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Fierro-Rosales VA, de Juan-Marcos L, Bermúdez-Cortés A, Lorenzo-Pérez R, Serafim-Reis PM. Diagnostic and therapeutic complexity of Susac syndrome. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2024:S2173-5794(24)00078-1. [PMID: 38710368 DOI: 10.1016/j.oftale.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/17/2024] [Indexed: 05/08/2024]
Abstract
A 40-year-old man who attended the emergency department with a scotoma in right eye. He mentioned hearing difficulties and headache for months and he had sensory and motor deficits in the previous days. In the ophthalmic examination, the right eye had areas of arterial occlusion. MRI revealed hyperintense lesions. The patient was diagnosed with Susac syndrome. He was treated with systemic steroids, however, it was not enough to control the condition. Rituximab and intravenous immunoglobulins were added, which allowed the improvement of neurological symptoms, but the alteration of the visual field and the hearing defect did not recover. Early diagnosis of this pathology is essential, since delaying treatment can cause irreversible consequences. Sometimes it is difficult given the wide variety of symptoms and the course of the disease. Ocular manifestations may raise suspicion when the general symptoms are nonspecific.
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Affiliation(s)
- V A Fierro-Rosales
- Servicio de Oftalmología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - L de Juan-Marcos
- Servicio de Oftalmología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
| | - A Bermúdez-Cortés
- Servicio de Oftalmología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - R Lorenzo-Pérez
- Servicio de Oftalmología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - P M Serafim-Reis
- Servicio de Oftalmología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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2
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Wilf-Yarkoni A, Zmira O, Tolkovsky A, Pflantzer B, Gofrit SG, Kleffner I, Paul F, Dörr J. Clinical Characterization and Ancillary Tests in Susac Syndrome: A Systematic Review. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200209. [PMID: 38364193 DOI: 10.1212/nxi.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 02/18/2024]
Abstract
Susac syndrome (SuS) is an orphan microangiopathic disease characterized by a triad of encephalopathy, visual disturbances due to branch retinal artery occlusions, and sensorineuronal hearing loss. Our previous systematic review on all cases of SuS reported until 2012 allowed for a better understanding of clinical presentation and diagnostic findings. Based on these data, we suggested diagnostic criteria in 2016 to allow early diagnosis and treatment of SuS. In view of the accumulation of new SuS cases reported in the last 10 years and improved diagnostic tools, we here aimed at updating the demographic and clinical features of SuS and to review the updated ancillary tests being used for SuS diagnosis. Therefore, based on the 2016 criteria, we systematically collected and evaluated data on SuS published from January 2013 to March 2022.
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Affiliation(s)
- Adi Wilf-Yarkoni
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ofir Zmira
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Assaf Tolkovsky
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Barak Pflantzer
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Shany G Gofrit
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Ilka Kleffner
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Friedemann Paul
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
| | - Jan Dörr
- From the Departmet of Neurology (A.W.-Y., A.T.), Rabin Medical Center, Petah Tikva; Department of Neurology and Neurosurgery (A.W.-Y., A.T., B.P., S.G.G.), Sackler Faculty of Medicine, Tel Aviv University; Department of Neurology (O.Z.), Hillel Yaffe Medical Center, Hadera; Department of Neurology (O.Z.), Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa; Department of Neurology (B.P., S.G.G.), Sheba Medical Center, Ramat Gan, Israel; Department of Neurology (I.K.), University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum; Experimental and Clinical Research Center (F.P., J.D.), Max Delbrueck Center for Molecular Medicine and Charité Universitaetsmedizin Berlin; and Multiple Sclerosis Center (J.D.), Neurology Department, Oberhavel Kliniken, Hennigsdorf, Germany
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Schuknecht A, Wiest MRJ, Said S, Bajka A, Hamann T, Muth DR, Fasler K, Blaser F, Barthelmes D, Zweifel S. Ophthalmological Outcomes in Patients with Susac Syndrome. Klin Monbl Augenheilkd 2024; 241:477-481. [PMID: 38653298 DOI: 10.1055/a-2243-4913] [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: 04/25/2024]
Abstract
BACKGROUND To report ophthalmological outcomes and treatment regimen in patients with Susac syndrome. METHODS This is a retrospective analysis of patients with Susac syndrome treated between November 2015 and March 2023. Multimodal imaging findings, ophthalmic examination data, information on neurological and sensorineural involvement, and therapeutic regimen were reviewed. Visual acuity was recorded as the logarithm of the minimum angle of resolution (logMAR). Ophthalmological manifestations and disease severity were assessed using the previously described clinical activity score (CAS). RESULTS Ten patients with Susac syndrome m : f = 5 : 5 were identified. The mean follow-up time was 31.2 ± 23.3 months (range 1 to 78 months). The mean age was 41.4 ± 13.8 years (range 21 to 59 years). At baseline, corrected distance visual acuity (CDVA) was 0.03 ± 0.08 logMAR. At the last follow-up, CDVA improved to 0.00 ± 0.03 logMAR (p = 0.029). Three of 20 eyes showed an improvement of 5 letters, while no loss of visual acuity was recorded during the follow-up time. Baseline CAS was 10.65 ± 12.69, and CAS at the last follow-up was 5.15 ± 5.49 (p = 0.068). Except for one patient, all were initially treated with intravenous (i. v.) steroids and subsequent oral tapering. Depending on the treatment response, cyclophosphamide (n = 4), i. v. immunoglobulins (IVIGs) (n = 4), anti-CD20 antibodies (n = 3), or plasmapheresis (n = 1) were applied. All patients under treatment for more than 1 month (n = 9) showed improvement in CAS and CDVA. CONCLUSION Susac syndrome is a rare autoimmune vascular endotheliopathy. Treatment of Susac syndrome appears to result in improving CAS and CDVA. The majority of patients, in addition to the systemic steroids, required systemic immunosuppressive agents. Interdisciplinary communication is crucial to reduce the time to diagnosis and initiation of therapy in patients with Susac syndrome.
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Affiliation(s)
| | | | - Sadiq Said
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
| | - Anahita Bajka
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
| | - Timothy Hamann
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
| | | | - Katrin Fasler
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
| | - Frank Blaser
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
| | - Daniel Barthelmes
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
- Ophthalmology, The University of Sydney Save Sight Institute, Sydney, Australia
| | - Sandrine Zweifel
- Department of Ophthalmology, Universitätsspital Zürich, Switzerland
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4
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Cohen DA, Tajfirouz D, Vodopivec I, Kyle K, Bouffard MA, Bhattacharyya S, Douglas VC, Rasool N, Bhatti MT, McKeon A, Pittock S, Flanagan EP, Prasad S, Nagagopal V, Egan RA, Chen JJ, Chwalisz BK. Fluorescein Angiography Findings in Susac Syndrome: A Multicenter Retrospective Case Series. J Neuroophthalmol 2023; 43:481-490. [PMID: 37075250 DOI: 10.1097/wno.0000000000001826] [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: 04/21/2023]
Abstract
BACKGROUND Susac syndrome is a vasculopathy, resulting in the classic triad of branch retinal artery occlusion (BRAO), inner ear ischemia, and brain ischemia. In this retrospective chart review, we characterize fluorescein angiography (FA) findings and other ancillary studies in Susac syndrome, including the appearance of persistent disease activity and the occurrence of new subclinical disease on FA. METHODS This multicenter, retrospective case series was institutional review board-approved and included patients with the complete triad of Susac syndrome evaluated with FA, contrasted MRI of the brain, and audiometry from 2010 to 2020. The medical records were reviewed for these ancillary tests, along with demographics, symptoms, visual acuity, visual field defects, and findings on fundoscopy. Clinical relapse was defined as any objective evidence of disease activity during the follow-up period after initial induction of clinical quiescence. The main outcome measure was the sensitivity of ancillary testing, including FA, MRI, and audiometry, to detect relapse. RESULTS Twenty of the 31 (64%) patients had the complete triad of brain, retinal, and vestibulocochlear involvement from Susac syndrome and were included. Median age at diagnosis was 43.5 years (range 21-63), and 14 (70%) were women. Hearing loss occurred in 20 (100%), encephalopathy in 13 (65%), vertigo in 15 (75%), and headaches in 19 (95%) throughout the course of follow-up. Median visual acuity at both onset and final visit was 20/20 in both eyes. Seventeen (85%) had BRAO at baseline, and 10 (50%) experienced subsequent BRAO during follow-up. FA revealed nonspecific leakage from previous arteriolar damage in 20 (100%), including in patients who were otherwise in remission. Of the 11 episodes of disease activity in which all testing modalities were performed, visual field testing/fundoscopy was abnormal in 4 (36.4%), MRI brain in 2 (18.2%), audiogram in 8 (72.7%), and FA in 9 (81.8%). CONCLUSIONS New leakage on FA is the most sensitive marker of active disease. Persistent leakage represents previous damage, whereas new areas of leakage suggest ongoing disease activity that requires consideration of modifying immunosuppressive therapy.
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Affiliation(s)
- Devon A Cohen
- Cleveland Clinic (DAC), Cleveland, Ohio; Mayo Clinic (DT, MTB, AM, SP, EPF, JJC), Rochester, Minnesota; Roche (IV), Basel, Switzerland; Massachusetts General Hospital (KK, VN, BKC), Boston, Massachusetts; Beth Israel Deaconess (MAB), Boston, Massachusetts; Brigham and Women's Hospital (SB, SP), Boston, Massachusetts; UCSF (VD, NR), San Francisco, California; and Eye and Vascular Neurology (RE), Carlton, Oregon
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5
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Plantone D, Sabatelli E, Locci S, Marrodan M, Laakso SM, Mateen FJ, Feresiadou A, Buelens T, Bianco A, Fiol MP, Correale J, Tienari P, Calabresi P, De Stefano N, Iorio R. Clinically relevant increases in serum neurofilament light chain and glial fibrillary acidic protein in patients with Susac syndrome. Eur J Neurol 2023; 30:3256-3264. [PMID: 37335505 DOI: 10.1111/ene.15939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND AND PURPOSE Serum levels of neurofilament light chain (sNfL) and glial fibrillary acidic protein (sGFAP) are promising neuro-axonal damage and astrocytic activation biomarkers. Susac syndrome (SS) is an increasingly recognized neurological condition and biomarkers that can help assess and monitor disease evolution are highly needed for the adequate management of these patients. sNfL and sGFAP levels were evaluated in patients with SS and their clinical relevance in the relapse and remission phase of the disease was assessed. METHODS As part of a multicentre study that enrolled patients diagnosed with SS from six international centres, sNfL and sGFAP levels were assessed in 22 SS patients (nine during a relapse and 13 in remission) and 59 age- and sex-matched healthy controls using SimoaTM assay Neurology 2-Plex B Kit. RESULTS Serum NfL levels were higher than those of healthy controls (p < 0.001) in SS patients and in both subgroups of patients in relapse and in remission (p < 0.001 for both), with significantly higher levels in relapse than in remission (p = 0.008). sNfL levels showed a negative correlation with time from the last relapse (r = -0.663; p = 0.001). sGFAP levels were slightly higher in the whole group of patients than in healthy controls (p = 0.046) and were more pronounced in relapse than in remission (p = 0.013). CONCLUSION In SS patients, both sNFL and sGFAP levels increased compared with healthy controls. Both biomarkers had higher levels during clinical relapse and much lower levels in remission. sNFL was shown to be time sensitive to clinical changes and can be useful to monitor neuro-axonal damage in SS.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Eleonora Sabatelli
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | - Sara Locci
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | | - Sini M Laakso
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Farrah J Mateen
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amalia Feresiadou
- Department of Neurology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Section of Neurology, Uppsala University, Uppsala, Sweden
| | - Tom Buelens
- Department of Ophthalmology, CHU St Pierre and Brugmann, Brussels, Belgium
| | - Assunta Bianco
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
| | | | - Jorge Correale
- Neurology Department, Fleni, Buenos Aires, Argentina
- Institute of Biological Chemistry and Biophysics (IQUIFIB) CONICET, University of Buenos Aires, Buenos Aires, Argentina
| | - Pentti Tienari
- Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Research Program of Translational Immunology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Raffaele Iorio
- Neurology Unit, Fondazione Policlinico Universitario 'A.Gemelli' IRCCS, Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Al-Azzawi A, Stapleton E. Blood tests as biomarkers for the diagnosis and prognosis of sudden sensorineural hearing loss in adults: a systematic review. J Laryngol Otol 2023; 137:977-984. [PMID: 36794400 DOI: 10.1017/s0022215123000282] [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: 02/17/2023]
Abstract
OBJECTIVE Sudden sensorineural hearing loss is considered idiopathic in up to 90 per cent of cases. This study explored the role of blood tests as biomarkers for the diagnosis and prognosis of sudden sensorineural hearing loss. METHOD Two researchers filtered 34 papers into the final review. This review was pre-registered on the Prospero database and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. RESULTS Raised inflammatory markers are almost universal in sudden sensorineural hearing loss, suggesting an inflammatory or autoimmune process. The most useful biomarkers are neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and fibrinogen level. Focused investigations should be deployed on a case-by-case basis to identify underlying metabolic, infective and autoimmune conditions. CONCLUSION A full blood count and coagulation screen (fibrinogen) is recommended in all cases of sudden sensorineural hearing loss. These are inexpensive, accessible and offer as much diagnostic and prognostic information as any other biomarker. There is emerging evidence regarding specific biomarkers for sudden sensorineural hearing loss prognosis, with heat shock protein-70, anti-endothelial cell antibody and prestin demonstrating potential; investigation of their validity through prospective, controlled research is recommended.
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Affiliation(s)
- A Al-Azzawi
- Medical School, University of Manchester, Manchester, UK
| | - E Stapleton
- Department of Otolaryngology, Manchester Royal Infirmary, Manchester, UK
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7
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Fisher L, David P, Sobeh T, Liberman RB, Amital H. Susac syndrome following COVID-19 vaccination: a case-based review. Clin Rheumatol 2023; 42:1713-1717. [PMID: 36877303 PMCID: PMC9986653 DOI: 10.1007/s10067-023-06564-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
COVID-19 vaccine circulation approval was a turning point for the coronavirus pandemic. The current approved COVID-19 vaccines, including messenger ribonucleic acid (mRNA)-based and adenovirus vector-based vaccines, were shown to significantly reduce the disease mortality and severity, and its adverse reactions are mainly mild ones. However, few cases of autoimmune conditions, both flare-ups and new-onset, were described in association with these vaccines. Susac vasculitis (SaS) is a rare autoimmune disease characterized by the clinical triad of encephalopathy, visual disturbances, and sensorineural hearing loss. Its pathogenesis is still not fully understood but is believed to be related to autoimmune processes, including autoantibodies to anti-endothelial cells and cellular immune processes that lead to microvascular damage and, consequently, micro-occlusions of the cerebral, inner ear, and retinal vessels. It has been previously described following vaccination and, most recently, few cases following coronavirus vaccines. We here describe a case of a previously healthy 49-year-old man diagnosed with SaS 5 days following the first dose of the BNT162b2 COVID-19 vaccine.
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Affiliation(s)
- Lior Fisher
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Paula David
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamer Sobeh
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Israel
| | - Roberta Bisker Liberman
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Pontifical Catholic University of São Paulo, São Paulo, Brazil
| | - Howard Amital
- Department of Medicine B, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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8
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Idiopathic systemic capillary leak syndrome, a unique complement and interferon mediated endotheliopathy syndrome: The role of the normal skin biopsy in establishing the diagnosis and elucidating pathogenetic mechanisms. Ann Diagn Pathol 2022; 61:152028. [DOI: 10.1016/j.anndiagpath.2022.152028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/01/2022]
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9
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Ahmad A, Tariq F, Zaheer M. Incomplete Susac’s Syndrome: A Case Report and Literature Review. Cureus 2022; 14:e27903. [PMID: 36110471 PMCID: PMC9464273 DOI: 10.7759/cureus.27903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 11/28/2022] Open
Abstract
Susac syndrome (SS) is rare microangiopathy of unclear etiology involving arteries of the brain, cochlea, and retina, affecting mainly middle-aged women. The diagnosis of Susac syndrome is based on a clinical evaluation of the signs and symptoms supported by imaging modalities. Immunosuppressants are the first-line treatment. Our patient is a 46-year-old man who was evaluated for right-sided visual loss and bilateral hearing loss. His ophthalmic examination revealed retinal artery occlusion. He showed a good response to rituximab and his vision remained stable. Our case is particularly unique as it shows an incomplete Susac syndrome involving the cochlea and retina only. This paper aims to increase awareness about the disease's symptoms, treatment, and prognosis.
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10
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Song KW, Manzano GS, Kharal GA, Venna N. Case Report of Spinal Cord Involvement in Susac Syndrome Masquerading as a Multiple Sclerosis Mimic. Neurohospitalist 2022; 12:556-558. [PMID: 35755220 PMCID: PMC9214945 DOI: 10.1177/19418744221097473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
We present a unique case of a 59-year-old woman with atypical Susac syndrome and prominent involvement of the spinal cord. She initially presented with progressive headaches, lower extremity weakness and hearing loss. Her MRI brain showed multiple enhancing lesions and her MRI spine showed a T8 enhancing lesion as well as a C2 cord infarct. She was treated with IV methylprednisolone with initial stabilization. However, she developed worsening encephalopathy and lower extremity weakness. Her repeat MRI brain showed new bilateral enhancing lesions and subacute infarcts. Given the increased burden of new lesions, she underwent a brain biopsy, which showed perivascular chronic inflammation within a small vessel distribution. Additionally, fluorescein angiography revealed bilateral branch retinal arterial occlusion (BRAO) and an audiogram demonstrated bilateral sensorineural hearing loss. She was diagnosed with Susac syndrome and treated with IV cyclophosphamide with improvement in her clinical exam. Spinal cord involvement is extremely rare for Susac syndrome, which commonly manifests as the classic triad of encephalopathy, BRAO and hearing loss. Her presentation with myelopathy highlights the importance of considering atypical presentations of well-established syndromes for optimal diagnosis and management.
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Affiliation(s)
- Kun-Wei Song
- Department of Neuro-oncology, Dana-Farber Cancer Center/Massachusetts General Hospital, Boston, MA, USA
| | - Giovanna S. Manzano
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - G. Abbas Kharal
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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A Comprehensive Update on Retinal Vasculitis: Etiologies, Manifestations and Treatments. J Clin Med 2022; 11:jcm11092525. [PMID: 35566655 PMCID: PMC9101900 DOI: 10.3390/jcm11092525] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 12/18/2022] Open
Abstract
Retinal vasculitis is characterized by inflammatory involvement of retinal arterioles, venules and/or capillaries and can be associated with a myriad of systemic and ophthalmic diseases. In this review, we have comprehensively discussed the etiologies, clinical manifestations, and presentations of retinal vasculitis. We have also included newer advances in imaging in retinal vasculitis such as OCTA and widefield imaging.
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12
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Hoogewoud F, Kawasaki A, Borruat FX, Guex-Crosier Y. Susac Syndrome: A Case Series. Klin Monbl Augenheilkd 2022; 239:518-522. [PMID: 35472796 DOI: 10.1055/a-1766-6243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Susac syndrome (SS) is an autoimmune disorder that involves the eyes, the brain, and the ears. It is a rare cause of recurrent branch retinal artery occlusion. The purpose of this study was to report cases of SS, highlighting the clinical presentations, therapeutic options, and their outcome. PATIENTS AND METHODS Retrospective case series of patients seen at our institution for SS between 2005 and 2020. Demographics, clinical characteristics, treatment, and outcome were studied. RESULTS Four patients (3 females, mean age 29 years old) were included in the study. According to the recently revised diagnostic criteria, three patients had definite and one patient had probable SS (distinctive ophthalmological and brain involvement without ear involvement). Initial visual acuity (VA) was normal in all eyes, but two patients had unilateral visual field impairment. Gass plaques (defined as yellow-white plaques found in the arteriolar wall away from arterial bifurcations) were observed on fundus examination in all patients. Fluorescein angiography revealed arteriolar wall hyperfluorescence and branch retinal arterial occlusions (BRAOs) in the absence of other signs of intraocular inflammation in all patients. Initial treatment consisted of a high-dose corticosteroid (intravenous or oral) with additional immunosuppressive therapy (azathioprine, intravenous immunoglobulins, mycophenolate mofetil, and/or cyclophosphamide). Residual symptoms were present in all patients and included scotoma (n = 2) and hearing loss (n = 3). CONCLUSION SS is a rare disease with characteristic ophthalmological manifestation. The majority of patients present a crude form of the triad, and retinal findings may be the first initial manifestation. Ophthalmologists should consider the possibility of an SS in all young patients presenting with BRAOs.
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Affiliation(s)
- Florence Hoogewoud
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | - Aki Kawasaki
- Neuro-ophtalmology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
| | | | - Yan Guex-Crosier
- Ocular Immunology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Switzerland
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13
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Susac's syndrome - A new ocular finding and disease outcome. Eye (Lond) 2022; 36:781-788. [PMID: 33879856 PMCID: PMC8956676 DOI: 10.1038/s41433-021-01464-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/20/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Susac's syndrome, a rare autoimmune vasculo-occlusive disease, may pose a diagnostic challenge and result in a devastating ocular and systemic outcome. Our study identifies a new retinal finding and evaluates disease outcome. We aimed to assess clinical and imaging findings, systemic manifestations and disease outcome in patients with ocular Susac's syndrome under immunosuppressive/immunomodulation therapies. METHODS Retrospective tertiary center study including patients with a diagnosis of Susac's syndrome with >12 months follow up. Medical record review including ocular, neurological and auditory clinical and imaging findings, and treatment modalities. Main outcome measures were clinical manifestations and disease outcome. RESULTS Seven patients (14 eyes) with a mean age of 34.1 years were included. Mean follow-up was 31.9 months (12.4-72.4). All had bilateral ocular disease. Retinal microaneurysms, a new ocular finding, were demonstrated in 5 patients and persisted at the final visit. In 5 eyes, they further extended during follow-up. All were treated with immunosuppressive drugs and 5/7 additional immunomodulation therapy. At last examination, best corrected visual acuity was >20/40 in all eyes, 1/10 eyes had visual field deterioration, no eye had active ocular disease, all patients achieved neurological stability, and 1 patient had auditory deterioration. CONCLUSION Retinal microaneurysms, a new ocular finding in Susac's syndrome, were present in most of our patients, indicating ischemic retinal damage. Immunosuppressive and immunomodulation therapies seem to be highly effective in the control of disease activity.
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14
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Susac syndrome: A scoping review. Autoimmun Rev 2022; 21:103097. [DOI: 10.1016/j.autrev.2022.103097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/21/2022]
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15
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Susac Syndrome Following COVID-19 Vaccination: A Case Report. Vaccines (Basel) 2022; 10:vaccines10030363. [PMID: 35334994 PMCID: PMC8954499 DOI: 10.3390/vaccines10030363] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Due to the COVID-19 pandemic, numerous vaccines have been developed for the disease. However, with large-scale vaccination has come the gradual emergence of immunological phenomena caused by these new vaccines. Herein, we report a 48-year-old female with a sudden onset of inferior visual field defects in the left eye following her first dose of the ChAdOx1 vaccine. Dilated fundus examination combined with optical coherence tomography and fluorescein angiography confirmed the diagnosis of branch retinal artery occlusion. Within 4 weeks following vaccination, symptoms associated with hearing impairment developed, and magnetic resonance imaging revealed leptomeningeal enhancement. The diagnosis of Susac syndrome (SS) was confirmed. The development of SS may be caused by endotheliopathy resulting from the molecular mimicry of the ChAdOx1 vaccine. Clinicians should be aware of the symptoms of SS, which may develop after COVID-19 vaccination. Further experimental surveillance and case–control studies are required to confirm this relationship.
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16
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Wang A, Hu K, Yang Y, Yang B, Liu J, Chen X, Liu Y, Si Z. Susac syndrome with the typical clinical triad: A case report and literature review. J Neuroimmunol 2022; 367:577822. [DOI: 10.1016/j.jneuroim.2022.577822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/31/2021] [Accepted: 01/29/2022] [Indexed: 11/25/2022]
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17
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OUP accepted manuscript. Brain 2022; 145:858-871. [DOI: 10.1093/brain/awab476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
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18
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Bae SH, Yoo JE, Hong JW, Park HR, Noh B, Kim H, Kang M, Hyun YM, Gee HY, Choi JY, Jung J. LCCL peptide cleavage after noise exposure exacerbates hearing loss and is associated with the monocyte infiltration in the cochlea. Hear Res 2021; 412:108378. [PMID: 34735822 DOI: 10.1016/j.heares.2021.108378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/30/2021] [Accepted: 10/19/2021] [Indexed: 12/19/2022]
Abstract
Acoustic trauma induces an inflammatory response in the cochlea, resulting in debilitating hearing function. Clinically, amelioration of inflammation substantially prevents noise-induced hearing loss. The Limulus factor C, Cochlin, and Lgl1 (LCCL) peptide plays an important role in innate immunity during bacteria-induced inflammation in the cochlea. We aimed to investigate the LCCL-induced innate immune response to noise exposure and its impact on hearing function. METHODS We used Coch (encodes cochlin harboring LCCL peptide) knock-out and p.G88E knock-in mice to compare the immune responses before and after noise exposure. We explored their hearing function and hair cell degeneration. Moreover, we investigated distinct characteristics of immune responses upon noise exposure using flow cytometry and RNA sequencing. RESULTS One day after noise exposure, the LCCL peptide cleaved from cochlin increased over time in the perilymph space. Both Coch-/- and CochG88E/G88E mutant mice revealed more preserved hearing following acoustic trauma compared to wild-type mice. The outer hair cells were more preserved in Coch-/- than in wild-type mice upon noise exposure. The RNA sequencing data demonstrated significantly upregulated cell migration gene ontology in wild-type mice than in Coch-/- mice following noise exposure, indicating that the infiltration of immune cells was dependent on cochlin. Notably, infiltrated monocytes from blood (C11b+/Ly6G-/Ly6C+) were remarkably higher in wild-type mice than in Coch-/- mice at 1 day after noise exposure. CONCLUSIONS Noise-induced hearing loss was attributed to over-stimulated cochlin, and led to the cleavage and secretion of LCCL peptide in the cochlea. The LCCL peptide recruited more monocytes from the blood vessels upon noise stimulation, thus highlighting a novel therapeutic target for noise-induced hearing loss.
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Key Words
- AIED, Autoimmune Inner Ear Disease
- Acoustic trauma, animal study, inflammatory response, LCCL peptide, noise-induced hearing loss, Abbreviations, ABR, auditory brainstem response
- CCL2, C-C motif chemokine ligand 2
- DEGs, differentially expressed genes
- EDTA, ethylenediaminetetraacetic acid
- IL-1β, interleukin-1β
- IL-6, interleukin-6
- KO, knock-out
- LCCL, Limulus factor C, Cochlin, and Lgl1
- NIHL, noise-induced hearing loss
- RNA-seq, RNA sequencing
- RT-PCR, real-time polymerase chain reaction
- SDS, sodium dodecyl sulfate
- SPL, sound pressure level
- Tnf-α, tumor necrosis factor alpha
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Affiliation(s)
- Seong Hoon Bae
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Eun Yoo
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Won Hong
- Department of Pharmacology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Haeng Ran Park
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byunghwa Noh
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyoyeol Kim
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Minjin Kang
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Min Hyun
- Department of Anatomy, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Heon Yung Gee
- Department of Pharmacology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Young Choi
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinsei Jung
- Department of Otorhinolaryngology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea.
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INVESTIGATING MICROANGIOPATHY USING SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN PATIENTS WITH SUSAC SYNDROME. Retina 2021; 41:2172-2178. [PMID: 33758133 DOI: 10.1097/iae.0000000000003170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine whether optical coherence tomography angiography is of diagnostic utility for Susac syndrome (SuS) by quantifying microvascular retinal changes. METHODS We enrolled 18 eyes of 9 healthy controls and 18 eyes of 9 patients with chronic SuS (12 had previous branch retinal artery occlusions and 6 were clinically unaffected). Images of the fovea were taken using an optical coherence tomography angiography system. Analysis included vessel density, fractal dimension, vessel diameter, and measurements of the foveal avascular zone (area, eccentricity, acircularity index, and axis ratio) in deep and superficial retinal layers. RESULTS Skeleton density and inner ring vessel density were significantly lower in patients with SuS (skeleton density: Susac 0.11 ± 0.01 vs. controls 0.12 ± 0.01, P = 0.027. VD: SuS 0.39 ± 0.04 vs. controls 0.42 ± 0.02, P = 0.041). Eccentricity and axis ratio were significantly higher in patients with SuS (EC: Susac 0.61 ± 0.11, controls 0.51 ± 0.10, P = 0.003; axis ratio: Susac 1.57 ± 0.28, controls 1.39 ± 0.11, P = 0.005). SuS eyes (affected and unaffected) had poorer outcomes of the remaining vascular parameters compared with controls (P > 0.05). CONCLUSION Optical coherence tomography angiography identified chronic microvascular changes in the eyes of patients with chronic SuS. Even clinically unaffected SuS eyes showed poorer vascular parameters. Although further research is needed, this noninvasive imaging modality seems to have the potential to serve as a valuable additive diagnostic tool.
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20
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Ahmed A, Kok ZQ, Coles A, Scoffings DJ, Crisp SJ. Susac's syndrome as an autoimmune complication of alemtuzumab-associated immune reconstitution. J Neurol 2021; 269:1695-1697. [PMID: 34586449 DOI: 10.1007/s00415-021-10802-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/09/2021] [Accepted: 09/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Amir Ahmed
- School of Clinical Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Zi Qi Kok
- School of Clinical Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Alasdair Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Scoffings
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah J Crisp
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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21
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RECURRENT BRANCH RETINAL ARTERY OCCLUSION FROM SUSAC SYNDROME: CASE REPORT AND REVIEW OF LITERATURE. Retin Cases Brief Rep 2021; 14:315-320. [PMID: 29870024 DOI: 10.1097/icb.0000000000000751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report a patient with branch retinal artery occlusion predominant Susac syndrome and review the literature on current diagnostic modalities and therapeutic approaches for this rare condition. METHODS Case report. RESULTS A 23-year-old white male presented with a 5-month history of a scotoma in his right eye vision, headaches, and intermittent paresthesias of the lower extremities. Ophthalmic examination was normal with the exception of a hypopigmented small retinal area inferonasal to the fovea in the right eye. Optical coherence tomography demonstrated inner retinal atrophy and optical coherence tomography angiography showed deep capillary layer vessel dropout in both eyes. Ultra-wide-field fluorescein angiography revealed bilateral arteriolar wall hyperfluorescence. Corpus callosal lesions were present on magnetic resonance imaging. Lumbar puncture demonstrated elevated protein. Audiogram was normal. A diagnosis of Susac syndrome was made. The patient initially received oral steroids followed by intravenous steroids and mycophenolate mofetil because of new branch retinal artery occlusions. Thirteen months after initial presentation, the vision was stable at 20/20 in both eyes. CONCLUSION It is a diagnostic challenge when recurrent branch retinal artery occlusion secondary to Susac syndrome presents without the classic symptoms. Optical coherence tomography angiography and subtle magnetic resonance imaging findings aided in early recognition of the diagnosis in our patient. Ultra-wide-field fluorescein angiography was an important tool in disease monitoring. Aggressive management with intravenous corticosteroids and initiation of immunosuppression resulted in long-term preservation of vision and improvement in visual field.
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22
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Wiendl H, Gross CC, Bauer J, Merkler D, Prat A, Liblau R. Fundamental mechanistic insights from rare but paradigmatic neuroimmunological diseases. Nat Rev Neurol 2021; 17:433-447. [PMID: 34050331 DOI: 10.1038/s41582-021-00496-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 02/04/2023]
Abstract
The pathophysiology of complex neuroimmunological diseases, such as multiple sclerosis and autoimmune encephalitis, remains puzzling - various mechanisms that are difficult to dissect seem to contribute, hampering the understanding of the processes involved. Some rare neuroimmunological diseases are easier to study because their presentation and pathogenesis are more homogeneous. The investigation of these diseases can provide fundamental insights into neuroimmunological pathomechanisms that can in turn be applied to more complex diseases. In this Review, we summarize key mechanistic insights into three such rare but paradigmatic neuroimmunological diseases - Susac syndrome, Rasmussen encephalitis and narcolepsy type 1 - and consider the implications of these insights for the study of other neuroimmunological diseases. In these diseases, the combination of findings in humans, different modalities of investigation and animal models has enabled the triangulation of evidence to validate and consolidate the pathomechanistic features and to develop diagnostic and therapeutic strategies; this approach has provided insights that are directly relevant to other neuroimmunological diseases and applicable in other contexts. We also outline how next-generation technologies and refined animal models can further improve our understanding of pathomechanisms, including cell-specific and antigen-specific CNS immune responses, thereby paving the way for the development of targeted therapeutic approaches.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany.
| | - Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Münster, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - Doron Merkler
- Department of Pathology and Immunology, Division of Clinical Pathology, University and University Hospitals of Geneva, Geneva, Switzerland
| | - Alexandre Prat
- Department of Neuroscience, University of Montreal, Montreal, Canada
| | - Roland Liblau
- Infinity, Université Toulouse, CNRS, Inserm, Toulouse, France.,CHU Toulouse, Hôpital Purpan, Immunology Department, Toulouse, France
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23
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Nguyen M, Groenendyk J, Steker D, Goyal PK, Nguyen CV. Antimelanoma differentiation-associated gene 5 dermatomyositis associated with acute encephalopathy. JAAD Case Rep 2021; 13:20-22. [PMID: 34136619 PMCID: PMC8181587 DOI: 10.1016/j.jdcr.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Morgan Nguyen
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jacob Groenendyk
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Danielle Steker
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Parul Kathuria Goyal
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Cuong V Nguyen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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24
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David C, Sacré K, Papo T. [Update on Susac syndrome]. Rev Med Interne 2021; 43:26-30. [PMID: 34119343 DOI: 10.1016/j.revmed.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022]
Abstract
Susac syndrome is a rare disease affecting mainly young women, characterized by a microangiopathy limited to the cerebral, retinal, and cochlear vessels. Although the pathophysiology of Susac syndrome is not yet fully elucidated, recent advances favour a primitive vasculitis affecting the cerebral, retinal and cochlear small vessels. Susac syndrome must be recognized in the presence of the pathognomonic clinical triad associating: 1/subacute encephalopathy with unusual headache and pseudopsychiatric features associated with diffuse white matter, grey matter nuclei and specifically corpus callosum lesions on brain MRI; 2/eye involvement that may be pauci-symptomatic, with occlusions of the branches of the central artery of the retina at fundoscopy and arterial wall hyperfluorescence on fluorescein angiography; and 3/cochleo-vestibular damage with hearing loss predominating at low frequencies on the audiogram. Relapses are frequent during an active period lasting approximately 2 years. Eventually, the disease resolves but isolated retinal arterial wall hyperfluorescence without new occlusions may recur, which should not lead to treatment intensification. First-line treatment consists of a combination of anti-aggregants and high dose corticosteroids. In refractory patients or in case of relapse, immunomodulatory molecules such as intravenous immunoglobulins or immunosuppressive drugs such as mycophenolate mofetil, cyclophosphamide or rituximab should be started. Unfortunately, sequelae-mostly hearing loss- remain frequent in these young patients.
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Affiliation(s)
- C David
- Service de médecine interne, Hôpital Bichat, Paris, France
| | - K Sacré
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - T Papo
- Service de médecine interne, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
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Venditti L, Rousseau A, Ancelet C, Papo T, Denier C. Susac syndrome following COVID-19 infection. Acta Neurol Belg 2021; 121:807-809. [PMID: 33236280 PMCID: PMC7685681 DOI: 10.1007/s13760-020-01554-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Laura Venditti
- Department of Neurology, Centre Hospitalo-Universitaire de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
- Faculté de Médecine, Université Paris-Saclay, 63 Rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
| | - Antoine Rousseau
- Department of Ophtalmology, Centre Hospitalo-Universitaire de Bicêtre, AP-HP, 94275, Le Kremlin-Bicêtre, France
| | - Claire Ancelet
- Department of Neuroradiology, Centre Hospitalo-Universitaire de Bicêtre, AP-HP, 94275, Le Kremlin-Bicêtre, France
| | - Thomas Papo
- Department of Internal Medicine, Centre Hospitalo-Universitaire de Bichat, AP-HP, 75018, Paris, France
| | - Christian Denier
- Department of Neurology, Centre Hospitalo-Universitaire de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
- Faculté de Médecine, Université Paris-Saclay, 63 Rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France
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26
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Magro CM, Mulvey J, Kubiak J, Mikhail S, Suster D, Crowson AN, Laurence J, Nuovo G. Severe COVID-19: A multifaceted viral vasculopathy syndrome. Ann Diagn Pathol 2021; 50:151645. [PMID: 33248385 PMCID: PMC7553104 DOI: 10.1016/j.anndiagpath.2020.151645] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 01/08/2023]
Abstract
The objective of this study was to elucidate the pathophysiology that underlies severe COVID-19 by assessing the histopathology and the in situ detection of infectious SARS-CoV-2 and viral capsid proteins along with the cellular target(s) and host response from twelve autopsies. There were three key findings: 1) high copy infectious virus was limited mostly to the alveolar macrophages and endothelial cells of the septal capillaries; 2) viral spike protein without viral RNA localized to ACE2+ endothelial cells in microvessels that were most abundant in the subcutaneous fat and brain; 3) although both infectious virus and docked viral spike protein was associated with complement activation, only the endocytosed pseudovirions induced a marked up-regulation of the key COVID-19 associated proteins IL6, TNF alpha, IL1 beta, p38, IL8, and caspase 3. Importantly, this microvasculitis was associated with characteristic findings on hematoxylin and eosin examination that included endothelial degeneration and resultant basement membrane zone disruption and reduplication. It is concluded that serious COVID-19 infection has two distinct mechanisms: 1) a microangiopathy of pulmonary capillaries associated with a high infectious viral load where endothelial cell death releases pseudovirions into the circulation, and 2) the pseudovirions dock on ACE2+ endothelial cells most prevalent in the skin/subcutaneous fat and brain that activates the complement pathway/coagulation cascade resulting in a systemic procoagulant state as well as the expression of cytokines that produce the cytokine storm. The data predicts a favorable response to therapies based on either removal of circulating viral proteins and/or blunting of the endothelial-induced response.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NY, NY, USA
| | - Justin Mulvey
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, NY, NY, USA
| | - Jeffrey Kubiak
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NY, NY, USA
| | | | - David Suster
- Rutgers University Hospital Department of Pathology, Newark, NJ, USA
| | - A Neil Crowson
- Pathology Laboratory Associates, Oklahoma City, OK, USA; University of Oklahoma, Oklahoma City, OK, USA
| | - Jeffrey Laurence
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NY, NY, USA
| | - Gerard Nuovo
- Discovery Life Sciences, Powell, OH, USA; Ohio State University Comprehensive Cancer Center and Discovery Life Sciences, Columbus, OH, USA.
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Willekens B, Kleffner I. Susac syndrome and pregnancy: a review of published cases and considerations for patient management. Ther Adv Neurol Disord 2021; 14:1756286420981352. [PMID: 33796140 PMCID: PMC7970706 DOI: 10.1177/1756286420981352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/24/2020] [Indexed: 12/31/2022] Open
Abstract
Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.
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Affiliation(s)
- Barbara Willekens
- Department of Neurology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Ilka Kleffner
- University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Pérez PL, McCall AA, Hirsch BE. Scoping review of cochlear implantation in Susac's syndrome. World J Otorhinolaryngol Head Neck Surg 2021; 7:126-132. [PMID: 33997722 PMCID: PMC8103525 DOI: 10.1016/j.wjorl.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac’s Syndrome(SS) who have undergone cochlear implantation (CI). Data sources All published studies of CI in SS and contribution of two of our own patients who have not been reported previously. Methods A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac’s Syndrome, Cochlear Implantation. Results Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19–46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation. Conclusion Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.
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Affiliation(s)
- Philip L Pérez
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Andrew A McCall
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Barry E Hirsch
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Susac Syndrome and Pregnancy. Case Rep Neurol Med 2020; 2020:6049126. [PMID: 33425410 PMCID: PMC7775175 DOI: 10.1155/2020/6049126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
Susac syndrome (SuS) is a rare poorly characterised disorder that affects the brain, retina, and cochlea. Here, we present a case of a 31-year-old pregnant female with a new diagnosis of SuS that was successfully managed to 36 weeks of gestation with minimal disease burden to both the mother and newborn. She was treated initially using intravenous methylprednisolone followed by oral prednisone, and intravenous immunoglobulin (IVIg). We stress the importance of a multidisciplinary approach, involving both neurology and maternal-fetal medicine, and provide guidance in navigating the various options for immunosuppressive therapy during pregnancy.
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020; 30:393-399. [PMID: 33337398 DOI: 10.3233/ves-200007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse and the cervical vestibular-evoked myogenic potentials (cVEMPs). OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cVEMPs and the vHIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Oron Y, Handzel O, Habot-Wilner Z, Regev K, Karni A, Zur D, Baraquet D, Goldstein M, Elkayam O, Ungar OJ. Vestibular function assessment of Susac syndrome patients by the video head impulse test and cervical vestibular-evoked myogenic potentials. J Vestib Res 2020:VES200720. [PMID: 33164965 DOI: 10.3233/ves-200720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Susac syndrome (retino-cochleo-cerebral vasculopathy, SuS) is an autoimmune endotheliopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions and sensorineural hearing loss. In contrast to data regarding auditory function, data measuring vestibular function is sparse. OBJECTIVE To determine whether the video head impulse test (vHIT) can serve as a confirmatory assessment of vestibulocochlear dysfunction in cases of suspected SuS. METHODS Seven patients diagnosed with SuS underwent pure tone audiometry, a word recognition test, cervical vestibular-evoked myogenic potentials (cVEMPs), and the v-HIT. RESULTS Five patients were diagnosed with definite SuS, and two with probable SuS. Two patients were asymptomatic for hearing loss or tinnitus, and no sensorineural hearing loss was detected by audiograms. Four patients complained of tinnitus, and three patients reported experiencing vertigo. Three patients had abnormal cVEMPs results. All seven patients' vHIT results were normal, except for patient #2, who was one of the three who complained of vertigo. The calculated gain of her left anterior semicircular canal was 0.5, without saccades. CONCLUSIONS This is the first study to describe the results of the vHIT and cVEMPs among a group of patients with SuS. The results suggest that the vHIT should not be the only exam used to assess the function of the vestibular system of SuS patients.
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Affiliation(s)
- Yahav Oron
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zohar Habot-Wilner
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Keren Regev
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Karni
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dina Zur
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Baraquet
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michaella Goldstein
- Division of Ophthalmology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Papasavvas I, Teuchner B, Herbort CP. Susac syndrome (Retino-cochleo-cerebral vasculitis), the ophthalmologist in the role of the whistleblower. J Ophthalmic Inflamm Infect 2020; 10:27. [PMID: 33125601 PMCID: PMC7599291 DOI: 10.1186/s12348-020-00217-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Susac syndrome is a rare microangiopathy of suspected autoimmune origin affecting arteries of the retina, the cochlea and the brain. The aim of the study was to give a review of the disease entity and determine the proportion of cases and their characteristics in a uveitis referral centre. PATIENTS AND METHODS Charts of patients with the diagnosis of Susac syndrome seen in the Uveitis Clinic of the Centre for Ophthalmic Specialised Care (COS), Lausanne, Switzerland were reviewed retrospectively to determine the frequency of such cases in a uveitis referral centre. Clinical symptoms and signs, functional data, imaging signs and evolution were analysed in the 3 COS cases and one case shared with the Uveitis Clinic of the Department of Ophthalmology, University of Innsbruck, Austria. Characteristic signs were searched possibly allowing a prompt diagnosis. RESULTS During the period from 1994 to 2019 (24 years, 2045 patients), 3 charts with the diagnosis of Susac syndrome were found (0.15%). The whole collective, including the additional case, comprised three women aged 28, 32 and 63 at presentation and one man, aged 42. None of the 3 cases that were referred were diagnosed beforehand. The characteristic item found in all 4 cases was the abrupt arterial stop or segmental interruption of arteries and increased staining of arterial wall on angiography more clearly shown on indocyanine green angiography that can potentially be proposed as a crucial diagnostic element. All 4 cases responded to dual steroidal and non-steroidal immunosuppression. Under treatment, all four patients did not show any further evolution. CONCLUSION Susac syndrome is a multilocation arteritis of the head that can involve the eye, ear and brain often first diagnosed by the ophthalmologist. The diagnosis is rapidly reached in uveitis referral centres but seems to be missed otherwise, A helpful angiographic sign to be searched is an abrupt or segmental arterial stop and increased staining of the arterial wall more clearly seen on indocyanine green angiography. Patients often present first to the ophthalmologist who should be acting as a whistleblower to avoid severe involvement of the brain.
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Affiliation(s)
- Ioannis Papasavvas
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland
| | - Barbara Teuchner
- Department of Ophthalmology, University of Innsbruck, Innsbruck, Austria
| | - Carl Peter Herbort
- Retinal and Inflammatory Eye Diseases, Centre for Ophthalmic Specialized Care (COS), Clinic Montchoisi Teaching Centre, Lausanne, Switzerland.
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Sasikumar S, Micieli JA, Oh J. Mystery Case: Migraine, hearing loss, and blurred vision in a young woman. Neurology 2020; 95:e2945-e2950. [PMID: 33046618 DOI: 10.1212/wnl.0000000000011034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sanskriti Sasikumar
- From the Division of Neurology, Department of Medicine (S.S., J.A.M., J.O.), Department of Ophthalmology and Vision Sciences (J.A.M.), and St Michael's Hospital (J.A.M., J.O.), University of Toronto, Ontario, Canada.
| | - Jonathan A Micieli
- From the Division of Neurology, Department of Medicine (S.S., J.A.M., J.O.), Department of Ophthalmology and Vision Sciences (J.A.M.), and St Michael's Hospital (J.A.M., J.O.), University of Toronto, Ontario, Canada
| | - Jiwon Oh
- From the Division of Neurology, Department of Medicine (S.S., J.A.M., J.O.), Department of Ophthalmology and Vision Sciences (J.A.M.), and St Michael's Hospital (J.A.M., J.O.), University of Toronto, Ontario, Canada
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Wilf-Yarkoni A, Elkayam O, Aizenstein O, Oron Y, Furer V, Zur D, Goldstein M, Barequet D, Hallevi H, Karni A, Habot-Wilner Z, Regev K. Increased incidence of Susac syndrome: a case series study. BMC Neurol 2020; 20:332. [PMID: 32878610 PMCID: PMC7465403 DOI: 10.1186/s12883-020-01892-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Susac syndrome (SuS) is a rare condition characterized by a clinical triad of sensorineural hearing loss, branch artery occlusion and encephalopathy. This study reports an increased incidence of SuS in Israel. We describe the clinical characteristics of these patients, diagnostic procedures and the use and subsequent outcomes of newly published treatment guidelines. METHODS This is a single center retrospective study. Patients who were diagnosed with SuS between July 2017 and August 2018 were enrolled in this study. RESULTS Seven patients were diagnosed with SuS according to the diagnostic criteria in a time period of 13 months. The annual incidence was recently evaluated in Austria to be 0.024/100000, therefore, our case series represent at least a 5.4- fold increase in the annual incidence of SuS expected in Israel and a 7-fold increase in the annual incidence expected in our medical center. Mean time from the onset of the symptoms to diagnosis was three weeks and follow-up time was twenty four months. Recent exposure to cytomegalovirus was serologically evident in three patients and one patient had high titer of anti-streptolysin antibody. All patients underwent brain MRI, fluorescein angiography and audiometry. All patients were treated according to the newly recommended guidelines. All patients achieved clinical and radiological stability. CONCLUSIONS We report of an increased incidence of SuS in Israel. Infectious serological findings may imply a post infectious mechanism. The use of the recommended diagnostic procedures reduced the time to diagnosis. Newly published treatment guidelines led to favorable clinical outcomes.
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Affiliation(s)
- A Wilf-Yarkoni
- Neuro-Immunology Service and Department of Neurology Rabin Medical Center, 4941492, Petach Tikva, Israel.
| | - O Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Neuroradiology unit, Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Y Oron
- Department of ENT, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Furer
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Zur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - M Goldstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - D Barequet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Hallevi
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Karni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience Tel Aviv University, Tel Aviv, Israel
| | - Z Habot-Wilner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - K Regev
- Neuroimmunology and Multiple Sclerosis Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Chen D, Wang Z, Jia G, Mao H, Ni Y. The Role of Anti-Endothelial Cell Autoantibodies and Immune Response in Acute Low-Tone Hearing Loss. EAR, NOSE & THROAT JOURNAL 2020; 100:292S-300S. [PMID: 32865463 DOI: 10.1177/0145561320952501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Immunity is associated with acute low tone hearing loss. However, the exact pathophysiology of immunity-mediated acute low tone hearing loss remains unknown. In this study, we evaluated the presence, therapeutic effectiveness, and immunopathological mechanisms of anti-endothelial cell autoantibodies (AECEs) in patients with acute low-frequency hearing loss. MATERIAL AND METHODS Forty-nine patients who were treated as inpatients having acute low-frequency hearing loss and additional symptoms, such as ear fullness, tinnitus, dizziness, or hyperacusis, were enrolled in this study. Serum samples from these patients were collected for laboratory serum autoimmunity detection, including AECAs, antinuclear antibodies, immunoglobulin, and circular immune complex. Therapeutic responses to combination therapy in short-term outcome and serum cytokine levels were compared between AECA-positive and AECA-negative patients. RESULTS Anti-endothelial cell autoantibodies-positive patients tended to show significantly less response to standard therapy compared with AECAs controls (P < .05). Moreover, some serum cytokine levels elevated in both AECAs- and AECAs+ groups. Positive ratio of interleukin-8 and concentrations of macrophage inflammatory protein-1α were found higher in AECAs+ groups (P < .05). CONCLUSION The results supported that AECAs might wield influence on the short-term outcome of acute low-tone hearing loss (ALHL) treatment. Furthermore, AECA-mediated acute low-frequency hearing loss possibly involved dysregulation of inflammation process and release of cytokines.
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Affiliation(s)
- Diyan Chen
- ENT institute and Otorhinolaryngology Department of Shanghai Medical School, 159395Eye & ENT Hospital of Fudan University, Shanghai, People's Republic of China.,NHC Key Laboratory of Hearing Medicine, 12478Fudan University, Shanghai, People's Republic of China
| | - Zhujian Wang
- 159395Eye & ENT Hospital of Fudan University, Shanghai, People's Republic of China
| | - Gaogan Jia
- ENT institute and Otorhinolaryngology Department of Shanghai Medical School, 159395Eye & ENT Hospital of Fudan University, Shanghai, People's Republic of China.,NHC Key Laboratory of Hearing Medicine, 12478Fudan University, Shanghai, People's Republic of China
| | - Huanyu Mao
- ENT institute and Otorhinolaryngology Department of Shanghai Medical School, 159395Eye & ENT Hospital of Fudan University, Shanghai, People's Republic of China.,NHC Key Laboratory of Hearing Medicine, 12478Fudan University, Shanghai, People's Republic of China
| | - Yusu Ni
- ENT institute and Otorhinolaryngology Department of Shanghai Medical School, 159395Eye & ENT Hospital of Fudan University, Shanghai, People's Republic of China.,NHC Key Laboratory of Hearing Medicine, 12478Fudan University, Shanghai, People's Republic of China.,Otology and Skull Base Surgery Department, ENT Institute of Eye and ENT Hospital of Shanghai Medical School, Fudan University, Shanghai, People's Republic of China
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Agamanolis DP, Klonk C, Bigley K, Rennebohm RM. Neuropathological Findings in Susac Syndrome: An Autopsy Report. J Neuropathol Exp Neurol 2020; 78:515-519. [PMID: 31100145 DOI: 10.1093/jnen/nlz031] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A 24-year-old woman developed encephalopathy, branch retinal artery occlusion, hearing loss, and had "snowball" lesions in the corpus callosum, classic findings of Susac syndrome (SuS). Despite intensive immunosuppressive therapy, she lapsed into a coma, and died 7 months after the onset of her illness. Neuropathological examination, revealed perivascular inflammation and vasculitis involving small vessels, associated with vascular narrowing and occlusion, and numerous microinfarcts diffusely throughout the brain. The findings establish SuS as a neuroinflammatory condition that can include vasculitis. This represents the most comprehensive report of the neuropathological findings in SuS.
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Affiliation(s)
- Dimitri P Agamanolis
- Department of Pathology, Akron Children's Hospital.,Northeast Ohio Medical University (NEOMED), Akron, Ohio
| | - Collin Klonk
- Northeast Ohio Medical University (NEOMED), Akron, Ohio
| | - Kim Bigley
- Department of Neurology, Renoun Regional Medical Center, Reno, Nevada
| | - Robert M Rennebohm
- Formerly of the Department of Pediatric Rheumatology of the Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract
BACKGROUND Susac syndrome (SS) classically presents with the clinical triad of retinal artery occlusion, sensorineural hearing loss, and encephalopathy and the neuroimaging triad of white matter lesions, deep gray matter lesions, and leptomeningeal disease. However, patients can present with an incomplete clinical or neuroimaging triads making diagnosis difficult in certain situations. A standard treatment paradigm also is lacking in this illness. It is important for neuro-ophthalmologists to recognize clinical and radiographic findings that are pathognomonic for this syndrome and have a basic understanding of the available treatment options. EVIDENCE ACQUISITION Review of medical literature. RESULTS A definite diagnosis of SS is made when the clinical triad or the neuroimaging triad is present. There are numerous reports of 2 other imaging findings in this condition: arteriolar wall hyperfluorescence (AWH) on fluorescein angiography in retinal arterioles remote from retinal ischemia and central callosal lesions on MRI. Both of these imaging findings are diagnostic of SS. Gass plaques in retinal arterioles are almost always seen in the acute phase of the illness but are not pathognomonic for SS. The most common medications used in this syndrome are corticosteroids and intravenous immunoglobulin. A number of other medications have been used including mycopheolate, rituximab, azathioprine, and cyclophosphamide. CONCLUSIONS In the absence of the clinical triad or magnetic resonance imaging triad for SS, AWH remote from retinal vascular injury and central callosal lesions are confirmatory of the diagnosis because they have never been described in any other condition. The presence of Gass plaques in retinal arterioles should strongly suggest the diagnosis. Despite the lack of clinical trial data, patients with SS must be treated promptly and aggressively. In more fulminant cases, addition of mycophenolate mofetil or rituximab is required, followed by cyclophosphamide when disease is refractory to other medications.
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The Successful Use of Infliximab in a Relapsing Case of Susac's Syndrome. Case Rep Neurol Med 2020; 2020:9317232. [PMID: 32566335 PMCID: PMC7303758 DOI: 10.1155/2020/9317232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/22/2020] [Accepted: 05/22/2020] [Indexed: 12/31/2022] Open
Abstract
Susac's syndrome is a rare and debilitating disease characterized by the triad of encephalopathy, branch retinal artery occlusions, and sensorineural hearing loss. All manifestations may not be clinically apparent at presentation resulting in delayed diagnosis. Early recognition of the syndrome may prevent disease sequelae such as permanent cognitive, visual, and hearing loss. We present such a case of Susac's syndrome that was also refractory to conventionally prescribed combination of immunosuppressive treatments including high-dose potent corticosteroids, intravenous cyclophosphamide, methotrexate, plasma exchange, rituximab, and mycophenolate. His disease was stabilized with infliximab in combination with a tapering course of low-dose prednisone. After 2 years of remission with TNF treatment, consideration is being given to ceasing therapy. He has the sequelae of bilateral sensorineural hearing loss but no visual impairment or cognitive deficits on follow-up with neuropsychometric testing. This is the first case report to our knowledge of the successful use of infliximab for a patient with Susac's syndrome that was necessary following treatment with cyclophosphamide and then rituximab.
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Retinal vasculitis: A framework and proposal for a classification system. Surv Ophthalmol 2020; 66:54-67. [PMID: 32450158 DOI: 10.1016/j.survophthal.2020.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Retinal vasculitis, a poorly understood process involving inflammation or ischemia of the retinal vessel wall, may occur in association with a systemic process, although it can also be isolated to the retina. Because of the limited ability to perform histopathological studies on retinal vessels, there is no gold standard for diagnosis. Thus, there is utility in creating a classification system for retinal vasculitis and improving diagnostic strategies for this disease. We provide a framework for understanding retinal vasculitis based on size, location, and etiology. We hope that this information can be implemented in the clinical setting to provide some diagnostic strategies for this often confusing entity.
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Abdollahi M, Gao AF, Munoz DG. A case of disseminated microscopic demyelination with multifocal dystrophic calcification. Neuropathology 2020; 40:308-314. [PMID: 32128889 DOI: 10.1111/neup.12642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 10/24/2022]
Abstract
We present a 47-year-old woman with a 10-year disease course consisting of episodic confusion, aphasia, psychosis, depression, migrainous headaches and seizures. There was mild elevation of protein levels in the cerebrospinal fluid, progressive cerebral atrophy, and numerous small T1 hypointensities appearing as central "holes" in the corpus callosum on magnetic resonance imaging. She eventually expired due to status epilepticus and subsequent significant respiratory complications. In the central nervous system, there was generalized brain atrophy, and patchy labeling of blood vessels by antibodies to complement component 4d (C4d) and membrane attack complex. Innumerable small patches with loss of cell bodies (neurons and glial cells in gray matter and glial cells in white matter) and demyelination were scattered throughout the brain and spinal cord. There was no cavitation and the passing axons were mostly preserved. Large solid calcified foci were present predominantly in the pons along with disseminated focal calcification involving neuron cell bodies, neurites, and capillaries. Patchy labeling of glial cells and linear structures suggestive of myelin sheaths with C4d antibodies was observed while immunostains for SV40, tau, β-amyloid, alpha synuclein, p62, and trans-activation response DNA-binding protein 43 kDa were negative. Whole-exome sequencing did not reveal any clinically significant variants. Although the radiological findings are suggestive of Susac's syndrome (a rare condition characterized by encephalopathy, hearing loss, and branch retinal artery occlusion), in the absence of audiovisual manifestations, a definitive diagnosis cannot be rendered and therefore, this case may be representing a new entity. Further reports of similar cases are needed for clarification.
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Affiliation(s)
- Maryam Abdollahi
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew F Gao
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - David G Munoz
- Department of Laboratory Medicine and Pathobiology & Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Gross CC, Meyer C, Bhatia U, Yshii L, Kleffner I, Bauer J, Tröscher AR, Schulte-Mecklenbeck A, Herich S, Schneider-Hohendorf T, Plate H, Kuhlmann T, Schwaninger M, Brück W, Pawlitzki M, Laplaud DA, Loussouarn D, Parratt J, Barnett M, Buckland ME, Hardy TA, Reddel SW, Ringelstein M, Dörr J, Wildemann B, Kraemer M, Lassmann H, Höftberger R, Beltrán E, Dornmair K, Schwab N, Klotz L, Meuth SG, Martin-Blondel G, Wiendl H, Liblau R. CD8 + T cell-mediated endotheliopathy is a targetable mechanism of neuro-inflammation in Susac syndrome. Nat Commun 2019; 10:5779. [PMID: 31852955 PMCID: PMC6920411 DOI: 10.1038/s41467-019-13593-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/11/2019] [Indexed: 12/19/2022] Open
Abstract
Neuroinflammation is often associated with blood-brain-barrier dysfunction, which contributes to neurological tissue damage. Here, we reveal the pathophysiology of Susac syndrome (SuS), an enigmatic neuroinflammatory disease with central nervous system (CNS) endotheliopathy. By investigating immune cells from the blood, cerebrospinal fluid, and CNS of SuS patients, we demonstrate oligoclonal expansion of terminally differentiated activated cytotoxic CD8+ T cells (CTLs). Neuropathological data derived from both SuS patients and a newly-developed transgenic mouse model recapitulating the disease indicate that CTLs adhere to CNS microvessels in distinct areas and polarize granzyme B, which most likely results in the observed endothelial cell injury and microhemorrhages. Blocking T-cell adhesion by anti-α4 integrin-intervention ameliorates the disease in the preclinical model. Similarly, disease severity decreases in four SuS patients treated with natalizumab along with other therapy. Our study identifies CD8+ T-cell-mediated endotheliopathy as a key disease mechanism in SuS and highlights therapeutic opportunities.
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Affiliation(s)
- Catharina C Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Céline Meyer
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
| | - Urvashi Bhatia
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Lidia Yshii
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
| | - Ilka Kleffner
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Jan Bauer
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Anna R Tröscher
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sebastian Herich
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tilman Schneider-Hohendorf
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Henrike Plate
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Tanja Kuhlmann
- Institute of Neuropathology, University Hospital Münster, University of Münster, Pottkamp 2, 48149, Münster, Germany
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Straße 40, 37099, Göttingen, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - David-Axel Laplaud
- UMR 1064, INSERM, Centre de Recherche en Transplantation et Immunologie, Université de Nantes, CHU Nantes - Hôtel Dieu Bd Jean Monnet, 44093, Nantes Cedex 01, France
- Service Neurologie, CHU Nantes, Nantes, France
| | - Delphine Loussouarn
- Service d'Anatomo-Pathologie, CHU Nantes, Hôtel-Dieu, rez-de-jardin, 44093, Nantes Cedex 1, France
| | - John Parratt
- Department of Neurology, Royal North Shore Hospital, Sydney, Australia
- Australia Northern Clinical School, University of Sydney, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia
| | - Michael Barnett
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
| | - Michael E Buckland
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neuropathology, Royal Prince Alfred Hospital, 94, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
| | - Todd A Hardy
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, 2139, Australia
| | - Stephen W Reddel
- Brain and Mind Centre, Medical Faculty, University of Sydney, Mallett Street, Camperdown, Sydney, NSW, 2050, Australia
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, 2139, Australia
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Neurology, Center of Neurology und Neuropsychiatry, LVR-Klinikum, Heinrich Heine University Düsseldorf, Bergische Landstraße 2, 40629, Düsseldorf, Germany
| | - Jan Dörr
- Max Delbrueck Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, NeuroCure, Experimental and Clinical Research Center, Charitéplatz 1, 10117, Berlin, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Kraemer
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130, Essen, Germany
| | - Hans Lassmann
- Department of Neuroimmunology, Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Eduardo Beltrán
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians-University Munich, Großhaderner Straße 9, Martinsried, 82152, Munich, Germany
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig-Maximilians-University Munich, Großhaderner Straße 9, Martinsried, 82152, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Nicholas Schwab
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
- Cells in Motion (CiM), Münster, Germany
| | - Guillaume Martin-Blondel
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France
- Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, University of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
- Australia Northern Clinical School, University of Sydney, Reserve Road, St Leonards, Sydney, NSW, 2065, Australia.
- Cells in Motion (CiM), Münster, Germany.
| | - Roland Liblau
- Centre de Physiopathologie Toulouse-Purpan (CPTP), Université de Toulouse, CNRS, Inserm, UPS, CHU Purpan - BP 3028 - 31024, Toulouse Cedex 3, Toulouse, France.
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Agamanolis DP, Prayson RA, Asdaghi N, Gultekin SH, Bigley K, Rennebohm RM. Brain microvascular pathology in Susac syndrome: an electron microscopic study of five cases. Ultrastruct Pathol 2019; 43:229-236. [PMID: 31736417 DOI: 10.1080/01913123.2019.1692117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Susac syndrome is a rare, immune-mediated disease characterized by encephalopathy, branch retinal artery occlusion, and hearing loss. Herein, we describe the electron microscopic findings of three brain biopsies and two brain autopsies performed on five patients whose working clinical diagnosis was Susac syndrome. In all five cases, the key findings were basement membrane thickening and collagen deposition in the perivascular space involving small vessels and leading to thickening of vessel walls, narrowing, and vascular occlusion. These findings indicate that Susac syndrome is a microvascular disease. Mononuclear cells were present in the perivascular space, underlining the inflammatory nature of the pathology. Though nonspecific, the changes can be distinguished from genetic and acquired small vessel diseases. The encephalopathy of Susac syndrome overlaps clinically with degenerative and infectious conditions, and brain biopsy may be used for its diagnosis. Its vascular etiology may not be obvious on light microscopy, and electron microscopy is important for its confirmation.
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Affiliation(s)
- Dimitri P Agamanolis
- Department of Pathology, Akron Children's Hospital and Northeast Ohio Medical University (NEOMED), Akron, OH, USA
| | - Richard A Prayson
- Department of Pathology (Neuropathology), Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Negar Asdaghi
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sakir H Gultekin
- Department of Pathology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Kim Bigley
- Department of Neurology, Renoun Regional Medical Center, Reno, NV, USA
| | - Robert M Rennebohm
- Division of Pediatric Rheumatology, Formerly of the Cleveland Clinic Foundation, Institute of Pediatrics, Cleveland, OH, USA
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Russo FY, Ralli M, De Seta D, Mancini P, Lambiase A, Artico M, de Vincentiis M, Greco A. Autoimmune vertigo: an update on vestibular disorders associated with autoimmune mechanisms. Immunol Res 2019; 66:675-685. [PMID: 30270399 DOI: 10.1007/s12026-018-9023-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of the immune system in mediating cochleovestibular pathologies has received increasing attention in recent years. Autoimmune vertigo may be an invalidating condition and may worsen the quality of life of affected patients, especially in the cases of delayed diagnosis. Since the etiopathogenesis is still not clear, also the treatment is not yet completely delineated. According to the clinical presentation, autoimmune vertigo can present as an isolated disorder or in association with systemic autoimmune diseases. The main feature in autoimmune vertigo is the presence of an abnormal immune response, in either absence or presence of systemic autoimmune disease, directed against delicate components of the inner ear. This may determine a functional or anatomical alteration, with an inflammatory reaction often devastating for hearing and balance. Being the exact pathogenesis unknown, the diagnosis of autoimmune vertigo is based either on clinical criteria or on a positive response to steroids. The earlier the diagnosis is made, the sooner the therapy can be installed, giving a chance to the recovery of inner ear damages. Corticosteroids represent the most effective and universally accepted treatment, even if other immunomodulatory drugs are now having a more extensive use. HIGHLIGHTS: Vertigo is relatively frequent in autoimmune diseases; however, it is often misdiagnosed or attributed to central nervous system alterations rather to specific inner ear involvement. Vertigo and other audiovestibular symptoms may be the first manifestation of an autoimmune disease and if correctly addressed could significantly contribute to early diagnosis of the underlying autoimmune disease. Early diagnosis of immune-related vertigo can lead to prompt initiation of targeted therapy with elevate chances of preventing irreversible damages to the inner ear. The presence of alternating phases of well-being and disabling symptoms in patients with vertigo should always been considered, as they could suggest an underlying autoimmune condition.
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Affiliation(s)
- Francesca Yoshie Russo
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daniele De Seta
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy.
| | - Patrizia Mancini
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco Artico
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillo-facial Surgery, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
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Patel VA, Dunklebarger M, Zacharia TT, Isildak H. Otologic manifestations of Susac syndrome. ACTA ACUST UNITED AC 2019; 38:544-553. [PMID: 30623900 PMCID: PMC6325654 DOI: 10.14639/0392-100x-2166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
Susac syndrome, a rare autoimmune disorder first described as a classic triad (encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss) in 1979 by renowned physician John O. Susac, has been an advancing area of clinical interest and scientific research over the last several decades. This comprehensive review aims to succinctly highlight the breadth and detail of this enigmatic disease, with a primary focus on otologic manifestations. Topics discussed include epidemiology, pathophysiology, clinical manifestations, differential diagnoses, classification schema, laboratory investigations, characteristic audiometric findings, high-yield radiographic imaging, temporal bone histopathology, treatment strategies and overall prognosis.
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Affiliation(s)
- V A Patel
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - M Dunklebarger
- The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - T T Zacharia
- Department of Radiology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - H Isildak
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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Heng LZ, Bailey C, Lee R, Dick A, Ross A. A review and update on the ophthalmic implications of Susac syndrome. Surv Ophthalmol 2019; 64:477-485. [DOI: 10.1016/j.survophthal.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/26/2022]
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Coulette S, Lecler A, Saragoussi E, Zuber K, Savatovsky J, Deschamps R, Gout O, Sabben C, Aboab J, Affortit A, Charbonneau F, Obadia M. Diagnosis and Prediction of Relapses in Susac Syndrome: A New Use for MR Postcontrast FLAIR Leptomeningeal Enhancement. AJNR Am J Neuroradiol 2019; 40:1184-1190. [PMID: 31248864 DOI: 10.3174/ajnr.a6103] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 05/13/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Leptomeningeal enhancement can be found in a variety of neurologic diseases such as Susac Syndrome. Our aim was to assess its prevalence and significance of leptomeningeal enhancement in Susac syndrome using 3T postcontrast fluid-attenuated inversion recovery MR imaging. MATERIALS AND METHODS From January 2011 to December 2017, nine consecutive patients with Susac syndrome and a control group of 73 patients with multiple sclerosis or clinically isolated syndrome were included. Two neuroradiologists blinded to the clinical and ophthalmologic data independently reviewed MRIs and assessed leptomeningeal enhancement and parenchymal abnormalities. Follow-up MRIs (5.9 MRIs is the mean number per patient over a median period of 46 months) of patients with Susac syndrome were reviewed and compared with clinical and retinal fluorescein angiographic data evaluated by an independent ophthalmologist. Fisher tests were used to compare the 2 groups, and mixed-effects logistic models were used for analysis of clinical and imaging follow-up of patients with Susac syndrome. RESULTS Patients with Susac syndrome were significantly more likely to present with leptomeningeal enhancement: 5/9 (56%) versus 6/73 (8%) in the control group (P = .002). They had a significantly higher leptomeningeal enhancement burden with ≥3 lesions in 5/9 patients versus 0/73 (P < .001). Regions of leptomeningeal enhancement were significantly more likely to be located in the posterior fossa: 5/9 versus 0/73 (P < .001). Interobserver agreement for leptomeningeal enhancement was good (κ = 0.79). There was a significant association between clinical relapses and increase of both leptomeningeal enhancement and parenchymal lesion load: OR = 6.15 (P = .01) and OR = 5 (P = .02), respectively. CONCLUSIONS Leptomeningeal enhancement occurs frequently in Susac syndrome and could be helpful for diagnosis and in predicting clinical relapse.
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Affiliation(s)
- S Coulette
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - A Lecler
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - E Saragoussi
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - K Zuber
- Clinical Research Unit (K.Z.)
| | - J Savatovsky
- Neuroradiology Department (A.L.. E.S., J.S., F.C.)
| | - R Deschamps
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - O Gout
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - C Sabben
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - J Aboab
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
| | - A Affortit
- Ophthalmology Department (A.A.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | | | - M Obadia
- From the Neurology Department (S.C., R.D., O.G., C.S., J.A., M.O.)
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Magro CM, Halteh P, Olson LC, Kister I, Shapiro L. Linear scleroderma "en coup de sabre" with extensive brain involvement-Clinicopathologic correlations and response to anti-Interleukin-6 therapy. Orphanet J Rare Dis 2019; 14:110. [PMID: 31096996 PMCID: PMC6524280 DOI: 10.1186/s13023-019-1015-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/31/2019] [Indexed: 12/16/2022] Open
Abstract
Linear scleroderma “en coup de sabre” (LSES) variant is a cephalic subtype of localized scleroderma that can be associated with extracutaneous stigmata, such as epilepsy, dementia syndromes, as well as focal central nervous system neurologic deficits. While the pathophysiology of cutaneous linear scleroderma includes endothelial cell injury and up regulation of pro-fibrogenic pathways, the basis of LSES-associated neurologic complications is largely unknown. We report a patient with a history of LSES who developed intractable epilepsy and cognitive decline. Magnetic resonance imaging (MRI) of the brain exhibited numerous persistently enhancing brain lesions. Due to progressive neurologic deterioration over a period of 7 years, despite interventional therapy, a brain biopsy was performed. Neuropathologic analysis exhibited acute and chronic cortical ischemia associated with a small vessel lymphocytic vasculitis. Direct immunofluorescent studies showed C5b-9 and IgG deposition on endothelium while indirect immunofluorescent studies demonstrated reactivity of the patient’s serum with the microvasculature of the patient’s own brain tissue and generic human umbilical vein endothelial cells indicative of anti-endothelial cell antibodies. Therapy focusing on damaged endothelium was implemented. The interleukin-6 (IL-6) receptor inhibitor tocilizumab was used and the patient improved dramatically, likely reflecting the drug’s effect on the replenishment of endothelial progenitor cells.
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Affiliation(s)
- Cynthia M Magro
- Weill Cornell Medicine, Department of Pathology and Laboratory Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Pierre Halteh
- Weill Cornell Medicine, Department of Dermatology, 1305 York Avenue, New York, NY, 10021, USA
| | - Luke C Olson
- Weill Cornell Medicine, Department of Pathology and Laboratory Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Ilya Kister
- Department of Neurology, New York University Langone Medical Center, 240 East 38th Street, New York, NY, 10016, USA
| | - Lee Shapiro
- Community Care Rheumatology, 1 West Avenue, Saratoga Springs, NY, 12866, USA
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Lehman VT, Klaas JP, Makol A, Brinjikji W, Nasr DM, Mossa-Basha M, Petty GW, Huston rd J. High-resolution vessel wall imaging in Susac's Syndrome. J Neurosurg Sci 2019; 63:235-236. [DOI: 10.23736/s0390-5616.17.04127-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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