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Matthijs V, Vandenbussche N, Vanopdenbosch L. A 36-Year-Old Man with Persistent Headache. NEJM EVIDENCE 2024; 3:EVIDmr2400172. [PMID: 39189862 DOI: 10.1056/evidmr2400172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the story of a 36-year-old man who sought evaluation for a persistent headache and numbness on the cheek. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made.
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Affiliation(s)
- Vincent Matthijs
- from the Neurology Training Program at AZ Sint Jan, Brugge, Belgium
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Sempik I, Dziadkowiak E, Moreira H, Zimny A, Pokryszko-Dragan A. Primary Progressive Multiple Sclerosis-A Key to Understanding and Managing Disease Progression. Int J Mol Sci 2024; 25:8751. [PMID: 39201438 PMCID: PMC11354232 DOI: 10.3390/ijms25168751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/04/2024] [Accepted: 08/08/2024] [Indexed: 09/02/2024] Open
Abstract
Primary progressive multiple sclerosis (PPMS), the least frequent type of multiple sclerosis (MS), is characterized by a specific course and clinical symptoms, and it is associated with a poor prognosis. It requires extensive differential diagnosis and often a long-term follow-up before its correct recognition. Despite recent progress in research into and treatment for progressive MS, the diagnosis and management of this type of disease still poses a challenge. Considering the modern concept of progression "smoldering" throughout all the stages of disease, a thorough exploration of PPMS may provide a better insight into mechanisms of progression in MS, with potential clinical implications. The goal of this study was to review the current evidence from investigations of PPMS, including its background, clinical characteristics, potential biomarkers and therapeutic opportunities. Processes underlying CNS damage in PPMS are discussed, including chronic immune-mediated inflammation, neurodegeneration, and remyelination failure. A review of potential clinical, biochemical and radiological biomarkers is presented, which is useful in monitoring and predicting the progression of PPMS. Therapeutic options for PPMS are summarized, with approved therapies, ongoing clinical trials and future directions of investigations. The clinical implications of findings from PPMS research would be associated with reliable assessments of disease outcomes, improvements in individualized therapeutic approaches and, hopefully, novel therapeutic targets, relevant for the management of progression.
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Affiliation(s)
- Izabela Sempik
- Department of Neurology, Regional Hospital in Legnica, Iwaszkiewicza 5, 59-220 Legnica, Poland;
| | - Edyta Dziadkowiak
- Clinical Department of Neurology, University Centre of Neurology and Neurosurgery, Faculty of Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland;
| | - Helena Moreira
- Department of Basic Medical Sciences, Wroclaw Medical University, Borowska 211, 50-556 Wroclaw, Poland;
| | - Anna Zimny
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland;
| | - Anna Pokryszko-Dragan
- Clinical Department of Neurology, University Centre of Neurology and Neurosurgery, Faculty of Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland;
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Mandler JM, Härtl J, Cordts I, Sturm M, Hedderich DM, Bafligil C, Baki E, Becker B, Machetanz G, Haack TB, Berthele A, Hemmer B, Deschauer M. Uncovering genetic mimics in multiple sclerosis: A single-center clinical exome sequencing study. Mult Scler J Exp Transl Clin 2024; 10:20552173241263491. [PMID: 39072298 PMCID: PMC11273569 DOI: 10.1177/20552173241263491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/05/2024] [Indexed: 07/30/2024] Open
Abstract
Background Multiple sclerosis (MS) shares clinical/radiological features with several monogenic diseases that can mimic MS. Objective We aimed to determine if exome sequencing can identify monogenic diseases in patients diagnosed with MS according to the McDonald criteria thus uncovering them as being misdiagnosed. Methods We performed whole exome sequencing in a cohort of 278 patients with MS, clinically or radiologically isolated syndrome without cerebrospinal fluid-specific oligoclonal bands (CSF-OCBs) (n = 228), a positive family history of MS (n = 44), or both (n = 6), thereby focusing on individuals potentially more likely to have underlying monogenic conditions mimicking MS. We prioritized 495 genes associated with monogenic diseases sharing features with MS. Results A disease-causing variant in NOTCH3 was identified in one patient without CSF-OCBs, no spinal lesions, with non-response to immunotherapy, and a family history of dementia, thereby converting the diagnosis to cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Moreover, 18 patients (6.5% of total) carried variants of unclear significance. Conclusion Monogenic diseases being misdiagnosed as MS seem rare in patients diagnosed with MS according to the McDonald criteria, even in CSF-OCB negative cases. The detected pathogenic NOTCH3 variant emphasizes CADASIL as a rare differential diagnosis and highlights the relevance of genetic testing in selected MS cases with atypical presentations.
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Affiliation(s)
- Julia M Mandler
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Johanna Härtl
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Isabell Cordts
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Marc Sturm
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Dennis M Hedderich
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Cemsel Bafligil
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Enayatullah Baki
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Benedikt Becker
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Gerrit Machetanz
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
- Centre for Rare Diseases, University of Tübingen, Tübingen, Germany
| | - Achim Berthele
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
| | - Bernhard Hemmer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Marcus Deschauer
- Department of Neurology, Klinikum rechts der Isar, School of Medicine and Health, Technical University of Munich, München, Germany
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Gaetani L, Bellomo G, Di Sabatino E, Sperandei S, Mancini A, Blennow K, Zetterberg H, Parnetti L, Di Filippo M. The Immune Signature of CSF in Multiple Sclerosis with and without Oligoclonal Bands: A Machine Learning Approach to Proximity Extension Assay Analysis. Int J Mol Sci 2023; 25:139. [PMID: 38203309 PMCID: PMC10778830 DOI: 10.3390/ijms25010139] [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: 11/03/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Early diagnosis of multiple sclerosis (MS) relies on clinical evaluation, magnetic resonance imaging (MRI), and cerebrospinal fluid (CSF) analysis. Reliable biomarkers are needed to differentiate MS from other neurological conditions and to define the underlying pathogenesis. This study aimed to comprehensively profile immune activation biomarkers in the CSF of individuals with MS and explore distinct signatures between MS with and without oligoclonal bands (OCB). A total of 118 subjects, including relapsing-remitting MS with OCB (MS OCB+) (n = 58), without OCB (MS OCB-) (n = 24), and controls with other neurological diseases (OND) (n = 36), were included. CSF samples were analyzed by means of proximity extension assay (PEA) for quantifying 92 immune-related proteins. Neurofilament light chain (NfL), a marker of axonal damage, was also measured. Machine learning techniques were employed to identify biomarker panels differentiating MS with and without OCB from controls. Analyses were performed by splitting the cohort into a training and a validation set. CSF CD5 and IL-12B exhibited the highest discriminatory power in differentiating MS from controls. CSF MIP-1-alpha, CD5, CXCL10, CCL23 and CXCL9 were positively correlated with NfL. Multivariate models were developed to distinguish MS OCB+ and MS OCB- from controls. The model for MS OCB+ included IL-12B, CD5, CX3CL1, FGF-19, CST5, MCP-1 (91% sensitivity and 94% specificity in the training set, 81% sensitivity, and 94% specificity in the validation set). The model for MS OCB- included CX3CL1, CD5, NfL, CCL4 and OPG (87% sensitivity and 80% specificity in the training set, 56% sensitivity and 48% specificity in the validation set). Comprehensive immune profiling of CSF biomarkers in MS revealed distinct pathophysiological signatures associated with OCB status. The identified biomarker panels, enriched in T cell activation markers and immune mediators, hold promise for improved diagnostic accuracy and insights into MS pathogenesis.
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Affiliation(s)
- Lorenzo Gaetani
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Giovanni Bellomo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Elena Di Sabatino
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Andrea Mancini
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, 431 41 Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, 431 41 Mölndal, Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, 431 41 Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, 431 41 Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- UK Dementia Research Institute at UCL, London WC1E 6BT, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong 518172, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Lucilla Parnetti
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
| | - Massimiliano Di Filippo
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (L.G.)
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