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Kato T, Mizumoto C, Inoue F, Watanabe T, Yamanaka S, Fukuhara S, Nakao K. Methotrexate‑related other iatrogenic immunodeficiency‑associated lymphoproliferative disorder in the CNS and medication‑related osteonecrosis of the jaw occurring simultaneously: A case report. Exp Ther Med 2024; 27:41. [PMID: 38125353 PMCID: PMC10731409 DOI: 10.3892/etm.2023.12329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/11/2023] [Indexed: 12/23/2023] Open
Abstract
Methotrexate-related other iatrogenic immunodeficiency-associated lymphoproliferative disorder (MTX-OIIA-LPD) is prone to extranodal involvement but rarely involves the central nervous system (CNS). The present study reports a case of MTX-OIIA-LPD of the CNS discovered during medication-related osteonecrosis of the jaw (MRONJ) treatment in a 76-year-old woman with rheumatoid arthritis (RA). The chief complaint of the patient was bone exposure and pain in the right mandibular molar. The patient had been receiving MTX for RA and alendronate sodium hydrate for osteoporosis, followed by denosumab. Treatment was initiated based on a diagnosis of MRONJ. However, the patient experienced lightheadedness and floating dizziness afterwards. Examinations revealed scattered neoplastic lesions in the brain. The histopathological diagnosis was diffuse large B-cell lymphoma. A systemic search also revealed adrenal involvement. Since the patient was taking MTX, a diagnosis of MTX-OIIA-LPD was made and MTX was discontinued. Chemotherapeutic agents were administered since the central lesions became symptomatic. The MTX-OIIA-LPD lesions in the brain and adrenal glands completely resolved 8 months after onset. The physical condition of the patient improved, and the bone-exposed areas became epithelialized. Reports on MTX-LPD in the oral and maxillofacial region are few, which may delay its diagnosis. Therefore, biopsy of oral lesions in patients with MRONJ who are taking MTX and collaboration with related diagnostic departments, such as rheumatology and hematology, must be done to initiate the diagnosis and treatment of extraoral MTX-LPD.
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Affiliation(s)
- Tomoki Kato
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Fuminori Inoue
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shigeki Yamanaka
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shizuko Fukuhara
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kazumasa Nakao
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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2
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MIZUSHIMA M, ISHI Y, IKEDA H, ECHIZENYA I, OTSUKA T, MITSUHASHI T, YAMAGUCHI S, FUJIMURA M. Successful Treatment of Intracranial Methotrexate-associated Lymphoproliferative Disorder without Epstein-Barr Virus Infection Using Rituximab, Methotrexate, Procarbazine, and Vincristine: A Case Report. NMC Case Rep J 2022; 9:237-242. [PMID: 36061907 PMCID: PMC9398467 DOI: 10.2176/jns-nmc.2022-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Makoto MIZUSHIMA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Yukitomo ISHI
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Hiroshi IKEDA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Ikuma ECHIZENYA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | | | - Shigeru YAMAGUCHI
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Miki FUJIMURA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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3
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Ueno H, Ohno N, Abe T, Kimoto K, Matsuoka C, Giga M, Naito H, Kono T, Takasu M, Kidani N, Yamasaki R, Ichimura K, Nomura E. Prognosis Prediction Using Magnetic Resonance Spectroscopy and Oligoclonal Bands in Central Nervous System Methotrexate-associated Lymphoproliferative Disorder. Intern Med 2022; 61:3733-3738. [PMID: 35598995 PMCID: PMC9841117 DOI: 10.2169/internalmedicine.9296-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Central nervous system methotrexate-associated lymphoproliferative disorder (CNS-MTX-LPD) is rare, but its spontaneous regression has been observed in some patients after withdrawal of agents. We herein report three cases of primary CNS-MTX-LPD that received oral MTX for rheumatoid arthritis. Epstein-Barr virus and oligoclonal bands (OCBs) were positive, while proton magnetic resonance spectroscopy (1H-MRS) showed an elevated lipid peak and slightly elevated choline/N-acetylaspartate ratio in common. After MTX withdrawal, brain lesions showed spontaneous regression in all cases. Our patient's 1H-MRS findings and OCBs may reflect a non-monoclonal lymphoproliferative histology as benign-type lesions in CNS-MTX-LPD.
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Affiliation(s)
- Hiroki Ueno
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Narumi Ohno
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Takafumi Abe
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Kazuki Kimoto
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Chika Matsuoka
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Mayumi Giga
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Hiroyuki Naito
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Tomoyuki Kono
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Miyuki Takasu
- Department of Radiology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Naoya Kidani
- Department of Neurosurgery and Neuroendovascular Surgery, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Rie Yamasaki
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Koichi Ichimura
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Eiichi Nomura
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
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4
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Ohgaki F, Takemoto Y, Paku S, Tatezuki J, Kumagai J, Shuto T, Mochimatsu Y. Primary central nervous system other iatrogenic immunodeficiency-associated lymphoproliferative disorders presenting as extraosseous plasmacytoma with a progressive clinical course: A case report and literature review. Neuropathology 2022; 43:151-157. [PMID: 36065518 DOI: 10.1111/neup.12863] [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] [Received: 05/12/2022] [Revised: 08/07/2022] [Accepted: 08/14/2022] [Indexed: 11/29/2022]
Abstract
Other iatrogenic immunosuppressive-associated lymphoproliferative disorders (OIIA-LPDs) rarely occur in the central nervous system (CNS). Additionally, they almost always present as lymphoma and withdrawal by cessation of immunosuppressive treatment. We report a case of primary CNS OIIA-LPD that presented as extraosseous plasmacytoma (EP) with a progressive clinical course in spite of immunosuppressive treatment cessation. A 78-year-old man with a history of rheumatoid arthritis (RA) presented with a month-long headache. Magnetic resonance imaging showed mass lesions in the left temporal lobe, left middle fossa, and intradural cervical spine. The left temporal lesion was resected and diagnosed as EP histologically, and OIIA-LPD presented as plasmacytoma integrally due to his history of immunosuppressive treatment using tacrolimus for RA. Despite immunosuppressive treatment cessation, OIIA-LPD lesions did not regress but, on the contrary, showed a progressive clinical course. Considering his advanced age and renal dysfunction, postoperative treatment with radiation and moderate chemotherapy using prednisolone were administrated. Subsequently, the disease state stabilized, and the patient had a Karnofsky performance status score of 90 for 6 months; however, the tumor recurred with meningeal dissemination, and he died 8 months after treatment. Types of OIIA-LPD onset as EP and its progressive clinical course resistant to cessation of immunosuppressive treatment are rare. Moreover, this OIIA-LPD disease state worsened despite its radiosensitivity. We believe the progressive clinical course of this OIIA-LPD case with its high cell proliferation is similar to Epstein-Barr virus negative plasmablastic lymphoma, which could lead to a poor outcome.
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Affiliation(s)
- Fukutaro Ohgaki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yasunori Takemoto
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Sujong Paku
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Junya Tatezuki
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Jiro Kumagai
- Department of Pathology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Takashi Shuto
- Department of Stereotactic Radiotherapy Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yasuhiko Mochimatsu
- Department of Neurosurgery, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
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5
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Kawano H, Kitamura T, Higuchi K, Nozaki K. Primary Central Nervous System T-cell Lymphoma as Methotrexate-associated Lymphoproliferative Disorders: Case Report. NMC Case Rep J 2022; 8:253-259. [PMID: 35079472 PMCID: PMC8769407 DOI: 10.2176/nmccrj.cr.2020-0234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/11/2020] [Indexed: 11/20/2022] Open
Abstract
We report a rare case of primary central nervous system (CNS) lymphoma as methotrexate-associated lymphoproliferative disorders (MTX-LPD). A 75-year-old woman who had been treated for rheumatoid arthritis (RA) with MTX for 3 years was admitted to our hospital complaining of unsteady gait, nausea, and vomiting. T2-weighted image of magnetic resonance imaging (MRI) showed multiple high intensity mass-like lesions including right lateral, frontal and temporal lobes, and right cerebellar hemisphere. We performed surgical biopsy, and the pathological and immunohistochemical examinations identified T-cell lymphoma. The tumor regressed and the symptoms were resolved soon after MTX withdrawal. Primary CNS lymphoma due to MTX-LPD is a rare disease and only eight cases including ours are reported.
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Affiliation(s)
- Hiroto Kawano
- Department of Neurosurgery, Japanese Red Cross Nagahama Hospital, Nagahama, Shiga, Japan.,Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tomoaki Kitamura
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kazushi Higuchi
- Department of Neurosurgery, Japanese Red Cross Nagahama Hospital, Nagahama, Shiga, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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Anada M, Tohyama M, Oda Y, Kamoshima Y, Amino I, Nakano F, Miyazaki Y, Akimoto S, Minami N, Kikuchi S, Terae S, Niino M. Progressive Multifocal Leukoencephalopathy during Tocilizumab Treatment for Rheumatoid Arthritis. Intern Med 2020; 59:2053-2059. [PMID: 32448834 PMCID: PMC7492111 DOI: 10.2169/internalmedicine.4431-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 61-year-old woman was diagnosed with rheumatoid arthritis 12 years ago and received multiple treatment regimens before achieving symptomatic stability with methotrexate plus tocilizumab, a humanized monoclonal antibody against the IL-6 receptor, about 2 years prior to the current presentation. Sixteen months after tocilizumab initiation, she exhibited dysarthria and disorientation; five months later, she was hospitalized with movement difficulties. Her neurological symptoms deteriorated thereafter, accompanied by enlarged cerebral white matter lesions on magnetic resonance imaging. A biopsy of the right frontal lesion confirmed progressive multifocal leukoencephalopathy (PML). While several therapeutic monoclonal antibodies have been linked to PML, this is the first case associated with tocilizumab.
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Affiliation(s)
- Mamiko Anada
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | | | - Yoshitaka Oda
- Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Japan
| | - Yuuta Kamoshima
- Department of Neurosurgery, Sapporo Azabu Neurosurgical Hospital, Japan
| | - Itaru Amino
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Fumihito Nakano
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Yusei Miyazaki
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Sachiko Akimoto
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Seiji Kikuchi
- Department of Neurology, National Hospital Organization Hokkaido Medical Center, Japan
| | - Satoshi Terae
- Department of Diagnostic Radiology, Sapporo City General Hospital, Japan
| | - Masaaki Niino
- Department of Clinical Research, National Hospital Organization Hokkaido Medical Center, Japan
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Psychiatric Disturbance or Parkinsonism as a Presentation of CNS Lymphoma: Observational Retrospective Study and Review of Literature. Am J Clin Oncol 2020; 43:727-733. [PMID: 32694297 DOI: 10.1097/coc.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the incidence of and characterize the presentation of neuropsychiatric symptoms and/or Parkinsonism as a presentation of central nervous system lymphoma (CNSL) in either its primary CNSL form or when it spreads to the brain in systemic diffuse large B-cell lymphoma (secondary CNSL). PATIENTS AND METHODS With Institutional Review Board approval we identified patients who had been treated at Mayo Clinic from 1998 to 2018 and were recorded to have a combination of ICD 9/10 codes for CNSL and various psychiatric diagnoses. RESULTS A total of 20 of the 232 patients (9%) were noted to have neuropsychiatric symptoms preceding diagnosis. The average age at diagnosis was 62, with even split for sex. The majority (85%) of patients had primary CNSL. The average duration of symptoms before the diagnosis was 4.8 months. Confusion (80%), depression (40%), apathy (30%), anxiety (30%), and agitation (30%) were the most common symptoms identified. The majority (65%) of patients had subcortical lesions followed by the frontal lobe (50%). Parkinsonism was identified in 5 of the 20 patients with 4 demonstrating resolution of symptoms with treatment of the lymphoma. CONCLUSIONS Neuropsychiatric symptoms are a rare but notable symptom before the presentation of CNSL. There is an increasing awareness of neurological illness presenting as pure psychiatric disturbance, prompting the need to exclude organic and treatable diseases, particularly in elderly patients. Acknowledgment and diagnosis are important for an appropriate management as there is a significant impact on patient and caregiver quality of life.
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8
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Uneda A, Hirashita K, Kanda T, Yunoki M, Yoshino K, Kurozumi K, Date I. Primary Central Nervous System Methotrexate-associated Lymphoproliferative Disorder in a Patient with Rheumatoid Arthritis: Case Report and Review of Literature. NMC Case Rep J 2020; 7:121-127. [PMID: 32695560 PMCID: PMC7363643 DOI: 10.2176/nmccrj.cr.2019-0241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/24/2019] [Indexed: 11/20/2022] Open
Abstract
Methotrexate (MTX) is an immunosuppressor that is widely used to treat autoimmune diseases, including rheumatoid arthritis (RA). However, it can have serious adverse effects including a lymphoma: MTX-associated lymphoproliferative disorder (MTX-LPD). Extranodal lesions are common in MTX-LPD patients. However, MTX-LPD in the central nervous system (CNS) is extremely rare with few reported cases. Here, we describe a case of primary CNS MTX-LPD in a patient with RA, with a review of the literature. A 68-year-old woman who had received MTX for her RA for more than 10 years was referred to our hospital. Head magnetic resonance imaging (MRI) showed multiple lesions with heterogeneous contrast enhancement scattered throughout both hemispheres. As immunosuppression caused by MTX was suspected, MTX was discontinued, based on a working diagnosis of MTX-LPD. We performed an open biopsy of her right temporal lesion. Histopathologic examination showed atypical CD20+ lymphoid cells, leading to a definitive diagnosis of diffuse large B-cell lymphoma (DLBCL). In situ hybridization of an Epstein-Barr virus-encoded small RNA (EBER) was positive. Sanger sequencing confirmed that both MYD88 L265 and CD79B Y196 mutations were absent. The LPD regressed after stopping MTX. Follow-up head MRI at 8 months after surgery showed no evidence of recurrence. Although primary CNS MTX-LPD is extremely rare, it should be included in the differential diagnosis when a patient receiving MTX develops CNS lesions. Diagnosis by biopsy and MTX discontinuation are required as soon as possible.
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Affiliation(s)
- Atsuhito Uneda
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan.,Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Koji Hirashita
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Takahiro Kanda
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Masatoshi Yunoki
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Kimihiro Yoshino
- Department of Neurosurgery, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Kazuhiko Kurozumi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
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Kawazoe M, Kaneko K, Nanki T. Methotrexate-associated lymphoproliferative disorders in the central nervous system and stomach: A case report. Medicine (Baltimore) 2020; 99:e19850. [PMID: 32282749 PMCID: PMC7220667 DOI: 10.1097/md.0000000000019850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a serious complication in patients treated using methotrexate. It occasionally develops in extra-nodal sites, but rarely in the central nervous system (CNS) or in 2 different sites at the same time. We present the rare case of a patient with rheumatoid arthritis who developed lymphoma in the CNS and stomach during MTX therapy. PATIENT CONCERNS A 75-year-old Japanese man with rheumatoid arthritis who received methotrexate was admitted to our hospital because of gait ataxia and anorexia. DIAGNOSES Imaging findings and biopsy led to a diagnosis of 2 different types of MTX-LPD in the central nervous system and stomach. INTERVENTIONS The lesion in his stomach improved after methotrexate withdrawal, whereas the cerebellar mass required high-dose methotrexate and rituximab therapy. OUTCOMES Complete remission has been maintained for the 2 years following the initiation of chemotherapy. LESSONS In patients with RA who receive MTX and develop new neurological symptoms, CNS lymphoma as an MTX-LPD may be considered as a differential diagnosis.
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Tohma YA, Onalan G, Tepeoglu M, Bayraktar N, Colak E, Ozcimen EE, Zeyneloglu HB. Phosphodiesterase 4 inhibitor plus metformin is superior to metformin alone for the treatment of polycystic ovary syndrome: A rat model study. Exp Ther Med 2019; 17:4013-4022. [PMID: 30988783 PMCID: PMC6447905 DOI: 10.3892/etm.2019.7428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/19/2019] [Indexed: 01/07/2023] Open
Abstract
The role of metformin in the management of polycystic ovary syndrome (PCOS) and PCOS-related obesity remains controversial. Recent research on the treatment of PCOS-related obesity investigated novel therapeutic agents with the potential to work synergistically with metformin. The aim of the present study was to determine the synergistic effect of a phosphodiesterase 4 inhibitor (PDE4i) and metformin on weight and hormonal changes in a rat model of PCOS. A total of 40 female Sprague-Dawley rats were randomly divided into 4 groups (n=10/group): Sham; PCOS control (no medication after PCOS induction with dehydroepiandrosterone); metformin (300 mg/kg/day p.o. after PCOS induction); and metformin + PDE4i (300 mg/kg/day p.o. metformin + 0.5 mg/kg/day p.o. PDE4i after PCOS induction). The body weight was measured every 7 days, from day 1 to day 49. Vaginal smears were performed and examined daily via light microscopy for determination of the stage of each rat's estrous cycle. At the end of 21st day and at the end of the study, blood samples were collected from rats and the testosterone and insulin levels were measured. Immunohistochemical staining was performed to quantify phosphorylated cyclic AMP response element-binding protein expression in all groups. At the end of the study, the median body weight differed significantly among the groups (χ2=30.581, P<0.001), being the highest in the PCOS control group and the lowest in the metformin + PDE4i group. At the end of the study, the median testosterone level differed significantly among the groups (χ2=27.057, P<0.001), being the highest in the PCOS control group and the lowest in the metformin + PDE4i group. The cycle was restored to normal at the end of the study in all the rats in the metformin and metformin + PDE4i groups, whereas an irregular cycle persisted in all the rats in the PCOS control group. In conclusion, PDE4i + metformin was superior to metformin alone in reducing weight gain and decreasing the testosterone levels in a rat model of PCOS.
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Affiliation(s)
- Yusuf Aytac Tohma
- Department of Obstetrics and Gynecology, Başkent University School of Medicine, 06490 Ankara, Turkey
| | - Gogsen Onalan
- Department of Obstetrics and Gynecology, Başkent University School of Medicine, 06490 Ankara, Turkey
| | - Merih Tepeoglu
- Department of Pathology, Başkent University School of Medicine, 06490 Ankara, Turkey
| | - Nilufer Bayraktar
- Department of Biochemistry, Başkent University School of Medicine, 06490 Ankara, Turkey
| | - Eser Colak
- Department of Obstetrics and Gynecology, Başkent University School of Medicine, 42080 Konya, Turkey
| | - Emel Ebru Ozcimen
- Department of Obstetrics and Gynecology, Başkent University School of Medicine, 42080 Konya, Turkey
| | - Hulusi Bulent Zeyneloglu
- Department of Obstetrics and Gynecology, Başkent University School of Medicine, 06490 Ankara, Turkey
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Atzeni F, Talotta R, Masala IF, Gerardi MC, Casale R, Sarzi-Puttini P. Central nervous system involvement in rheumatoid arthritis patients and the potential implications of using biological agents. Best Pract Res Clin Rheumatol 2019; 32:500-510. [PMID: 31174819 DOI: 10.1016/j.berh.2019.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Central nervous system (CNS) involvement is quite unusual in patients with rheumatoid arthritis (RA), although cerebral vasculitis, rheumatoid nodules and meningitis have all been reported, and patients with RA may also have CNS comorbidities such as stroke and neuro-degenerative and demyelinating syndromes. It has been found that biological drugs, especially anti-tumour necrosis factor-alpha (anti-TNF-α) drugs, slightly increase the risk of developing demyelinating diseases, and they are consequently discouraged in patients with multiple sclerosis and related disorders. Furthermore, the risk of opportunistic CNS infections is increased in immunosuppressed patients. To review the current literature concerning CNS involvement in patients with RA (including RA-related forms and comorbidities) and the incidence of new-onset CNS diseases in patients with RA undergoing biological treatment (anti-TNF or non-anti-TNF drugs), the Medline database was searched using the key words 'rheumatoid arthritis', 'central nervous system', 'anti-TNF', 'abatacept', 'tocilizumab', 'rituximab' and 'anakinra'. Abstracts not in English were excluded. We selected 76 articles published between 1989 and 2017, which were divided into four groups on the basis of whether CNS involvement was RA-related or not and according to the type of biological agent used (TNF inhibitors or other agents). The RA-related diseases included aseptic meningitis, vasculitis and cerebral rheumatoid nodules, which benefit from immunosuppressive treatments. CNS comorbidities included stroke, seizures, dementia and neuropsychiatric disorders, which have been frequently described in biological agent-naïve patients with RA, and other rarely reported neurological diseases, such as extra-pyramidal syndromes and demyelinating disorders. CNS comorbidities are relatively frequent among patients with RA and may be related to systemic inflammation or concomitant medications. The use of anti-TNF drugs is associated with the risk of developing demyelinating diseases, and CNS infections have been described in patients treated with anti-TNF and non-anti-TNF agents. Non-anti-TNF drugs may be preferred in the case of demyelinating diseases, cerebral vasculitis or neurolupus. Patients with RA may suffer from CNS involvement as a manifestation of RA or as a comorbidity. The treatment of such medical conditions should be guided on the basis of their etiopathogenesis: steroids and immunosuppressants are useful in the case of RA-related CNS diseases but are often detrimental in other situations. Similarly, the choice of biological agents in patients with RA with CNS complications should be guided by a correct diagnosis in order to prevent further complications.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, University of Messina, Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Rossella Talotta
- Post-graduate School of Pharmacology and Clinical Toxicology, University of Milan, Piazza Ospedale Maggiore 3, 20152, Milano, Italy.
| | - Ignazio Francesco Masala
- Orthopedic and Trauma Unit, Santissima Trinità Hospital, Via Is Mirrionis 92, 09121, Cagliari, Italy.
| | - Maria Chiara Gerardi
- Rheumatology Unit, Spedali Civili di Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
| | - Roberto Casale
- Habilita Hospitals & Research Rehabilitation Unit, Bergamo, Zingonia, Italy.
| | - Piercarlo Sarzi-Puttini
- Department of Rheumatology, University Hospital ASST-Fatebenefratelli-Sacco, Via GB Grassi 74, 20157, Milano, Italy.
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12
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Uchida Y, Hokkoku K, Hatanaka Y, Kikuchi Y, Tashiro H, Sonoo M. [Primary central nervous system methotrexate associated lymphoproliferative disorders in a patient with rheumatoid arthritis]. Rinsho Shinkeigaku 2018; 58:485-491. [PMID: 30068810 DOI: 10.5692/clinicalneurol.cn-001157] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report on a 52-year-old woman with rheumatoid arthritis (RA) who developed methotrexate associated lymphoproliferative disorders (MTX-LPD) in the central nervous system (CNS) in the course of immunosuppressive therapy for RA. The patient was admitted because of monoplegia in her left hand. She had been receiving methotrexate (MTX) for her RA for several years and etanercept had also been introduced because of a worsening of the arthritis six months before admission. Brain MRI revealed multiple lesions with enhancement scattered throughout both hemispheres. 18F-fluorodeoxyglucose-positron emission tomography/computed tomography showed abnormal accumulation suggesting malignancy in the right frontal lobe where abnormal enhancement was observed on the MRI. A brain biopsy was performed at the identified site and it confirmed diffuse large B-cell lymphoma (DLBCL). We therefore diagnosed her as MTX-LPD. According to previous reports, most MTX-LPD cases tend to show regression after the cessation of MTX. However, our case showed no regression and even needed chemotherapy. The patient had a poorer prognosis than previous cases and died 17 months after the onset. Although it is an uncommon complication, particularly in the CNS, MTX-LPD should be considered as a critical differential diagnosis if a patient receiving MTX develops central nervous system lesions. Immediate medical intervention including brain biopsy is required.
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Affiliation(s)
- Yudai Uchida
- Department of Neurology, Teikyo University School of Medicine
| | - Keiichi Hokkoku
- Department of Neurology, Teikyo University School of Medicine
| | - Yuki Hatanaka
- Department of Neurology, Teikyo University School of Medicine
| | | | - Haruko Tashiro
- Department of Internal Medicine, Teikyo University School of Medicine
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine
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Mikkelsen K, Stojanovska L, Prakash M, Apostolopoulos V. The effects of vitamin B on the immune/cytokine network and their involvement in depression. Maturitas 2016; 96:58-71. [PMID: 28041597 DOI: 10.1016/j.maturitas.2016.11.012] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 11/14/2016] [Indexed: 02/07/2023]
Abstract
Increasing evidence indicates that there are various interactions between the nervous system and the immune system, and that the immune system plays an important role in the pathogenesis of depression. Pro-inflammatory cytokines (such as IL-1, IL-6, TNF-α) have been implicated in the neurobiological manifestations of depression. The immune/cytokine network has a powerful influence on the brain. In addition, deficiency in B vitamins has been linked to depression. Hence, greater knowledge of how immune cells change in the presence of vitamin B derivatives could improve understanding of how immune changes may correlate with depression, all of which are discussed herein.
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Affiliation(s)
- Kathleen Mikkelsen
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14426, Melbourne, VIC 8001, Australia
| | - Lily Stojanovska
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14426, Melbourne, VIC 8001, Australia
| | - Monica Prakash
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14426, Melbourne, VIC 8001, Australia
| | - Vasso Apostolopoulos
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, PO Box 14426, Melbourne, VIC 8001, Australia.
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