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Ramirez-Bermudez J, Restrepo-Martinez M, Espinola-Nadurille M, Martinez-Angeles V, Lopez-Hernandez JC, Hernandez-Vanegas LE, Martinez-Carrillo F, Ruiz-Garcia R, Rivas-Alonso V, Flores-Rivera J, Pollak TA. Examining the Features of Neuroleptic Malignant Syndrome in Anti-NMDA Receptor Encephalitis: A Case-Control Study. J Acad Consult Liaison Psychiatry 2023:S2667-2960(23)00853-4. [PMID: 38151160 DOI: 10.1016/j.jaclp.2023.12.002] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE) is a neuroimmunological disorder that frequently improves with immunotherapy. Symptomatic treatment with antipsychotics is common in the early stages when psychiatric symptoms predominate, and their use has been associated with serious side effects including neuroleptic malignant syndrome (NMS). The observation of an adverse response to antipsychotics, raising the suspicion of NMS, has been included as a criterion for possible autoimmune psychosis. METHODS This case-control study included patients who received antipsychotics before referral to the National Institute of Neurology and Neurosurgery of Mexico, where they were diagnosed as having definite ANMDARE, and patients with ANMDARE who did not receive antipsychotics before referral. The neurologic and systemic features that are used to measure an adverse response to antipsychotics, raising the suspicion of NMS, were measured in both groups, including akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, and hyperthermia. A logistic regression analysis was used to determine the relationship between the previous use of antipsychotics and the occurrence of NMS-like reactions. RESULTS A total sample of 112 patients with definite ANMDARE were included in the study. Fifty patients received antipsychotics before being referred to our institution. In this group, thirty-six patients (72%) were initially classified as having an adverse response, raising the suspicion of NMS, with the following features: akinesia (64%), autonomic instability (58%), generalized rigidity (52%), elevated concentrations of creatine phosphokinase (50%), and hyperthermia (14%). Six patients fulfilled the criteria for NMS (12%). The comparison with patients who did not receive antipsychotics before the clinical assessment did not show a significant difference between groups regarding the frequency of akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, or hyperthermia. Among different antipsychotics, only haloperidol was significantly associated with generalized rigidity as compared to patients who did not receive antipsychotics. CONCLUSIONS Our study supports previous observations about the high frequency of autonomic dysfunction, hyperthermia, tachycardia, rigidity, and elevated creatine phosphokinase levels in patients with anti-NMDAR encephalitis following the administration of antipsychotic medications. Nevertheless, our study does not suggest a causal link between atypical antipsychotics and the onset of these neurological symptoms, as they were equally frequent among the group of patients who did not receive antipsychotic treatment.
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Affiliation(s)
- Jesus Ramirez-Bermudez
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.
| | - Miguel Restrepo-Martinez
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Mariana Espinola-Nadurille
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Victoria Martinez-Angeles
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Juan Carlos Lopez-Hernandez
- Department of Neurological Emergencies, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Laura E Hernandez-Vanegas
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Francisco Martinez-Carrillo
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Ramiro Ruiz-Garcia
- Departments of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Veronica Rivas-Alonso
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Jose Flores-Rivera
- Department of Clinical Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London
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Espinola-Nadurille M, Restrepo-Martínez M, Bayliss L, Flores-Montes E, Rivas-Alonso V, Vargas-Cañas S, Hernández L, Martínez-Juarez I, Gonzalez-Aguilar A, Solis-Vivanco R, Fricchione GL, Flores-Rivera J, Ramirez-Bermudez J. Neuropsychiatric phenotypes of anti-NMDAR encephalitis: a prospective study. Psychol Med 2023; 53:4266-4274. [PMID: 35534479 DOI: 10.1017/s0033291722001027] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis (ANMDARE) show a wide range of behavioral abnormalities and are often mistaken for primary psychiatric presentations. We aimed to determine the behavioral hallmarks of ANMDARE with the use of systematic neuropsychiatric and cognitive assessments. METHODS A prospective study was conducted, with 160 patients admitted to the National Institute of Neurology and Neurosurgery of Mexico, who fulfilled criteria for possible autoimmune encephalitis and/or red flags along a time window of seven years. Cerebrospinal fluid (CSF) antibodies against the NR1 subunit of the NMDAR were processed with rat brain immunohistochemistry and cell-based assays with NMDA expressing cells. Systematic cognitive, neuropsychiatric, and functional assessments were conducted before knowing NMDAR antibodies results. A multivariate analysis was used to compare patients with and without definite ANMDARE according to antibodies in CSF. RESULTS After obtaining the CSF antibodies results in 160 consecutive cases, 100 patients were positive and classified as having definite ANMDARE. The most frequent neuropsychiatric patterns were psychosis (81%), delirium (75%), catatonia (69%), anxiety-depression (65%), and mania (27%). Cognition was significantly impaired. A total of 34% of the patients had a predominantly neuropsychiatric presentation without seizures. After multivariate analysis, the clinical hallmarks of ANMDARE consisted of a catatonia-delirium comorbidity, tonic-clonic seizures, and orolingual dyskinesia. CONCLUSIONS Our study supports the notion of a neurobehavioral phenotype of ANMDARE characterized by a fluctuating course with psychotic and affective symptoms, catatonic signs, and global cognitive dysfunction, often accompanied by seizures and dyskinesia. The catatonia-delirium comorbidity could be a distinctive neurobehavioral phenotype of ANMDARE.
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Affiliation(s)
- M Espinola-Nadurille
- Department of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - M Restrepo-Martínez
- Department of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - L Bayliss
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - E Flores-Montes
- Department of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - V Rivas-Alonso
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - S Vargas-Cañas
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - L Hernández
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - I Martínez-Juarez
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - A Gonzalez-Aguilar
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - R Solis-Vivanco
- Laboratory of Cognitive and Clinical Neurophysiology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - G L Fricchione
- Psychiatry Department, Massachusetts General Hospital, Boston, MA, USA
| | - J Flores-Rivera
- Department of Neurology, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - J Ramirez-Bermudez
- Department of Neuropsychiatry, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
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Charvet B, Brunel J, Pierquin J, Iampietro M, Decimo D, Queruel N, Lucas A, Encabo-Berzosa MDM, Arenaz I, Marmolejo TP, Gonzalez AI, Maldonado AC, Mathieu C, Küry P, Flores-Rivera J, Torres-Ruiz F, Avila-Rios S, Salgado Montes de Oca G, Schoorlemmer J, Perron H, Horvat B. SARS-CoV-2 awakens ancient retroviral genes and the expression of proinflammatory HERV-W envelope protein in COVID-19 patients. iScience 2023; 26:106604. [PMID: 37091988 PMCID: PMC10079620 DOI: 10.1016/j.isci.2023.106604] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 10/20/2022] [Revised: 01/29/2023] [Accepted: 03/30/2023] [Indexed: 04/25/2023] Open
Abstract
Patients with COVID-19 may develop abnormal inflammatory response, followed in some cases by severe disease and long-lasting syndromes. We show here that in vitro exposure to SARS-CoV-2 activates the expression of the human endogenous retrovirus (HERV) HERV-W proinflammatory envelope protein (ENV) in peripheral blood mononuclear cells from a subset of healthy donors, in ACE2 receptor and infection-independent manner. Plasma and/or sera of 221 COVID-19 patients from different cohorts, infected with successive SARS-CoV-2 variants including the Omicron, had detectable HERV-W ENV, which correlated with ENV expression in T lymphocytes and peaked with the disease severity. HERV-W ENV was also found in postmortem tissues of lungs, heart, gastrointestinal tract, brain olfactory bulb, and nasal mucosa from COVID-19 patients. Altogether, these results demonstrate that SARS-CoV-2 could induce HERV-W envelope protein expression and suggest its involvement in the immunopathogenesis of certain COVID-19-associated syndromes and thereby its relevance in the development of personalized treatment of patients.
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Affiliation(s)
| | | | | | - Mathieu Iampietro
- CIRI, International Center for Infectiology Research, INSERM U1111, CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Didier Decimo
- CIRI, International Center for Infectiology Research, INSERM U1111, CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, Lyon, France
| | | | - Alexandre Lucas
- We-Met platform, I2MC/Inserm/Université Paul Sabatier UMR1297, Toulouse, France
| | | | - Izaskun Arenaz
- Biobanco del Sistema de Salud de Aragón, Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza, Spain
| | - Tania Perez Marmolejo
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, México Ciudad, México
| | - Arturo Ivan Gonzalez
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, México Ciudad, México
| | | | - Cyrille Mathieu
- CIRI, International Center for Infectiology Research, INSERM U1111, CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, Lyon, France
| | - Patrick Küry
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Jose Flores-Rivera
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Fernanda Torres-Ruiz
- Centro de investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México Ciudad, México
| | - Santiago Avila-Rios
- Centro de investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México Ciudad, México
| | - Gonzalo Salgado Montes de Oca
- Centro de investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México Ciudad, México
| | - Jon Schoorlemmer
- ARAID Fundación; Instituto Aragonés de Ciencias de la Salud (IACS); Grupo B46_20R de la DGA and GIIS-028 del IISA; all Zaragoza, Spain
| | - Hervé Perron
- GeNeuro Innovation, Lyon, France
- GeNeuro, Plan les Ouates, Geneva, Switzerland
| | - Branka Horvat
- CIRI, International Center for Infectiology Research, INSERM U1111, CNRS UMR5308, Université de Lyon, Université Claude Bernard Lyon 1, Ecole Normale Supérieure de Lyon, Lyon, France
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Petzold A, Fraser CL, Abegg M, Alroughani R, Alshowaeir D, Alvarenga R, Andris C, Asgari N, Barnett Y, Battistella R, Behbehani R, Berger T, Bikbov MM, Biotti D, Biousse V, Boschi A, Brazdil M, Brezhnev A, Calabresi PA, Cordonnier M, Costello F, Cruz FM, Cunha LP, Daoudi S, Deschamps R, de Seze J, Diem R, Etemadifar M, Flores-Rivera J, Fonseca P, Frederiksen J, Frohman E, Frohman T, Tilikete CF, Fujihara K, Gálvez A, Gouider R, Gracia F, Grigoriadis N, Guajardo JM, Habek M, Hawlina M, Martínez-Lapiscina EH, Hooker J, Hor JY, Howlett W, Huang-Link Y, Idrissova Z, Illes Z, Jancic J, Jindahra P, Karussis D, Kerty E, Kim HJ, Lagrèze W, Leocani L, Levin N, Liskova P, Liu Y, Maiga Y, Marignier R, McGuigan C, Meira D, Merle H, Monteiro MLR, Moodley A, Moura F, Muñoz S, Mustafa S, Nakashima I, Noval S, Oehninger C, Ogun O, Omoti A, Pandit L, Paul F, Rebolleda G, Reddel S, Rejdak K, Rejdak R, Rodriguez-Morales AJ, Rougier MB, Sa MJ, Sanchez-Dalmau B, Saylor D, Shatriah I, Siva A, Stiebel-Kalish H, Szatmary G, Ta L, Tenembaum S, Tran H, Trufanov Y, van Pesch V, Wang AG, Wattjes MP, Willoughby E, Zakaria M, Zvornicanin J, Balcer L, Plant GT. Diagnosis and classification of optic neuritis. Lancet Neurol 2022; 21:1120-1134. [PMID: 36179757 DOI: 10.1016/s1474-4422(22)00200-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 03/16/2022] [Accepted: 04/20/2022] [Indexed: 11/28/2022]
Abstract
There is no consensus regarding the classification of optic neuritis, and precise diagnostic criteria are not available. This reality means that the diagnosis of disorders that have optic neuritis as the first manifestation can be challenging. Accurate diagnosis of optic neuritis at presentation can facilitate the timely treatment of individuals with multiple sclerosis, neuromyelitis optica spectrum disorder, or myelin oligodendrocyte glycoprotein antibody-associated disease. Epidemiological data show that, cumulatively, optic neuritis is most frequently caused by many conditions other than multiple sclerosis. Worldwide, the cause and management of optic neuritis varies with geographical location, treatment availability, and ethnic background. We have developed diagnostic criteria for optic neuritis and a classification of optic neuritis subgroups. Our diagnostic criteria are based on clinical features that permit a diagnosis of possible optic neuritis; further paraclinical tests, utilising brain, orbital, and retinal imaging, together with antibody and other protein biomarker data, can lead to a diagnosis of definite optic neuritis. Paraclinical tests can also be applied retrospectively on stored samples and historical brain or retinal scans, which will be useful for future validation studies. Our criteria have the potential to reduce the risk of misdiagnosis, provide information on optic neuritis disease course that can guide future treatment trial design, and enable physicians to judge the likelihood of a need for long-term pharmacological management, which might differ according to optic neuritis subgroups.
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Kerik-Rotenberg N, Diaz-Meneses I, Hernandez-Ramirez R, Muñoz-Casillas R, Reynoso-Mejia C, Aguilar-Palomeque C, Flores-Rivera J, Espinola-Nadurille M, Ramirez-Bermudez J. "Reply: Methodological and Ethical Concerns in the Study of AntiNMDA Encephalitis With Positron Emission Tomography". Psychosomatics 2020; 61:863-864. [PMID: 32312524 DOI: 10.1016/j.psym.2020.02.009] [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] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Nora Kerik-Rotenberg
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
| | - Ivan Diaz-Meneses
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Hernandez-Ramirez
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Muñoz-Casillas
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos Reynoso-Mejia
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos Aguilar-Palomeque
- PET-CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jose Flores-Rivera
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Jesus Ramirez-Bermudez
- Department of Neuropsychiatry, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Kerik-Rotenberg N, Diaz-Meneses I, Hernandez-Ramirez R, Muñoz-Casillas R, Reynoso-Mejia CA, Flores-Rivera J, Espinola-Nadurille M, Ramirez-Bermudez J, Aguilar-Palomeque C. A Metabolic Brain Pattern Associated With Anti-N-Methyl-D-Aspartate Receptor Encephalitis. Psychosomatics 2019; 61:39-48. [PMID: 31611047 DOI: 10.1016/j.psym.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis causes substantial neurological disability. Autoantibodies causing encephalitis directed against the neuronal cell surface or synapse are of diagnostic importance giving the possibility of successful immunotherapy. OBJECTIVE In this study, we aim to provide supporting evidence that brain 18F-FDG-PET may be helpful in identifying likely patterns of regional brain glucose metabolism. METHODS Thirty-three patients (18 men and 15 women; age range of 17-55 y) with positive NMDA receptor antibody encephalitis that underwent an 18F-FDG-PET imaging examination were prospectively selected and compared with a reference group of 14 brain 18F-FDG-PET scans from healthy volunteers using voxel-based statistical analysis. Clusters of hyper- and hypo-metabolism were reported for the whole sample of patients (FWE-corrected P < 0.05), and uncorrected at P < 0.005 for a group of relapsed patients. RESULTS Mixed metabolic patterns (focal/bilateral hypermetabolism in the temporal lobe, insula, and cerebellum; associated with severe bilateral hypometabolism in the occipital and parietal lobes) were found. CONCLUSIONS Our findings suggest that 18F-FDG-PET should be included as an imaging tool when assessing affected patients in the clinical workup to rule out anti-NMDA encephalitis and help determine the most effective treatment.
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Affiliation(s)
- Nora Kerik-Rotenberg
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
| | - Ivan Diaz-Meneses
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Hernandez-Ramirez
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Rodrigo Muñoz-Casillas
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos A Reynoso-Mejia
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jose Flores-Rivera
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Mariana Espinola-Nadurille
- Department of Neuropsychiatry, Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jesus Ramirez-Bermudez
- Department of Neuropsychiatry, Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Carlos Aguilar-Palomeque
- PET/CT Molecular Imaging Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Espinola-Nadurille M, Flores-Rivera J, Rivas-Alonso V, Vargas-Cañas S, Fricchione GL, Bayliss L, Martinez-Juarez IE, Hernandez-Vanegas LE, Martinez-Hernandez R, Bautista-Gomez P, Solis-Vivanco R, Perez-Esparza R, Bustamante-Gomez PA, Restrepo-Martinez M, Ramirez-Bermudez J. Catatonia in patients with anti-NMDA receptor encephalitis. Psychiatry Clin Neurosci 2019; 73:574-580. [PMID: 31115962 DOI: 10.1111/pcn.12867] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
AIM There is a lack of studies related to the frequency, phenomenology, and associated features of catatonic syndrome in patients with anti-NMDA receptor encephalitis (ANMDARE). This study aimed to measure the frequency of catatonia in this condition and to delineate its particular symptoms. METHODS A prospective study was done with all inpatients who fulfilled the criteria of definite ANMDARE admitted to the National Institute of Neurology and Neurosurgery of Mexico from January 2014 to September 2018. The Bush-Francis Catatonia Rating Scale and Braünig Catatonia Rating Scale were administered at admission. RESULTS Fifty-eight patients were included and catatonia was diagnosed in 41 of these patients (70.6%). Immobility, staring, mutism, and posturing were the most frequent catatonic signs. Catatonia was associated with delirium, hallucinations, psychomotor agitation, generalized electroencephalography dysfunction, and previous use of antipsychotics. Mortality was present in 10% of the total sample; it was associated with status epilepticus, and was less frequent in the catatonia group. After immunotherapy, all cases showed a complete recovery from catatonic signs. CONCLUSION This systematic assessment of catatonic syndrome shows that it is a frequent feature in patients with ANMDARE as part of a clinical pattern that includes delirium, psychomotor agitation, and hallucinations. The lack of recognition of this pattern may be a source of diagnostic and therapeutic errors, as most physicians associate catatonia with schizophrenia and affective disorders.
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Affiliation(s)
- Mariana Espinola-Nadurille
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.,Center of Neurology and Neurosurgery, Medica Sur, Mexico City, Mexico
| | - Jose Flores-Rivera
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Veronica Rivas-Alonso
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Steven Vargas-Cañas
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Gregory L Fricchione
- Intensive Care Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Leo Bayliss
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | | | | | - Ruben Martinez-Hernandez
- Neurology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Paola Bautista-Gomez
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Rodolfo Solis-Vivanco
- Neuropsychology Department, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico.,School of Psychology, National Autonomous University of Mexico, Mexico City, Mexico
| | - Rodrigo Perez-Esparza
- Addiction Research Laboratory, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | | | | | - Jesus Ramirez-Bermudez
- Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
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8
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Bhattarai R, Carabin H, Proaño JV, Flores-Rivera J, Corona T, Flisser A, León-Maldonado L, Budke CM. The monetary burden of cysticercosis in Mexico. PLoS Negl Trop Dis 2019; 13:e0007501. [PMID: 31291239 PMCID: PMC6645581 DOI: 10.1371/journal.pntd.0007501] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/22/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022] Open
Abstract
Background Taenia solium cysticercosis is a public health and agricultural problem in many low and middle-income countries where health education, sanitation, pig management practices and meat inspection infrastructure are insufficient. Cysticercosis affects both human and animal health and has important economic consequences. Very few studies have been conducted to evaluate the monetary burden of cysticercosis. This study aimed at estimating the 2015 costs associated with cysticercosis in humans and pigs in Mexico. Methods The monetary burden of human cysticercosis was estimated based on costs incurred by living with and treating epilepsy and severe chronic headaches associated with neurocysticercosis (NCC). The estimated cost of porcine cysticercosis took into consideration losses due to the reduction in the price of cysticercosis-infected animals. Epidemiologic and economic data were obtained from the published literature, government reports, and setting-specific questionnaires. Latin hypercube sampling methods were employed to sample the distributions of uncertain parameters and to estimate 95% credible regions (95% CRs). All results are reported in 2015 U.S.$. Findings The overall monetary burden associated with NCC morbidity was estimated at U.S.$215,775,056 (95% CR U.S.$109,309,560 –U.S.$361,924,224), with U.S.$436 (95% CR: U.S.$296 –U.S.$604) lost per patient. If loss of future years of income and productivity due to NCC-associated deaths was included, this value increased by U.S.$54.26 million, assuming that these individuals earned Mexico’s median wage salary. An additional U.S.$19,507,171 (95% CR U.S.$5,734,782 –U.S.$35,913,487) was estimated to be lost due to porcine cysticercosis. Conclusions This study suggests that T. solium cysticercosis results in considerable monetary losses to Mexico. Taenia solium cysticercosis is a parasitic disease, which can be transmitted between humans and pigs in areas of the world where pigs are raised in a traditional manner and latrines are not always used by the local population. Because cysticercosis affects humans and pigs, it is important to assess how much this infection costs both the public health and agricultural sectors in endemic countries such as Mexico. Costs associated with infection of both humans and pigs, in Mexico, were estimated using the literature, questionnaires, and publicly available data. Study findings suggest that T. solium cysticercosis results in considerable monetary losses to Mexico. The methodology developed here can be applied to estimate the monetary burden of cysticercosis in other regions in order to better prioritize disease control initiatives.
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Affiliation(s)
- Rachana Bhattarai
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, Texas, United States of America
| | - Hélène Carabin
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Canada
| | - Jefferson V. Proaño
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Jose Flores-Rivera
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Ana Flisser
- Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Christine M. Budke
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, Texas, United States of America
- * E-mail:
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Espinola-Nadurille M, Bustamante-Gomez P, Ramirez-Bermudez J, Bayliss L, Rivas-Alonso V, Flores-Rivera J. Frequency of neuropsychiatric disturbances in anti-NMDA receptor encephalitis. Acta Psychiatr Scand 2018; 138:483-485. [PMID: 30367468 DOI: 10.1111/acps.12963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- M Espinola-Nadurille
- Department of Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico (NINN), Mexico City, Mexico
| | - P Bustamante-Gomez
- Department of Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico (NINN), Mexico City, Mexico
| | - J Ramirez-Bermudez
- Department of Neuropsychiatric Unit, National Institute of Neurology and Neurosurgery of Mexico (NINN), Mexico City, Mexico.,Commission of the National Institutes of Health, Mexico City, Mexico
| | - L Bayliss
- Department of Neurology, NINN, Mexico City, Mexico
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Bhattarai R, Carabin H, Flores-Rivera J, Corona T, Proaño JV, Flisser A, Budke CM. Pre-hospitalization, hospitalization, and post-hospitalization costs of patients with neurocysticercosis treated at the Instituto Nacional de Neurologia y Neurocirugia (INNN) in Mexico City, Mexico. Rev Inst Med Trop Sao Paulo 2018; 60:e20. [PMID: 29846471 PMCID: PMC5975722 DOI: 10.1590/s1678-9946201860020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 03/01/2018] [Indexed: 11/22/2022] Open
Abstract
The objective of this study was to estimate the direct costs associated with the diagnosis and treatment of neurocysticercosis (NCC) during pre-hospitalization, hospitalization, and post-hospitalization periods for 108 NCC patients treated at the Instituto Nacional de Neurologia y Neurocirugia (INNN) in Mexico City, Mexico. Information on clinical manifestations, diagnostic tests, hospitalizations, surgical procedures, prescription medication, and other treatments was collected via medical chart reviews. Uncertain values for costs and frequency of treatments were imputed using bootstrap techniques. The average per-patient pre-hospitalization and hospitalization costs were US$ 257 (95% CI: 185 - 329) and US$ 2,576 (95% CI: 2,244 - 2,908), respectively. Post-hospitalization costs tended to decrease over time, with estimates for the first five years post-hospitalization of US$ 475 (95% CI: 423 - 527), US$ 228 (95% CI: 167 - 288), US$ 157 (95% CI: 111 - 202), US$ 150 (95% CI: 106 - 204), and US$ 91 (95% CI: 27 - 154), respectively. NCC results in a significant economic burden for patients requiring hospitalization, with this burden continuing years post-hospitalization.
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Affiliation(s)
- Rachana Bhattarai
- Texas A&M University College of Veterinary Medicine &
Biomedical Sciences, Department of Veterinary Integrative Biosciences, College
Station, Texas, United States
| | - Hélène Carabin
- University of Oklahoma Health Sciences Center, Department of
Biostatistics and Epidemiology, Oklahoma City, Oklahoma, United States
| | - Jose Flores-Rivera
- Laboratorio Clinico de Enfemedades Neurodegeneraivas, Instituto
Nacional de Neurología y Neurocirugía, Mexico DF, Mexico
| | - Teresa Corona
- Laboratorio Clinico de Enfemedades Neurodegeneraivas, Instituto
Nacional de Neurología y Neurocirugía, Mexico DF, Mexico
| | - Jefferson V. Proaño
- Hospital de Especialidades, Centro Medico Nacional Siglo XXI,
Instituto Mexicano del Seguro Social, Mexico DF, Mexico
| | - Ana Flisser
- Universidad Nacional Autonoma de Mexico, Facultad de Medicina,
Departamento de Microbiologia y Parasitologia, Mexico DF, Mexico
| | - Christine M. Budke
- Texas A&M University College of Veterinary Medicine &
Biomedical Sciences, Department of Veterinary Integrative Biosciences, College
Station, Texas, United States
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Bhattarai R, Carabin H, Proaño JV, Flores-Rivera J, Corona T, Flisser A, Budke CM. Cost of neurocysticercosis patients treated in two referral hospitals in Mexico City, Mexico. Trop Med Int Health 2015; 20:1108-19. [PMID: 25726958 DOI: 10.1111/tmi.12497] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To estimate annual costs related to the diagnosis, treatment and productivity losses among patients with neurocysticercosis (NCC) receiving treatment at two referral hospitals, the Instituto Nacional de Neurologia y Neurocirugia (INNN) and the Hospital de Especialidades of the Instituto Mexicano del Seguro Social (HE-IMSS), in Mexico City from July 2007 to August 2008. METHODS Information on presenting clinical manifestations, diagnostic tests, hospitalisations, surgical procedures and other treatments received by NCC outpatients was collected from medical charts, and supplemented by an individual questionnaire regarding productivity losses and out-of-pocket expenses related to NCC. RESULTS The annual average per-patient direct costs were US$ 503 (95% CI: 414-592) and US$ 438 (95% CI: 322-571) for patients without a history of hospitalisation and/or surgery seen at the INNN and the HE-IMSS, respectively. These costs increased to US$ 2506 (95% CI: 1797-3215) and US$ 2170 (95% CI: 1303-3037), respectively, for patients with a history of hospitalisation and/or surgery. The average annual per-patient indirect costs were US$ 246 (95% CI: 165-324) and US$ 114 (95% CI: 51-178), respectively, using minimum salary wages for individuals not officially employed. CONCLUSIONS The total annual cost for patients who had and had not been hospitalised and/or undergone a surgical procedure for the diagnosis or treatment of NCC corresponded to 212% and 41% of an annual minimum wage salary, respectively. The disease tends to affect rural socioeconomically disadvantaged populations and creates health disparities and significant economic losses in Mexico.
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Affiliation(s)
- Rachana Bhattarai
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Hélène Carabin
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jefferson V Proaño
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México DF, Mexico
| | - Jose Flores-Rivera
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, México DF, Mexico
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, México DF, Mexico
| | - Ana Flisser
- Facultad de Medicina, Universidad Nacional Autónoma de México, México DF, Mexico
| | - Christine M Budke
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
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Abstract
OBJECTIVE We analysed past and current sun exposure in multiple sclerosis (MS) patients as compared with matched controls in Mexico, a country with tropical climate. METHODS In a case-controlled study that include 83 MS patients and 166 matched controls, we inquired about sunlight exposure in two different periods: during adolescence and during the immediate past 5 years. Indicators were: exposure on quotidian and weekend outdoor activities with direct sunlight contact as expressed on frequency by mean number of days, daytime (morning, noon, afternoon), number of hours, visits to sunny places, and use of sunblocking agents. Additional elements were socioeconomic status, skin colour, and antecedent of varicella infection during childhood. RESULTS MS patients showed a larger proportion of white skin. MS patients had more sunlight exposure during adolescence (80% versus 60%, P = 0·002); this tendency prevailed on current indicators (46% versus 30%, P = 0·02). However, current exposure on weekends (10% versus 22%, P = 0·02) and visits to the beach (64% versus 98%, P = 0·002) were lower in MS than in controls. DISCUSSION Mexico gets more sunlight through the year than areas with high incidence of MS; nevertheless, its prevalence has greatly increased over the last decades, making it a relevant emerging disease. Our results indicate that in a tropical country, there is no association between sunlight exposure and the risk to develop MS, given the immunological effects of sunlight exposure either through UV radiation or vitamin D metabolism.
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Bhattarai R, Budke CM, Carabin H, Proaño JV, Flores-Rivera J, Corona T, Ivanek R, Snowden KF, Flisser A. Estimating the non-monetary burden of neurocysticercosis in Mexico. PLoS Negl Trop Dis 2012; 6:e1521. [PMID: 22363827 PMCID: PMC3283554 DOI: 10.1371/journal.pntd.0001521] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 12/23/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neurocysticercosis (NCC) is a major public health problem in many developing countries where health education, sanitation, and meat inspection infrastructure are insufficient. The condition occurs when humans ingest eggs of the pork tapeworm Taenia solium, which then develop into larvae in the central nervous system. Although NCC is endemic in many areas of the world and is associated with considerable socio-economic losses, the burden of NCC remains largely unknown. This study provides the first estimate of disability adjusted life years (DALYs) associated with NCC in Mexico. METHODS DALYs lost for symptomatic cases of NCC in Mexico were estimated by incorporating morbidity and mortality due to NCC-associated epilepsy, and morbidity due to NCC-associated severe chronic headaches. Latin hypercube sampling methods were employed to sample the distributions of uncertain parameters and to estimate 95% credible regions (95% CRs). FINDINGS In Mexico, 144,433 and 98,520 individuals are estimated to suffer from NCC-associated epilepsy and NCC-associated severe chronic headaches, respectively. A total of 25,341 (95% CR: 12,569-46,640) DALYs were estimated to be lost due to these clinical manifestations, with 0.25 (95% CR: 0.12-0.46) DALY lost per 1,000 person-years of which 90% was due to NCC-associated epilepsy. CONCLUSION This is the first estimate of DALYs associated with NCC in Mexico. However, this value is likely to be underestimated since only the clinical manifestations of epilepsy and severe chronic headaches were included. In addition, due to limited country specific data, some parameters used in the analysis were based on systematic reviews of the literature or primary research from other geographic locations. Even with these limitations, our estimates suggest that healthy years of life are being lost due to NCC in Mexico.
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Affiliation(s)
- Rachana Bhattarai
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine, Texas A&M University, College Station, Texas, United States of America
| | - Christine M. Budke
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine, Texas A&M University, College Station, Texas, United States of America
- * E-mail:
| | - Hélène Carabin
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Jefferson V. Proaño
- Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México Distrito Federal, Mexico
| | - Jose Flores-Rivera
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, México Distrito Federal, Mexico
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, México Distrito Federal, Mexico
| | - Renata Ivanek
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine, Texas A&M University, College Station, Texas, United States of America
| | - Karen F. Snowden
- Department of Veterinary Pathobiology, College of Veterinary Medicine, Texas A&M University, College Station, Texas, United States of America
| | - Ana Flisser
- Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), México Distrito Federal, Mexico
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Bhattarai R, Budke CM, Carabin H, Proaño JV, Flores-Rivera J, Corona T, Cowan LD, Ivanek R, Snowden KF, Flisser A. Quality of life in patients with neurocysticercosis in Mexico. Am J Trop Med Hyg 2011; 84:782-6. [PMID: 21540389 DOI: 10.4269/ajtmh.2011.10-0646] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The objective of this study was to compare quality of life measures in patients with neurocysticercosis (NCC) to those of a matched control group. The NCC outpatients and their controls were recruited from two neurology referral hospitals in Mexico City, Mexico during 2007-2008. The quality of life of 224 NCC patients was compared with 224 age-sex-hospital-day matched controls using the short form 12 v2 (SF-12 v2) quality of life survey. Medical chart reviews were also conducted for the NCC outpatients to evaluate presenting clinical manifestations. Compared with the controls, NCC patients had a significantly lower score for each of the eight domains of health evaluated and significantly lower Physical and Mental Component Summary scores. Chart reviews indicated that hydrocephalus (48%), severe headaches (47%), and epilepsy (31%) were the most common clinical manifestations in these NCC outpatients.
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Affiliation(s)
- Rachana Bhattarai
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA.
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Ordoñez G, Martinez-Palomo A, Corona T, Pineda B, Flores-Rivera J, Gonzalez A, Chavez-Munguia B, Sotelo J. Varicella zoster virus in progressive forms of multiple sclerosis. Clin Neurol Neurosurg 2010; 112:653-7. [PMID: 20483530 DOI: 10.1016/j.clineuro.2010.04.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 03/22/2010] [Accepted: 04/26/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The apparent association between varicella zoster virus (VZV) and multiple sclerosis (MS) has been described. In patients with relapse/remission (R/R) MS we have found high loads of VZV DNA in lymphocytes and in cerebrospinal fluid (CSF), as well as abundant viral particles in CSF visualized by electron microscopy at the time of relapse. Both, the molecular and the ultrastructural evidence of VZV became negative in the same patients at the time of remission. METHODS In the present study we analyzed the presence of VZV in patients with progressive forms of MS; DNA from VZV was searched by real-time PCR in blood lymphocytes and in CSF of 20 patients with progressive MS. Ultrastructural study searching for viral particles in CSF was made with transmission electron microscopy. RESULTS VZV DNA was found in the CSF from 65% of cases with progressive MS- and VZV-like viral particles were found in 30% of these patients. Nonetheless, the amount of DNA and the number of viral particles were lower than those that have been found in MS patients with R/R at the time of relapse, but higher than those found during remission. CONCLUSION Similar to findings in patients with R/R MS, VZV might be associated to progressive MS, but in minor quantity. In these cases, the virus may produce a chronic, relentless infection or trigger a process of immune-mediated demyelination.
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Affiliation(s)
- Graciela Ordoñez
- Neuroimmunology Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico
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Flores-Rivera J, González-Carmona S, Yescas P, Morales J, Mendoza G, Corona T. FP24-TU-05 Absence of multiple sclerosis (MS) and neuromyelitis optica (NMO) among Mexican Lacandonians. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Flores-Rivera J, Corona T, Sánchez T, Rodríguez P, Spaz G, Aguirre L. PO27-TH-02 Indirect immunofluorescence can be used to assess Aquaporin-4 expression in porcine cysticerci. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)71172-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Flores-Rivera J, Arrambide G, Mendoza G, Corona T. PO10-TU-44 Use of monthly cyclophosphamide and methylprednisolone in rapidly progressive multiple sclerosis: a pilot study. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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