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Clardy SL, Smith TL. Therapeutic Approach to Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1226-1258. [PMID: 39088294 DOI: 10.1212/con.0000000000001463] [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: 08/03/2024]
Abstract
OBJECTIVE Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases. LATEST DEVELOPMENTS Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future. ESSENTIAL POINTS Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.
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Marcoval J, Iriarte A, Rocamora G, Martínez-Yélamos S, Mañá J. Specific Cutaneous Lesions in Patients With Neurosarcoidosis. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:393-397. [PMID: 37832866 DOI: 10.1016/j.ad.2023.07.021] [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: 03/27/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 10/15/2023] Open
Abstract
Neurosarcoidosis is an uncommon but potentially serious disease of the central nervous system that can cause major sequelae. We analyzed the presence and diagnostic usefulness of specific cutaneous lesions in 58 patients with neurosarcoidosis. Sixteen patients (27.6%) had specific cutaneous lesions (14 men and 2 women; mean age, 50 years [range, 20-84 years]). Twenty-four types of neurological lesions were observed: cranial neuropathy (n=7), parenchymal lesions (n=4), meningeal lesions (n=3), myelopathy (n=3), pituitary lesions (n=1), hydrocephalus (n=2), and peripheral neuropathy (n=4). Twenty types of specific cutaneous lesions were observed: maculopapular lesions (n=6), plaques (n=9), lupus pernio (n=1), and scar sarcoidosis (n=4). These last lesions coexisted with maculopapular lesions in 2 patients and plaques in another 2. Specific cutaneous lesions were present at diagnosis of neurosarcoidosis in 13 patients. Recognition of specific cutaneous lesions in a patient with suspected neurosarcoidosis is important as biopsy can accelerate diagnosis.
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Affiliation(s)
- J Marcoval
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Barcelona, España.
| | - A Iriarte
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España
| | - G Rocamora
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España
| | - S Martínez-Yélamos
- Servicio de Neurología, Hospital Universitari de Bellvitge, Barcelona, España
| | - J Mañá
- Servicio de Medicina Interna, Clínicas Corachan y Sagrada Familia, Barcelona, España
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Marcoval J, Iriarte A, Rocamora G, Martínez-Yélamos S, Mañá J. [Translated article] Specific Cutaneous Lesions in Patients With Neurosarcoidosis. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T393-T397. [PMID: 38331168 DOI: 10.1016/j.ad.2023.07.029] [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: 03/27/2023] [Accepted: 07/03/2023] [Indexed: 02/10/2024] Open
Abstract
Neurosarcoidosis is an uncommon but potentially serious disease of the central nervous system that can cause major sequelae. We analyzed the presence and diagnostic usefulness of specific cutaneous lesions in 58 patients with neurosarcoidosis. Sixteen patients (27.6%) had specific cutaneous lesions (14 men and 2 women; mean age, 50 years [range, 20-84 years]). Twenty-four types of neurological lesions were observed: cranial neuropathy (n=7), parenchymal lesions (n=4), meningeal lesions (n=3), myelopathy (n=3), pituitary lesions (n=1), hydrocephalus (n=2), and peripheral neuropathy (n=4). Twenty types of specific cutaneous lesions were observed: maculopapular lesions (n=6), plaques (n=9), lupus pernio (n=1), and scar sarcoidosis (n=4). These last lesions coexisted with maculopapular lesions in 2 patients and plaques in another 2. Specific cutaneous lesions were present at diagnosis of neurosarcoidosis in 13 patients. Recognition of specific cutaneous lesions in a patient with suspected neurosarcoidosis is important as biopsy can accelerate diagnosis.
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Affiliation(s)
- J Marcoval
- Servicio de Dermatología, Hospital Universitari de Bellvitge, Barcelona, Spain.
| | - A Iriarte
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - G Rocamora
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - S Martínez-Yélamos
- Servicio de Neurología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J Mañá
- Servicio de Medicina Interna, Clínicas Corachan y Sagrada Familia, Barcelona, Spain
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Voortman M, Drent M, Stern BJ. Neurosarcoidosis and Neurologic Complications of Sarcoidosis Treatment. Clin Chest Med 2024; 45:91-103. [PMID: 38245373 DOI: 10.1016/j.ccm.2023.08.005] [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] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is an immune-mediated multisystem granulomatous disorder. Neurosarcoidosis (NS) accounts for 5% to 35% of cases. The diagnostic evaluation of NS can be a clinical challenge. Gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard to evaluate central nervous system NS. In almost all cases treatment is warranted. Although glucocorticoids remain the first-line therapy in patients with sarcoidosis, in NS timely initiation of second- or third-line treatment is strongly recommended. Of these, tumor necrosis factor-alpha inhibitors are the most promising. However, the treatment itself may be responsible for/associated with developing neurologic symptoms mimicking NS. Thus, it is important to consider the possibility of drug-induced neurologic symptoms in sarcoidosis.
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Affiliation(s)
- Mareye Voortman
- Department of Pulmonology, Division of Heart & Lungs, University Medical Centre Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands.
| | - Marjolein Drent
- Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands; Department of Respiratory Medicine, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands; ILD Care Foundation Research Team, Heideoordlaan 8, Ede 6711NR, The Netherlands
| | - Barney J Stern
- Department of Neurology, School of Medicine, Johns Hopkins University, 601 North Caroline Street, Neurology Room 5066B, Baltimore, MD 21287, USA
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Obi ON. Anti-inflammatory Therapy for Sarcoidosis. Clin Chest Med 2024; 45:131-157. [PMID: 38245362 DOI: 10.1016/j.ccm.2023.08.010] [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] [Indexed: 01/22/2024]
Abstract
Over 50% of patients with sarcoidosis will require anti-inflammatory therapy at some point in their disease course. Indications for therapy are to improve health-related quality of life, prevent or arrest organ dysfunction (or organ failure) or avoid death. Recently published treatment guidelines recommended a stepwise approach to therapy however there are some patients for whom up front combination or more intense therapy maybe reasonable. The last decade has seen an explosion of studies and trials evaluating novel therapeutic agents and treatment strategies. Currently available anti-inflammatory therapies and several novel therapies are discussed here.
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Affiliation(s)
- Ogugua Ndili Obi
- Department of Internal Medicine, Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Noroozi Gilandehi S, Wong KH, Francis T, Wright MA, Lord J, Stehlik J, Kemeyou L, Smith T, Clardy SL. Cardiac Involvement in Neurosarcoidosis: A Single-Center Investigation. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200196. [PMID: 38181319 DOI: 10.1212/nxi.0000000000200196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/06/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND AND OBJECTIVES Sarcoidosis is a multisystem inflammatory granulomatous disease. Among systemic sarcoidosis manifestations, cardiac or nervous system involvement can result in significant morbidity and mortality. We describe the overlapping incidence of cardiac sarcoidosis (CS) within a neurosarcoidosis (NS) cohort and determine the frequency of other nonsarcoid cardiac diseases in these patients. METHODS We performed a retrospective chart review of patients evaluated at the University of Utah from 2010 to 2022. Patients were included if they had (1) at least one instance of a diagnostic code for sarcoidosis in their medical record-International Classification of Diseases (ICD) 9 code 135 or ICD 10 code D86; (2) at least one outpatient visit in the Neurology Department within the University of Utah electronic health record with a diagnosis of definite, probable, or possible NS based on 2018 consensus criteria; (3) at least one outpatient visit in the Cardiology Department within the University of Utah electronic health record; and (4) ECG available in their medical record for review. Of 64 definite, probable, or possible patients with NS in the University of Utah cohort, 52 met our inclusion criteria and were included in this study. RESULTS Of 52 patients with NS who met our inclusion criteria, 65.38% were female, with an average age of 60.9 years (range 38-84). More than half (58%) were obese (BMI ≥ 30). CS was diagnosed in 6 patients with NS (12%). Symptoms suggestive of possible cardiac dysfunction included lower extremity edema (50%), palpitations (46%), chest pain (44%), and shortness of breath (27%). ECG abnormalities included nonspecific T-wave change (40%) and right bundle branch block (17%). Three patients experienced ventricular tachycardia: sustained in one patient and nonsustained in 2 patients. Cardiac MRI was performed in 17 patients (32.7%) and in 3 patients (17.6%), which revealed diffuse myocardial enhancement suggesting CS. DISCUSSION In this cohort, 12% of patients with NS also had confirmed CS. In addition, these patients had a high burden of cardiovascular disease not directly attributed to sarcoidosis. Our data suggest that patients with NS require comprehensive cardiac evaluation. Future studies are needed to clarify the extent of the direct contribution of granulomatous inflammation on the cardiovascular system from the indirect contribution of treatments such as glucocorticoids that lead to increased risk of cardiovascular disease in sarcoidosis.
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Affiliation(s)
- Sama Noroozi Gilandehi
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Ka-Ho Wong
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Trieste Francis
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Melissa A Wright
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Jennifer Lord
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Josef Stehlik
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Line Kemeyou
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Tammy Smith
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
| | - Stacey L Clardy
- From the Department of Neurology (S.N.G., K.-H.W., T.F., M.A.W., J.L., T.S., S.L.C.); Division of Cardiovascular Medicine (J.S., L.K.), Department of Internal Medicine, University of Utah; Department of Neurology (J.S., L.K., T.S., S.L.C.); Geriatric Research Education and Clinical Center (T.S.), George E. Whalen Department of Veterans Affairs Medical Center; and Department of Pathology (T.S.), University of Utah, Salt Lake City
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Chaiyanarm S, Satiraphan P, Apiraksattaykul N, Jitprapaikulsan J, Owattanapanich W, Rungjirajittranon T, Nanthasi W. Infliximab in neurosarcoidosis: a systematic review and meta-analysis. Ann Clin Transl Neurol 2024; 11:466-476. [PMID: 38087813 PMCID: PMC10863903 DOI: 10.1002/acn3.51968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/18/2023] [Accepted: 11/28/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES To evaluate the clinical outcomes and relapse rates in neurosarcoidosis patients administered infliximab. METHODS A systematic review was conducted using the MEDLINE, EMBASE, SCOPUS, and Cochrane Library databases. The search included studies from their inception to March 2023. We included case-series studies with at least 10 neurosarcoidosis patients undergoing any treatment type. Studies were also required to report at least one of the following outcomes: response rate, overall survival rate, or relapse rate. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random-effects model facilitated the analysis of proportional treatment outcomes. Study quality was evaluated using the modified Newcastle-Ottawa quality assessment scale, while a funnel plot helped detect any publication bias. RESULTS Seven studies comprising 237 patients with neurosarcoidosis were included in the analysis. Of these patients, 184 (77.6%) received treatment with infliximab. The pooled proportion of patients showing clinical improvement after infliximab treatment was 0.74 (95% CI 0.64-0.84, I2 = 49.73%). Relapse rates, derived from four studies, stood at 0.38 (95% CI 0.22-0.55, I2 = 56.92%). Most studies reported successful tapering or cessation of corticosteroid dosage in patients receiving infliximab. Adverse effects were reported in 52 (29.4%) patients, of which 39 out of 54 events (72.2%) were linked to infections. INTERPRETATION Infliximab demonstrated potential improvement in clinical outcomes for patients with refractory neurosarcoidosis and showed potential for reducing the dosage of concurrent corticosteroids. However, a degree of relapse was observed, with infections being the primary concern for adverse events.
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Affiliation(s)
| | - Piraya Satiraphan
- Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
| | - Natnasak Apiraksattaykul
- Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
| | - Jiraporn Jitprapaikulsan
- Siriraj Neuroimmunology Center, Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
| | - Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
| | - Tarinee Rungjirajittranon
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
| | - Witsarut Nanthasi
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok10700Thailand
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Bekkour I, Courtin E, Dulau-Metras C, Duffau P, Kremer L, Mathey G. Defining the course of neurosarcoidosis according to presentation at onset and disease modifying treatment: a cohort study of 84 patients. Ther Adv Neurol Disord 2023; 16:17562864231205954. [PMID: 38143513 PMCID: PMC10748905 DOI: 10.1177/17562864231205954] [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: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 12/26/2023] Open
Abstract
Background Neurosarcoidosis is a rare manifestation of sarcoidosis with heterogeneous presentations. Patient management is challenging due to the current lack of knowledge about the long-term disease course. Objective To identify specific disease courses of neurosarcoidosis according to the clinical and paraclinical presentations at onset. Methods We conducted an observational multicenter cohort study by retrospectively collecting data from the medical records of 84 patients diagnosed with definite, probable, or possible neurosarcoidosis in three tertiary referral centers in France (Nancy, Strasbourg, and Bordeaux). We collected demographic characteristics, clinical and paraclinical data at the beginning of patient management, and during follow-up under the different treatment lines. Two expert neurologists determined disease course profiles. Results The mean follow-up was 6.6 years. Almost every patient (96.4%) received steroids at some point of their follow-up. Tumor Necrosis Factor-alpha blockers were given in 10.7% as first-line treatment and in 33.3% during follow-up. Every patient presented with a relapsing disease, often monophasic (75%) and sometimes polyphasic with the recurrence of identical manifestations (11.9%). Patients developing new neurological symptoms during follow-up were a minority (13.1%). No patients exhibited a progressive course. Patients with isolated cranial nerves injury or aseptic meningitis always exhibited a monophasic course, and 62.5-75% of them had a full recovery after first-line treatments. This proportion was 15.6% in other forms of the disease. Those with peripheral presentations were more likely to present a polyphasic course than patients with other forms of neurosarcoidosis. Spinal cord presentations were monophasic, but resulted in sequelae and exhibited poor response to first-line treatments despite frequent use of TNF-alpha blockers. Conclusion Identification of these disease course profiles, based on the initial clinical and paraclinical presentation, could guide the clinician to select the optimal therapeutic approach and follow-up modalities for their patients with neurosarcoidosis.
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Affiliation(s)
- Inès Bekkour
- Department of Neurology, Nancy University Hospital, Nancy, France
| | - Edouard Courtin
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | | | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, Bordeaux University Hospital, Bordeaux, France
- CNRS, ImmunoConcEpT, UMR 5164, University of Bordeaux, Bordeaux, France
| | - Laurent Kremer
- Department of Neurology, Strasbourg University Hospital, Strasbourg, France
- INSERM U1119, Strasbourg, France
| | - Guillaume Mathey
- Service de Neurologie, Hopital Central, CHRU de Nancy, 1 Avenue du Maréchal de Lattre de Tassigny, Nancy 54000, France
- Department of Neurology, Nancy University Hospital, Nancy, France
- CIC-Epidémiologie Clinique, Nancy University Hospital, INSERM, Université de Lorraine, Nancy, France
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Bou GA, El Sammak S, Chien LC, Cavanagh JJ, Hutto SK. Tumefactive brain parenchymal neurosarcoidosis. J Neurol 2023; 270:4368-4376. [PMID: 37219604 DOI: 10.1007/s00415-023-11782-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/12/2023] [Accepted: 05/13/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Enhancing brain parenchymal disease, and especially tumefactive lesions, are an uncommon manifestation of neurosarcoidosis. Little is known about the clinical features of tumefactive lesions and their impact on management and outcomes, which this study aims to characterize. METHODS Patients with pathologically-confirmed sarcoidosis were retrospectively reviewed and included if brain lesions were: (1) intraparenchymal, (2) larger than 1 cm in diameter, and (3) associated with edema and/or mass effect. RESULTS Nine patients (9/214, 4.2%) were included. Median onset age was 37 years. Diagnosis was confirmed by brain parenchymal biopsies in 5 (55.6%). Median modified Rankin scale (mRS) score was 2 (range 1-4) at initial presentation. Common manifestations included headache (77.8%), cognitive dysfunction (66.7%), and seizures (44.4%). Sixteen lesions were present in 9 patients. The frontal lobe (31.3%) was most affected, followed by the subinsular region (12.5%), basal ganglia (12.5%%), cerebellum (12.5%), and pons (12.5%). MRI characteristics of the dominant lesions included spherical morphology (77.8%), perilesional edema (100.0%), mass effect (55.6%), well-demarcated borders (66.7%), and contrast enhancement (100.0%; 55.6% heterogeneous). Leptomeningitis was frequently present (77.8%). All required corticosteroid-sparing treatments, and most (55.6%) needed at least a third line of treatment (infliximab used in 44.4%). All patients relapsed (median 3 relapses, range 1-9). Median last mRS was 1.0 after median follow-up of 86 months, with significant residual deficits in 55.6%. CONCLUSION Tumefactive brain parenchymal lesions are uncommon, usually affect the supratentorial brain along with leptomeningitis, and are refractory to initial treatments with a high risk of relapse. Significant sequelae were encountered despite a favorable median last mRS.
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Affiliation(s)
- Gabriela A Bou
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Sally El Sammak
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Ling-Chen Chien
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Julien J Cavanagh
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA.
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Tana C, Azorin DG, Cinetto F, Mantini C, Tana M, Caulo M, Ricci F, Martelletti P, Cipollone F, Giamberardino MA. Common Clinical and Molecular Pathways between Migraine and Sarcoidosis. Int J Mol Sci 2023; 24:ijms24098304. [PMID: 37176011 PMCID: PMC10179000 DOI: 10.3390/ijms24098304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/07/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Migraine and sarcoidosis are two distinct medical conditions that may have some common biological and clinical pathways. Sarcoidosis is a chronic granulomatous disease characterized by the formation of granulomas in various organs, including the lungs, skin, cardiovascular system, lymph nodes, and brain. Migraine is a common comorbidity in sarcoidosis patients and a common neurological disorder characterized by recurrent headaches that can be accompanied by other symptoms, such as nausea, vomiting, and sensitivity to light and sound. There have been several reports of individuals with neurosarcoidosis experiencing migraines, though the exact relationship between the two disorders is not well understood. Both conditions have been associated with inflammation and the activation of the immune system. In sarcoidosis, the formation of granulomas is thought to be an immune response to the presence of an unknown antigen. Similarly, the pain and other symptoms associated with migraines are thought to be caused by inflammation in the brain and the surrounding blood vessels. There is also evidence to suggest an interplay of environmental and genetic factors playing a role in both conditions, but evidence is inconsistent with the hypothesis of shared genetic susceptibility. This review aims to illustrate common clinical and biological pathways between migraine and sarcoidosis, including inflammation and dysregulation of the immune system, with a focus on the cumulative burden of concurrent disorders and therapeutic implications.
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Affiliation(s)
- Claudio Tana
- Center of Excellence on Headache, Geriatrics and COVID-19 Clinic, SS Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - David Garcia Azorin
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca' Foncello Hospital-AULSS2 Marca Trevigiana and Department of Medicine-DIMED, University of Padova, 35122 Padova, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marco Tana
- 2nd Internal Medicine Unit, SS. Medical Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
- University Cardiology Division, Heart Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Cipollone
- Medical Clinic, Department of Medicine and Science of Aging, SS. Annunziata Hospital of Chieti, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Maria Adele Giamberardino
- Center of Excellence on Headache, Geriatrics and COVID-19 Clinic, SS Annunziata Hospital of Chieti, 66100 Chieti, Italy
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Chakales PA, Herman MC, Chien LC, Hutto SK. Pachymeningitis in Biopsy-Proven Sarcoidosis. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/6/e200028. [PMID: 36163175 PMCID: PMC9513981 DOI: 10.1212/nxi.0000000000200028] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022]
Abstract
Background and Objectives Meningeal inflammation is one of the most common manifestations of neurosarcoidosis, occurring in 16%–69% of affected patients. While the clinical and radiographic features of leptomeningitis in neurosarcoidosis are well known, those of pachymeningitis are far less clear. Our primary aim was to study the clinicoradiographic features of pachymeningeal involvement in neurosarcoidosis and its evolution over time in response to treatment. Methods Patients with a diagnosis of neurosarcoidosis seen at Emory University (January 2011–August 2021) were included if pachymeningeal involvement was evident by MRI and the patient's sarcoidosis was pathologically confirmed (from a CNS or non-CNS site). Results Twenty-six of 215 (12.1%) patients with neurosarcoidosis qualified for inclusion. Pathologic confirmation came from CNS tissue in 50%. The median age of onset was 43.5 years; most were male (16/26, 61.5%). Symptoms were primarily related to pachymeningitis in 20/26 (76.9%). Headache (19/26, 73.1%), visual dysfunction (12/26, 46.2%), and seizures (7/26, 26.9%) were the most common symptoms. All patients had cranial pachymeningitis; only a single patient undergoing spinal imaging (1/11, 9.1%) had spinal pachymeningitis. The falx cerebri (16/26, 61.5%) was the most commonly affected dural structure, but the anterior and middle cranial fossae and tentorium cerebelli were frequently involved (12/26 each, 46.2%). The pachymeningeal lesions were unifocal (11/26, 42.3%) or multifocal (15/26, 57.7%) in distribution, nodular morphologically (23/25, 92.0%), and homogeneously enhancing (24/25, 96.0%). Symptomatic improvement occurred with steroids initially in 22/25 (88.0%). Ultimately, 23/26 (88.5%) required initiation of steroid-sparing immunosuppressants, including 8/26 (30.8%) eventually undergoing TNF inhibition. Pachymeningeal relapses occurred in 7/26 (26.9%). The median clinical follow-up was 48 months. The median modified Rankin scale score at last follow-up improved to 1.0 from 2.0 at presentation. Discussion Pachymeningitis due to sarcoidosis often presents with headaches, visual dysfunction, and seizures; it usually affects the dura of the falx cerebri, anterior and middle cranial fossae, and tentorium cerebelli and tends to require steroid-sparing immunosuppressants. It has the potential to relapse, but the prospect for recovery is good.
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12
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Sambon P, Sellimi A, Kozyreff A, Gheysens O, Pothen L, Yildiz H, van Pesch V. Epidemiology, clinical presentation, treatment, and outcome of neurosarcoidosis: A mono-centric retrospective study and literature review. Front Neurol 2022; 13:970168. [PMID: 36388212 PMCID: PMC9641157 DOI: 10.3389/fneur.2022.970168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Neurosarcoidosis is a rare granulomatous disorder, and treatment guidelines are mainly based on retrospective studies. Materials and methods This retrospective study was performed to provide a detailed description of the clinical characteristics and treatment outcomes of patients with neurosarcoidosis followed at Cliniques Universitaires Saint Luc in Belgium. The second objective of our study was to perform a comparative literature review of neurosarcoidosis, with a focus on treatment outcomes with the use of TNF-α antagonist. Results Among 180 patients with sarcoidosis followed in our hospital, 22 patients with neurosarcoidosis were included in the final analysis. Our literature research identified 776 articles of which 35 articles met our inclusion criteria, including 1,793 patients diagnosed with neurosarcoidosis. In our cohort, the majority of patients (86%) were diagnosed with systemic sarcoidosis which was similar to that reported in the literature (83%). Serum CRP and calcemia were elevated only in 33 and 18% of patients, respectively. Serum lysozyme and angiotensin-converting enzyme were elevated in 79 and 16% of patients, respectively. Lumbar puncture and CSF fluid analysis were performed in 15/22 patients and were abnormal in all patients. Brain MRI was performed in 21/22 patients and showed abnormalities in 16 patients consisting of parenchymal lesions in 63%, hypothalamic-pituitary axis lesions in 38%, and meningeal enhancement in 31%. In both cohort patients, methotrexate was the most frequently used treatment (>45% of cases) with a favorable outcome in an average of 50% of patients. A TNF-α antagonist was administered in 9% of patients in our cohort and in 27% of patients in the literature review. The proportion of favorable outcomes in literature research was significantly higher in patients treated with TNF-α antagonists compared to methotrexate (p < 0.0001), mycophenolate mofetil (p < 0.0001), or azathioprine (p < 0.0001). Conclusion The results of our cohort and literature review confirm that neurosarcoidosis occurred most frequently in the context of systemic sarcoidosis. Methotrexate is the most frequent second-line therapy. The effectiveness of therapy with TNF-α antagonists is well-demonstrated and associated with a better outcome. Their earlier use during the disease course among aggressive and/or refractory neurosarcoidosis should be considered.
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Affiliation(s)
- Pauline Sambon
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Amina Sellimi
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alexandra Kozyreff
- Department of Ophthalmology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Lucie Pothen
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- *Correspondence: Vincent van Pesch
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Young M, Goldman-Yassen A, Anderson M, Thakral A, Dutt M, Wolf D, Morris M, Gombolay G. Neurosarcoidosis in children: A systematic review and summary of cases, imaging and management. J Neuroimmunol 2022; 371:577938. [PMID: 35944453 PMCID: PMC9703361 DOI: 10.1016/j.jneuroim.2022.577938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/18/2022] [Accepted: 07/28/2022] [Indexed: 10/16/2022]
Abstract
Neurosarcoidosis is a rare disorder in children. We identified 30 pediatric NS cases through a systematic review. Twenty-one (70%) had systemic sarcoidosis with 30% having primary neurosarcoidosis. Eyes (37%), lymph nodes (37%) and lungs (30%) were most commonly involved. Isolated neurosarcoidosis were more likely in children (30%) than in adults (6%, p = 0.0005). Seizures and optic neuritis were also more common in children than adults (33% vs 14%, p = 0.002; and 30% versus 6%, p = 0.008, respectively). Evaluation, imaging, laboratory findings, and treatments are discussed. Additional research, including multi-center studies, is needed.
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Affiliation(s)
- Morgan Young
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine; 6965 Cumberland Gap Pkwy, Harrogate, TN 37752, USA.
| | - Adam Goldman-Yassen
- Emory University School of Medicine, Departments of Radiology and Imaging Sciences & Pediatrics, and Children's Healthcare of Atlanta, Department of Radiology, 1405 Clifton Road NE, Atlanta, GA, USA.
| | - Monique Anderson
- Department of Neurology, Emory University School of Medicine, 201 Dowman Dr., Atlanta, GA 30322, USA.
| | - Amit Thakral
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Rheumatology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Monideep Dutt
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - David Wolf
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Morgan Morris
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Grace Gombolay
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
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Liberio R, Kramer E, Memon AB, Reinbeau R, Feizi P, Joseph J, Wu J, Sriwastava S. Relevance of Medullary Vein Sign in Neurosarcoidosis. Neurol Int 2022; 14:638-647. [PMID: 35997361 PMCID: PMC9397064 DOI: 10.3390/neurolint14030052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Central nervous system involvement is uncommon in patients with sarcoidosis. It remains a diagnostic challenge for clinicians, as there is a broad differential diagnosis that matches the presenting neurological signs. Often, the imaging findings also overlap with other disease entities. One understudied finding in patients with neurosarcoidosis is the presence of medullary vein engorgement on SWI imaging, termed the “medullary vein sign”, which has been postulated to be a specific sign for neurosarcoidosis. This study aims to provide an understanding of the diagnostic potential of the medullary vein sign. Methods: Thirty-two patients who presented with neurologic signs concerning for possible neurosarcoidosis were analyzed retrospectively for the presence of the medullary vein sign. Results: Out of these cases, 7 cases of definitive neurosarcoidosis cases were found based on other imaging signs, biopsy and CSF analysis; the remaining were classified into groups as possible (16), probable (5) and (4) cases of other infectious meningoencephalitis including 2 cases of autoimmune encephalitis. Seven patients among all of these cases were found to have the medullary vein sign on imaging, with five cases with confirmed and two cases from possible neurosarcoidosis. The sensitivity of the medullary vein sign in this study was 71.4%, and the specificity was 92.3%. Discussion: The benefits of improving diagnostic criteria for neurosarcoidosis include more rapid diagnosis leading to more prompt treatment, less exposure to potentially harmful antibiotics or antifungals, and less long-term neurological effects. Our results support that the medullary vein sign will potentially fill in the diagnostic gaps that have challenged the timely diagnosis of neurosarcoidosis. Conclusions: Our findings support that the medullary vein sign has a high specificity and should be included in the diagnostic criteria for neurosarcoidosis.
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Affiliation(s)
- Richard Liberio
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Emily Kramer
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Anza B. Memon
- Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Ryan Reinbeau
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Parissa Feizi
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Joe Joseph
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Janet Wu
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Shitiz Sriwastava
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26506, USA
- Correspondence: ; Tel.: +1-304-581-1903
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Bou GA, Garcia-Santibanez R, Castilho AJ, Hutto SK. Neurosarcoidosis of the Cauda Equina. NEUROLOGY - NEUROIMMUNOLOGY NEUROINFLAMMATION 2022; 9:9/4/e1170. [PMID: 35487693 PMCID: PMC9128042 DOI: 10.1212/nxi.0000000000001170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/10/2022] [Indexed: 01/28/2023]
Abstract
Background and ObjectivesSarcoidosis is a multisystem granulomatous disease affecting the nervous system in 3%–5% of cases. It can affect almost any component of the nervous system. Involvement of the cauda equina is an understudied phenotype, and questions remain regarding its natural history and optimal approach to management. This study aims to study the long-term clinical evolution of neurosarcoidosis affecting the cauda equina, response to treatment, and clinical and radiographic outcomes.MethodsPatients with neurosarcoidosis treated at Emory University between January 1, 2011, and December 8, 2021, were retrospectively evaluated for manifestations of cauda equina disease and included if disease of the cauda equina could be substantiated by MRI or EMG.ResultsOf 216 cases, 14 (6.5%) involved the cauda equina. The median age was 49.5 years, and most were female (85.7%) and African American (64.3%). Chronic (>28 days) presentations were most common (78.6%), but acute (<7 days, 14.3%) and subacute (7–28 days, 7.1%) were also seen. The median modified Rankin Scale (mRS) score at nadir was 3 (range 2–4). Symptoms were asymmetric in 78.6% and included leg numbness (85.7%), leg weakness (64.3%), perineal numbness (35.7%), pain (42.3%), and incontinence (21.4%). On MRI, the cauda equina enhanced in 100%, appeared nodular in 78.6%, and was diffusely involved in 71.4%. Coexisting myelitis was common (cervical 28.6%, thoracic 35.7%, and conus medullaris 28.6%). Intracranial inflammation included leptomeningitis (71.4%) and cranial neuropathies (57.1%). Electrodiagnostic studies were conducted in 3 with only one showing features consistent with a radicular process. Serum and CSF angiotensin-converting enzyme levels were elevated in 38.5% and 0.0%, respectively. CSF white blood cell and protein were elevated in 92.9%. Corticosteroids were tried in all patients with durable stabilization or improvement in only 3 (21.4%). Second-line agents associated with improvement included methotrexate/infliximab (3/4, 75%), methotrexate (3/4, 75.0%), and azathioprine (1/1, 100%). During a median follow-up of 22.5 months, the final median mRS score was 3. Relapses occurred at a median of 6 months in 21.4%. In 9 patients with MRI follow-up, 6 improved (66.7%), 1 stabilized (11.1%), and 2 worsened (22.2%).DiscussionCharacteristic features of cauda equina involvement by neurosarcoidosis include chronically delayed presentations, nodular enhancement on MRI, poor response to corticosteroids, and substantial resultant neurologic disability.
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16
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Nwebube CO, Bou GA, Castilho AJ, Hutto SK. Facial nerve palsy in neurosarcoidosis: clinical course, neuroinflammatory accompaniments, ancillary investigations, and response to treatment. J Neurol 2022; 269:5328-5336. [PMID: 35583659 DOI: 10.1007/s00415-022-11189-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Facial nerve palsy is a cardinal manifestation of neurosarcoidosis, but dedicated studies of this disease feature have not been conducted. We sought to clarify the impact of facial palsy on the diagnosis of neurosarcoidosis, its subsequent clinicoradiographic evolution, and eventual treatment decisions. METHODS A single-center retrospective analysis of patients with neurosarcoidosis and facial palsy was conducted over the preceding 10 years (01/01/2011-08/12/2021). RESULTS 23/218 (10.6%) patients with neurosarcoidosis developed facial neuropathy. It was the inaugural manifestation of neurosarcoidosis in 17/23 (73.9%) and presented in isolation of other neurologic deficits or extra-facial MRI abnormalities in 12/23 (52.2%). At onset, facial palsy was unilateral in 20/23 (87.0%), and multiple cranial neuropathies were seen in 8/23 (34.8%). Non-facial inflammatory MRI abnormalities were observed in 6/15 (40.0%) patients at onset with leptomeningitis being most common (5/15, 33.3%). 13/23 (56.5%) experienced a second attack of neurosarcoidosis at a median of 8 months, including 3/23 (13.0%) with recurrent facial palsies. In the 12 patients with isolated facial paresis at onset, 4/12 (33.3%) remained free of new deficits or neuroimaging abnormalities by last follow-up. 17/23 (73.9%) eventually required initiation of steroid-sparing immunosuppressants, almost all for development of non-facial disease. The final median House-Brackmann score was 1. CONCLUSION Facial neuropathy occurred less commonly than historically reported, and it often acts as a forerunner to systemic sarcoidosis and more widespread neurologic disease. Recurrent attacks of neurosarcoidosis occur early at high frequency following facial palsy. Recovery of facial nerve function is typically excellent.
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Affiliation(s)
- Chineze O Nwebube
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Gabriela A Bou
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Alexander J Castilho
- Division of Neuroradiology, Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA.
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Abstract
Sarcoidosis is a multisystem disease of unknown cause with heterogenous clinical manifestations and variable course. Spontaneous remissions occur in some patients while others have progressive disease impacting survival, organ function, and quality of life. Four high-risk sarcoidosis phenotypes associated with chronic inflammation have recently been identified as high-priority areas for research. These include treatment-refractory pulmonary disease, cardiac sarcoidosis, neurosarcoidosis and multiorgan sarcoidosis. Significant gaps currently exist in understanding of these high-risk manifestations of sarcoidosis, including their natural history, diagnostic criteria, biomarkers, and the treatment strategy such as the ideal agent, optimal dose and treatment duration. The use of registries with well-phenotyped patients is a critical first step to study high-risk sarcoidosis manifestations systematically. We review the diagnostic and treatment approach to high-risk sarcoidosis manifestations. Appropriately identifying these disease sub-groups will help enroll well-phenotyped patients in sarcoidosis registries and clinical trials, a necessary step to narrow existing gaps in understanding of this enigmatic disease.
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Hilezian F, Maarouf A, Boutiere C, Rico A, Demortiere S, Kerschen P, Sene T, Bensa-Koscher C, Giannesini C, Capron J, Mekinian A, Camdessanché JP, Androdias G, Marignier R, Collongues N, Casez O, Coclitu C, Vaillant M, Mathey G, Ciron J, Pelletier J, Audoin B. TNF-α inhibitors used as steroid-sparing maintenance monotherapy in parenchymal CNS sarcoidosis. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325665. [PMID: 34103339 PMCID: PMC8292597 DOI: 10.1136/jnnp-2020-325665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the efficacy of tumour necrosis factor-α (TNF-α) inhibitors used as steroid-sparing monotherapy in central nervous system (CNS) parenchymal sarcoidosis. METHODS The French Multiple Sclerosis and Neuroinflammation Centers retrospectively identified patients with definite or probable CNS sarcoidosis treated with TNF-α inhibitors as steroid-sparing monotherapy. Only patients with CNS parenchymal involvement demonstrated by MRI and imaging follow-up were included. The primary outcome was the minimum dose of steroids reached that was not associated with clinical or imaging worsening during a minimum of 3 months after dosing change. RESULTS Of the identified 38 patients with CNS sarcoidosis treated with TNF-α inhibitors, 23 fulfilled all criteria (13 females). Treatments were infliximab (n=22) or adalimumab (n=1) for a median (IQR) of 24 (17-40) months. At treatment initiation, the mean (SD) age was 41.5 (10.5) years and median (IQR) disease duration 22 (14-49.5) months. Overall, 60% of patients received other immunosuppressive agents before a TNF-α inhibitor. The mean (SD) minimum dose of steroids was 31.5 (33) mg before TNF-α inhibitor initiation and 6.5 (5.5) mg after (p=0.001). In all, 65% of patients achieved steroids dosing <6 mg/day; 61% showed clinical improvement, 30% stability and 9% disease worsening. Imaging revealed improvement in 74% of patients and stability in 26%. CONCLUSION TNF-α inhibitors can greatly reduce steroids dosing in patients with CNS parenchymal sarcoidosis, even refractory. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that TNF-α inhibitor used as steroid-sparing monotherapy is effective for patients with CNS parenchymal sarcoidosis.
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Affiliation(s)
- Frédéric Hilezian
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
| | - Adil Maarouf
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
| | - Clemence Boutiere
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
| | - Audrey Rico
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
| | - Sarah Demortiere
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
| | - Philippe Kerschen
- Service de Neurologie, Centre Hospitalier de Luxembourg, Luxembourg-Ville, Luxembourg
| | - Thomas Sene
- Service de Médecine Interne, Hôpital Rothschild, Paris, France
| | | | - Claire Giannesini
- Service de Neurologie, Hôpital Saint-Antoine, AP-HP, Paris, France
- Sorbonne Université, Paris, France
| | - Jean Capron
- Service de Neurologie, Hôpital Saint-Antoine, AP-HP, Paris, France
- Sorbonne Université, Paris, France
| | - Arsene Mekinian
- Sorbonne Université, Paris, France
- Service de Medecine Interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | | | - Géraldine Androdias
- Service de Neurologie, Sclérose en Plaques, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Lyon/Bron, France
| | - Romain Marignier
- Pathologies de la myéline et neuro-inflammation, et Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Lyon/Bron, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Collongues
- Servie de Neurologie, Hôpital Universitaire de Strasbourg, Strasbourg, France
- Centre d'investigation clinique, U1434, INSERM, Strasbourg, France
| | - Olivier Casez
- Clinique de Neurologie, Pathologies Inflammatoires du Système Nerveux, Hôpital Universitaire Grenoble Alpes, Grenoble, France
| | - Catalina Coclitu
- Clinique de Neurologie, Pathologies Inflammatoires du Système Nerveux, Hôpital Universitaire Grenoble Alpes, Grenoble, France
| | - Mathieu Vaillant
- Clinique de Neurologie, Pathologies Inflammatoires du Système Nerveux, Hôpital Universitaire Grenoble Alpes, Grenoble, France
| | - Guillaume Mathey
- Service de Neurologie, Hôpital Universitaire de Nancy, Nancy, France
- APEMAC, EA 4360, Université de Lorraine, Nancy, France
| | - Jonathan Ciron
- Service de Neurologie, CRC-SEP, Hôpital Universitaire de Toulouse, Toulouse, France
| | - Jean Pelletier
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
| | - Bertrand Audoin
- Service de Neurologie, Hôpital de la Timone, Hôpitaux Universitaires de Marseille, Marseille, France
- Aix-Marseille Université, CNRS, CRMBM, Marseille, France, Marseille, France
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Raibagkar P, Ramineni A. Autoimmune Neurologic Emergencies. Neurol Clin 2021; 39:589-614. [PMID: 33896534 DOI: 10.1016/j.ncl.2021.01.006] [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] [Indexed: 11/17/2022]
Abstract
Over the past decade, understanding of autoimmune neurologic disorders has exponentially increased. Many patients present as a neurologic emergency and require timely evaluation with rapid management and intensive care. However, the diagnosis is often either missed or delayed, which may lead to a significant burden of disabling morbidity and even mortality. A high level of suspicion in the at-risk population should be maintained to facilitate more rapid diagnosis and prompt treatment. At present, there is no all-encompassing algorithm specifically applicable to the management of fulminant autoimmune neurologic disorders. This article discusses manifestations and management of various autoimmune neurologic emergencies.
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Affiliation(s)
- Pooja Raibagkar
- Concord Hospital Neurology Associates, 246 Pleasant Street, Concord, NH 03301, USA.
| | - Anil Ramineni
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, 41 Mall Road, Burlington, MA 01803, USA
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Gelfand JM. Tumour necrosis factor inhibitor monotherapy for CNS neurosarcoidosis. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2021-326267. [PMID: 33785576 DOI: 10.1136/jnnp-2021-326267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Jeffrey Marc Gelfand
- Department of Neurology, Division of Neuroimmunology and Glial Biology, University of California, San Francisco (UCSF), San Francisco CA 94158, California, USA
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Effects of immunotherapies and clinical outcomes in neurosarcoidosis: a retrospective cohort study. J Neurol 2021; 268:2466-2472. [PMID: 33515298 DOI: 10.1007/s00415-021-10421-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/12/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Neurosarcoidosis is associated with a significant degree of morbidity and mortality and its treatments are varied and complex. There is a paucity of information in current literature on patterns of treatment and long term outcomes. This study aimed to evaluate the clinical outcomes and responses to immunosuppressive therapy in a large cohort of neurosarcoidosis patients . METHODS We enrolled 80 patients with a diagnosis of neurosarcoidosis. Prescription patterns and clinical outcomes before and after treatment and differences between the treatment groups were compared using Kruskal-Wallis and Mann-Witney U tests. RESULTS Patients with cranial mononeuropathy other than optic neuropathy were more likely to be treated with steroids alone whereas patients with other presentations were likely to require second and third level treatments. These included azathioprine, methotrexate, mycophenolate, infliximab, and cyclophosphamide often used in combination. Prednisolone alone at onset failed in 67% of patients but appeared most effective in those with isolated facial nerve palsy. Patients treated with prednisolone plus a standard immunosuppression first line generally did well except for those with brain parenchymal disease and /or hydrocephalus who responded better to the addition of infliximab, or cyclophosphamide. Triple therapy with prednisolone + azathioprine + infliximab was associated with significantly greater improvement on the Modified Rankin Scale than prednisolone alone whether used first line (p = 0.001 corrected) or subsequently (p = 0.021 corrected). Overall favourable outcomes in the form of improvement of MRS were reported in 87%, CONCLUSIONS: Our results provides evidence that early immunosuppressive treatments, with azathioprine, methotrexate and infliximab could effectively improve clinical outcomes in many patients with neurosarcoidosis.
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Ogbue OD, Malhotra P, Akku R, Jayaprakash T, Khan S. Biologic Therapies in Sarcoidosis and Uveitis: A Review. Cureus 2020; 12:e9057. [PMID: 32782876 PMCID: PMC7413313 DOI: 10.7759/cureus.9057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sarcoidosis and uveitis are chronic inflammatory conditions with potentially debilitating effects on quality of life. Steroids form the mainstay standard therapy in both conditions. Biologic agents are considered to be appropriate alternatives for treatment in steroid-refractory sarcoidosis and uveitis due to the role of tumor necrosis factor (TNF) in mediating the inflammatory cascade seen in both conditions. We performed a thorough literature search using PubMed to compare the extent of use, efficacy, and safety profile of individual anti-TNF agents in the management of these conditions. Our review consists of two systematic reviews with meta-analysis, thirteen observational studies, and fifteen case series/reports. Infliximab had the widest range of organ-system usage in extra-pulmonary sarcoidosis but is equivalent to adalimumab in terms of efficacy. In uveitis, adalimumab was found to be the most efficacious agent for maintaining disease remission in adults and children with chronic non-infectious uveitis. Etanercept was neither used widely, nor was it efficacious in the management of either condition. In terms of safety profile, biologic agents were found to be well tolerated and have a similar safety profile. More randomized clinical trials are needed to inform evidence-based use of biologic agents in these conditions.
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