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Chen A, Chwalisz BK. Update on Neuro-ophthalmic Manifestations of Immune Checkpoint Inhibitors. Curr Neurol Neurosci Rep 2024; 24:113-122. [PMID: 38498093 DOI: 10.1007/s11910-024-01336-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/19/2024]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitor (ICI) use has been on the rise for treatment of many different malignancies. Subsequently, more has been learned about immune-related adverse events (irAEs) that occur up to 12 months after treatment. This review summarizes the latest findings and management of neuro-ophthalmic associated irAEs. RECENT FINDINGS irAEs can affect the afferent and efferent neuro-ophthalmic pathways, thereby targeting central and peripheral nervous systems. As more cases are being reported, it is becoming apparent that neuro-ophthalmic irAEs often present with atypical features when compared to their spontaneous autoimmune counterparts. These neuro-ophthalmic presentations can also be signs of a more extensive inflammatory process that spans other organ systems, such as myopathies, endocrinopathies, and paraneoplastic syndromes. Awareness of neuro-ophthalmic irAEs and their atypical presentations can lead to early detection, termination of ICI treatment, and immunosuppressant therapy initiation.
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Affiliation(s)
- Amalie Chen
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, MA, USA.
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McEntire CRS, Chwalisz BK. Cranial nerve involvement, visual complications and headache syndromes in Lyme disease. Curr Opin Ophthalmol 2024; 35:265-271. [PMID: 38518069 DOI: 10.1097/icu.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW To provide a summary of the visual manifestations and cranial neuropathies seen in Lyme disease. RECENT FINDINGS Lyme facial palsy remains the most common manifestation of Lyme neuroborreliosis. Recent investigations show likely evidence of vagal involvement in Lyme disease. SUMMARY The literature on Lyme neuroborreliosis continues to evolve. Lyme disease can affect nearly any cranial nerve in addition to causing various headache syndromes. The most common manifestation is Lyme disease facial palsy, occurring in up to 5-10% of patients with documented Lyme disease. Headache syndromes are common in the context of facial palsy but can occur in isolation, and more specific headache syndromes including trigeminal and geniculate neuralgias can occur rarely. Signs and symptoms indicative of vestibulocochlear nerve involvement are relatively common, although it could be that these represent other vestibular involvement rather than a specific cranial neuropathy. Optic neuritis is a controversial entity within Lyme disease and is likely overdiagnosed, but convincing cases do exist. Physicians who see any cranial neuropathy, including optic neuritis, in an endemic area can consider Lyme disease as a possible cause.
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Affiliation(s)
- Caleb R S McEntire
- Massachusetts General Hospital-Harvard Medical School
- Brigham and Women's Hospital-Harvard Medical School, Department of Neurology
| | - Bart K Chwalisz
- Massachusetts General Hospital-Harvard Medical School
- Massachusetts Eye and Ear-Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts, USA
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Chung SA, Huang AJ, Murali MR, Chwalisz BK, Wallace ZS, Kozanno LN. Case 11-2024: An 82-Year-Old Woman with Falls and Cognitive Decline. N Engl J Med 2024; 390:1312-1322. [PMID: 38598798 DOI: 10.1056/nejmcpc2312725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Sharon A Chung
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Ambrose J Huang
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Mandakolathur R Murali
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Bart K Chwalisz
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Zachary S Wallace
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Liana N Kozanno
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
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Varma-Doyle A, Chwalisz BK, Linnoila J. Anti-Immunoglobulin-Like Cell Adhesion Molecule-5 (IgLON5) Associated Neurological Disease Presenting With Bilateral Intraocular Optic Neuritis as an Initial Presentation: Expanding Clinical Phenotype of the Disease. J Neuroophthalmol 2024:00041327-990000000-00586. [PMID: 38437022 DOI: 10.1097/wno.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Aditi Varma-Doyle
- Department of Neurology (AVD, BKC, JL), Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology (BKC), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, Massachusetts; and Johns Hopkins Bloomberg School of Public Health (AVD), Baltimore, Maryland
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Chwalisz BK, Kelly HR, Flaherty AW, Jorge AM, Murali MR. Case 38-2023: A 68-Year-Old Woman with Abnormal Movements and Confusion. N Engl J Med 2023; 389:2277-2285. [PMID: 38091534 DOI: 10.1056/nejmcpc2309349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Bart K Chwalisz
- From the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Massachusetts General Hospital, the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston
| | - Hillary R Kelly
- From the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Massachusetts General Hospital, the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston
| | - Alice W Flaherty
- From the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Massachusetts General Hospital, the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston
| | - April M Jorge
- From the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Massachusetts General Hospital, the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston
| | - Mandakolathur R Murali
- From the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Massachusetts General Hospital, the Departments of Neurology (B.K.C., A.W.F.), Radiology (H.R.K.), Psychiatry (A.W.F.), Medicine (A.M.J., M.R.M.), and Pathology (M.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston
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Cohen DA, Tajfirouz D, Vodopivec I, Kyle K, Bouffard MA, Bhattacharyya S, Douglas VC, Rasool N, Bhatti MT, McKeon A, Pittock S, Flanagan EP, Prasad S, Nagagopal V, Egan RA, Chen JJ, Chwalisz BK. Fluorescein Angiography Findings in Susac Syndrome: A Multicenter Retrospective Case Series. J Neuroophthalmol 2023; 43:481-490. [PMID: 37075250 DOI: 10.1097/wno.0000000000001826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
BACKGROUND Susac syndrome is a vasculopathy, resulting in the classic triad of branch retinal artery occlusion (BRAO), inner ear ischemia, and brain ischemia. In this retrospective chart review, we characterize fluorescein angiography (FA) findings and other ancillary studies in Susac syndrome, including the appearance of persistent disease activity and the occurrence of new subclinical disease on FA. METHODS This multicenter, retrospective case series was institutional review board-approved and included patients with the complete triad of Susac syndrome evaluated with FA, contrasted MRI of the brain, and audiometry from 2010 to 2020. The medical records were reviewed for these ancillary tests, along with demographics, symptoms, visual acuity, visual field defects, and findings on fundoscopy. Clinical relapse was defined as any objective evidence of disease activity during the follow-up period after initial induction of clinical quiescence. The main outcome measure was the sensitivity of ancillary testing, including FA, MRI, and audiometry, to detect relapse. RESULTS Twenty of the 31 (64%) patients had the complete triad of brain, retinal, and vestibulocochlear involvement from Susac syndrome and were included. Median age at diagnosis was 43.5 years (range 21-63), and 14 (70%) were women. Hearing loss occurred in 20 (100%), encephalopathy in 13 (65%), vertigo in 15 (75%), and headaches in 19 (95%) throughout the course of follow-up. Median visual acuity at both onset and final visit was 20/20 in both eyes. Seventeen (85%) had BRAO at baseline, and 10 (50%) experienced subsequent BRAO during follow-up. FA revealed nonspecific leakage from previous arteriolar damage in 20 (100%), including in patients who were otherwise in remission. Of the 11 episodes of disease activity in which all testing modalities were performed, visual field testing/fundoscopy was abnormal in 4 (36.4%), MRI brain in 2 (18.2%), audiogram in 8 (72.7%), and FA in 9 (81.8%). CONCLUSIONS New leakage on FA is the most sensitive marker of active disease. Persistent leakage represents previous damage, whereas new areas of leakage suggest ongoing disease activity that requires consideration of modifying immunosuppressive therapy.
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Affiliation(s)
- Devon A Cohen
- Cleveland Clinic (DAC), Cleveland, Ohio; Mayo Clinic (DT, MTB, AM, SP, EPF, JJC), Rochester, Minnesota; Roche (IV), Basel, Switzerland; Massachusetts General Hospital (KK, VN, BKC), Boston, Massachusetts; Beth Israel Deaconess (MAB), Boston, Massachusetts; Brigham and Women's Hospital (SB, SP), Boston, Massachusetts; UCSF (VD, NR), San Francisco, California; and Eye and Vascular Neurology (RE), Carlton, Oregon
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Kyle K, Hutto SK, Reda H, Zonozi R, Farhad K, Jeyabalan A, Chwalisz BK. Small fiber neuropathy associated with ANCA positivity: a case series and brief literature review. Neurol Sci 2023; 44:4473-4479. [PMID: 37453951 DOI: 10.1007/s10072-023-06954-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Small fiber neuropathy [SFN] is a common peripheral neurologic disorder with a vast array of implicated etiologies. It has previously been proposed that some forms of immune-mediated small fiber neuropathy are driven by vasculitis, though antinuclear cytoplasmic antibodies [ANCA] antibodies have not commonly been reported in association with SFN, thus far. We present this case series to discuss the observation of a possible novel association between ANCA and SFN. METHODS This is a retrospective case series of 6 patients with SFN and ANCA positivity, with and without systemic manifestations. Patients included were diagnosed with SFN by skin biopsy or autonomic function testing and were seropositive for ANCA by ELISA. RESULTS Six patients are outlined, including 4 females and 2 males. Antigen specific antibodies were MPO alone in 4 cases, PR3 alone in 1 case and both MPO and PR3 in 1 case. Systemic vasculitis was noted in 2 patients. Five patients received immunosuppression. Three patients experienced partial improvement, while symptoms stabilized in 3 patients. DISCUSSION This is the first series of patients with suspected immune-mediated SFN and ANCA antibody positivity, raising the possibility of ANCA mediated isolated SFN. This is in contradistinction to the more typical ANCA-mediated peripheral neuropathy manifestations of mononeuropathy multiplex or axonal sensorimotor neuropathy. We cannot unequivocally prove ANCA-associated vasculitis [AAV] causality in these cases; however, the stabilization in SFN symptomatology and associated improvement in ANCA antibody titer, after AAV treatment, may be indicative of an association.
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Affiliation(s)
- Kevin Kyle
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA.
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Haatem Reda
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Reza Zonozi
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Khosro Farhad
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
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Gluckstein JA, Chwalisz BK, Gilbert AL, Bouffard MA. SARS-CoV-2 Parainfectious Optic Neuropathy: 3 Case Reports and a Review of the Literature. J Neuroophthalmol 2023; 43:491-498. [PMID: 37974364 DOI: 10.1097/wno.0000000000001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Parainfectious optic neuritis is an inflammatory reaction that occurs shortly after an infection without direct invasion by a pathogen. The clinical profile depends on the infectious organism. Cases of SARS-CoV-2 parainfectious optic neuritis have been reported in the literature, but there are no reviews that have applied strict inclusion criteria to more definitively establish the clinical profile associated with SARS-CoV-2. METHODS We present 3 new cases of SARS-CoV-2 parainfectious optic neuritis. We also review the literature for definite cases by selecting only those with unambiguous clinical features and MRI findings of optic neuritis, positive SARS-CoV-2 polymerase chain reaction or serology, and the absence of myelin oligodendrocyte-glycoprotein or aquaporin-4 antibodies or other diseases associated with optic neuritis. RESULTS We report 2 cases of monophasic, unilateral SARS-CoV-2 parainfectious optic neuritis with optic disc edema and nadir visual acuities of finger counting. We report 1 case of mild SARS-CoV-2 parainfectious optic neuritis that featured cotton wool spots, peripapillary wrinkles and hemorrhages, and recurrence after an initial steroid taper. We identified 6 cases of unambiguous SARS-CoV-2 parainfectious optic neuritis from the literature. Combining our case series with the case reports in the literature, the average age was 42.8 years, 3/9 had bilateral disease, 6/8 had optic disc edema, 8/9 had nadir visual acuity of finger counting or worse, and all recovered visual acuity to 20/40 or better after therapy with steroids. CONCLUSIONS SARS-CoV-2 parainfectious optic neuritis has a clinical profile that is atypical for idiopathic optic neuritis but fairly typical of parainfectious forms of optic neuritis with a severely reduced nadir visual acuity, high likelihood of bilaterality, high incidence of optic disc edema, and prompt and significant response to corticosteroids. Further study with long-term follow-up and epidemiologic investigation will be needed to further characterize this clinical entity.
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Affiliation(s)
- Jeffrey A Gluckstein
- Neuro-ophthalmology (JAG, BKC, MAB), Massachusetts Eye and Ear, Boston, Massachusetts; Neurology (BKC), Massachusetts General Hospital, Boston, Massachusetts; Ophthalmology and Neuro-Ophthalmology (ALG), Kaiser Permanente Vallejo Medical Center, Vallejo, California; and Neuro-Ophthalmology (MAB), Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Tofade TO, Chwalisz BK. Neuro-ophthalmic complications of varicella-zoster virus. Curr Opin Ophthalmol 2023; 34:470-475. [PMID: 37603549 DOI: 10.1097/icu.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
PURPOSE OF REVIEW This review broadly describes recent neuro-ophthalmic manifestations of varicella-zoster virus (VZV) reported in literature. RECENT FINDINGS Despite varicella vaccination, the incidence of herpes zoster continues to rise, potentially leading to devastating consequences when ocular complications occur.A small but growing literature documents cases of retinal disease because of varicella reactivation after SARS-CoV-2 vaccination, ischemic optic neuropathy occurring during herpes zoster ophthalmicus, VZV-induced orbital apex syndrome, and immune-mediated ocular complications in patients with prior neuro-ophthalmic manifestations of VZV. SUMMARY It is important for clinicians to keep abreast of the diverse neuro-ophthalmic manifestations of VZV as early diagnosis and treatment often lead to better visual outcomes.
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Affiliation(s)
- Toluwalase O Tofade
- Department of Neurology, Massachusetts General Hospital - Harvard Medical School
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital - Harvard Medical School
- Department of Ophthalmology, Massachusetts Eye and Ear - Harvard Medical School, Boston, Massachusetts, USA
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Vakharia JD, Muhammed M, Remba-Shapiro I, Marsiglia M, Hadaway N, Chwalisz BK, Nachtigall LB. A novel approach to hypophysitis: outcomes using non-glucocorticoid immunosuppressive therapy. Eur J Endocrinol 2023; 189:309-317. [PMID: 37602514 PMCID: PMC10473830 DOI: 10.1093/ejendo/lvad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/08/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To determine pituitary function before and after nonglucocorticoid immunosuppressive therapy (NGIT) in subjects with hypophysitis and evaluate their clinical and radiologic outcomes. DESIGN Retrospective, longitudinal study. METHODS We reviewed a large database, selected subjects with hypophysitis treated with NGIT, and collected information on the duration of therapy, and clinical, hormonal, and radiologic outcomes. RESULTS Twelve subjects met the inclusion criteria. Five subjects had primary hypophysitis (PH), while seven had secondary hypophysitis (SH) due to an underlying systemic inflammatory disease. Mean age ± SD was 48.0 ± 15.7 years and 40.9 ± 13.0 years, for PH and SH, respectively. The majority were female (PH 60% and SH 86%). BMI ± SD at presentation was 25.2 ± 2.5 kg/m2 and 26.8 ± 6.7 kg/m2 for PH and SH, respectively. The most common symptom at presentation was fatigue (75%). All PH subjects (100%) and 2 (28.6%) SH subjects had polyuria/polydipsia. There was a significant decrease in mean pituitary stalk thickness after NGIT (P = .0051) (mean duration 16.5 ± 4.8 months). New hormone loss or recovery occurred rarely. Mycophenolate mofetil was the most used NGIT: adverse effects prompted discontinuation in 2 out of 7 subjects. CONCLUSIONS Subjects with hypophysitis receiving NGIT had stable or improved brain/pituitary magnetic resonance imaging findings with a significant decrease in pituitary stalk thickness. NGITs did not improve anterior pituitary function. Our findings suggest that NGIT may be considered as an alternative therapy for patients with hypophysitis who require immunosuppression.
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Affiliation(s)
- Janaki D Vakharia
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Maged Muhammed
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ilan Remba-Shapiro
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela Marsiglia
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Natalia Hadaway
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Balaban DT, Hutto SK, Panzarini BP, O'Shea A, Varma A, Jones PS, Chwalisz BK, Stone JH, Venna N. Treatment of IgG4-related disease-associated hypertrophic pachymeningitis with intrathecal rituximab: a case report. Front Neurol 2023; 14:1189778. [PMID: 37292126 PMCID: PMC10244657 DOI: 10.3389/fneur.2023.1189778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
IgG4-related disease-associated hypertrophic pachymeningitis (IgG4RD-HP) is a fibroinflammatory autoimmune disorder in which diagnosis is difficult without biopsy. Guidance on management of disease refractory to glucocorticoids and intravenous rituximab is limited. We present the case of a 68-year-old woman with IgG4RD-HP who developed sensorineural hearing loss with associated bulky basilar pachymeningeal enhancement. Her cerebrospinal fluid was inflammatory and had an elevated IgG4 concentration, strongly suggestive of IgG4RD-HP. Biopsy of involved meninges was not possible due to surgical risk. Over years she developed bilateral optic neuropathies and hydrocephalus, requiring intravenous rituximab and ventriculoperitoneal shunt. Her disease was refractory to glucocorticoids. Despite maintenance intravenous rituximab, she developed slowly progressive symptoms of intracranial hypertension and hydrocephalus with persistently inflammatory spinal fluid. Switching to intrathecal rituximab therapy led to dramatic improvement in gait and headache and reduced pachymeningeal bulk and metabolic activity. In patients with IgG4RD-HP refractory to glucocorticoids and intravenous rituximab, intrathecal rituximab may be an efficacious therapy.
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Affiliation(s)
- Denis T. Balaban
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Spencer K. Hutto
- Division of Hospital Neurology, Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Bruno P. Panzarini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aileen O'Shea
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aditi Varma
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Pamela S. Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bart K. Chwalisz
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuro-Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - John H. Stone
- Department of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Disease, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Abstract
Despite the high incidence of optic neuritis (ON), and the growing number of therapeutic options for the long-term treatment of diseases associated with ON including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and MOG antibody associated disease (MOGAD), there are still only limited therapeutic options for treating an acute event of optic neuritis. These include steroids, plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). High-dose steroids remain the mainstay of acute treatment. However, evidence is emerging that when optic neuritis is accompanied with certain atypical features that suggest a more unfavorable outcome this mandates special consideration such as early addition of other therapeutic agents or tapering the steroid very slowly. This review will distinguish between typical and atypical neuritis and discuss acute treatment options.
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Affiliation(s)
- Kiandokht Keyhanian
- Neuro-ophthalmology Division, Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-ophthalmology Division, Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, Boston, MA, USA
- Neuro-immunology Division, Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Carelli V, Newman NJ, Yu-Wai-Man P, Biousse V, Moster ML, Subramanian PS, Vignal-Clermont C, Wang AG, Donahue SP, Leroy BP, Sergott RC, Klopstock T, Sadun AA, Rebolleda Fernández G, Chwalisz BK, Banik R, Girmens JF, La Morgia C, DeBusk AA, Jurkute N, Priglinger C, Karanjia R, Josse C, Salzmann J, Montestruc F, Roux M, Taiel M, Sahel JA. Indirect Comparison of Lenadogene Nolparvovec Gene Therapy Versus Natural History in Patients with Leber Hereditary Optic Neuropathy Carrying the m.11778G>A MT-ND4 Mutation. Ophthalmol Ther 2023; 12:401-429. [PMID: 36449262 PMCID: PMC9834474 DOI: 10.1007/s40123-022-00611-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/28/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Lenadogene nolparvovec is a promising novel gene therapy for patients with Leber hereditary optic neuropathy (LHON) carrying the m.11778G>A ND4 mutation (MT-ND4). A previous pooled analysis of phase 3 studies showed an improvement in visual acuity of patients injected with lenadogene nolparvovec compared to natural history. Here, we report updated results by incorporating data from the latest phase 3 trial REFLECT in the pool, increasing the number of treated patients from 76 to 174. METHODS The visual acuity of 174 MT-ND4-carrying patients with LHON injected in one or both eyes with lenadogene nolparvovec from four pooled phase 3 studies (REVERSE, RESCUE and their long-term extension trial RESTORE; and REFLECT trial) was compared to the spontaneous evolution of an external control group of 208 matched patients from 11 natural history studies. RESULTS Treated patients showed a clinically relevant and sustained improvement in their visual acuity when compared to natural history. Mean improvement versus natural history was - 0.30 logMAR (+ 15 ETDRS letters equivalent) at last observation (P < 0.01) with a maximal follow-up of 3.9 years after injection. Most treated eyes were on-chart as compared to less than half of natural history eyes at 48 months after vision loss (89.6% versus 48.1%; P < 0.01) and at last observation (76.1% versus 44.4%; P < 0.01). When we adjusted for covariates of interest (gender, age of onset, ethnicity, and duration of follow-up), the estimated mean gain was - 0.43 logMAR (+ 21.5 ETDRS letters equivalent) versus natural history at last observation (P < 0.0001). Treatment effect was consistent across all phase 3 clinical trials. Analyses from REFLECT suggest a larger treatment effect in patients receiving bilateral injection compared to unilateral injection. CONCLUSION The efficacy of lenadogene nolparvovec in improving visual acuity in MT-ND4 LHON was confirmed in a large cohort of patients, compared to the spontaneous natural history decline. Bilateral injection of gene therapy may offer added benefits over unilateral injection. TRIAL REGISTRATION NUMBERS NCT02652780 (REVERSE); NCT02652767 (RESCUE); NCT03406104 (RESTORE); NCT03293524 (REFLECT); NCT03295071 (REALITY).
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Affiliation(s)
- Valerio Carelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Via Altura, 3, 40139, Bologna, BO, Italy.
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Patrick Yu-Wai-Man
- Department of Clinical Neurosciences, Cambridge Centre for Brain Repair and MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Valerie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark L Moster
- Department of Neurology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
- Department of Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
| | - Prem S Subramanian
- Sue Anschutz-Rodgers University of Colorado Eye Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine Vignal-Clermont
- Department of Neuro Ophthalmology and Emergencies, Rothschild Foundation Hospital, Paris, France
- Centre d'Investigation Clinique, Centre Hospitalier National d'Ophtalmologie des Quinze Vingts, Paris, France
| | - An-Guor Wang
- Department of Ophthalmology, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sean P Donahue
- Department of Ophthalmology, Neurology, and Pediatrics, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Bart P Leroy
- Department of Ophthalmology and Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
- Department of Head & Skin, Ghent University, Ghent, Belgium
| | - Robert C Sergott
- Department of Neurology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
- Department of Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Alfredo A Sadun
- David Geffen, Doheny Eye Institute, School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear, Harvard Medical School, Boston, MA, USA
| | - Rudrani Banik
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean François Girmens
- Centre d'Investigation Clinique, Centre Hospitalier National d'Ophtalmologie des Quinze Vingts, Paris, France
| | - Chiara La Morgia
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Via Altura, 3, 40139, Bologna, BO, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Adam A DeBusk
- Department of Neurology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
- Department of Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
| | - Neringa Jurkute
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
- Institute of Ophthalmology, University College London, London, UK
- Department of Neuro-Ophthalmology, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Claudia Priglinger
- Department of Ophthalmology, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rustum Karanjia
- David Geffen, Doheny Eye Institute, School of Medicine, University of California, Los Angeles, CA, USA
- Department of Ophthalmology, University of Ottawa Eye, Ottawa, ON, Canada
| | - Constant Josse
- eXYSTAT, Data Management and Statistic, Malakoff, France
| | | | | | | | | | - José-Alain Sahel
- Institut de la Vision, Sorbonne Université, INSERM, CNRS, Paris, France
- Rothschild Foundation Hospital, Paris, France
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Institut Hospitalo-Universitaire FOReSIGHT, INSERM-DGOS CIC 1423, Paris, France
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Vignal-Clermont C, Yu-Wai-Man P, Newman NJ, Carelli V, Moster ML, Biousse V, Subramanian PS, Wang AG, Donahue SP, Leroy BP, Sadun AA, Klopstock T, Sergott RC, Fernandez R, Chwalisz BK, Banik R, Taiel M, Roux M, Sahel JA. Safety of Lenadogene Nolparvovec Gene Therapy Over 5 Years in 189 Patients With Leber Hereditary Optic Neuropathy. Am J Ophthalmol 2022; 249:108-125. [PMID: 36496192 DOI: 10.1016/j.ajo.2022.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/04/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the safety profile of lenadogene nolparvovec (Lumevoq) in patients with Leber hereditary optic neuropathy. DESIGN Pooled analysis of safety data from 5 clinical studies. METHODS A total of 189 patients received single unilateral or bilateral intravitreal injections of a recombinant adeno-associated virus 2 (rAAV2/2) vector encoding the human wild-type ND4 gene. Adverse events (AEs) were collected throughout the studies, up to 5 years. Intraocular inflammation and increased intraocular pressure (IOP) were ocular AEs of special interest. Other assessments included ocular examinations, vector bio-dissemination, and systemic immune responses against rAAV2/2. RESULTS Almost all patients (95.2%) received 9 × 1010 viral genomes and 87.8% had at least 2 years of follow-up. Most patients (75.1%) experienced at least one systemic AE, but systemic treatment-related AEs occurred in 3 patients; none were serious. Intraocular inflammation was reported in 75.6% of lenadogene nolparvovec-treated eyes. Almost all intraocular inflammations occurred in the anterior chamber (58.8%) or in the vitreous (40.3%), and were of mild (90.3%) or moderate (8.8%) intensity; most resolved with topical corticosteroids alone. All IOP increases were mild to moderate in intensity. No AE led to study discontinuation. Bio-dissemination of lenadogene nolparvovec and systemic immune response were limited. The safety profile was comparable for patients treated bilaterally and unilaterally. CONCLUSIONS Lenadogene nolparvovec had a good overall safety profile with excellent systemic tolerability, consistent with limited bio-dissemination. The product was well tolerated, with mostly mild ocular side effects responsive to conventional ophthalmologic treatments.
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Affiliation(s)
- Catherine Vignal-Clermont
- From Department of Neuro Ophthalmology and Emergencies, Rothschild Foundation Hospital, Paris, France (C.V-C.); Centre Hospitalier National d'Ophtalmologie des Quinze Vingts, Paris, France (C.V-C.).
| | - Patrick Yu-Wai-Man
- Cambridge Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK (P.Y-W-M.); Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK (P.Y-W-M.); UCL Institute of Ophthalmology, University College London, London, UK (P.Y-W-M.); Moorfields Eye Hospital, London, UK
| | - Nancy J Newman
- Departments of Ophthalmology, Neurology and Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA (P.Y-W-M.)
| | - Valerio Carelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Bologna, Italy (V.C.); Unit of Neurology, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy (V.C.)
| | - Mark L Moster
- Departments of Neurology and Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA (M.L.M.)
| | - Valerie Biousse
- Departments of Ophthalmology, Neurology and Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA (P.Y-W-M.)
| | - Prem S Subramanian
- Sue Anschutz-Rodgers University of Colorado Eye Center, University of Colorado School of Medicine, Aurora, CO, USA (P.S.S.)
| | - An-Guor Wang
- Department of Ophthalmology, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan (A-G.W.)
| | - Sean P Donahue
- Department of Ophthalmology, Neurology, and Pediatrics, Vanderbilt University, and Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA (S.P.D.)
| | - Bart P Leroy
- Department of Ophthalmology and Center for Medical Genetics, Ghent University Hospital, and Department of Head & Skin, Ghent University, Ghent, Belgium (B.P.L.)
| | - Alfredo A Sadun
- Doheny Eye Institute, Los Angeles, CA, USA (A.A.S.); Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (A.A.S.)
| | - Thomas Klopstock
- Friedrich Baur Institute at the Department of Neurology, University Hospital, LMU Munich, Munich, Germany (T.K.); German Center for Neurodegenerative Diseases (DZNE), Munich, Germany (T.K.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (T.K.)
| | - Robert C Sergott
- Departments of Neurology and Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA (M.L.M.)
| | | | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear, Harvard Medical School, Boston, MA, USA (B.K.C.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA (B.K.C.)
| | - Rudrani Banik
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA (R.B.)
| | | | - Michel Roux
- GenSight Biologics, Paris, France (M.T., M.R.)
| | - José-Alain Sahel
- Sorbonne Université, INSERM, CNRS, Institut de la Vision, Paris, France (J-A.S.); Rothschild Foundation Hospital, Paris, France (J-A.S.); Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (J-A.S.); Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Institut Hospitalo-Universitaire FOReSIGHT, INSERM-DGOS CIC, Paris, France (J-A.S.)
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15
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Levy M, Chwalisz BK, Kozak BM, Yoon MK, Shih HA, Stagner AM. Case 36-2022: A 30-Year-Old Woman with Decreased Vision and Headache. N Engl J Med 2022; 387:1980-1989. [PMID: 36416771 DOI: 10.1056/nejmcpc2211355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Levy
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
| | - Bart K Chwalisz
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
| | - Benjamin M Kozak
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
| | - Michael K Yoon
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
| | - Helen A Shih
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
| | - Anna M Stagner
- From the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Massachusetts General Hospital, the Departments of Neurology (M.L., B.K.C.), Radiology (B.M.K.), Ophthalmology (M.K.Y.), Radiation Oncology (H.A.S.), and Pathology (A.M.S.), Harvard Medical School, and the Department of Ophthalmology, Massachusetts Eye and Ear (B.K.C., M.K.Y., A.M.S.) - all in Boston
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16
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Newman NJ, Yu-Wai-Man P, Subramanian PS, Moster ML, Wang AG, Donahue SP, Leroy BP, Carelli V, Biousse V, Vignal-Clermont C, Sergott RC, Sadun AA, Fernández GR, Chwalisz BK, Banik R, Bazin F, Roux M, Cox ED, Taiel M, Sahel JA. Randomized trial of bilateral gene therapy injection for m.11778G > A MT-ND4 Leber optic neuropathy. Brain 2022; 146:1328-1341. [PMID: 36350566 PMCID: PMC10115230 DOI: 10.1093/brain/awac421] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/20/2022] [Accepted: 10/02/2022] [Indexed: 11/11/2022] Open
Abstract
Leber hereditary optic neuropathy (LHON) is an important example of mitochondrial blindness with the m.11778G > A mutation in the MT-ND4 gene being the most common disease-causing mitochondrial DNA (mtDNA) variant worldwide. The REFLECT phase 3 pivotal study is a randomized, double-masked, placebo-controlled trial investigating the efficacy and safety of bilateral intravitreal injection of lenadogene nolparvovec in patients with a confirmed m.11778G > A mutation, using a recombinant adeno-associated virus vector 2, serotype 2 (rAAV2/2-ND4). The first-affected eye received gene therapy; the fellow (affected/not-yet-affected) eye was randomly injected with gene therapy or placebo. The primary endpoint was the difference in change from baseline of best-corrected visual acuity (BCVA) in second-affected/not-yet-affected eyes treated with lenadogene nolparvovec versus placebo at 1.5 years post-treatment, expressed in logarithm of the minimal angle of resolution (LogMAR). Forty-eight patients were treated bilaterally and 50 unilaterally. At 1.5 years, the change from baseline in BCVA was not statistically different between second-affected/not-yet-affected eyes receiving lenadogene nolparvovec and placebo (primary endpoint). A statistically significant improvement in BCVA was reported from baseline to 1.5 years in lenadogene nolparvovec-treated eyes: -0.23 LogMAR for the first-affected eyes of bilaterally treated patients (p < 0.01); and -0.15 LogMAR for second-affected/not-yet-affected eyes of bilaterally treated patients and the first-affected eyes of unilaterally treated patients (p < 0.05). The mean improvement in BCVA from nadir to 1.5 years was -0.38 (0.052) LogMAR and -0.33 (0.052) LogMAR in first-affected and second-affected/not-yet-affected eyes treated with lenadogene nolparvovec, respectively (bilateral treatment group). A mean improvement of -0.33 (0.051) LogMAR and -0.26 (0.051) LogMAR was observed in first-affected lenadogene nolparvovec-treated eyes and second-affected/not-yet-affected placebo-treated eyes, respectively (unilateral treatment group). The proportion of patients with one or both eyes on-chart at 1.5 years was 85.4% and 72.0% for bilaterally and unilaterally treated patients, respectively. The gene therapy was well tolerated, with no systemic issues. Intraocular inflammation, which was mostly mild and well controlled with topical corticosteroids, occurred in 70.7% of lenadogene nolparvovec-treated eyes versus 10.2% of placebo-treated eyes. Among eyes treated with lenadogene nolparvovec, there was no difference in the incidence of intraocular inflammation between bilaterally and unilaterally treated patients. Overall, the REFLECT trial demonstrated an improvement of BCVA in LHON eyes carrying the m.11778G > A mtDNA mutation treated with lenadogene nolparvovec or placebo to a degree not reported in natural history studies and supports an improved benefit/risk profile for bilateral injections of lenadogene nolparvovec relative to unilateral injections.
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Affiliation(s)
- Nancy J Newman
- Departments of Ophthalmology, Neurology and Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Patrick Yu-Wai-Man
- Cambridge Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
- Moorfields Eye Hospital, London, UK
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Prem S Subramanian
- Sue Anschutz-Rodgers University of Colorado Eye Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark L Moster
- Departments of Neurology and Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
| | - An-Guor Wang
- Department of Ophthalmology, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sean P Donahue
- Department of Ophthalmology, Neurology, and Pediatrics, Vanderbilt University, and Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bart P Leroy
- Department of Ophthalmology and Center for Medical Genetics, Ghent University Hospital, and Department of Head & Skin, Ghent University, Ghent, Belgium
| | - Valerio Carelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Bologna, Italy
- Unit of Neurology, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Valerie Biousse
- Departments of Ophthalmology, Neurology and Neurological Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Catherine Vignal-Clermont
- Department of Neuro Ophthalmology and Emergencies, Rothschild Foundation Hospital, Paris, France
- Centre Hospitalier National D'Ophtalmologie des Quinze Vingts, Paris, France
| | - Robert C Sergott
- Departments of Neurology and Ophthalmology, Wills Eye Hospital and Thomas Jefferson University, Philadelphia, PA, USA
| | - Alfredo A Sadun
- Doheny Eye Institute, UCLA School of Medicine, Los Angeles, CA, USA
| | | | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Rudrani Banik
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - José-Alain Sahel
- Sorbonne Université, INSERM, CNRS, Institut de la Vision, Paris, France
- Fondation Ophtalmologique A. de Rothschild, Paris, France
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- CHNO des Quinze-Vingts, Institut Hospitalo-Universitaire FOReSIGHT, INSERM-DGOS CIC, Paris, France
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Abstract
PURPOSE OF REVIEW This review paper aims at discussing pathogenesis, etiology, clinical features, management, and prognosis of OPN. RECENT FINDINGS Optic perineuritis (OPN) is an inflammatory process primarily involving the optic nerve sheath. Clinically, OPN usually presents with unilateral, gradual decline of visual function, eye pain, and/or pain on eye movements, disc edema and various features of optic nerve dysfunction, including visual field defects. It can mimic typical optic neuritis. In most cases of OPN, the disease is isolated with no specific etiology being identified, however, it can also occur secondary to a wide range of underlying systemic diseases. OPN is clinically diagnosed and radiologically confirmed based on the finding of circumferential perineural enhancement of the optic nerve sheath on magnetic resonance imaging (MRI). SUMMARY Unlike optic nerve, OPN is not typically self-limited without treatment. High-dose oral corticosteroids are the mainstay of treatment in OPN. The initiation of therapy usually causes rapid and dramatic improvement in signs and symptoms. In general, OPN usually has a relatively good visual prognosis, which is influenced by delays between the onset of visual loss and the initiation of steroid therapy as well as the presence of underlying systemic diseases.
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Affiliation(s)
- George Saitakis
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, Massachusetts, USA
- Athens Eye Hospital, Athens, Greece
| | - Bart K Chwalisz
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts, USA
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18
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Subramanian PS, Newman NJ, Moster M, Wang AG, Yu-Wai-Man P, Donahue S, Leroy BP, Carelli V, Biousse V, Vignal-Clermont C, Sergott RC, Sadun AA, Rebolleda G, Chwalisz BK, Banik R, Bazin F, Cox E, Roux M, Taiel M, Sahel JA. Study design and baseline characteristics for the reflect gene therapy trial ofm.11778g>A/ ND4-LHON. BMJ Open Ophthalmol 2022. [DOI: 10.1136/bmjophth-2022-001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ObjectiveREFLECT is the first randomised, double-masked, placebo-controlled multicentre phase 3 clinical trial that evaluated the efficacy and safety of bilateral intravitreal (IVT) injection of lenadogene nolparvovec in subjects with Leber hereditary optic neuropathy carrying the m.11778G>A mutation.Methods and analysisA total of 98 subjects were enrolled with vision loss of ≤12 months. The subjects were randomised to one of two treatment arms with all subjects receiving an intravitreal (IVT) injection of lenadogene nolparvovec in their first affected eye and the second-affected eye randomised to receive IVT of either lenadogene nolparvovec or placebo.ResultsThe majority of subjects were male with a mean duration of vision loss of 8.3 months. All but one subject experienced bilateral loss of vision at the time of injection. The mean best-corrected visual acuity of first-affected eyes was worse compared with second/not-yet-affected eyes. Analysis of retinal anatomical parameters showed increased thinning in the first-affected eyes when compared with the second/not-yet-affected eyes with both treatment arms showing significant changes compared with unaffected individuals.ConclusionThe REFLECT trial is the third and the largest phase 3 clinical study evaluating lenadogene nolparvovec in m.11778G>A Leber hereditary optic neuropathy (LHON) subjects. The observed demographics in REFLECT are consistent with previous reports in LHON subjects in the acute and dynamic phases of LHON disease. Combined with the visual function and anatomical parameters obtained in the previous RESCUE and REVERSE trials, REFLECT has provided a uniformly collected data set that should help direct future LHON clinical trials.
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Lin LY, Reshef ER, Lansberg MP, Barshak MB, Chwalisz BK, Holbrook EH, Wolkow N. Posterior Ischemic Optic Neuropathy in the Setting of Cocaine-Induced Orbital and Sinonasal Inflammation. Ophthalmic Plast Reconstr Surg 2022; 38:e141-e144. [PMID: 35470323 DOI: 10.1097/iop.0000000000002181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intranasal cocaine abuse can lead to significant sinus and orbital complications, including optic neuropathy. A 46-year-old man with a history of recurrent cocaine-induced sino-orbital inflammation and infection with bony destruction presented with acute, painless, vision loss. Examination revealed no light perception vision. MRI of the orbits demonstrated new restricted diffusion of the right optic nerve on diffusion-weighted imaging and apparent diffusion coefficient sequences, consistent with posterior ischemic optic neuropathy. This is the first among cases of cocaine-induced optic neuropathy in the literature to illustrate ischemic changes on MRI in the optic nerve, highlighting the utility of diffusion-weighted imaging/apparent diffusion coefficient sequences when optic neuropathy is suspected and further suggesting an underlying ischemic etiology in similar cases.
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Affiliation(s)
- Lisa Y Lin
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Marianella Paz Lansberg
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Massachusetts, U.S.A
| | - Miriam B Barshak
- Division of Infectious Disease, Massachusetts General Hospital, Harvard Medical School, Massachusetts, U.S.A
| | - Bart K Chwalisz
- Neuro-ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Massachusetts, U.S.A
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Massachusetts, U.S.A
| | - Eric H Holbrook
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Massachusetts, U.S.A
| | - Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
- David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Massachusetts, U.S.A
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20
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Liebman DL, Tam EK, Lithgow MY, Kane JE, Fischbein NJ, Lefebvre DR, Chwalisz BK, Gaier ED. Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia. J Neuroophthalmol 2022; 42:272-277. [PMID: 35421041 PMCID: PMC9124683 DOI: 10.1097/wno.0000000000001538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.
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MESH Headings
- Aged
- Diabetes Mellitus, Type 2/complications
- Edema
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Male
- Meningitis, Cryptococcal/complications
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Orbit
- Pain/complications
- Vision Disorders
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Affiliation(s)
| | - Emily K. Tam
- Department of Ophthalmology, Boston Medical Center, Boston, MA
| | | | - Joseph E. Kane
- Department of Optometry, Boston VA Medical Center, Boston, MA
| | - Nancy J. Fischbein
- Department of Radiology, Stanford University Medical Center, Stanford, CA
| | - Daniel R. Lefebvre
- Department of Ophthalmology, Boston VA Medical Center, Boston, MA
- Division of Ophthalmic Plastic and Reconstructive Surgery, Mass Eye and Ear, Boston, MA
| | - Bart K. Chwalisz
- Division of Neuro-Ophthalmology, Mass Eye and Ear, Boston, MA
- Division of Neuro-Immunology, Massachusetts General Hospital, Boston, MA
| | - Eric D. Gaier
- Department of Ophthalmology, Mass Eye and Ear, Boston, MA
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA
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21
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Liou VD, Yoon MK, Maher M, Chwalisz BK. Orbital Inflammation in Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease: A Case Report and Review of the Literature. J Neuroophthalmol 2022; 42:e56-e62. [PMID: 34999653 DOI: 10.1097/wno.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To present 2 patients with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease with unilateral orbital inflammation, optic nerve head edema, and abnormalities of the optic nerve and nerve sheath on imaging. We review the most current literature on this important and uncommon clinical phenotype. METHODS A case report of 2 patients and a comprehensive review of the relevant literature on orbital inflammation in MOG antibody-associated disease (MOG-AD). RESULTS Two patients presented with decreased vision and unilateral orbital inflammation. Both had optic nerve head edema and abnormalities of the optic nerve and nerve sheath on imaging. The patients were treated with immunosuppressants and had improvement of vision changes as well as their orbital inflammatory signs. MOG antibody was positive in high titers in both patients. Only 3 other cases of orbital inflammation associated with MOG antibody have been described. In all cases, orbital signs responded rapidly to intravenous methylprednisolone, but the improvement in visual acuity was variable and less robust. CONCLUSION Orbital inflammation is a unique and underrecognized phenotype of MOG-AD with only a few reports in the literature. In patients who present with vision loss and orbital inflammation, MOG-AD should be considered in the differential.
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Affiliation(s)
- Victor D Liou
- Ophthalmic Plastic Surgery (VDL, MKY), Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts; Department of Radiology (MM), Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts; Neuro-ophthalmology (BKC), Department of Ophthalmology, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts; and Department of Neurology (BKC), Massachusetts General Hospital / Harvard Medical School, Boston, Massachusetts
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22
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Abstract
BACKGROUND To review the literature and provide a summary of COVID-19-related neurologic and neuro-ophthalmic complications. METHODS The currently available literature was reviewed on PubMed and Google Scholar using the following keywords for searches: CNS, Neuro-Ophthalmology, COVID-19, SARS-CoV-2, coronavirus, optic neuritis, pseudotumor cerebri, Acute Disseminated Encephalomyelitis, posterior reversible encephalopathy syndrome (PRES), meningitis, encephalitis, acute necrotizing hemorrhagic encephalopathy, and Guillain-Barré and Miller Fisher syndromes. RESULTS Neuroradiologic findings of neurologic and neuro-ophthalmologic complications in relationship to COVID-19 infection were reviewed. Afferent visual pathway-related disorders with relevant imaging manifestations included fundus nodules on MRI, papilledema and pseudotumor cerebri syndrome, optic neuritis, Acute Disseminated Encephalomyelitis, vascular injury with thromboembolism and infarct, leukoencephalopathy, gray matter hypoxic injury, hemorrhage, infectious meningitis/encephalitis, acute necrotizing hemorrhagic encephalopathy, and PRES. Efferent visual pathway-related complications with relevant imaging manifestations were also reviewed, including orbital abnormalities, cranial neuropathy, Guillain-Barré and Miller Fisher syndromes, and nystagmus and other eye movement abnormalities related to rhombencephalitis. CONCLUSION COVID-19 can cause central and peripheral nervous system disease, including along both the afferent and efferent components of visual axis. Manifestations of disease and long-term sequela continue to be studied and described. Familiarity with the wide variety of neurologic, ophthalmic, and neuroradiologic presentations can promote prompt and appropriate treatment and continue building a framework to understand the underlying mechanism of disease.
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Abstract
Purpose of review
This review highlights the epidemiology, clinical and radiologic characteristics of chronic relapsing inflammatory optic neuropathy (CRION) and treatment modalities.
Recent findings
Summary
CRION is an inflammatory optic neuropathy that is characterized by a chronic and relapsing course, that is characterized by pain associated with subacute vision loss. It is favorably responsive but highly dependent on corticosteroids with frequent relapses in the setting of steroid tapering. Additional diagnostic biomarkers and further studies are required to better diagnose and treat this rare but potentially debilitating condition.
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Affiliation(s)
- Loulwah Mukharesh
- Department of Ophthalmology, Division of Neuro-Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Paraskevi Douglas
- Department of Ophthalmology, Division of Neuro-Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Bart K Chwalisz
- Department of Ophthalmology, Division of Neuro-Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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24
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Douglas KAA, Douglas VP, Gaier ED, Chwalisz BK. Ptosis as Clinical Presentation in a Patient With Emery-Dreifuss Muscular Dystrophy Type 5. J Neuroophthalmol 2021; 41:e333-e334. [PMID: 33630782 PMCID: PMC8373992 DOI: 10.1097/wno.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Konstantinos AA Douglas
- Massachusetts Eye and Ear Infirmary/Harvard Medical School, Neuro-Ophthalmology Service, Boston, MA
| | - Vivian Paraskevi Douglas
- Massachusetts Eye and Ear Infirmary/Harvard Medical School, Neuro-Ophthalmology Service, Boston, MA
| | - Eric D Gaier
- Boston Children’s Hospital/Harvard Medical School, Department of Ophthalmology, Boston, MA
- Picower Institute for Learning and Memory, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA
| | - Bart K Chwalisz
- Massachusetts Eye and Ear Infirmary/Harvard Medical School, Neuro-Ophthalmology Service, Boston, MA
- Picower Institute for Learning and Memory, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA
- Department of Neurology, Massachusetts General Hospital / Harvard Medical School, Boston MA
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Abstract
History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed.
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Affiliation(s)
- Vivian Paraskevi Douglas
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Konstantinos A A Douglas
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Katherine L Reinshagen
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Bart K Chwalisz
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
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26
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Bhattacharyya S, Gonzalez RG, Chwalisz BK, Champion SN. Case 22-2021: A 64-Year-Old Woman with Cognitive Impairment, Headache, and Memory Loss. N Engl J Med 2021; 385:358-368. [PMID: 34289280 DOI: 10.1056/nejmcpc2103460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Shamik Bhattacharyya
- From the Department of Neurology, Brigham and Women's Hospital (S.B.), the Departments of Radiology (R.G.G.), Neurology (B.K.C.), and Pathology (S.N.C.), Massachusetts General Hospital, and the Departments of Neurology (S.B., B.K.C.), Radiology (R.G.G.), and Pathology (S.N.C.), Harvard Medical School - all in Boston
| | - R Gilberto Gonzalez
- From the Department of Neurology, Brigham and Women's Hospital (S.B.), the Departments of Radiology (R.G.G.), Neurology (B.K.C.), and Pathology (S.N.C.), Massachusetts General Hospital, and the Departments of Neurology (S.B., B.K.C.), Radiology (R.G.G.), and Pathology (S.N.C.), Harvard Medical School - all in Boston
| | - Bart K Chwalisz
- From the Department of Neurology, Brigham and Women's Hospital (S.B.), the Departments of Radiology (R.G.G.), Neurology (B.K.C.), and Pathology (S.N.C.), Massachusetts General Hospital, and the Departments of Neurology (S.B., B.K.C.), Radiology (R.G.G.), and Pathology (S.N.C.), Harvard Medical School - all in Boston
| | - Samantha N Champion
- From the Department of Neurology, Brigham and Women's Hospital (S.B.), the Departments of Radiology (R.G.G.), Neurology (B.K.C.), and Pathology (S.N.C.), Massachusetts General Hospital, and the Departments of Neurology (S.B., B.K.C.), Radiology (R.G.G.), and Pathology (S.N.C.), Harvard Medical School - all in Boston
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27
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Guidon AC, Burton LB, Chwalisz BK, Hillis J, Schaller TH, Amato AA, Betof Warner A, Brastianos PK, Cho TA, Clardy SL, Cohen JV, Dietrich J, Dougan M, Doughty CT, Dubey D, Gelfand JM, Guptill JT, Johnson DB, Juel VC, Kadish R, Kolb N, LeBoeuf NR, Linnoila J, Mammen AL, Martinez-Lage M, Mooradian MJ, Naidoo J, Neilan TG, Reardon DA, Rubin KM, Santomasso BD, Sullivan RJ, Wang N, Woodman K, Zubiri L, Louv WC, Reynolds KL. Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002890. [PMID: 34281989 PMCID: PMC8291304 DOI: 10.1136/jitc-2021-002890] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.
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Affiliation(s)
- Amanda C Guidon
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Leeann B Burton
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Hillis
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Anthony A Amato
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Priscilla K Brastianos
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tracey A Cho
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Justine V Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, PA, USA
| | - Jorg Dietrich
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher T Doughty
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Divyanshu Dubey
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Jeffrey T Guptill
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Douglas B Johnson
- Division of Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vern C Juel
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Noah Kolb
- Division of Neuromuscular Medicine, Department of Neurology, University of Vermont, Burlington, VT, USA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jenny Linnoila
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Maria Martinez-Lage
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuropathology, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan J Mooradian
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarushka Naidoo
- Medical Oncology, Department of Medicine, Beaumont Hospital Dublin and RCSI University of Health Sciences, Dublin, Ireland
- Upper Aerodigestive Division, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center/Johns Hopkins University, Baltimore, MD, USA
| | - Tomas G Neilan
- Harvard Medical School, Boston, Massachusetts, USA
- Cardio-oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David A Reardon
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Neuro-oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Krista M Rubin
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bianca D Santomasso
- Department of Neurology, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karin Woodman
- Section of Cancer Neurology, Department of Neuro-Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Leyre Zubiri
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Dohlman JC, Chwalisz BK, Stephen CD. Clinical Reasoning: A 28-Year-Old Woman With Vision Loss and an Unusual Gait. Neurology 2021; 97:e1860-e1865. [PMID: 34187863 DOI: 10.1212/wnl.0000000000012446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jenny C Dohlman
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, MA
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, MA.,Department of Neurology, Massachusetts General Hospital, Boston, MA
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29
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Abstract
PURPOSE To provide a summary of the neuro-ophthalmic manifestations of coronavirus disease 19 (COVID-19) documented in the literature thus far. METHODS The PubMed and Google Scholar databases were searched using the keywords: Neuro-Ophthalmology, COVID-19, SARS-CoV-2, and coronavirus. A manual search through reference lists of relevant articles was also performed. RESULTS/CONCLUSIONS The literature on COVID-associated neuro-ophthalmic disease continues to grow. Afferent neuro-ophthalmic complications associated with COVID-19 include optic neuritis, papillophlebitis, papilledema, visual disturbance associated with posterior reversible encephalopathy syndrome, and vision loss caused by stroke. Efferent neuro-ophthalmic complications associated with COVID-19 include cranial neuropathies, Miller Fisher syndrome, Adie's pupils, ocular myasthenia gravis, nystagmus and eye movement disorders. Proposed mechanisms of neurologic disease include immunologic upregulation, vasodilation and vascular permeability, endothelial dysfunction, coagulopathy, and direct viral neurotropism. When patients present to medical centers with new onset neuro-ophthalmic conditions during the pandemic, COVID-19 infection should be kept on the differential.
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Affiliation(s)
- Alanna K Tisdale
- Department of Ophthalmology and Visual Sciences (AKT), University of Iowa Hospital and Clinics, University of Iowa Carver College of Medicine, Iowa City, Iowa; Departments of Ophthalmology and Neurology (MD), New York- Presbyterian Hospital, Weill Cornell Medical College, New York City, New York; Department of Ophthalmology (BKC), Massachusetts Eye & Ear; and Department of Neurology (BKC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Guidon AC, Burton LB, Chwalisz BK, Hillis JM, Schaller T, Reynolds KL. Consensus disease definitions for the spectrum of neurologic immune related adverse events. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.2647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2647 Background: Expanding FDA-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in both therapeutic success and immune related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes evidence-based treatments and research progress. The objectives of this study were to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. Methods: A working group of 4 neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the Neuro irAE Disease Definition Panel, consisting of neurologists, oncologists, neuro-oncologists and irAE subspecialists. A modified Delphi consensus process was used, with 2 rounds of anonymous ratings by panelists and 2 virtual meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. The working group aggregated survey responses and incorporated them into revised definitions. Consensus was based on numeric ratings using the RAND/UCLA Appropriateness Method with prespecified definitions. Results: Twenty-seven panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for 7 core disorders: irMeningitis, irEncephalitis/Encephalomyelitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, 6 sub-classifications are described: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation and present or absent concurrent irAE. Conclusions: These disease definitions standardize irAE-N classification. They are being incorporated into a multi-institutional registry that our group has initiated to study irAEs. Given consensus on their accuracy and usability from a representative panel group, we anticipate that they can be used broadly across clinical and research settings.
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Douglas VP, Douglas KAA, Reinshagen KL, Chwalisz BK. Case 292. Radiology 2021; 299:234-236. [PMID: 33750226 DOI: 10.1148/radiol.2021201712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed (Figs 1, 2).
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Affiliation(s)
- Vivian Paraskevi Douglas
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Konstantinos A A Douglas
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Katherine L Reinshagen
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
| | - Bart K Chwalisz
- From the Departments of Ophthalmology (V.P.D., K.A.A.D., B.K.C.) and Radiology (K.L.R.), Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114; and Department of Neurology, Neuro-Ophthalmology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (B.K.C.)
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Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is emerging as a fibro-inflammatory entity affecting multiple organs, including manifold neurologic manifestations. This review discusses general characteristics of IgG4-RD neurologic disease including epidemiology, histology, clinical picture and treatment approaches. RECENT FINDINGS IgG4-RD is increasingly recognized as an important underlying pathophysiology in multiple disorders of neurologic interest, including orbital inflammation, infundibulo-hypophysitis, hypertrophic pachymeningitis, and even in rare cases CNS parenchymal disease and cranial vascular involvement. These were previously considered idiopathic and unrelated to any systemic disease but now known to share a common histopathology. New knowledge regarding the pathogenesis, clinical features and epidemiology of IgG4 is emerging, and new neurological manifestations continue to be described. Diagnostic progress includes CT-PET imaging, the use of flow cytometry for plasmablast quantification, and the use of reverse passive latex agglutination aiming to overcome the prozone phenomenon. Histopathologic confirmation of IgG4-RD remains the gold standard method of diagnosis but new diagnostic criteria for systemic and organ-specific disease are being proposed. Though glucorticoids remain the mainstay of therapy, relapses and incomplete recovery are frequent. Rituximab is a promising treatment in IgG4-RD that is severe, refractory or glucocorticoid dependent. Initiation of immunosuppression at an early stage of disease should be considered in order to avoid development of refractory fibrosis. SUMMARY The current review emphasizes the neurologic manifestations of IgG4-RD.
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Affiliation(s)
- G Saitakis
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA
| | - B K Chwalisz
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
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Abstract
Inflammatory cerebral amyloid angiopathy is a largely reversible inflammatory vasculopathy that develops in an acute or subacute fashion in reaction to amyloid protein deposition in the central nervous system blood vessels. There are two recognized pathologically characterized variants: cerebral amyloid angiopathy-related inflammation (CAAri) and A beta-related angiitis (ABRA). Both variants produce a clinical picture that resembles primary angiitis of the CNS but is distinguished by a characteristic radiologic appearance. Although originally defined as a clinicopathologic diagnosis, it can now often be diagnosed based on clinicoradiologic criteria, though confirmation with brain and meningeal biopsy is still required in some cases. This disorder typically responds to steroids but addition of other immune suppressants may be needed in some cases to control the disease.
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Affiliation(s)
- B K Chwalisz
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, 15 Parkman Street, Suite 835, Boston, MA 02114, USA; Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA.
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Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the field of oncology by modulating the immune cell-cancer cell interaction and thereby promoting immune system disinhibition in order to target several types of malignancies. There are three classes of immune checkpoint inhibitors (ICIs): anti-cytotoxic T-lymphocyte associated antigen 4 (CTLA-4), anti-programmed cell death protein-1 (PD-1), and anti-programmed cell death ligand-1 (PD-L1).It is not uncommon for physicians across all specialties to encounter a patient with a history of malignancy and ICI exposure, necessitating familiarity with their potential complications. In this review article, we discuss the most common immune-related adverse events (irAEs) pertaining to the central and peripheral nervous systems and their potential afferent and efferent neuro-ophthalmic manifestations. Early recognition and treatment of these irAEs, and discontinuation of the offending ICI are all critical steps to prevent morbidity and mortality.
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Affiliation(s)
- Loulwah Mukharesh
- Department of Ophthalmology, Massachusetts Eye & Ear/Harvard Medical School, Boston, MA, USA
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear/Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Bouffard MA, Chwalisz BK, Romero JM, Arrillaga-Romany IC, Massoth LR. Case 6-2021: A 65-Year-Old Man with Eye Pain and Decreased Vision. N Engl J Med 2021; 384:745-753. [PMID: 33626257 DOI: 10.1056/nejmcpc2027089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Marc A Bouffard
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Bart K Chwalisz
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Javier M Romero
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Isabel C Arrillaga-Romany
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
| | - Lucas R Massoth
- From the Department of Neurology, Beth Israel Deaconess Medical Center (M.A.B.), the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C.), Radiology (J.M.R.), Neuro-oncology (I.C.A.-R.), and Pathology (L.R.M.), Harvard Medical School - all in Boston
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Webb LM, Chen JJ, Aksamit AJ, Bhattacharyya S, Chwalisz BK, Balaban D, Manzano GS, Ali AS, Lord J, Clardy SL, Samudralwar RD, Mao-Draayer Y, Garrity JA, Bhatti MT, Turner LE, Flanagan EP. A multi-center case series of sarcoid optic neuropathy. J Neurol Sci 2020; 420:117282. [PMID: 33358503 DOI: 10.1016/j.jns.2020.117282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/27/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of sarcoid optic neuropathy is time-sensitive, as delayed treatment risks irreversible vision loss. We sought to analyze its characteristics and outcomes. METHODS We performed a multi-center retrospective study of sarcoid optic neuropathy among 5 USA medical centers. Inclusion criteria were: 1) clinical optic neuropathy; 2) optic nerve/sheath enhancement on neuroimaging; 3) pathological confirmation of systemic or nervous system sarcoidosis. RESULTS Fifty-one patients were included. The median onset age of sarcoid optic neuropathy was 50 years (range, 17-70 years) and 71% were female. The median visual acuity at nadir in the most affected eye was 20/80 (range, 20/20 to no-light-perception). Thirty-four of 50 (68%) patients had radiologic evidence of other nervous system involvement and 20 (39%) patients had symptoms/signs of other cranial nerve dysfunction. Cerebrospinal fluid analysis revealed an elevated white blood cell count in 22 of 31 (71%) patients (median: 14/μL; range: 1-643/μL). Pathologic confirmation of sarcoidosis was by biopsy of systemic/pulmonary site, 34 (67%); optic nerve/sheath, 9 (18%); or other nervous system region, 8 (16%). Forty patients improved with treatment (78%), 98% receiving corticosteroids and 65% receiving steroid-sparing immunosuppressants, yet 11/46 patients (24%) had a visual acuity of 20/200 or worse at last follow-up. CONCLUSIONS Sarcoid optic neuropathy frequently occurs with other clinical and radiologic abnormalities caused by neurosarcoidosis and diagnostic confirmation occasionally requires optic nerve/sheath biopsy. Improvement with treatment is common but most patients have some residual visual disability. Improved recognition and a more expeditious diagnosis and treatment may spare patients from permanent vision loss.
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Affiliation(s)
- Lauren M Webb
- Mayo Clinic Alix School of Medicine, 200 1st St. SW, Rochester, MN, USA
| | - John J Chen
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA; Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Allen J Aksamit
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Shamik Bhattacharyya
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Bart K Chwalisz
- Massachusetts General Hospital, Department of Neurology, Department of Ophthalmology, and Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA, USA
| | - Denis Balaban
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Giovanna S Manzano
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Ahya S Ali
- Brigham and Women's Hospital, Department of Neurology, 75 Francis St., Boston, MA, USA
| | - Jennifer Lord
- University of Utah, Department of Neurology, 50 N. Medical Dr., Salt Lake City, UT, USA
| | - Stacey L Clardy
- University of Utah, Department of Neurology, 50 N. Medical Dr., Salt Lake City, UT, USA
| | - Rohini D Samudralwar
- University of Texas Health Science Center, Department of Neurology, 6410 Fannin St., Houston, TX, USA
| | - Yang Mao-Draayer
- University of Michigan, Department of Neurology, 1500 E. Medical Center Dr., Ann Arbor, MI, USA
| | - James A Garrity
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA
| | - M Tariq Bhatti
- Mayo Clinic, Department of Ophthalmology, 200 1st St. SW, Rochester, MN, USA; Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA
| | - Lindsey E Turner
- Mayo Clinic, Graduate School of Biomedical Sciences, 200 1st St. SW, Rochester, MN, USA
| | - Eoin P Flanagan
- Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN, USA.
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Douglas VP, Douglas KAA, Rizzo JF, Chwalisz BK. Reply to: Cluster headache by orbital myositis. Comment: Orbital myositis triggering oxygen-responsive cluster headache. Cephalalgia 2020; 40:1680. [DOI: 10.1177/0333102420961561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Joseph F Rizzo
- Massachusetts Eye and Ear Infirmary – Ophthalmology, Boston, MA, USA
| | - Bart K Chwalisz
- Massachusetts Eye and Ear Infirmary – Ophthalmology, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW This review discusses general features and organ-specific presentations of Susac syndrome as well as diagnosis and treatment. RECENT FINDINGS Latest literature regarding demographics, new diagnostic modalities such as optical coherence tomography and treatment options for Susac syndrome are discussed in detail in this review, summarizing the most recent updated information. SUMMARY Susac syndrome is a rare, underdiagnosed, and often misdiagnosed disease that can lead to severe complications such as deafness, vision loss, dementia, and death. It involves the central nervous system and may mimic other neurological and neuro-ophthalmological diseases.
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Affiliation(s)
- Yael Redler
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW To provide a summary of the neuro-ophthalmic manifestations of coronavirus disease 19 (COVID-19), documented in the literature thus far. RECENT FINDINGS A small but growing literature documents cases of new onset neuro-ophthalmic disease, in the setting of COVID-19 infection. Patients with COVID-19 have experienced acute onset vision loss, optic neuritis, cranial neuropathies, and Miller Fisher syndrome. In addition, COVID-19 increases the risk of cerebrovascular diseases that can impact the visual system. SUMMARY The literature on COVID-19 continues to evolve. Although COVID-19 primarily impacts the respiratory system, there are several reports of new onset neuro-ophthalmic conditions in COVID-infected patients. When patients present with new onset neuro-ophthalmic issues, COVID-19 should be kept on the differential. Testing for COVID-19 should be considered, especially when fever or respiratory symptoms are also present. When screening general patients for COVID-19-associated symptoms, frontline physicians can consider including questions about diplopia, eye pain, pain with extraocular movements, decreased vision, gait issues, and other neurologic symptoms. The presence of these symptoms may increase the overall probability of viral infection, especially when fever or respiratory symptoms are present. More research is needed to establish a causal relationship between COVID-19 and neuro-ophthalmic disease, and better understand pathogenesis.
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Affiliation(s)
- Alanna K Tisdale
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye & Ear
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Douglas VP, Douglas KAA, Chwalisz BK. Hemorrhagic Papilledema Secondary to Craniopharyngioma. JAMA Ophthalmol 2020; 138:e200880. [DOI: 10.1001/jamaophthalmol.2020.0880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Bart K. Chwalisz
- Neuro-Ophthalmology Service, Massachusetts Eye and Ear, Harvard Medical School, Boston
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Regenhardt RW, Thon JM, Das AS, Thon OR, Charidimou A, Viswanathan A, Gurol ME, Chwalisz BK, Frosch MP, Cho TA, Greenberg SM. Association Between Immunosuppressive Treatment and Outcomes of Cerebral Amyloid Angiopathy-Related Inflammation. JAMA Neurol 2020; 77:1261-1269. [PMID: 32568365 PMCID: PMC7309570 DOI: 10.1001/jamaneurol.2020.1782] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/20/2020] [Indexed: 07/27/2023]
Abstract
IMPORTANCE Cerebral amyloid angiopathy-related inflammation (CAA-ri), a distinct subtype of cerebral amyloid angiopathy, is characterized by an autoimmune reaction to cerebrovascular β-amyloid deposits. Outcomes and response to immunosuppressive therapy for CAA-ri are poorly understood. OBJECTIVE To identify clinical, neuroimaging, laboratory, pathologic, or treatment-related associations with outcomes after an episode of CAA-ri. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of prospectively identified individuals who presented from July 3, 1998, to November 27, 2017, with a median follow-up of 2.7 years (interquartile range, 1.0-5.5 years). The study included 48 consecutive patients with CAA-ri meeting diagnostic criteria who had at least 1 disease episode and subsequent outcome data. No patients refused or were excluded. EXPOSURES Prespecified candidate variables were immunosuppressive therapies, cerebrospinal fluid pleocytosis, magnetic resonance imaging findings of recent infarcts or contrast enhancement, and histopathologic evidence of vessel wall inflammation. MAIN OUTCOMES AND MEASURES Clinical improvement and worsening were defined by persistent changes in signs or symptoms, radiographic improvement by decreased subcortical foci of T2 hyperintensity or T1 enhancement, and radiographic worsening by increased subcortical T2 hyperintensity, T1 enhancement, or infarcts. Disease recurrence was defined as new-onset clinical symptoms associated with new imaging findings. RESULTS The 48 individuals in the study included 29 women and had a mean (SD) age of 68.9 (9.9) years. Results of presenting magnetic resonance imaging revealed that 10 of 29 patients with CAA-ri (34%) had T1 contrast enhancement, 30 of 32 (94%) had subcortical T2 hyperintensity (22 of 30 [73%] asymmetric), 7 of 32 (22%) had acute or subacute punctate infarcts, and 27 of 31 (87%) had microbleeds. Immunosuppressive treatments after first episodes included corticosteroids (33 [69%]), cyclophosphamide (6 [13%]), and mycophenolate (2 [4%]); 14 patients (29%) received no treatment. Clinical improvement and radiographic improvement were each more likely in individuals treated with an immunosuppressive agent than with no treatment (clinical improvement: 32 of 34 [94%] vs 7 of 14 [50%]; odds ratio, 16.0; 95% CI, 2.72-94.1; radiographic improvement: 24 of 28 [86%] vs 4 of 14 [29%]; odds ratio, 15.0; 95% CI, 3.12-72.1). Recurrence was less likely if CAA-ri was treated with any immunosuppressant agent than not (9 of 34 [26%] vs 10 of 14 [71%]; hazard ratio, 0.19; 95% CI, 0.07-0.48). When controlling for treatment, no variables were associated with outcomes aside from an association between APOE ɛ4 and radiographic improvement (odds ratio, 4.49; 95% CI, 1.11-18.2). CONCLUSIONS AND RELEVANCE These results from a relatively large series of patients with CAA-ri support the effectiveness of immunosuppressive treatment and suggest that early treatment may both improve the initial disease course and reduce the likelihood of recurrence. These results raise the possibility that early blunting of CAA-ri and the autoimmune response may have long-term benefits for the subsequent disease course.
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Affiliation(s)
- Robert W. Regenhardt
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jesse M. Thon
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alvin S. Das
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Olga R. Thon
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andreas Charidimou
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - M. Edip Gurol
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Bart K. Chwalisz
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew P. Frosch
- Neuropathology Service, C. S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Tracey A. Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Steven M. Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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Affiliation(s)
- Bart K Chwalisz
- Department of Ophthalmology, Massachusetts Eye and Ear and Massachusetts General Hospital (BKC), Harvard Medical School, Boston Massachusetts; and Departments of Ophthalmology and Neurology (MJD), Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
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Affiliation(s)
- Aneesh B Singhal
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - R Gilberto Gonzalez
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - Bart K Chwalisz
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - Shibani S Mukerji
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
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Affiliation(s)
- Bart K Chwalisz
- From the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Harvard Medical School - both in Boston
| | - Bradley R Buchbinder
- From the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Harvard Medical School - both in Boston
| | - Jeremy D Schmahmann
- From the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Harvard Medical School - both in Boston
| | - Wesley R Samore
- From the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Massachusetts General Hospital, and the Departments of Neurology (B.K.C., J.D.S.), Radiology (B.R.B.), and Pathology (W.R.S.), Harvard Medical School - both in Boston
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Abstract
BACKGROUND Orbital myositis is an idiopathic, non-infectious condition, typically seen in young females and usually affecting one extraocular muscle. Orbital myositis mimicking cluster headache is a rare clinical entity, and this is the first description of a case of a secondary trigeminal autonomic cephalalgia from orbital myositis responsive to high-flow oxygen. CASE A young woman presented with new-onset, oxygen-responsive headache, periorbital pain and autonomic features. She had associated vertical diplopia on downgaze and subtle ocular misalignment. An initial diagnosis of cluster headache was made. Initial brain MRI was unrevealing, but dedicated MRI of the orbits showed enhancement of orbital muscles. The diplopia and the imaging findings were consistent with orbital myositis. CONCLUSION Orbital myositis mimicking cluster headache is rare, and not previously reported as an oxygen-responsive headache.
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Affiliation(s)
- Vivian P Douglas
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Konstantinos Aa Douglas
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Joseph F Rizzo
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Bart K Chwalisz
- Neuro-Ophthalmology Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Thon JM, Regenhardt RW, Thon OR, Charidimou A, Viswanathan A, Gurol ME, Chwalisz BK, Frosch M, Cho TA, Greenberg SM. Abstract WP426: Cerebral Amyloid Angiopathy-related Inflammation: Immunosuppressive Treatment and Outcome. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral amyloid angiopathy-related inflammation (CAAri) is characterized by altered cognition, headaches, and seizures and is associated with vasogenic edema and an anti-amyloid immune response on imaging and histology. Optimal treatments are poorly understood. Our objective was to analyze clinical features and treatment strategies in CAAri to identify predictors of outcome.
Methods:
We retrospectively reviewed the records of 56 consecutive patients with pathologically or radiographically diagnosed CAAri at Massachusetts General Hospital. Clinical, laboratory, pathology, and treatment data were collected for analysis. Inflammatory events were defined by previously described clinical and radiographic parameters. Chi-Square analyses were used to determine if treatment with immunotherapy was associated with outcomes.
Results:
Of the 56 subjects, 8 had vessel wall inflammation on pathology, 21 had perivascular inflammation on pathology, and 48 had probable CAAri by validated imaging criteria. Thirty-five were female, 49 presented with an inflammatory event, and the mean age at first event was 69.3+/-10.2 years. First events included headache (n=21), cognitive/behavioral change (29), focal deficit (9), seizure (20), and other (6). CSF was examined in 26 subjects after first event (6 with WBC>5, 24 with protein>45, 1 without abnormality). Treatments included steroids (33), cyclophosphamide (6), mycophenolate (2), and no treatment (14). After first event, clinical improvement (n=39) was more likely if treated with any immunotherapy than not (32/34 vs 7/14, p=0.001). Radiographic improvement (28) was more likely if treated than not (24/28 vs 4/14, p<0.0001). Radiographic worsening (13) was less likely if treated than if not treated (3/28 vs. 10/14, p<0.0001). Only 3 had clinical worsening and 0 were unchanged. At least 1 recurrent event (19) was more likely if not treated than if treated (10/13 vs 9/31, p=0.005); 10 had multiple recurrences and 1 died during an event.
Conclusion:
This study of the largest CAAri patient population to-date suggests treatment with immunosuppression is associated with improved clinical and radiographic outcomes and decreased recurrence of events.
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Affiliation(s)
- Jesse M Thon
- Neurology, Hosp of the Univ of Pennsylvania, Philadelphia, PA
| | | | - Olga R Thon
- Neurology, Drexel Univ College of Medicine, Philadelphia, PA
| | | | | | | | | | | | - Tracey A Cho
- Neurology, Univ of Iowa Carver College of Medicine, Iowa City, IA
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