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Ide T, Ebashi R, Eriguchi M, Aishima S, Abe T, Hara H. Fulminant demyelinating disease of the central nervous system effectively treated with a combination of decompressive craniectomy and immunotherapy: A case report and literature review. Clin Case Rep 2024; 12:e9059. [PMID: 38988893 PMCID: PMC11233259 DOI: 10.1002/ccr3.9059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/08/2024] [Accepted: 05/25/2024] [Indexed: 07/12/2024] Open
Abstract
Key Clinical Message Accurately identifying fulminant demyelinating diseases is important for sudden onset of asymmetric cerebral white matter lesions with mass effect. Initially, immunotherapy should be administered; however, surgical intervention should be performed with poor response to medical management and evident signs of cerebral herniation. Abstract A case of fulminant demyelinating disease of the central nervous system that required decompressive craniectomy 8 days after symptom onset is presented. The patient recovered without sequelae after a combination of neurosurgery and immunotherapy with steroids and has remained relapse-free for 4 years.
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Affiliation(s)
- Toshihiro Ide
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine Saga University Saga Japan
| | - Ryo Ebashi
- Department of Neurosurgery, Faculty of Medicine Saga University Saga Japan
| | - Makoto Eriguchi
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine Saga University Saga Japan
| | - Shinichi Aishima
- Department of Pathology and Microbiology, Faculty of Medicine Saga University Saga Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine Saga University Saga Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine Saga University Saga Japan
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2
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Czeisler BM. Emergent Management of Central Nervous System Demyelinating Disorders. Continuum (Minneap Minn) 2024; 30:781-817. [PMID: 38830071 DOI: 10.1212/con.0000000000001436] [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: 06/05/2024]
Abstract
OBJECTIVE This article reviews the various conditions that can present with acute and severe central nervous system demyelination, the broad differential diagnosis of these conditions, the most appropriate diagnostic workup, and the acute treatment regimens to be administered to help achieve the best possible patient outcomes. LATEST DEVELOPMENTS The discovery of anti-aquaporin 4 (AQP4) antibodies and anti-myelin oligodendrocyte glycoprotein (MOG) antibodies in the past two decades has revolutionized our understanding of acute demyelinating disorders, their evaluation, and their management. ESSENTIAL POINTS Demyelinating disorders comprise a large category of neurologic disorders seen by practicing neurologists. In the majority of cases, patients with these conditions do not require care in an intensive care unit. However, certain disorders may cause severe demyelination that necessitates intensive care unit admission because of numerous simultaneous multifocal lesions, tumefactive lesions, or lesions in certain brain locations that lead to acute severe neurologic dysfunction. Intensive care may be necessary for the management and prevention of complications for patients who have severely altered mental status, rapidly progressive neurologic worsening, elevated intracranial pressure, severe cerebral edema, status epilepticus, or respiratory failure.
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3
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Zhang Z, Wang W, Huang X, Liu G. Distributed loss-amplification modeling for the mid-infrared signal propagating in the myelinated and demyelinated nerve. APPLIED OPTICS 2023; 62:8606-8613. [PMID: 38037977 DOI: 10.1364/ao.503485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/20/2023] [Indexed: 12/02/2023]
Abstract
The terahertz (THz) to infrared (IR) neural signal model is a potential mechanism for explaining neural communication. Myelinated neurons could be a lossy dielectric waveguide that can propagate these THz-IR neural signals. We propose an electromagnetic loss-amplification model to describe the propagation characteristics of mid-IR signals on myelinated neurons. During transmission with loss and amplification, neural signal intensity can be consistently maintained at 15.9 pW in bands 55 to 75 THz. This phenomenon becomes more pronounced as the number of myelin sheaths increases. However, escalated degrees of demyelination result in a reduction of signal intensity from 15.9 to 10 pW. This phenomenon eventually disrupts the process of loss amplification, consequently impeding the transmission of the signal. These results may contribute to a deeper understanding of mid-IR signal propagation mechanisms in myelinated nerves and studies of diseases associated with demyelination.
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Stoian A, Bajko Z, Stoian M, Cioflinc RA, Niculescu R, Arbănași EM, Russu E, Botoncea M, Bălașa R. The Occurrence of Acute Disseminated Encephalomyelitis in SARS-CoV-2 Infection/Vaccination: Our Experience and a Systematic Review of the Literature. Vaccines (Basel) 2023; 11:1225. [PMID: 37515041 PMCID: PMC10385010 DOI: 10.3390/vaccines11071225] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/30/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The neurological complications of coronavirus disease 2019 (COVID-19) infection and the side effects of vaccination include immune-mediated diseases of the central nervous system (CNS) such as acute disseminated encephalomyelitis (ADEM). It is an acute-onset demyelinating disease that involves a rapid evolution and multifocal neurological deficits that develops following a viral or bacterial infection or, less frequently, following vaccination. Acute hemorrhagic leukoencephalitis (AHLE) is the hemorrhagic variant of ADEM that presents a more severe evolution which can be followed by coma and death. The objectives of this study consist in evaluating the diagnosis, clinical characteristics, imaging and laboratory features, evolution, and treatment of ADEM and AHLE following COVID-19 infection or vaccination. METHODS We performed a systematic review of the medical literature according to PRISMA guidelines that included ADEM cases published between 1 January 2020 and 30 November 2022 following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vaccination and also included our own clinical experience regarding this pathology. RESULTS A total number of 74 patients were diagnosed with ADEM, 45 following COVID-19 infection and 29 after a SARS-CoV-2 vaccine. A total of 13 patients (17.33%) presented AHLE. The moderate form of COVID-19 presented a positive correlation with AHLE (r = 0.691, p < 0.001). The existence of coma and AHLE was correlated with poor outcomes. The following more aggressive immunomodulatory therapies applied in severe cases were correlated with poor outcomes (major sequelae and death): therapeutic plasma exchange (TPE) treatment (r = 382, p = 0.01) and combined therapy with corticosteroids and TPE (r = 0.337, p = 0.03). CONCLUSIONS Vaccinations are essential to reduce the spread of the COVID-19 pandemic, and the monitoring of adverse events is an important part of the strategic fight against SARS-CoV-2. The general benefits and the overall good evolution outweigh the risks, and prompt diagnosis is associated with a better prognosis in these patients.
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Affiliation(s)
- Adina Stoian
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Zoltan Bajko
- Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Mircea Stoian
- Department Anesthesiology and Critical Care Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | | | - Raluca Niculescu
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Emil Marian Arbănași
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, 540142 Targu Mures, Romania
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | - Eliza Russu
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | - Marian Botoncea
- Department of General Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Rodica Bălașa
- Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
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5
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Shen X. Research progress on pathogenesis and clinical treatment of neuromyelitis optica spectrum disorders (NMOSDs). Clin Neurol Neurosurg 2023; 231:107850. [PMID: 37390569 DOI: 10.1016/j.clineuro.2023.107850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 04/11/2023] [Accepted: 06/23/2023] [Indexed: 07/02/2023]
Abstract
Neuromyelitis optica spectrum disorders (NMOSDs) are characteristically referred to as various central nervous system (CNS)-based inflammatory and astrocytopathic disorders, often manifested by the axonal damage and immune-mediated demyelination targeting optic nerves and the spinal cord. This review article presents a detailed view of the etiology, pathogenesis, and prescribed treatment options for NMOSD therapy. Initially, we present the epidemiology of NMOSDs, highlighting the geographical and ethnical differences in the incidence and prevalence rates of NMOSDs. Further, the etiology and pathogenesis of NMOSDs are emphasized, providing discussions relevant to various genetic, environmental, and immune-related factors. Finally, the applied treatment strategies for curing NMOSD are discussed, exploring the perspectives for developing emergent innovative treatment strategies.
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Affiliation(s)
- Xinyu Shen
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200000, PR China.
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6
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Boyle T, Fernando SL, Drummond J, Fontes A, Parratt J. Phenotyping variants of tumefactive demyelinating lesions according to clinical and radiological features-A case series. Front Neurol 2023; 14:1092373. [PMID: 36816572 PMCID: PMC9935935 DOI: 10.3389/fneur.2023.1092373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/18/2023] [Indexed: 02/05/2023] Open
Abstract
Background Tumefactive demyelinating lesions (TDLs) are defined as lesions >2 cm on MRI of the brain. They are identified in a range of demyelinating diseases including massive demyelination due to Marburg's acute MS, Schilder's Disease, Balo's concentric sclerosis, and Tumefactive MS. Apart from the rare demyelinating variants which are often diagnosed histologically, there are no detailed data to phenotype TDLs. Methods We describe the clinical and radiological features of four similar patients with very large TDLs (>4 cm), that are not consistent with the rare demyelinating variants and may represent a distinct phenotype. Results All patients presented with hemiplegia and apraxia. The mean age at onset was 37 years with an equal sex distribution. All patients were diagnosed with Tumefactive demyelination based on MRI and CSF analysis, precluding the need for brain biopsy. All responded to potent immunotherapy (including high dose corticosteroids, plasma exchange, rituximab, and/or cyclophosphamide). The mean lag from diagnosis to treatment was 1 day. The median EDSS at presentation was six and recovery to a median EDSS of two occurred over 6 months. Conclusion We propose that Tumefactive lesions larger than 4 cm are termed "Giant demyelinating lesions" (GDLs) not only on the basis of size, but a rapid and fulminant demyelinating presentation leading to acute, severe neurological disability that is, nonetheless, responsive to immunotherapy. Further clinical studies are required to ratify this proposed phenotype, establish the immunological profile and best treatment for such patients.
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Affiliation(s)
- Thérèse Boyle
- Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, NSW, Australia,Immunology Laboratory, Royal North Shore Hospital, St Leonards, NSW, Australia,Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,*Correspondence: Thérèse Boyle ✉
| | - Suran L. Fernando
- Clinical Immunology and Allergy, Royal North Shore Hospital, St Leonards, NSW, Australia,Immunology Laboratory, Royal North Shore Hospital, St Leonards, NSW, Australia,Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - James Drummond
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neuroradiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ariadna Fontes
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neurology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John Parratt
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia,Department of Neurology, Royal North Shore Hospital, St Leonards, NSW, Australia
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Weil EL, Nakawah MO. Recurrent tumefactive demyelinating lesions in an elderly woman. Radiol Case Rep 2022; 17:4570-4574. [PMID: 36193269 PMCID: PMC9526022 DOI: 10.1016/j.radcr.2022.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 12/04/2022] Open
Abstract
Here we describe a 72-year old Caucasian woman who presented with progressive left hemiparesis and hemisensory deficits due to a pathology-confirmed tumefactive demyelinating lesion in the right frontoparietal region. Symptoms improved with glucocorticoids and plasmapheresis, but five months following initial presentation, the patient developed right visual field deficits and acute encephalopathy. Brain imaging revealed near resolution of the initial lesion with interval development of new multifocal tumefactive demyelinating lesions. This case highlights several atypical features associated with tumefactive demyelinating disease, including an older age of onset and recurrent, treatment-resistant lesions. Clinical and neuroimaging features which may be helpful in diagnosing this rare disorder are reviewed.
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8
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Deng R, Wu Y, Xu L, Liu K, Huang X, Zhang X. Clinical risk factors and prognostic model for idiopathic inflammatory demyelinating diseases after haploidentical hematopoietic stem cell transplantation in patients with hematological malignancies. Am J Hematol 2021; 96:1407-1419. [PMID: 34350623 DOI: 10.1002/ajh.26312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/16/2021] [Accepted: 08/02/2021] [Indexed: 01/09/2023]
Abstract
Idiopathic inflammatory demyelinating diseases (IIDDs) of the central nervous system (CNS) are rare but serious neurological complications of haploidentical hematopoietic stem cell transplantation (haplo-HSCT). However, the risk factors and a method to predict the prognosis of post-transplantation CNS IIDDs are not available. This retrospective study first reviewed data from 4532 patients who received haplo-HSCT during 2008-2019 in our center, and 184 patients (4.1%) with IIDDs after haplo-HSCT were identified. Grades II to IV acute graft-versus-host disease (aGVHD) (p < 0.001) and chronic GVHD (cGVHD) (p = 0.009) were identified as risk factors for developing IIDDs after haplo-HSCT. We then divided the 184 IIDD patients into a derivation cohort and validation cohort due to transplantation time to develop and validate a model for predicting the prognosis of IIDDs. In the multivariate analysis of the derivation cohort, four candidate predictors were entered into the final prognostic model: cytomegalovirus (CMV) infection, Epstein-Barr virus (EBV) infection, IgG synthesis (IgG-syn) and spinal cord lesions. The prognostic model had an area under the receiver operating characteristic curve of 0.864 (95% CI: 0.803-0.925) in the internal validation cohort and 0.871 (95% CI: 0.806-0.931) in the external validation cohort. The calibration plots showed a high agreement between the predicted and observed outcomes. Decision curve analysis indicated that IIDD patients could benefit from the clinical application of the prognostic model. The identification of IIDD patients after allo-HSCT who have a poor prognosis might allow timely treatment and improve patient survival and outcomes.
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Affiliation(s)
- Rui‐Xin Deng
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
| | - Ye‐Jun Wu
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
| | - Lan‐Ping Xu
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
| | - Kai‐Yan Liu
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
| | - Xiao‐Jun Huang
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
| | - Xiao‐Hui Zhang
- Peking University People's Hospital Peking University Institute of Hematology Beijing China
- Collaborative Innovation Center of Hematology Peking University Beijing China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
- National Clinical Research Center for Hematologic Disease Beijing China
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9
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Ki SM, Jeong HS, Lee JE. Primary Cilia in Glial Cells: An Oasis in the Journey to Overcoming Neurodegenerative Diseases. Front Neurosci 2021; 15:736888. [PMID: 34658775 PMCID: PMC8514955 DOI: 10.3389/fnins.2021.736888] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/31/2021] [Indexed: 12/29/2022] Open
Abstract
Many neurodegenerative diseases have been associated with defects in primary cilia, which are cellular organelles involved in diverse cellular processes and homeostasis. Several types of glial cells in both the central and peripheral nervous systems not only support the development and function of neurons but also play significant roles in the mechanisms of neurological disease. Nevertheless, most studies have focused on investigating the role of primary cilia in neurons. Accordingly, the interest of recent studies has expanded to elucidate the role of primary cilia in glial cells. Correspondingly, several reports have added to the growing evidence that most glial cells have primary cilia and that impairment of cilia leads to neurodegenerative diseases. In this review, we aimed to understand the regulatory mechanisms of cilia formation and the disease-related functions of cilia, which are common or specific to each glial cell. Moreover, we have paid close attention to the signal transduction and pathological mechanisms mediated by glia cilia in representative neurodegenerative diseases. Finally, we expect that this field of research will clarify the mechanisms involved in the formation and function of glial cilia to provide novel insights and ideas for the treatment of neurodegenerative diseases in the future.
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Affiliation(s)
- Soo Mi Ki
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Hui Su Jeong
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Ji Eun Lee
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
- Samsung Medical Center, Samsung Biomedical Research Institute, Seoul, South Korea
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10
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Sacco S, Callegari I, Canavero I, Coloberti E, Farina LM, Ravaglia S, Simoncelli A, Pichiecchio A, Micieli G. Fulminant inflammatory demyelination presenting as stroke-in-evolution in an elderly subject. Brain Behav 2021; 11:e01967. [PMID: 33615744 PMCID: PMC8413797 DOI: 10.1002/brb3.1967] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Fulminant inflammatory demyelination is a possible presentation of inflammatory demyelinating disorders, thus representing a potential stroke mimic especially in younger patients. AIMS OF THE STUDY To describe clinical and diagnostic pitfalls in a case of fulminant inflammatory demyelination presenting with stroke-like symptoms in an elderly patient. METHODS Case report and case-based review of the literature. RESULTS A 67-year-old woman, who accessed the emergency room as suspect stroke for hyperacute onset of rapidly worsening speech impairment and drowsiness, was later diagnosed with a huge brain inflammatory demyelination. Clinical, laboratory, and neuroimaging tests did not allow to put a more specific diagnosis. Due to the rapidly deteriorating course, she received immunosuppression with benefit. CONCLUSION This report is meant to highlight the diagnostic challenges connected with fulminant inflammatory demyelination, which sometime can resemble a stroke-in evolution and appear clinically unfitting for inclusion in any specific pathological entities within the broad-spectrum of inflammatory demyelinating disorders.
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Affiliation(s)
- Simone Sacco
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, Institute of Radiology, University of Pavia, Pavia, Italy
| | - Ilaria Callegari
- Neuroscience Consortium, Monza Policlinico and Pavia Mondino, University of Pavia, Pavia, Italy
| | | | - Elisa Coloberti
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Sabrina Ravaglia
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Anna Simoncelli
- Diagnostic Radiology, Interventional Radiology and Neuroradiology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Pichiecchio
- Neuroradiology Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Giuseppe Micieli
- Emergency Neurology Unit, IRCCS Mondino Foundation, Pavia, Italy
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11
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Almaghrabi N, Saab A. Adult onset acute disseminated encephalomyelitis: A case report. Radiol Case Rep 2021; 16:2469-2473. [PMID: 34257782 PMCID: PMC8260756 DOI: 10.1016/j.radcr.2021.05.052] [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: 04/21/2021] [Revised: 05/22/2021] [Accepted: 05/23/2021] [Indexed: 11/26/2022] Open
Abstract
Acute disseminated encephalomyelitis is an immune mediated demyelinating disorder of the central nervous system, it predominantly affects children in the age group between of 5-8 years. Is most widely thought to be a post-viral, post-vaccination autoimmune phenomenon. We present a case of 40 years old Pakistani male arrived to ER agitated with decrease level of consciousness and delirium, develop tonic-clonic convulsion and it was relieved by DIAZEPAM. This is the first attack to the patient with no past medical history of similar presentation. MRI showed supra and infratentorial white matter high T2/FLAIR signal abnormalities, involving supratentorial cortical and subcortical parito-occipital region, also to less extent at deep white matter predominantly right tempro-occipital region in asymmetric pattern. Involvement of juxta cortical and U fibers. MRI raised the possibility of adult onset Acute disseminated encephalomyelitis, after exclusion of other causes of juxta cortical and U fibers involvement (based on imaging analysis with consideration of clinical presentation and available lab results).
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Affiliation(s)
- Nizar Almaghrabi
- Radiology resident, King Abdulaziz Hospital, Makkah, Saudi Arabia
| | - Abeer Saab
- Neuroradiology Consultant, King Abdulaziz Hospital, Makkah, Saudi Arabia
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12
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McLendon LA, Rao CK, Da Hora CC, Islamovic F, Galan FN. Post-COVID-19 Acute Disseminated Encephalomyelitis in a 17-Month-Old. Pediatrics 2021; 147:peds.2020-049678. [PMID: 33762311 DOI: 10.1542/peds.2020-049678] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Abstract
Neurologic manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pediatric patients have been reported in the acute and postinfectious stages of coronavirus disease 2019. Acute disseminated encephalomyelitis (ADEM) typically presents in children after a viral illness at a mean age of 3 to 7 years. A total of 60% to 90% of literature-reported pediatric patients with ADEM have minimal to no neurologic deficits at long-term follow-up. We present a 17-month-old developmentally typical girl with parental complaints of irritability, upper extremity weakness, and gait disturbance. She presented to the hospital afebrile and irritable with right-sided nasolabial fold flattening, neck stiffness, left upper extremity rigidity, right upper extremity paresis, bilateral lower extremity hyperreflexia, and truncal ataxia. During her hospital course, she became somnolent with autonomic instability and was transferred to intensive care. Contrasted brain MRI revealed diffuse patchy T2 hyperintensities without contrast enhancement. Nasopharyngeal SARS-CoV-2 polymerase chain reaction and serum antibody testing results were positive. Cerebral spinal fluid analysis was unremarkable. Respiratory viral panel and autoimmune encephalitis and demyelinating disorders panel results were negative. She was started on high-dose methylprednisolone and intravenous immunoglobulin, with improvement in mental status, focal deficits, and ambulation. After hospital discharge, she received inpatient rehabilitation for 2 weeks and at 2 month follow-up had a full neurologic recovery. We report the youngest case of postinfectious ADEM due to SARS-CoV-2 in a toddler. Early recognition of autoimmune and inflammatory complications of SARS-CoV-2 is vital for early aggressive immunomodulatory treatment and, consequently, improved morbidity in these patients.
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Affiliation(s)
- Loren A McLendon
- Division of Child and Adolescent Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.,Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
| | - Chethan K Rao
- Division of Child and Adolescent Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.,Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
| | - Cintia Carla Da Hora
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | - Florinda Islamovic
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | - Fernando N Galan
- Division of Pediatric Neurology, Nemours Children Specialty Clinic, Jacksonville, Florida; and
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13
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Kawashima H, Abe Y, Matsui K, Yamada K. Perivascular abnormalities in pediatric encephalopathy with fulminant brain edema. Brain Dev 2021; 43:719-723. [PMID: 33597110 DOI: 10.1016/j.braindev.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute encephalopathy with acute brain swelling (ABS) is a recently proposed disease of unknown etiology, characterized by rapid progression to whole-brain swelling. To our knowledge, we reported the first case of a patient with acute encephalopathy with ABS wherein brain magnetic resonance imaging (MRI) abnormalities were noted prior to the diffuse brain swelling onset. CASE PRESENTATION An 11-year-old boy was admitted to our unit owing to prolonged disturbance of consciousness following febrile status epilepticus. At the initial visit, the vital signs were within the normal range, except for the body temperature and consciousness level (Glasgow Coma Scale 6; E1V1M4). The initial laboratory results showed elevated inflammatory marker levels and mild hyponatremia. Cerebrospinal fluid analysis revealed albuminocytologic dissociation, whereas the myelin basic protein level was not elevated. Electroencephalography showed diffuse, high-amplitude slow waves. No abnormalities were detected on the initial brain computed tomography (CT) scan. However, at 11 h after the seizure onset, diffuse hyperintense lesions were observed throughout the cerebrum on T2-weighted brain MRI. The patient was diagnosed with acute encephalopathy and received methylprednisolone-pulse therapy (1 g) with high-dose gamma globulin (1 g/kg) administration. At 14 h after the seizure onset, the patient was declared brain-dead; the brain CT findings revealed whole-brain swelling and herniation. CONCLUSION Our findings were suggestive of a perivascular pathophysiology and may be used for subtyping acute encephalopathy. In cases where such findings are observed, subsequent development of severe diffuse brain swelling should be considered.
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Affiliation(s)
- Hideshi Kawashima
- Division of Pediatrics, Niigata City General Hospital, Niigata, Japan
| | - Yuki Abe
- Division of Pediatrics, Niigata City General Hospital, Niigata, Japan
| | - Kou Matsui
- Division of Pediatrics, Niigata City General Hospital, Niigata, Japan
| | - Kenichi Yamada
- Center for Integrated Human Brain Science, Brain Research Institute, University of Niigata, Japan.
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Boziki M, Sintila SA, Ioannidis P, Grigoriadis N. Biomarkers in Rare Demyelinating Disease of the Central Nervous System. Int J Mol Sci 2020; 21:ijms21218409. [PMID: 33182495 PMCID: PMC7665127 DOI: 10.3390/ijms21218409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 12/29/2022] Open
Abstract
Rare neurological diseases are a heterogeneous group corresponding approximately to 50% of all rare diseases. Neurologists are among the main specialists involved in their diagnostic investigation. At the moment, a consensus guideline on which neurologists may base clinical suspicion is not available. Moreover, neurologists need guidance with respect to screening investigations that may be performed. In this respect, biomarker research has emerged as a particularly active field due to its potential applications in clinical practice. With respect to autoimmune demyelinating diseases of the Central Nervous System (CNS), although these diseases occur in the frame of organ-specific autoimmunity, pathology of the disease itself is orchestrated among several anatomical and functional compartments. The differential diagnosis is broad and includes, but is not limited to, rare neurological diseases. Multiple Sclerosis (MS) needs to be differentially diagnosed from rare MS variants, Acute Disseminated Encephalomyelitis (ADEM), the range of Neuromyelitis Optica Spectrum Disorders (NMOSDs), Myelin Oligodendrocyte Glycoprotein (MOG) antibody disease and other systemic inflammatory diseases. Diagnostic biomarkers may facilitate timely diagnosis and proper disease management, preventing disease exacerbation due to misdiagnosis and false treatment. In this review, we will describe advances in biomarker research with respect to rare neuroinflammatory disease of the CNS.
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Therapeutic plasma exchange vs conventional treatment with intravenous high dose steroid for neuromyelitis optica spectrum disorders (NMOSD): a systematic review and meta-analysis. J Neurol 2020; 268:4549-4562. [DOI: 10.1007/s00415-020-10257-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 12/15/2022]
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Febyan, Sutrisno S, Ronny, Wetarini K. Neuroimaging features of tumefactive demyelinating lesions: A rare case report. Eur J Radiol Open 2020; 7:100247. [PMID: 32884980 PMCID: PMC7452373 DOI: 10.1016/j.ejro.2020.100247] [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: 05/13/2020] [Accepted: 08/14/2020] [Indexed: 10/25/2022] Open
Abstract
Tumefactive demyelinating lesion is a special type of neuro-inflammatory disease with unusual variants to be found in magnetic resonance imaging. It manifests as a solitary or multiple lesion greater than 2 cm in diameter and often clinically challenging because of its varieties of symptoms. We present a rare case of a 40-year-old male, presented with initial complaints of headache and unconsciousness. Yet, the physical examination findings showed normal results. Magnetic resonance imaging revealed a tumefactive demyelinating lesion suspected with brain neoplasm.
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Affiliation(s)
- Febyan
- Department of Medicine, Faculty of Medicine, Krida Wacana Christian University, Jakarta, Indonesia
| | - Sony Sutrisno
- Department of Radiology, Faculty of Medicine, Krida Wacana Christian University, Jakarta, Indonesia
| | - Ronny
- Department of Radiology, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Krisnhaliani Wetarini
- Department of Medicine, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
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Gaba S, Garg S, Gupta M, Gupta R. Haemorrhagic encephalitis in the garb of scrub typhus. BMJ Case Rep 2020; 13:13/8/e235790. [PMID: 32859623 DOI: 10.1136/bcr-2020-235790] [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] [Indexed: 11/04/2022] Open
Abstract
A 19-year-old girl presented with fever, headache, vomiting and drowsiness. She had grade 1 papilloedema and neck rigidity but no focal deficits or seizures. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis, slightly elevated protein and normal glucose. MRI of the brain showed a hyperintense lesion in left ganglio-capsular region on the fluid attenuation inversion recovery sequence with perilesional oedema and mild midline shift. Haemorrhage was seen in the region on susceptibility weighted imaging . The patient was thoroughly investigated for known causes of meningoencephalitis, but the diagnosis of scrub typhus was delayed till the 10th day of illness. She was treated with doxycycline for 2 weeks and had marked improvement, both clinically and radiologically. Literature review has revealed that although meningoencephalitis in scrub typhus is not uncommon, such atypical lesions on brain MRI are a rarity. Serial imaging was performed to document the disease progression and resolution on treatment.
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Affiliation(s)
- Saurabh Gaba
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Swati Garg
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Monica Gupta
- Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
| | - Rekha Gupta
- Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India
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Acute Disseminated Encephalomyelitis: An Unusual Presentation of Human Immunodeficiency Virus Infection. Case Rep Infect Dis 2020; 2020:1020274. [PMID: 32566331 PMCID: PMC7294351 DOI: 10.1155/2020/1020274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/23/2020] [Accepted: 05/21/2020] [Indexed: 11/17/2022] Open
Abstract
Background Acute disseminated encephalomyelitis (ADEM) is a rare inflammatory and demyelinating disorder of the central nervous system, with a distinct tendency to a perivenous localization of pathological changes. Children are the most affected population and frequently presented after exanthematous viral infections or vaccination. Due to the rarity of this disease, the annual incidence rate in the population is not precisely known. Case Presentation. Here, we present a 28-year-old male HIV-1 positive patient with an acute confusional state, a diminished alert status characterized by somnolence, hypoprosexia, and complex visual hallucinations. Neuroimages reported white matter demyelinating lesions, mainly affecting the semioval centers, the frontal lobe, and the left parietal lobe; hypointense on T1-weighted images, hyperintense on T2-weighted images and fluid-attenuated inversion recovery weighted images, DWI with restricted diffusion, and a parietal ring-enhancing lesion after IV gadolinium administration. Discussion. In HIV positive patients, the demyelinating disorders have a broader clinical spectrum that could be explained by the immunosuppressed state of the patients, the evolution of the disease, the use of medications, the opportunistic infections, and the environment. Due to this highly variable clinical spectrum, ADEM is a significant challenge for the physicians in HIV positive patients, causing a delay in the diagnosis and treatment. Conclusion We suggest that ADEM should be considered among the differential diagnosis in HIV-infected patients with focal or multifocal neurological symptoms, particularly in encephalopathies with multifocal central nervous system involvement without severe immunosuppression.
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Abstract
We aim to review the imaging appearance of fulminant demyelinating disorders of central nervous system that have different pathological features, clinical course, clinical features, and imaging findings different from classic multiple sclerosis. Routine magnetic resonance imaging (MRI) can help in accurate localization of the lesions, detection of associated lesions, and monitoring of these patients. Advanced MRI combined with routine MRI can aid in differentiation fulminant demyelinating lesions from simulating malignancy. Tumefactive demyelination lesions are located in supratentorial white matter mainly frontal and parietal regions with incomplete rim enhancement. Baló concentric sclerosis shows characteristic concentric onion skin appearance. Schilder disease is subacute or acute demyelinating disorders with one or more lesions commonly involving the centrum semiovale. Marburg disease is the most severe demyelinating disorder with diffuse infiltrative lesions and massive edema involving both the cerebral hemisphere and brain stem.
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Acute Disseminated Encephalomyelitis (ADEM) and Increased Intracranial Pressure Associated With Anti-Myelin Oligodendrocyte Glycoprotein Antibodies. Pediatr Neurol 2019; 99:64-68. [PMID: 31248672 DOI: 10.1016/j.pediatrneurol.2019.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/02/2019] [Accepted: 03/08/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Antibodies to the myelin oligodendrocyte glycoprotein (MOG) have been identified in about 40% of children with acute disseminated encephalomyelitis (ADEM). The objective of this report is to describe three individuals with fulminant ADEM complicated by increased intracranial pressure associated with the presence of the anti-MOG antibodies. METHODS This is a retrospective case series. Informed consent was obtained from the concerned patients or caregivers. RESULTS High intracranial pressure associated with ADEM in the presence of MOG antibodies can result in cerebral edema, herniation, prolonged hospital stay (average intensive care unit stay: 22 days, average hospital stay: 50.6 days), and long-term disability. CONCLUSION Increased intracranial pressure complicating MOG antibody-related ADEM is a unique finding in our cases. This can complicate the clinical picture of ADEM and confers high morbidity. Long-term immunosuppression is warranted in selected cases with persistent seropositivity.
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Sandi D, Bereg E, Biernacki T, Vörös E, Klivényi P, Bereczki C, Vécsei L, Bencsik K. Pediatric multiple sclerosis and fulminant disease course: Features and approaches to treatment - A case report and review of the literature. J Clin Neurosci 2018; 53:13-19. [PMID: 29731272 DOI: 10.1016/j.jocn.2018.04.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
Multiple sclerosis (MS) is the autoimmune, neurodegenerative disease of the central nervous system (CNS). Typically, it affects the young adult population, however, up to 10% of the cases, it can develop in childhood. Atypical manifestations, such as the tumefactive variant (tMS) or acute disseminated encephalomyelitis (ADEM), especially coupled with fulminant disease course, are even more rare and pose a considerable differential diagnostic and therapeutic challenge. Recently, the therapeutic strategy on the use of disease modifying therapies (DMTs) in MS has shifted to the direction of a more individualized approach, that takes the personal differences heavily into account, in particular regard to the activity and prognosis of the disease. Despite this change has only been applied to adults yet, it is plausible to predict, that it will soon be applied to pediatric patients as well, particularly, as several randomized studies are under way concerning DMTs in pediatric populations. To our best knowledge, we are the first to report a successful natalizumab treatment of pediatric fulminant tMS, in case of a 13.5 years old girl. We feel that this report demonstrates the need of early and adequate treatment in such an aggressive case, because it can reverse the course of a possibly fatal disease.
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Affiliation(s)
- Dániel Sandi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Edit Bereg
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Tamás Biernacki
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Erika Vörös
- Department of Radiology, University of Szeged, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, University of Szeged, Szeged, Hungary
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Geschwind MD, Murray K. Differential diagnosis with other rapid progressive dementias in human prion diseases. HANDBOOK OF CLINICAL NEUROLOGY 2018; 153:371-397. [PMID: 29887146 DOI: 10.1016/b978-0-444-63945-5.00020-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prion diseases are unique in medicine as in humans they occur in sporadic, genetic, and acquired forms. The most common human prion disease is sporadic Creutzfeldt-Jakob disease (CJD), which commonly presents as a rapidly progressive dementia (RPD) with behavioral, cerebellar, extrapyramidal, and some pyramidal features, with the median survival from symptom onset to death of just a few months. Because human prion diseases, as well as other RPDs, are relatively rare, they can be difficult to diagnose, as most clinicians have seen few, if any, cases. Not only can prion diseases mimic many other conditions that present as RPD, but some of those conditions can present similarly to prion disease. In this article, the authors discuss the different etiologic categories of conditions that often present as RPD and also present RPDs that had been misdiagnosed clinically as CJD. Etiologic categories of conditions are presented in order of the mnemonic used for remembering the various categories of RPDs: VITAMINS-D, for vascular, infectious, toxic-metabolic, autoimmune, mitochondrial/metastases, iatrogenic, neurodegenerative, system/seizures/sarcoid, and demyelinating. When relevant, clinical, imaging, or other features of an RPD that overlap with those of CJD are presented.
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Affiliation(s)
- Michael D Geschwind
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, United States.
| | - Katy Murray
- Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, United Kingdom
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23
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Algahtani H, Shirah B, Alassiri A. Tumefactive demyelinating lesions: A comprehensive review. Mult Scler Relat Disord 2017; 14:72-79. [DOI: 10.1016/j.msard.2017.04.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/17/2017] [Accepted: 04/07/2017] [Indexed: 12/29/2022]
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Suchdev K, Razmjou S, Venkatachalam P, Khan OA, Mohamed W, Ibrahim MS. Late onset neuromyelitis optica mimicking an acute stroke in an elderly patient. J Neuroimmunol 2017; 309:1-3. [PMID: 28601277 DOI: 10.1016/j.jneuroim.2017.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) was recently proposed as a unifying term for Neuromyelitis optica (NMO) and related syndromes to incorporate patients with NMO antibody but without the full clinical spectrum. NMO is a rare, demyelinating condition which predominantly affects females with a peak incidence in the third and fourth decade of life. We report a case of NMOSD in an elderly patient with extremely late onset (>80years) of disease. The patient presented with findings of sudden onset unilateral symptoms, which is extremely unusual for NMOSD. She had frequent relapses which were treated with high dose steroids and plasmapheresis but has not had any relapse since being started on immunosuppressive therapy and continues to do well. Our case also highlights the varied clinical presentations of NMOSD and we believe that the diagnosis of NMOSD should be considered in elderly patients in the appropriate clinical setting despite the presence of unconventional symptoms.
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Affiliation(s)
- Kushak Suchdev
- Department of Neurology, Wayne State University School of Medicine, Detroit, USA.
| | - Sara Razmjou
- Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | | | - Omar A Khan
- Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Wazim Mohamed
- Department of Neurology, Wayne State University School of Medicine, Detroit, USA
| | - Mohammed S Ibrahim
- Department of Neurology, Wayne State University School of Medicine, Detroit, USA
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Hampshire-Araújo F, Bergmann A, Alvarenga RMP, Vasconcelos CCF. Malignant multiple sclerosis: clinical and demographic prognostic factors. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:139-141. [DOI: 10.1590/0004-282x20170010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/21/2016] [Indexed: 11/22/2022]
Abstract
ABSTRACT Patients with malignant multiple sclerosis (MMS) reach a significant level of disability within a short period of time (Expanded Disability Status Scale score of 6 within five years). The clinical profile and progression of the disease were analyzed in a Brazilian cohort of 293 patients. Twenty-five (8,53%) patients were found to have MMS and were compared with the remaining 268 (91,47%). Women, non-white patients, older age at disease onset, shorter intervals between the first attacks, and more attacks in the first two years of the disease were all more common in the MMS group. These findings could serve as prognostic factors when making therapeutic decisions.
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Kotov AS, Firsov KV, Bunak MS. Marburg’s variant of multiple sclerosis: a case report. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:54-59. [DOI: 10.17116/jnevro20171172254-59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Yang Z, Sun G. Bilateral abducens nerve palsy in an infant case of fulminant acute disseminated encephalomyelitis: a case report. BMC Ophthalmol 2016; 16:185. [PMID: 27782818 PMCID: PMC5080722 DOI: 10.1186/s12886-016-0365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/14/2016] [Indexed: 11/29/2022] Open
Abstract
Background Sixth (abducens) nerve palsy (ANP) is far less frequent in children and has not been reported as a sign of acute disseminated encephalomyelitis (ADEM). We present an infant case of ADEM with bilateral abducens nerve palsy (BANP). Case presentation We report one case of BANP in a 15-month-old boy of fulminant ADEM. The patient underwent physical examinations and brain MRI scan three times during about six months follow-up. The patient had BANP and developmental regression when he regained consciousness from a coma, and the signs had persisted for 6-months. Conclusions BANP can be a symptom of ADEM.
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Affiliation(s)
- Zhiliang Yang
- Department of Pediatrics, The First Affiliated Hospital of China Medical University, No. 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China.
| | - Guilian Sun
- Department of Pediatrics, The First Affiliated Hospital of China Medical University, No. 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning, China
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Naidoo A, Paruk H, Bhagwan B, Moodley A. Atypical presentations of acute disseminated encephalomyelitis (ADEM) in HIV infection. J Neurovirol 2016; 23:160-170. [PMID: 27687126 DOI: 10.1007/s13365-016-0481-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/04/2016] [Accepted: 09/06/2016] [Indexed: 11/25/2022]
Abstract
Acute disseminated encephalomyelitis is a monophasic demyelinating disorder of the central nervous system associated with various viral infections including HIV infection. We present the findings of seven HIV-infected patients with mild to moderate immunosuppression presenting with atypical features. Four patients had a multiphasic course; three patients had tumefactive lesions, and two patients had corpus callosum lesions. Two patients with the multiphasic course also had tumefactive lesions. Their clinical and radiological findings are presented. Despite the few cases, we propose that the dysimmune process lying between marked immunosuppression (CD4 < 200 cells/μL) and normal CD4 counts (CD4 > 500 cells/μL) might be responsible for these atypical presentations.
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Affiliation(s)
- Ansuya Naidoo
- Department of Neurology, Greys Hospital, Pietermaritzburg, South Africa.,Department of Neurology, University of Kwazulu-Natal, Durban, South Africa
| | - Hoosain Paruk
- Department of Neurology, University of Kwazulu-Natal, Durban, South Africa.,Department of Neurology, Inkosi Albert Luthuli Hospital, Durban, South Africa
| | - Bhupendra Bhagwan
- Department of Neurology, University of Kwazulu-Natal, Durban, South Africa
| | - Anand Moodley
- Department of Neurology, Greys Hospital, Pietermaritzburg, South Africa. .,Department of Neurology, University of Kwazulu-Natal, Durban, South Africa.
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29
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Everything Old is New Again. Can J Neurol Sci 2016; 43:213-8. [PMID: 27182570 DOI: 10.1017/cjn.2015.309] [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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Acute hemorrhagic leukoencephalitis (Weston-Hurst syndrome) in a patient with relapse-remitting multiple sclerosis. J Neuroinflammation 2015; 12:175. [PMID: 26376717 PMCID: PMC4574135 DOI: 10.1186/s12974-015-0398-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/10/2015] [Indexed: 01/21/2023] Open
Abstract
Acute hemorrhagic leukoencephalitis is a fulminant demyelinating disease and commonly considered as a rare and severe variant of acute disseminated encephalomyelitis. Here, we report the clinical, magnetic resonance imaging, and brain biopsy findings of a 35-year-old female with relapsing-remitting multiple sclerosis, who developed acute hemorrhagic leukoencephalitis. Magnetic resonance imaging revealed symmetrical hemorrhagic lesions in the basal ganglia including the thalami. Disease progression was consistent with acute hemorrhagic leukoencephalitis with rapid deterioration of consciousness and seizures. Besides hemorrhage, infiltration of neutrophils was detected in brain biopsy. Acute hemorrhagic leukoencephalitis, also known as Weston-Hurst syndrome, is an excessive immunological response of unknown etiology. So far, an association with multiple sclerosis has not been reported. The present case raises the question, whether acute hemorrhagic leukoencephalitis is a specific hyperacute form of acute disseminated encephalomyelitis, a severe and unspecific form of an immune response in the central nervous system, or belongs to the spectrum of tumefactive multiple sclerosis.
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A Case of Acute Disseminated Encephalomyelitis in a Middle-Aged Adult. Case Rep Neurol Med 2015; 2015:601706. [PMID: 26180647 PMCID: PMC4477182 DOI: 10.1155/2015/601706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/02/2015] [Indexed: 12/02/2022] Open
Abstract
Objectives. Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disorder that is often preceded by infection or recent vaccination. Encephalopathy and focal neurological deficits are usually manifest several weeks after a prodromal illness with rapidly progressive neurologic decline. ADEM is most commonly seen in children and young adults, in which prognosis is favorable, but very few cases have been reported of older adults with ADEM and thus their clinical course is unknown. Methods. Here we present a case of ADEM in a middle-aged adult that recovered well after treatment. Results. A 62-year-old man presented with encephalopathy and rapid neurological decline following a gastrointestinal illness. A brain MRI revealed extensive supratentorial white matter hyperintensities consistent with ADEM and thus he was started on high dose intravenous methylprednisolone. He underwent a brain biopsy showing widespread white matter inflammation secondary to demyelination. At discharge, his neurological exam had significantly improved with continued steroid treatment and four months later, he was able to perform his ADLs. Conclusions. This case of ADEM in a middle-aged adult represents an excellent response to high dose steroid treatment with a remarkable neurological recovery. Thus it behooves one to treat suspected cases of ADEM in an adult patient aggressively, as outcome can be favorable.
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Kantorová E, Marcinek J, Zeleňák K, Kantor K, Michalik J, Sivák Š, Kurča E, Plank L. Tumefactive demyelination of the spinal cord: a case report. Spinal Cord 2015; 53:877-80. [PMID: 26123208 DOI: 10.1038/sc.2015.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 02/11/2015] [Accepted: 02/24/2015] [Indexed: 11/10/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVES We report on a 52-year-old male patient with tumefactive demyelination of the spinal cord. SETTING University Hospital and Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia. BACKGROUND In contrast to relatively frequent tumefactive fulminant lesions in the brain, cases affecting the spinal cord in isolation have been reported less frequently. METHODS Description of the case report. RESULTS Clinical, neuroradiological and necropsy findings are described in a 52-year-old man with tumefactive fulminant demyelination of the spinal cord. Progression of the demyelination process produced paraplegia, mild paresis of the right upper limb, neurogenic bladder and sensitive loss over 2 weeks. MRI scans revealed several ovoid lesions in cervical segments and tumefactive T2-hyperintense signals with oedema and post-contrast enhancement located in thoracic segments Th3 to Th6. Cerebrospinal fluid (CSF) examination displayed lymphomonocytic pleocytosis with normal proteinorhachia, positive CSF oligoclonal IgG bands (OCB) and elevated IgG index (1.55). Serum anti-AQP4-Ab was not tested. Stored frozen CSF samples were later repeatedly examined with negative findings of anti-AQP4-Ab. Treatment with high-dose methylprednisolon and plasma exchange had limited effect. Immunosuppressive medication was interrupted because of an acute urinary infection. The patient died suddenly because of pulmonary embolism as a secondary complication. Histopathology of the spinal cord confirmed active demyelination. We considered that tumefactive demyelination could be a variant of neuromyelitis optica. CONCLUSION Our case could be anti-AQP4-Ab-negative longitudinally extensive transverse myelitis, a variant of neuromyelitis optica.
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Affiliation(s)
- E Kantorová
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - J Marcinek
- Department of Pathological Anatomy, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - K Zeleňák
- Radiology Clinic, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - K Kantor
- Faculty of Medicine, Palacky University in Olomouc, Olomouc, Czech Republic
| | - J Michalik
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - Š Sivák
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - E Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
| | - L Plank
- Department of Pathological Anatomy, Jessenius Faculty of Medicine in Martin, Comenius University, Martin, Slovakia
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Sutter R, Kaplan PW. What to see when you are looking at confusion: a review of the neuroimaging of acute encephalopathy. J Neurol Neurosurg Psychiatry 2015; 86:446-59. [PMID: 25091365 DOI: 10.1136/jnnp-2014-308216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Acute encephalopathy is a clinical conundrum in neurocritical care facing physicians with diagnostic and therapeutic challenges. Encephalopathy arises from several concurrent causes, and delayed diagnosis adds to its grim prognosis. Diagnosis is reached by melding clinical, neurophysiological and biochemical features with various neuroimaging studies. We aimed to compile the pathophysiology of acute encephalopathies in adults, and the contribution of cerebral CT, MRI, MR spectroscopy (MRS), positron emission tomography (PET) and single-photon emission CT (SPECT) to early diagnosis, treatment and prognostication. Reports from 1990 to 2013 were identified. Therefore, reference lists were searched to identify additional publications. Encephalopathy syndromes best studied by neuroimaging emerge from hypoxic-ischaemic injury, sepsis, metabolic derangements, autoimmune diseases, infections and rapidly evolving dementias. Typical and pathognomonic neuroimaging patterns are presented. Cerebral imaging constitutes an important component of diagnosis, management and prognosis of acute encephalopathy. Its respective contribution is dominated by rapid exclusion of acute cerebral lesions and further varies greatly depending on the underlying aetiology and the range of possible differential diagnoses. CT has been well studied, but is largely insensitive, while MRI appears to be the most helpful in the evaluation of encephalopathies. MRS may provide supplementary biochemical information and determines spectral changes in the affected brain tissue. The less frequently used PET and SPECT may delineate areas of high or low metabolic activity or cerebral blood flow. However, publications of MRS, PET and SPECT are limited only providing anecdotal evidence of their usefulness and sensitivity.
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Affiliation(s)
- Raoul Sutter
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA Clinic of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter W Kaplan
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Mader EC, Richeh W, Ochoa JM, Sullivan LL, Gutierrez AN, Lovera JF. Tumefactive multiple sclerosis and hepatitis C virus 2a/2C infection: Dual benefit of long-term interferon beta-1a therapy? J Neurol Sci 2015; 349:239-42. [PMID: 25575859 DOI: 10.1016/j.jns.2014.12.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/18/2014] [Accepted: 12/23/2014] [Indexed: 12/14/2022]
Abstract
Hepatitis C virus (HCV) infection has been implicated in triggering acute disseminated encephalomyelitis but not tumefactive multiple sclerosis. We report the case of a 17-year-old female who presented with a 5-day history of left hemiparesis and hemisensory loss followed by a right third nerve palsy. Tumefactive multiple sclerosis was diagnosed based on the absence of encephalopathic signs, the presence of tumefactive brain lesions, the exclusion of neoplastic and infectious causes of the lesions by biopsy, and the occurrence of relapse after a period of remission. The patient was at risk for HCV infection due to parenteral drug abuse and multiple sexual partners. Serial HCV antibody tests and RNA polymerase chain reaction assays revealed acute HCV infection and genotyping showed HCV genotype 2a/2c. She was treated with high-dose methylprednisolone and discharged with only mild left hand weakness. Interferon beta-1a 30mcg was administered intramuscularly once a week. Remission from HCV infection was achieved in three years without standard anti-HCV therapy. This case suggests that CNS myelin is a potential target of the immune response to HCV 2a/2c infection, the HCV 2a/2c virus may be involved in triggering autoimmune tumefactive brain lesions, and interferon beta-1a is effective against HCV 2a/2c infection. We recommend serial HCV antibody testing and HCV RNA PCR assay, preferably with HCV genotyping, in all patients with acute inflammatory demyelinating diseases of the CNS.
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Affiliation(s)
- Edward C Mader
- Louisiana State University Health Sciences Center, Department of Neurology, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Wael Richeh
- Louisiana State University Health Sciences Center, Department of Neurology, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Joaquin Maury Ochoa
- Louisiana State University Health Sciences Center, Department of Neurology, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Lacey L Sullivan
- Tulane University Health Sciences, Department of Pathology and Laboratory Medicine, 1430 Tulane Avenue SL-79, New Orleans, LA 70112, USA.
| | - Amparo N Gutierrez
- Louisiana State University Health Sciences Center, Department of Neurology, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Jesus F Lovera
- Louisiana State University Health Sciences Center, Department of Neurology, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
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Mahboobi N, Nolden-Hoverath S, Rieker O, Bauer H. Multiple Sclerosis Presenting as a Delirium: A Case Report. Med Princ Pract 2015; 24:388-90. [PMID: 26043929 PMCID: PMC5588250 DOI: 10.1159/000430446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 04/13/2015] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To report a case of multiple sclerosis (MS) with delirium as the first presentation. CLINICAL PRESENTATION AND INTERVENTION A 34-year-old female was referred to our department with an acute onset of drowsiness, withdrawal from routine activities and aggression, followed by neurologic deficits after a couple of days. Clinical and radiographic examinations were performed, leading to the initial diagnosis of MS. A vast range of differential diagnoses was excluded to confirm the diagnosis of MS. CONCLUSION Neurological examination and appropriate imaging enabled the diagnosis of MS with delirium in this patient followed by the appropriate treatment.
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Affiliation(s)
- Nastaran Mahboobi
- Department of Neurology, Teaching Hospital of Bonn University, Euskirchen, Germany
| | | | - Olaf Rieker
- Department of Radiology, Marien Hospital Euskirchen, Teaching Hospital of Bonn University, Euskirchen, Germany
| | - Hartmut Bauer
- Department of Neurology, Teaching Hospital of Bonn University, Euskirchen, Germany
- *Dr. med. Hartmut Bauer, Neurology Department, Marien Hospital Euskirchen, Teaching Hospital of Bonn University, Gottfried-Disse-Stra�e 40, DE–53879 Euskirchen (Germany), E-Mail
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Abstract
Neurocritical care aims to improve outcomes in patients with life-threatening neurologic illness. The scope of neurocritical care extends beyond the more commonly encountered and important field of cerebrovascular disease, as described previously. This article focuses on neuromuscular, neuroinfectious, and neuroimmunologic conditions that are significant causes of morbidity and mortality in the acutely neurologically ill patient. As understanding continues to increase regarding the physiology of these conditions and the best treatment, rapid identification, triage, and treatment of these patients in the emergency department is paramount.
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Affiliation(s)
- Anthony Noto
- Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical Care, Departments of Emergency Medicine and Neurology, Yale University School of Medicine, 464 Congress St. Suite 260, New Haven, CT 06519, USA
| | - Evie Marcolini
- Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical Care, Departments of Emergency Medicine and Neurology, Yale University School of Medicine, 464 Congress St. Suite 260, New Haven, CT 06519, USA.
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Open-ring enhancement in pseudotumoral multiple sclerosis: important radiological aspect. Case Rep Neurol Med 2014; 2014:951690. [PMID: 24839572 PMCID: PMC4009287 DOI: 10.1155/2014/951690] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/22/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Observation of open-ring enhancement in magnetic resonance imaging (MRI) is considered a specificity marker for diagnosing pseudotumoral multiple sclerosis (MS). This finding is of great value in the differential diagnosis of tumefactive lesions. Case Report. We describe a 55-year-old white woman, with previous history of ovarian cancer and recent history of fatigue and bilateral retroorbital pain. Important bilateral visual impairment evolved over one month. Physical examination detected the presence of right homonymous hemianopia. Cranial MRI showed an expanding lesion with open-ring enhancement. Given the range of diagnostic possibilities, a stereotactic biopsy was performed, and histopathological examination was consistent with an active demyelinating disease. The patient was treated with 1 g of methylprednisolone and symptoms improved following a significant reduction in the lesion. Conclusions. We highlight the MRI results suggestive of pseudotumoral MS, especially open-ring enhancement, which is an important radiologic aspect to diagnosis and can assist in avoiding unnecessary biopsies.
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Gordon J. Moral distress caused by an uncertain prognosis: when the surrogate and the physician bring different priorities to the discussion. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:55-56. [PMID: 24978420 DOI: 10.1080/15265161.2014.923716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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