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Abrantes FFD, Moraes MPMD, Pedroso JL, Barsottini OG. Diffuse leptomeningeal enhancement in neurosarcoidosis-related longitudinally extensive myelitis. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1016-1017. [PMID: 37832599 PMCID: PMC10689102 DOI: 10.1055/s-0043-1772604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/03/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Fabiano Ferreira de Abrantes
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | | | - José Luiz Pedroso
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Orlando G. Barsottini
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
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Cao L, Liu M, Guo L, Li M, Xu M, Wang R. The pathogenesis hypothesis and research progress of CLIPPERS: A literature review. Medicine (Baltimore) 2023; 102:e33211. [PMID: 36930124 PMCID: PMC10019105 DOI: 10.1097/md.0000000000033211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023] Open
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is still a rare autoimmune disease in the world. In recent years, there are more and more reports about the clinical manifestations of CLIPPERS, but the specific etiology and pathogenesis are not clear. In this paper, by collating the literature reported in recent years, in the reported effective treatment cases, we found the current hypothesis about the pathogenesis of CLIPPERS. Three pathogenesis hypotheses: organ-specific autoimmunity; virus infection affects autoimmunity; and helper T lymphocyte 17 mediates autoimmunity. Although it is hypothetical, it is expected to further clarify the pathogenesis, evolution characteristics, and treatment of CLIPPERS, so as to provide a reference for further understanding of the disease. In the future, more observations and studies are needed to further verify the feasibility of the hypothesis. This article expands on atypical clinical manifestations and summarizes treatment options. Hope to provide a reference for clinical diagnosis and treatment of CLIPPERS.
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Affiliation(s)
- Long Cao
- College of Acupuncture and Massage, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Meiping Liu
- First College of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Li Guo
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Mingyan Li
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Min Xu
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Rui Wang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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4
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Harris MJ, Cossburn MD, Pengas G. Multiple cerebral infarcts: a rare complication of neurosarcoidosis. Pract Neurol 2019; 19:246-249. [PMID: 30700504 DOI: 10.1136/practneurol-2018-002133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2019] [Indexed: 11/04/2022]
Abstract
A 52-year-old man experienced a relapse of neurosarcoidosis, characterised by obstructive hydrocephalus and multiple posterior circulation infarcts. He was taking methotrexate, but his prednisolone was being weaned because of adverse effects. Stroke is rare in neurosarcoidosis and typically relates to granulomatous inflammation with a predilection for the perforator arteries. Sarcoidosis generally responds well to corticosteroids; however, patients with leptomeningeal involvement usually require additional immunosuppression as relapses can occur on weaning of corticosteroids. It is worth considering tumour necrosis factor-α antagonists for cases that progress despite first-line therapy.
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Affiliation(s)
- Matthew John Harris
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - George Pengas
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Hamdan N, Billon Grand R, Moreau J, Thines L. Cryptococcal meningitis in an immunocompetent patient with obstructive hydrocephalus: A case report. Neurochirurgie 2018; 64:324-326. [PMID: 30195720 DOI: 10.1016/j.neuchi.2018.05.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 05/14/2018] [Accepted: 05/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cryptococcal infections of the central nervous system are very rare in immunocompetent patients. They usually present as meningitis or as fungal cysts with or without hydrocephalus. Rapid diagnosis and treatment is crucial to the prognosis. CASE REPORT We report the case of an immunocompetent 40-year-old male patient with no medical or surgical history and no recent travel, who was hospitalized in our neurosurgery department because of a rapidly worsening headache. The neurological examination revealed no focal deficit but worrying signs of increased intracranial pressure. Magnetic resonance imaging (MRI) with contrast showed thick and large-scale cortico-pial cerebellar enhancements, associated with severe obstructive hydrocephalus. This required emergency endoscopic ventriculocisternostomy during which we observed cottony tissues along the ventricular walls. Biopsied tissues and cerebrospinal fluid samples (CSF) were not contributive. A CT scan of the chest and abdomen and blood markers of common primary tumors were all negative. No evidence of HIV infection or any cause of immunosuppression was identified. Symptoms and a second MRI slightly improved with intravenous corticosteroid therapy. The hypothesis of a lymphoma or granulomatous disease was made initially for which direct surgical biopsies were scheduled. The diagnosis of cryptococcal meningitis was obtained later on by simultaneous plasma and CSF Cryptococcus antigen detection. Cryptococcus neoformans (formerly C. neoformans var. grubii [serotype A]) was then identified by PCR. Clinical improvement was obtained with antifungal therapy. CONCLUSION Cryptococcal meningitis is a well-known condition in immunocompromised patients, often causing hydrocephalus requiring neurosurgical management. The diagnosis is more difficult in patients with no history of HIV or organ transplant. Neurologists and neurosurgeons must consider this possibility in case of diffuse, thick leptomeningeal enhancement on MRI.
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Affiliation(s)
- N Hamdan
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France.
| | - R Billon Grand
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France
| | - J Moreau
- Service de maladies infectieuses et tropicales, CHRU Jean-Minjoz, 25030 Besançon, France
| | - L Thines
- Service de neurochirurgie, CHRU Jean-Minjoz, 25030, Besançon, France
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Galnares-Olalde JA, Berebichez-Fridman R, Gómez-Garza G, Mercado M, Moreno-Sánchez F, Alegría-Loyola MA. Not everything is as it seems: neurosarcoidosis presenting as leptomeningitis. Clin Case Rep 2018; 6:596-602. [PMID: 29636921 PMCID: PMC5889254 DOI: 10.1002/ccr3.1418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 01/01/2018] [Accepted: 01/20/2018] [Indexed: 12/17/2022] Open
Abstract
Involvement of the central nervous system in sarcoidosis is rare; neurosarcoidosis, although unusual, can present as leptomeningitis. The diagnosis is usually difficult because of the vague and broad symptomatology; therefore, a prompt diagnosis should be made, and adequate treatment should be administered to reduce morbidity and mortality.
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Affiliation(s)
- Javier Andrés Galnares-Olalde
- American British Cowdray Medical Center Mexico City Mexico.,School of Medicine Faculty of Health Sciences Anahuac University Mexico North Campus Huixquilucan Mexico
| | - Roberto Berebichez-Fridman
- American British Cowdray Medical Center Mexico City Mexico.,School of Medicine Faculty of Health Sciences Anahuac University Mexico North Campus Huixquilucan Mexico
| | | | - Moisés Mercado
- American British Cowdray Medical Center Mexico City Mexico
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Cação G, Branco A, Meireles M, Alves JE, Mateus A, Silva AM, Santos E. Neurosarcoidosis according to Zajicek and Scolding criteria: 15 probable and definite cases, their treatment and outcomes. J Neurol Sci 2017; 379:84-88. [PMID: 28716286 DOI: 10.1016/j.jns.2017.05.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/09/2017] [Accepted: 05/26/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Neurosarcoidosis occurs in about 5% to 15% of patients with sarcoidosis. The purpose of this study was to identify and characterize a cohort of neurosarcoidosis patients and to review the largest previously reported neurosarcoidosis case series. METHODS This retrospective study enrolled all patients with the diagnosis of probable or definitive neurosarcoidosis according to Zajicek and Scolding criteria, followed at the neurology department of a tertiary center in Portugal from January 1989 to December 2015. RESULTS A total of 15 patients presented a diagnosis of probable or definitive neurosarcoidosis, with a mean age at time of diagnosis of 38.5years. The presenting neurologic syndrome was isolated cranial neuropathy, aseptic meningitis, myelitis, brain parenchymal lesion, myelorradiculitis and meningomyelorradiculitis. MRI study most often presented different enhancing lesions and the CSF analysis commonly revealed a lymphocytic pleocytosis and raised proteins. Thirteen patients had histopathology confirmation of systemic sarcoidosis and one preformed a spinal cord biopsy. Corticosteroids was the most often used treatment alone or in combination with immunosuppressive drugs. After a mean follow-up of 86.1months, the majority of patients fully recovered to a mRankin 0. DISCUSSION Fully comprehension of neurosarcoidosis is still a challenge due to its rarity and limited number of large published series, which renders the epidemiological study of this disease very difficult. In this study, the thoroughly medical records review and the summarize of previous published cohorts allow to add some information in the epidemiological and clinical knowledge of this entity.
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Affiliation(s)
- Gonçalo Cação
- Neurology Department, Centro Hospitalar do Porto, Porto, Portugal.
| | - Ana Branco
- Internal Medicine Department, Centro Hospitalar da Cova da Beira, Covilha, Portugal
| | - Mariana Meireles
- Internal Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | | | - Andrea Mateus
- Internal Medicine Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Centro Hospitalar do Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Portugal
| | - Ernestina Santos
- Neurology Department, Centro Hospitalar do Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Portugal
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SARCOIDOSE EXCLUSIVA DO SISTEMA NERVOSO CENTRAL: SUCESSO TERAPÊUTICO COM CICLOFOSFAMIDA E CORTICÓIDE. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Wang K, He X, Wang W, Niu H, Wang Y, Cai X, Yang S. Isolated neurosarcoidosis mimicking multifocal meningiomas: a diagnosis pitfall: A case report. Medicine (Baltimore) 2016; 95:e4994. [PMID: 27861333 PMCID: PMC5120890 DOI: 10.1097/md.0000000000004994] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Neurosarcoidosis accounts for approximately 5% of the sarcoidosis, which develops exclusively in the nervous system and is always difficult to diagnose. We describe a rare case of isolated neurosarcoidosis mimicking as multifocal meningiomas. A 27-year-old male was admitted to our hospital with a history of unconsciousness and convulsion 1 month ago, which was suspected as a seizure. The results showed no abnormalities in complete blood count; serum electrolytes; erythrocyte sedimentation rate and ultrasonography of the liver, pancreas, spleen, kidney and parotid gland, and so on. Chest radiograph and electroencephalogram were also normal. Serum-angiotensin-converting enzyme slightly increased. Normal opening pressure was shown in cerebrospinal fluid sampling, which includes 8/μL white blood cells, 0.93 g/L protein, and 3.03 mmol/L glucose. Enhanced magnetic resonance imaging revealed multifocal enhancement lesions, including left sphenoid wing region, left temporal and bilateral occipitoparietal region, which were suspected as multiple "meningioma". A left frontotemporal craniotomy was further performed. Both necrotizing and non-necrotizing granulomas were revealed in the pathological specimen, most of which were associated with multinucleated giant cells and macrophages. We could also see the fibrosis and inflammatory reaction in the sample composed of lymphocytes, histiocytes, and plasma cells. Histopathological examination showed that the cells were positive for human CD68 (KP1), CD68 (PGM1), and CD163; however, they were negative for the AF, epithelial membrane antigen, and glial fibrillary acidic protein. Tuberculosis-deoxyribonucleic acid test and special stains for acid-fast bacilli and fungi were negative. The diagnosis was finally made as isolated neurosarcoidosis. Then the patient was treated with additional corticosteroid therapy. Serial imaging examination 4 months later revealed that the lesions extremely decreased. CONCLUSION The diagnosis of isolated central nervous system sarcoidosis was still difficult because of limitations of available diagnostic tests. So neurosarcoidosis in the clinical work should never be neglected.
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Affiliation(s)
- Kun Wang
- Department of Neurosurgery, Hangzhou Xiasha Hospital
| | | | - Wei Wang
- Department of Pharmacy, Hangzhou Xiasha Hospital
| | | | | | - Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University, Hangzhou, People's Republic of China
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Leonhard SE, Fritz D, Eftimov F, van der Kooi AJ, van de Beek D, Brouwer MC. Neurosarcoidosis in a Tertiary Referral Center: A Cross-Sectional Cohort Study. Medicine (Baltimore) 2016; 95:e3277. [PMID: 27057889 PMCID: PMC4998805 DOI: 10.1097/md.0000000000003277] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to evaluate clinical characteristics, diagnostic strategy, and treatment in patients with neurosarcoidosis in a tertiary referral centre.In a cross-sectional study, we included all patients with neurosarcoidosis treated at our tertiary referral center between September 2014 and April 2015.We identified 52 patients, among them 1 patient was categorized as having definite neurosarcoidosis, 37 probable neurosarcoidosis, and 14 possible neurosarcoidosis. Neurologic symptoms were the first manifestation of sarcoidosis in 37 patients (71%). Chronic aseptic meningitis was the most common presentation (19/52 patients [37%]), followed by cranial neuropathy (16/52 patients [31%]). Serum angiotensin-converting enzyme and lysozyme levels were elevated in 18 of 41 (44%) and 12 of 26 cases (46%). Pulmonary or lymph node sarcoidosis was identified by chest X-ray in 21 of 39 cases (54%) and by computed tomography of the chest in 25 of 31 cases (81%); Fluorodeoxyglucose-Positron emission tomography showed signs of sarcoidosis in 15 of 19 cases (79%). Thirty-one of the 46 cases receiving treatment (67%) improved, 13 cases (28%) stabilized, and 2 cases (4%) deteriorated. First-line treatment with corticosteroids resulted in satisfactory reduction of symptoms in 21 of 43 patients (49%). Seventeen patients (33%) needed second-line cytostatic treatment, and 10 patients (19%) were treated with tumor necrosis factor-α inhibitors.The majority of patients with neurosarcoidosis present with chronic meningitis without a history of systemic sarcoidosis. The diagnosis can be difficult to make because of the poor sensitivity of most diagnostic tests. Half of patients had a satisfactory reduction of symptoms on first-line therapy.
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Affiliation(s)
- Sonja E Leonhard
- From the Academic Medical Center, Center of Infection and Immunity Amsterdam (CINIMA), Department of Neurology (SEL, DF, FE, AJV, DV, MCB), Amsterdam, the Netherlands
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Touati N, Mansour M, Bedoui I, Kacem A, Derbali H, Riahi A, Messelmani M, Zaouali J, Fekih-Mrissa N, Mrissa R. [Neurologic manifestations of sarcoidosis: A study of 18 cases]. Rev Neurol (Paris) 2015; 171:773-81. [PMID: 26648345 DOI: 10.1016/j.neurol.2015.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 07/13/2015] [Accepted: 07/22/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Sarcoidosis is a multisystemic granulomatous disease of unknown aetiology. Neurologic manifestations are found in 5 to 10% of cases. PATIENTS AND METHODS We conducted a retrospective study over 6-year period including 18 patients diagnosed with neurosarcoidosis in the Neurologic department of the Military Hospital of Instruction of Tunis. Clinical, radiological, therapeutic features and outcome were studied. RESULTS The mean age was 43.44 years. Neurologic signs were the first symptom in 10 cases. Peripheral nervous system impairment was often found. Meningitis was noted in 8 cases. Biological tests are not contributive for the diagnosis. The brain magnetic resonance imaging was pathologic in 10 cases. Corticosteroids were administrated in the majority of cases. Eight patients did not show any sign of improvement. Ten cases improved with treatment. DISCUSSION AND CONCLUSION Diagnosis of neurosarcoidosis is difficult because of its clinical and radiological polymorphism. It is based on a clinical history suggestive of neurosarcoidosis, laboratory, imaging and histological studies.
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Affiliation(s)
- N Touati
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie.
| | - M Mansour
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - I Bedoui
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - A Kacem
- Service de médecine, hôpital régional de Jendouba, avenue de l'UMA 8100, Jendouba, Tunisie
| | - H Derbali
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - A Riahi
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - M Messelmani
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - J Zaouali
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - N Fekih-Mrissa
- Service d'hématologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
| | - R Mrissa
- Service de neurologie, hôpital militaire principal d'instruction de Tunis, Mont Fleury, 1008 Tunis, Tunisie
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Yoshitomi M, Uchikado H, Hattori G, Sugita Y, Morioka M. Endoscopic biopsy for the diagnosis of neurosarcoidosis at the fourth ventricle outlet with hydrocephalus. Surg Neurol Int 2015; 6:S633-6. [PMID: 26682088 PMCID: PMC4672579 DOI: 10.4103/2152-7806.170466] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/16/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Fourth ventricle mass lesion in neurosarcoidosis is very rare and difficult to be diagnosed pathologically. We report a rare case of progressive hydrocephalus associated with neurosarcoidosis mass lesion located at the fourth ventricle outlet and suprasellar region. CASE DESCRIPTION A 23-year-old man had a disturbance of consciousness and neck stiffness with fever. Magnetic resonance imaging revealed diffuse leptomeningeal enhancement, and the obstructive mass lesions at the outlet of the fourth ventricle. We performed an endoscopic biopsy of the enhanced lesion at the foramen Magendie, via foramen Monro and the aqueduct of the midbrain. Pathologically, the diagnosis of neurosarcoidosis was confirmed, and we started treatment with prednisolone. His neurological symptoms disappeared after ventriculo-peritoneal shunt and steroid therapy, and he was discharged without deficit 40 days after emergent admission. CONCLUSION Endoscopic procedure is less invasive and more effective for biopsy of neurosarcoidosis with hydrocephalus, even if the lesion is located at the fourth ventricle outlet.
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Affiliation(s)
- Munetake Yoshitomi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yasuo Sugita
- Department of Pathology, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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