrent disease. Binary logistic regression revealed 3 main significant predictors of recurrence: cord expansion (OR, 5.30; 95% CI, 1.33-21.11), contrast enhancement (OR, 5.05; 95% CI, 1.25-20.34), and bright spotty lesions (OR, 3.63; 95% CI, 1.06-12.43). None of the imaging variables showed significant correlation with the disability scores. CONCLUSIONS Cord expansion, contrast enhancement, and the presence of bright spotty lesions could be used as early MR imaging predictors of relapse in patients with acute transverse myelitis of unidentified etiology. Collaborative studies with a larger number of patients are required to validate these findings.
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Affiliation(s)
- E Bulut
- From the Departments of Radiology (E.B.)
| | - T Shoemaker
- Department of Neurology (T.S., M.A.M., M.L.)
- Department of Neurological Sciences (T.S.), Rush University Medical Center, Chicago, Illinois
| | - J Karakaya
- Statistics (J.K.), Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - D M Ray
- Division of Neuroradiology (D.M.R., I.I.), The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M A Mealy
- Department of Neurology (T.S., M.A.M., M.L.)
| | - M Levy
- Department of Neurology (T.S., M.A.M., M.L.)
- Department of Neurology (M.L.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - I Izbudak
- Division of Neuroradiology (D.M.R., I.I.), The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Jarius S, Wildemann B. Devic's index case: A critical reappraisal - AQP4-IgG-mediated neuromyelitis optica spectrum disorder, or rather MOG encephalomyelitis? J Neurol Sci 2019; 407:116396. [PMID: 31726278 DOI: 10.1016/j.jns.2019.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/01/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022]
Abstract
In 1894, Eugène Devic (1858-1930) and his doctoral student Fernand Gault (1873-1936) reported on a patient with optic neuritis (ON) and myelitis and proposed the name "neuro-myélite optique" for this syndrome. Subsequently, Devic became the eponym of neuromyelitis optica (NMO), which was then referred to as "Devic's syndrome", "Devic's disease" or "Morbus Devic". Thereby, the case became a historical index case of NMO. For many decades little attention was paid to NMO, which most authors considered a clinical variant of multiple sclerosis. However, the discovery of pathogenic antibodies to aquaporin-4 at the beginning of the 21st century revived interest in the syndrome, and AQP4-IgG-positive NMO spectrum disorders (NMOSD) are now studied as prototypical autoimmune diseases. More recently, antibodies to full-length myelin oligodendrocyte glycoprotein (MOG) have been detected in patients with ON as well as in patients with myelitis, some of whom exhibit a clinical phenotype very similar to that described by Devic. This raises the question of whether Devic's patient might have suffered from MOG encephalomyelitis rather than classic NMOSD. In this article, we summarise and discuss the available evidence for and against that hypothesis. We also discuss differential diagnoses and the question whether Devic's patient, who worked as a hatter and had initially been admitted for nervous hyperexcitability and tremor, might have suffered from co-existing erethism ('mad hatter disease'), which is caused by chronic occupational exposure to mercury.
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Affiliation(s)
- S Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Germany.
| | - B Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Germany.
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Devi A, Singh K, Gupta S, Bhutani N, Agarwal P. A descriptive study of clinical and radiological profile of longitudinal extensive myelitis in a tertiary hospital in Rajasthan, India. Clin Neurol Neurosurg 2019; 181:33-40. [DOI: 10.1016/j.clineuro.2019.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/06/2019] [Accepted: 04/07/2019] [Indexed: 10/27/2022]
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Seyedali S, Alpert DR. Longitudinal extensive transverse myelitis: a rare neurological complication of systemic lupus erythematosus. BMJ Case Rep 2019; 12:12/4/e228950. [PMID: 31028050 DOI: 10.1136/bcr-2018-228950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We present a 47-year-old woman with recently diagnosed systemic lupus erythematosus who developed progressive numbness and tingling of her upper and lower extremities, followed by weakness and difficulty ambulating. She was diagnosed with longitudinal extensive transverse myelitis involving her entire cervical and thoracic spinal cord. Infectious workup was unrevealing. She failed to respond to pulse-dose intravenous steroids, but slowly improved with the addition of plasmapheresis and cyclophosphamide. Following maintenance treatment with mycophenolate mofetil and slow tapering of oral steroids, she has maintained complete remission with significant recovery of neurological function.
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Affiliation(s)
- Sara Seyedali
- Department of Rheumatology, Cooper University Hospital, Camden, New Jersey, USA
| | - Deborah R Alpert
- Medicine/Rheumatology, Jersey Shore University Medical Center, Neptune, New Jersey, USA
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Golub D, Williams F, Wong T, Iyengar N, Jolley H, Sabadiah S, Rhee D, Gold-von Simson G. A Longitudinally Extensive Spinal Cord Lesion Restricted to Gray Matter in an Adolescent Male. Front Neurol 2019; 10:270. [PMID: 30949125 PMCID: PMC6435483 DOI: 10.3389/fneur.2019.00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/28/2019] [Indexed: 01/19/2023] Open
Abstract
Longitudinally extensive spinal cord lesions (LECL) restricted to gray matter are poorly understood as are their neurodevelopmental repercussions in children. We herein report the critical case of a 13-year-old male presenting with progressive quadriparesis found to have cervical LECL restricted to the anterior horns. Challenged with a rare diagnostic dilemma, the clinical team systematically worked through potential vascular, genetic, infectious, rheumatologic, and paraneoplastic diagnoses before assigning a working diagnosis of acute inflammatory myelopathy. Nuanced consideration of and workup for both potential ischemic causes (arterial dissection, fibrocartilaginous embolism, vascular malformation) and specific inflammatory conditions including Transverse Myelitis, Neuromyelitis Optica Spectrum Disorders (NMOSD), Multiple Sclerosis (MS), Acute Disseminated Encephalomyelitis (ADEM), and Acute Flaccid Myelitis (AFM) is explained in the context of a comprehensive systematic review of the literature on previous reports of gray matter-restricted longitudinally extensive cord lesions in children. Treatment strategy was ultimately based on additional literature review of treatment-refractory acute inflammatory neurological syndromes in children. A combination of high-dose steroids and plasmapheresis was employed with significant improvement in functional outcome, suggesting a potential benefit of combination immune-modulatory treatment in these patients. This case furthermore highlights quality clinical reasoning with respect to the elusive nature of diagnosis, nuances in neuroimaging, and multifocal treatment strategies in pediatric LECL.
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Affiliation(s)
- Danielle Golub
- New York University School of Medicine, New York, NY, United States
| | - Faith Williams
- School of Medicine, Washington University School of Medicine, Saint Louis, MO, United States
| | - Taylor Wong
- New York University School of Medicine, New York, NY, United States
| | - Nishanth Iyengar
- New York University School of Medicine, New York, NY, United States
| | - Hannah Jolley
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Sakinah Sabadiah
- Department of Neurology, New York University School of Medicine, New York, NY, United States
| | - David Rhee
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Gabrielle Gold-von Simson
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States.,Health and Hospitals, Clinical Translational Science Institute, New York University, New York, NY, United States
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Ciccarelli O, Cohen JA, Reingold SC, Weinshenker BG, Amato MP, Banwell B, Barkhof F, Bebo B, Becher B, Bethoux F, Brandt A, Brownlee W, Calabresi P, Chatway J, Chien C, Chitnis T, Ciccarelli O, Cohen J, Comi G, Correale J, De Sèze J, De Stefano N, Fazekas F, Flanagan E, Freedman M, Fujihara K, Galetta S, Goldman M, Greenberg B, Hartung HP, Hemmer B, Henning A, Izbudak I, Kappos L, Lassmann H, Laule C, Levy M, Lublin F, Lucchinetti C, Lukas C, Marrie RA, Miller A, Miller D, Montalban X, Mowry E, Ourselin S, Paul F, Pelletier D, Ranjeva JP, Reich D, Reingold S, Rocca MA, Rovira A, Schlaerger R, Soelberg Sorensen P, Sormani M, Stuve O, Thompson A, Tintoré M, Traboulsee A, Trapp B, Trojano M, Uitdehaag B, Vukusic S, Waubant E, Weinshenker B, Wheeler-Kingshott CG, Xu J. Spinal cord involvement in multiple sclerosis and neuromyelitis optica spectrum disorders. Lancet Neurol 2019; 18:185-197. [DOI: 10.1016/s1474-4422(18)30460-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022]
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Abstract
Brain has been considered as an immune-privileged site for centuries owing to the presence of blood-brain barrier, absent lymphatic drainage, and antigen-presenting cells. However, the present prevailing concept is of immune surveillance where brain is continuously surveyed by immune cells. However, the presence of immune cells in central nervous system (CNS) brings the risk of inflammation and autoimmunity involving both T and B cell mediated pathways. These mechanisms form the underlying pathology in a wide spectrum of pediatric CNS diseases manifesting as acquired neurological deficits. Overlapping, heterogenous, and ambiguous clinical features often delays the diagnosis. Although not always pathognomonic, magnetic resonance imaging can be an important biomarker leading to early diagnosis, prognostication, and systematic follow-up pf these diseases. This review describes the spectrum of different pediatric inflammatory disorders and their pertinent imaging features illustrated with clinical examples.
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Affiliation(s)
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Manohar Shroff
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
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