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Târtea AE, Mocanu CL, Ștefănescu Dima AȘ, Tănasie AC, Maria V, Dan AO, Bălășoiu AT. Neurofibromatosis Type 1-Retinal Alterations Detectable with Optical Coherence Tomography Angiography. Diagnostics (Basel) 2024; 14:1447. [PMID: 39001337 PMCID: PMC11240892 DOI: 10.3390/diagnostics14131447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
Neurofibromatosis type 1 (NF 1) is a multisystemic genetic disorder involving aberrant proliferation of multiple tissues of a neural crest origin. It represents a tumor predisposition syndrome characterized by a wide range of clinical manifestations, such as benign tumors, which primarily affect the skin and the nervous system. The most frequent clinical signs of NF 1 include café-au-lait spots all over the surface of the skin and axillary freckling; however, these signs can be accompanied by more severe manifestations such as the growth of both benign and malignant nervous system tumors and skeletal dysplasia, as well as a wide range of ocular manifestations. We report the rare case of retinal microvascular alterations and choroidal nodules in a 15 year old male patient with NF 1, detectable on optical coherence tomography angiography (OCTA). The hyperreflective choroidal nodules modified the profile of the choroidal vasculature. The retinal microvascular alterations in the form of clustered capillaries were detected in the superficial capillary plexus located nasally to the macular region. Retinal vascular abnormalities undetectable on fundus photography or fundoscopy can be present in patients with NF 1. Indirect ophthalmoscopy of our study patient was unremarkable. However, retinal vascular abnormalities were seen on OCTA scans in the superficial capillary plexus and choroidal nodules were detected on raster OCT scans. OCTA represents a useful imaging technique for detecting retinal microvascular abnormalities, which can be considered additional distinctive signs of NF 1.
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Affiliation(s)
- Anca Elena Târtea
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Carmen Luminița Mocanu
- Department of Ophthalmology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | | | - Andreea Cornelia Tănasie
- Department of Ophthalmology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Veronica Maria
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Alexandra Oltea Dan
- Department of Ophthalmology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Andrei Theodor Bălășoiu
- Department of Ophthalmology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Armstrong AE, Belzberg AJ, Crawford JR, Hirbe AC, Wang ZJ. Treatment decisions and the use of MEK inhibitors for children with neurofibromatosis type 1-related plexiform neurofibromas. BMC Cancer 2023; 23:553. [PMID: 37328781 PMCID: PMC10273716 DOI: 10.1186/s12885-023-10996-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/22/2023] [Indexed: 06/18/2023] Open
Abstract
Neurofibromatosis type 1 (NF1), the most common tumor predisposition syndrome, occurs when NF1 gene variants result in loss of neurofibromin, a negative regulator of RAS activity. Plexiform neurofibromas (PN) are peripheral nerve sheath tumors that develop in patients with NF1 and are associated with substantial morbidity and for which, until recently, the only treatment was surgical resection. However, surgery carries several risks and a proportion of PN are considered inoperable. Understanding the genetic underpinnings of PN led to the investigation of targeted therapies as medical treatment options, and the MEK1/2 inhibitor selumetinib has shown promising efficacy in pediatric patients with NF1 and symptomatic, inoperable PN. In a phase I/II trial, most children (approximately 70%) achieved reduction in tumor volume accompanied by improvements in patient-reported outcomes (decreased tumor-related pain and improvements in quality of life, strength, and range of motion). Selumetinib is currently the only licensed medical therapy indicated for use in pediatric patients with symptomatic, inoperable NF1-PN, with approval based on the results of this pivotal clinical study. Several other MEK inhibitors (binimetinib, mirdametinib, trametinib) and the tyrosine kinase inhibitor cabozantinib are also being investigated as medical therapies for NF1-PN. Careful consideration of multiple aspects of both disease and treatments is vital to reduce morbidity and improve outcomes in patients with this complex and heterogeneous disease, and clinicians should be fully aware of the risks and benefits of available treatments. There is no single treatment pathway for patients with NF1-PN; surgery, watchful waiting, and/or medical treatment are options. Treatment should be individualized based on recommendations from a multidisciplinary team, considering the size and location of PN, effects on adjacent tissues, and patient and family preferences. This review outlines the treatment strategies currently available for patients with NF1-PN and the evidence supporting the use of MEK inhibitors, and discusses key considerations in clinical decision-making.
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Affiliation(s)
- Amy E Armstrong
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John R Crawford
- CHOC Neuroscience Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, Division of Child Neurology University of California Irvine, Orange, CA, USA
| | - Angela C Hirbe
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Zhihong J Wang
- Division of Hematology and Oncology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
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Saleh M, Dib A, Beaini S, Saad C, Faraj S, El Joueid Y, Kotob Y, Saoudi L, Emmanuel N. Neurofibromatosis type 1 system-based manifestations and treatments: a review. Neurol Sci 2023; 44:1931-1947. [PMID: 36826455 DOI: 10.1007/s10072-023-06680-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/11/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Neurofibromatosis type 1 (NF1) is a genetic disorder caused by a mutation in the NF1 gene. This disease presents with various system-based manifestations, including cardiac, musculoskeletal, and neuronal issues, which have been well-studied in previous research and have prompted the development of current and emerging treatments. These treatments, mainly medications targeting specific manifestations of NF1, aim to mitigate the negative impacts of the disease on patients' lives. NF1 is associated with an increased risk of malignancy and a significant decrease in life expectancy. In this paper, we review the current and emerging treatments for NF1 in relation to its system-based manifestations. METHODS We conducted an extensive literature search using specific keywords through databases such as PubMed, Scopus, and Cochrane. The articles we found were compiled and subjected to strict inclusion and exclusion criteria. RESULTS Pharmacological advances have led to the development of products that hold promise as future treatments for NF1. Given the diverse manifestations that can affect multiple organ systems in patients with NF1, it is important to consider a variety of treatment options to achieve optimal results. However, one of the major challenges in diagnosing and treating NF1 is that patients present asymptomatically, making it necessary to rely on clinical features for diagnosis. CONCLUSION In conclusion, NF1 is a complex disease with varying manifestations and a growing field of pharmacologic treatments. The information presented in this article synthesizes current knowledge and available therapies for NF1.
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Affiliation(s)
- Mustafa Saleh
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - AlFadel Dib
- Faculty of Medicine & Medical Sciences, University of Balamand, Koura, Lebanon
| | - Sarah Beaini
- Faculty of Medicine, Université Saint Joseph de Beirut, Damascus Street, Lebanon
| | - Charbel Saad
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Sary Faraj
- Department of Anatomy, Cell Biology, and Physiological Cell Sciences, AUB- FM and MC, Beirut, Lebanon
| | - Youssef El Joueid
- Department of Medicine, School of Health Sciences, University of Georgia, Tbilisi, Georgia
| | - Yasmine Kotob
- Faculty of Medicine, Université Saint Joseph de Beirut, Damascus Street, Lebanon
| | - Lara Saoudi
- Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Nancy Emmanuel
- Department of Dermatology, Faculty of Medicine of the University of São Paulo, São Paulo, Brazil.
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Depietri G, Carli N, Sica A, Oliviero D, Costagliola G, Striano P, Bonuccelli A, Frisone F, Peroni D, Consolini R, Foiadelli T, Orsini A. Therapeutic aspects of Sydenham's Chorea: an update. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021414. [PMID: 35441610 PMCID: PMC9179053 DOI: 10.23750/abm.v92is4.12663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 12/15/2022]
Abstract
Sydenham’s Chorea (SC) is a hyperkinetic movement disorder associated with neuropsychiatric manifestations. It is believed to be caused by the autoimmune response following a group A beta-hemolytic streptococcal (GABHS) pharyngitis, and it is one of the major diagnostic criteria for Acute Rheumatic Fever (ARF) diagnosis. Despite having been known and studied for centuries, there are still no standardized therapies or official guidelines for SC treatment, so that it is necessarily left to physicians’ clinical experience. Antibiotic treatment, symptomatic therapies, and immunomodulatory treatment are the three pillars upon which SC patients’ management is currently based, but they still lack a solid scientific basis. The aim of this writing is precisely to review the state of the art of SC’s treatment, with an overview of the advances made in the last 5 years. However, since the therapeutic uncertainties are a mere reflection of the severe gap of knowledge that concerns SC’s pathogenesis and manifestations, the importance of high-quality research studies based on homogenized methodologies, instruments, and measured outcomes will also be stressed. (www.actabiomedica.it)
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Affiliation(s)
- Greta Depietri
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Niccolo Carli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Attilio Sica
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Domenico Oliviero
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa.
| | - Giorgio Costagliola
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Pasquale Striano
- Pediatric Neurology Unit, Dinogmi, Giannina Gaslini's. Istitute, University of Genoa, Italy.
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Flavia Frisone
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Diego Peroni
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Rita Consolini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia.
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy.
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Marchese P, Lardone C, Canepele A, Biondi S, Roggi C, Massart F, Bonuccelli A, Peroni D, Giotta Lucifero A, Luzzi S, Foiadelli T, Orsini A. Pediatric traumatic brain injury: a new relation between outcome and neutrophil-to-lymphocite ratio. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021417. [PMID: 35441607 PMCID: PMC9179059 DOI: 10.23750/abm.v92is4.12666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 11/23/2022]
Abstract
Leading causes of death in industrialized countries are traumatic injuries and acquired disability, and entry to the emergency department in childhood. TBI (traumatic brain injury) may involve the onset of both primary lesions and a complex immune response (sterile immune reaction to brain injury), which, in addition to neuro-protective effects, can mediate secondary neurological injury. The neutrophil-to-lymphocyte ratio (NLR), as a circulating inflammatory marker, has been related to outcomes in adult patients with non-neurologic diseases (such as gut tumours) or neurologic diseases (such as stroke or brain tumours), and to the prognosis of traumatic brain injury in adolescents and adults. However, the potential role of NLR in predicting outcomes in paediatric head trauma is not clearly defined. The aim of this retrospective observational study is to evaluate the association between clinical features predictive of intracranial and extracranial lesions in TBI and NLR and to establish whether an elevation of NLR is indirectly associated with adverse outcomes in pediatric patients with TBI. We analysed a sample of 219 pediatric patients, between 2-18 years old, after a TBI, and evaluated if differences in NLR were associated with neurological signs or positive CT in pediatric patients. We then compared the NLR values between healthy subjects and patients with TBI. (www.actabiomedica.it)
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Affiliation(s)
| | | | | | | | | | | | | | - Diego Peroni
- Department of Pediatrics, University of Pisa, Italy.
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy.
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Sur ML, Armat I, Sur G, Pop DC, Samasca G, Lupan I, Timis TL, Florian IA, Sur D. Neurofibromatosis in Children: Actually and Perspectives. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9010040. [PMID: 35053664 PMCID: PMC8774615 DOI: 10.3390/children9010040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/18/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022]
Abstract
The three types of neurofibromatosis, namely type 1, type 2, and schwannomatosis, are generally associated with various benign tumors affecting the skin and the nervous system. On rare occasions, especially in patients with neurofibromatosis type 1 (NF1), malignant neoplasms may also be present, several of them possessing a more aggressive course than in individuals without this syndrome. As such, a clear delineation between the three variants of neurofibromatosis is crucial to establish the correct diagnosis and management, as well as predict the neoplasm-related outcomes. Neurofibromin, the principal product of the NF1 gene, is a potent inhibitor of cellular proliferation, having been linked to several key signaling pathways involved in tumor growth. Therefore, it may provide a useful therapeutic target for tumor management in these patients. In this article, we want to present the association between deficiency of neurofibromin and the consequences of the lack of this protein leading to different kinds of malignant tumors. The therapy is still uncertain and most therapeutic options are in development or clinical trials.
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Affiliation(s)
- Maria Lucia Sur
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (M.L.S.); (D.-C.P.); (D.S.)
- Children Emergency Clinical Hospital, 400006 Cluj-Napoca, Romania;
| | - Ionel Armat
- Cardiovascular and Transplant Emergency Institute of Târgu Mureș, 540136 Targu Mures, Romania;
| | - Genel Sur
- Children Emergency Clinical Hospital, 400006 Cluj-Napoca, Romania;
| | - Diana-Cristina Pop
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (M.L.S.); (D.-C.P.); (D.S.)
| | - Gabriel Samasca
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (M.L.S.); (D.-C.P.); (D.S.)
- Children Emergency Clinical Hospital, 400006 Cluj-Napoca, Romania;
- Correspondence: ; Tel.: +40-264532216
| | - Iulia Lupan
- Department of Molecular Biology, Babes-Bolyai University, 400084 Cluj-Napoca, Romania;
| | - Teodora-Larisa Timis
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Ioan-Alexandru Florian
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Daniel Sur
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (M.L.S.); (D.-C.P.); (D.S.)
- Institute of Oncology “Ion Chiricuta”, 400015 Cluj-Napoca, Romania
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Foiadelli T, Rossi V, Paolucci S, Rovida F, Novazzi F, Orsini A, Brambilla I, Marseglia GL, Baldanti F, Savasta S. Human Herpes Virus 7-related encephalopathy in children. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021415. [PMID: 35441609 PMCID: PMC9179060 DOI: 10.23750/abm.v92is4.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Primary HHV7 infection is almost ubiquitous, and it can present as exanthema subitem. Little is known on the clinical relevance of HHV7 neuroinvasion in immunocompetent children. METHODS We describe 12 patients (median age 9.45 years, 50% males) with acute encephalopathy and active HHV7 infection. In all patients, HHV7-DNA was detected on cerebrospinal fluid (CSF) by RT-PCR. RESULTS 7/12 patients had meningoencephalitis (two with ADEM and one with MOG antibody-associated CIS); 5/12 showed acute neuropsychiatric symptoms. EEG showed anomalies exclusively in patients with meningoencephalitis. Six patients had RMN anomalies. CSF HHV7 copies ranged between 20 and 3,500 copies/mL (median 66 copies/mL) and mean HHV7 CSF/blood ratio was 0.75. Outcome was favorable in all children, although 3/12 had minor neurobehavioral sequelae. Mean follow-up period of 5.2 months. CONCLUSIONS HHV7 can determine neuroinvasion in immunocompetent children, leading to acute encephalopathy. Blood-brain barrier damage and high CSF/blood viral copies ratio correlated with a more severe presentation. We speculate on the importance of immune-mediated mechanisms in provoking clinical features.
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Affiliation(s)
- Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, Pavia, Italy, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Virginia Rossi
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Stefania Paolucci
- Molecular Virology Unit, Department of Diagnostic Medicine, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Francesca Rovida
- Molecular Virology Unit, Department of Diagnostic Medicine, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Federica Novazzi
- Molecular Virology Unit, Department of Diagnostic Medicine, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric University Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Italy
| | - Ilaria Brambilla
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, Pavia, Italy, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Fausto Baldanti
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy, Molecular Virology Unit, Department of Diagnostic Medicine, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Salvatore Savasta
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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