Central nervous system involvement in connective tissue diseases

Hashimoto Encephalopathy of a Middle-Aged Man With Progressive Symptoms of Dementia

Autoimmune encephalitis is caused by immunological reactions showing unconsciousness, agitation, and other neurological symptoms. Autoimmune diseases can be related to autoantibodies, causing encephalitis. These autoantibody-related encephalitides could appear in various clinical courses. As laboratory tests for detecting these antibodies are limited, diagnosis is difficult. Hashimoto’s encephalopathy is autoimmune encephalitis caused by antibodies against the thyroid gland. This time, we experienced a case of a 69-year-old man with a chief complaint of subacute progression of amnesia and suspected autoimmune encephalitis, who was finally diagnosed with Hashimoto’s encephalopathy in a rural community hospital. In this case, clinicians should consider Hashimoto's encephalopathy as a differential diagnosis and measure antithyroid antibodies when acute or subacute onset cognitive impairment is observed in middle-aged patients. As a super-aging society significantly affects community hospitals, general physicians need to start treatments for encephalopathy and encephalitis when clinicians suspect the disease and rule out other critical diseases.

Neurovascular disease, diagnosis, and therapy: Cervical and intracranial atherosclerosis, vasculitis, and vasculopathy

Stroke is a leading cause of death, disability, and financial burden in the United States. Perhaps more than any other disease process, the rapidity with which the diagnosis and treatment of stroke are successfully achieved is paramount to the reduction of its associated morbidity and mortality. Steno-occlusive intracranial vascular disease, the most notorious culprit of cerebral ischemia and/or hemorrhage, traces its etiology to native and embolic atherosclerosis as well as various forms of vascular inflammation, insult, and dysfunction. Distinguishing between these causes is a critical first step in the diagnosis and treatment of a patient presenting with cerebrovascular compromise. In this chapter, we delineate the clinical and imaging features of cervical and intracranial atherosclerosis, vasculitis, and vasculopathy, along with the evidence behind the treatments which comprise their current-day standard of care. The modern imaging armamentarium is diverse and complex, with contrast-enhanced and non-contrast MR angiography, CT angiography, digital subtraction angiography, and ultrasound; each playing an important role in providing rapid insight into the patient's disease process. Understanding these imaging techniques and their application in the acute setting is critical for the provider caring for stroke patients.

Refractory antineutrophil cytoplasmic antibody-associated vasculitis successfully treated with rituximab: a case report

A 63-year-old-man was diagnosed in March 2002 with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis because of mononeuritis multiplex, interstitial pneumonia and a positive finding for myeloperoxidase (MPO)-ANCA. Although treated with prednisolone and oral cyclophosphamide, he suffered repeated remission and deterioration of his conditon, which was complicated by hypertrophic pachymeningitis and sinusitis. In July 2006, he was diagnosed with an exacerbation of ANCA-associated vasculitis because of pyrexia, general malaise, numbness in his face and legs, and elevated serum CRP level. Steroid pulse therapy was thus initiated and the patient's clinical symptoms improved. However, serum CRP levels elevated again (5.18 mg/dl) in September 2006. We began administration of rituximab (500 mg/bodyx4 times) in November 2006 and his symptom and laboratory data significantly improved. The dose of prednisolone was slowly decreased without suffering a relapse. Rituximab has been administered every one year, and good disease control has been achieved. Diagnosis of Wegener's granulomatosis was made from the findings of a nodular lesion in the left lung. Rituximab should be considered for patients with refractory ANCA-associated vasculitis.

Isolated angiitis in the hypothalamus mimicking brain tumor

A 64-year-old female presented with exaggerating somnolence without contributory medical and lifestyle histories. She was not aware of any preceding infection or headache. Cerebral magnetic resonance imaging demonstrated an isolated enhanced mass in the hypothalamus without meningeal enhancement. Blood and cerebrospinal fluid examinations showed no significant findings except for hypernatremia and hyperprolactinemia. She underwent an open biopsy via the interhemispheric route. Histological examination revealed marked perivascular lymphocytic aggregation with polyclonal immunostaining both for B and T lymphocytes. No findings suggestive of underlying malignancy were recognized. Extensive work-up aiming at systemic vasculitis and lymphoma revealed no signs of extracranial lesion, so the most probable diagnosis was isolated angiitis in the hypothalamus. Angiitis may originate from the hypothalamus and should be considered in the differential diagnosis of hypothalamic lesion mimicking brain tumor on neuroimaging.