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Sriwastava S, Elkhooly M, Amatya S, Shrestha K, Kagzi Y, Bhatia D, Gupta R, Jaiswal S, Lisak RP. Recent advances in the treatment of primary and secondary progressive Multiple Sclerosis. J Neuroimmunol 2024; 390:578315. [PMID: 38554666 DOI: 10.1016/j.jneuroim.2024.578315] [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] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/26/2024] [Accepted: 02/14/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The article highlights upcoming potential treatments, which target different phases of inflammation and offer remyelinating strategies as well as direct and indirect neuroprotective and oligodendrocyte protective effects, providing a hopeful outlook for patients with primary and secondary progressive multiple sclerosis (PPMS and SPMS). OBJECTIVES The review aims to identify potential treatments and ongoing clinical trials for PPMS and SPMS, and compare their mechanisms of action, efficacy, and side effects with current treatments. METHODS We reviewed ongoing clinical trials for PPMS and SPMS on the NIH website, as well as articles from PubMed, Embase, and clinicaltrails.gov since 2010. RESULTS BTKIs like, tolebrutinib, and fenebrutinib are being explored as potential PMS treatments. Vidofludimus calcium, an orally available treatment, has shown a reduction of active and new MRI lesions. Other treatments like simvastatin, N-acetylcysteine (NAC), and alpha-lipoic acid are being explored for their antioxidant properties. AHSCT and mesenchymal stem cell therapy are experimental options for younger patients with high inflammatory activity. CONCLUSIONS SPMS and PPMS are being studied for new treatments and future trials should consider combination therapies targeting inflammation, demyelination, and neuronal death, as the pathogenesis of PMS involves complex factors.
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Affiliation(s)
- Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
| | - Mahmoud Elkhooly
- Department of Neurology, Southern Illinois university, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Dipika Bhatia
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Rajesh Gupta
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shruti Jaiswal
- Department of Neuro-Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Robert P Lisak
- Department of Neurology, Wayne state University, Detroit, MI, USA
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Akkus S, Amatya S, Shrestha K, Sriwastava S, Karides DA. Late-onset Parry-Romberg Syndrome with atypical neurological manifestations: A case report. Radiol Case Rep 2024; 19:459-463. [PMID: 38046926 PMCID: PMC10692462 DOI: 10.1016/j.radcr.2023.10.032] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 12/05/2023] Open
Abstract
Parry-Romberg Syndrome (PRS) is a rare neurocutaneous disorder characterized by gradual facial hemiatrophy. We present a case study of a 64-year-old woman with late-onset PRS and linear scleroderma. The patient exhibited atypical PRS symptoms including leg numbness, hyper-reflexia, trigeminal neuralgia, and severe headaches. Diagnostic evaluations revealed chronic left-sided cerebral infarction, microhemorrhages, and nerve involvement. Treatment options for PRS are limited and aim to manage symptoms. This case highlights the diagnostic challenges of late-onset PRS, emphasizing interdisciplinary approach. Further research and improved therapies are essential for better patient outcomes.
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Affiliation(s)
- Sema Akkus
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
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Gupta A, Um D, Samant R, Hasbun R, Samudralwar RD, Sriwastava S, Gupta RK. Idiopathic Hypertrophic Spinal Pachymeningitis. J Med Cases 2023; 14:405-412. [PMID: 38186557 PMCID: PMC10769654 DOI: 10.14740/jmc4149] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/02/2023] [Indexed: 01/09/2024] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare presentation with duramater thickening and fibrosis which can result in cranial or spinal compressive disease. Most cases of spinal HP require surgical management. We present an uncommon case of idiopathic hypertrophic spinal pachymeningitis (IHSP) in a 40-year-old male who showed complete improvement to steroids without any further relapses. The patient presented with bilateral upper limb weakness with magnetic resonance imaging (MRI) spine showing diffuse dural thickening of the entire spine with cervical cord compression. He had an extensive workup for underlying etiology and worsening symptoms until he was diagnosed with IHSP. Later, he was started on high-dose steroids with good response and no relapse after 2 years. A descriptive analysis of IHSP cases since 2009 including ours showed that it usually occurs after 50s with female preponderance. Weakness and sensory loss are the most common complaints with 50% patients showing clinical signs of myelopathy like hyperreflexia, clonus, Babinski sign and sensory level. Cerebrospinal fluid (CSF) and inflammatory markers like erythrocytic sedimentation rate (ESR) and C-reactive protein (CRP) can be used to assess disease progression and prognosis. Surgical removal of HP followed by steroids is the best line of management while steroids alone can be tried in cases where clinical signs of myelopathy are absent.
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Affiliation(s)
- Ashutosh Gupta
- McGovern Medical School, UT Health Science Center at Houston, Houston, TX 77030, USA
| | - Daniel Um
- McGovern Medical School, UT Health Science Center at Houston, Houston, TX 77030, USA
| | - Rohan Samant
- Department of Radiology, UT Health Science Center at Houston, TX 77030, USA
| | - Rodrigo Hasbun
- Department of Infectious Disease, UT Health Science Center at Houston, TX 77030, USA
| | | | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Rajesh K. Gupta
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Akkus S, Elkhooly M, Amatya S, Shrestha K, Sharma K, Kagzi Y, Khan E, Gupta R, Piquet AL, Jaiswal S, Wen S, Tapia M, Samant R, Sista SR, Sriwastava S. Autoimmune and paraneoplastic neurological disorders: A review of relevant neuroimaging findings. J Neurol Sci 2023; 454:120830. [PMID: 37856996 DOI: 10.1016/j.jns.2023.120830] [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: 08/21/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Paraneoplastic neurologic syndromes (PNS) and autoimmune encephalitis (AIE) are immune-mediated disorders. PNS is linked to cancer, while AIE may not Their clinical manifestations and imaging patterns need further elucidation. OBJECTIVE/AIMS To investigate the clinical profiles, antibody associations, neuroimaging patterns, treatments, and outcomes of PNS and AIE. METHODS A systematic review of 379 articles published between 2014 and 2023 was conducted. Of the 55 studies screened, 333 patients were diagnosed with either PNS or AIE and tested positive for novel antibodies. Data on demographics, symptoms, imaging, antibodies, cancer associations, treatment, and outcomes were extracted. RESULTS The study included 333 patients (mean age 54 years, 67% males) with PNS and AIE positive for various novel antibodies. 84% had central nervous system issues like cognitive impairment (53%), rhombencephalitis (17%), and cerebellar disorders (24%). Neuroimaging revealed distinct patterns with high-risk antibodies associated with brainstem lesions in 98%, cerebellar in 91%, hippocampal in 98%, basal ganglia in 75%, and spinal cord in 91%, while low/intermediate-risk antibodies were associated with medial temporal lobe lesions in 71% and other cortical/subcortical lesions in 55%. High-risk antibodies were associated with younger males, deep brain lesions, and increased mortality of 61%, while low/intermediate-risk antibodies were associated with females, cortical/subcortical lesions, and better outcomes with 39% mortality. Associated cancers included seminomas (23%), lung (19%), ovarian (2%), and breast (2%). Treatments included IVIG, chemotherapy, and plasmapheresis. Overall mortality was 25% in this cohort. CONCLUSION PNS and AIE have distinct clinical and radiological patterns based on antibody profiles. High-risk antibodies are associated with increased mortality while low/intermediate-risk antibodies are associated with improved outcomes. Appropriate imaging and antibody testing are critical for accurate diagnosis.
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Affiliation(s)
- Sema Akkus
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne state University, Detroit, MI, USA; Department of Neurology, Southern Illinois university, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | - Suban Amatya
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kriti Shrestha
- Department of Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Erum Khan
- Department of Neurology, University of Alabama at Birmingham, Al, USA
| | - Rajesh Gupta
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Amanda L Piquet
- Neuroimmunology, Neuroinfectious Disease and Neurohospitalist Sections, University of Colorado School of Medicine, CO, USA
| | - Shruti Jaiswal
- Department of Neuro-oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Michaela Tapia
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Rohan Samant
- Department of Neuroradiology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sri Raghav Sista
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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Khan E, Kagzi Y, Elkhooly M, Surpur S, Wen S, Sharma K, Sriwastava S. Disease modifying therapy and pregnancy outcomes in multiple sclerosis: A systematic review and meta-analysis. J Neuroimmunol 2023; 383:578178. [PMID: 37672841 DOI: 10.1016/j.jneuroim.2023.578178] [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] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES To report pregnancy outcomes among multiple sclerosis (MS) patients treated with disease-modifying therapies (DMTs). METHODS We performed a retrospective chart review of articles published from June 1996 to May 2023. Additional information was acquired from the drug registries of individual pharmaceutical companies. A comparison was also made with pregnancy data of the general population using the World Health Organization database. Summary analysis was achieved using R statistical software (v3.6), and the overall prevalence of outcomes was estimated using a random effects model. RESULTS A meta-analysis of 44 studies was conducted. Dimethyl fumarate had the highest prevalence of premature births at 0.6667% (SD:0.5236-0.7845). The highest rates of stillbirths and infant deaths (perinatal and neonatal) were observed with interferons at 0.004% (SD:0.001-0.010) and 0.009% (SD:0.005-0.0015), respectively. Cladribine had the majority of ectopic pregnancies (0.0234%, SD:0.0041-1217), while natalizumab had the highest prevalence of spontaneous abortions (0.1177%, SD:0.0931-0.1477) and live birth defects (0.0755%, SD:0.0643-0.0943).None of the outcomes were significantly different from those of the general population (p > 0.05), except ectopic pregnancy and spontaneous abortion (p < 0.001), where the odds were 0.665 (0.061-0.886) and 0.537(0.003-0.786), respectively. The pooled prevalence of MS relapses was 221% for a single episode (SD:0.001-0.714), 0.075% for more than one episode (SD:0.006-0.167), and 0.141% for at least one episode requiring steroids (SD:0.073-0.206) none of these reached clinical significance. CONCLUSION Existing research suggests that DMT use in MS patients during pregnancy is generally considered safe. This study supports their utilization on a case-by-case basis. However, further primary research on this topic with clinical trials is warranted.
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Affiliation(s)
- Erum Khan
- Department of Neurology, University of Alabama at Birmingham, AL,USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Mahmoud Elkhooly
- Department of Neurology, Wayne State University, Detroit, MI, USA; Department of Neurology, Southern Illinois University, Springfield, IL, USA; Department of Neuropsychiatry, Minia University, Egypt
| | | | - Sijin Wen
- West Virginia Clinical Transitional Science, Morgantown, WV, USA
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX,USA.
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Tolaymat S, Sharma K, Kagzi Y, Sriwastava S. Anti-CD20 monoclonal antibody (mAb) therapy and colitis: A case series and review. Mult Scler Relat Disord 2023; 75:104763. [PMID: 37229799 DOI: 10.1016/j.msard.2023.104763] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/04/2023] [Accepted: 05/14/2023] [Indexed: 05/27/2023]
Abstract
The US Food and Drug Administration (FDA) recently issued a warning regarding ocrelizumab due to reports of colitis among patients taking this medication. Since it is the only FDA-approved therapy for primary progressive multiple sclerosis (PPMS), further research on this adverse event is necessary, and healthcare professionals should be informed of potential treatment options. In this review, we summarize the available data on the incidence of inflammatory colitis associated with anti-CD20 monoclonal antibodies (mAbs), such as ocrelizumab and rituximab, used in MS treatment. Although the exact pathophysiology of anti-CD20-induced colitis remains unknown, immunological dysregulation through treatment-mediated B-cell depletion has been proposed as a possible mechanism. Our study highlights the importance of clinicians being aware of this potential side effect, and patients taking these medications should be closely monitored for any new-onset gastrointestinal symptoms or diarrheal illness. Research indicates that prompt intervention with endoscopic examination and medical or surgical therapies can ensure timely and effective management, thus improving patient outcomes. However, large-scale studies are still needed to determine the associated risk factors and to establish definitive guidelines for the clinical evaluation of MS patients on anti-CD20 medications.
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Affiliation(s)
- Sarah Tolaymat
- Department of Neurology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Kanika Sharma
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yusuf Kagzi
- Mahatma Gandhi Memorial Medical College, Indore, India
| | - Shitiz Sriwastava
- Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA; West Virginia Clinical Transitional Science, Morgantown, WV, USA.
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Joseph J, Feizi P, Pasham SR, Sharma K, Srivastava S, Elkhooly M, Nirwan L, Jaiswal S, Sriwastava S. Relevance of bright spotty lesions in neuromyelitis optica spectrum disorders (NMOSD): a case series. Egypt J Neurol Psychiatry Neurosurg 2022. [DOI: 10.1186/s41983-022-00601-7] [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: 12/25/2022] Open
Abstract
Abstract
Background
Neuromyelitis optica (NMO), or neuromyelitis optica spectrum disorder (NMOSD), is an autoimmune CNS condition which often has a complex clinical course. Longitudinally extensive transverse myelitis (LETM) is an important and sensitive MRI finding but is not very specific to NMOSD and is seen in other causes of myelitis.
Case presentations
We report 11 NMO cases, all seen in women from 25 to 75 years at the time of diagnosis, with most above 65 years of age. All patients were seropositive for AQP4–IgG antibodies, and none had anti-MOG antibodies. Clinical presentations were diverse, the most common being paralytic and visual changes. In this study, 5 of the 11 seropositive NMO patients (45%) had bright spotty lesion (BSLs) on their MRI spine, as opposed to none (0%) in the control group. BSLs were defined as hyperintense foci of signal abnormality on T2-weighted images compared to the surrounding CSF. Treatment included symptomatic management and immunotherapy; timely management led to improvement in all the cases, with partial recovery seen in most (91%) and complete recovery seen only in one.
Conclusions
BSLs are a newly defined spinal MRI finding with high specificity, but low sensitivity for NMOSD. The absence of BSLs in the control group establishes its prolific role in distinguishing NMO from MS, ITM, MOGAD and other forms of myelitis. The main aim of this retrospective case–control study was to determine the diagnostic importance and specificity of bright spotty lesions (BSLs) in NMOSD and its ability to discriminate NMOSD from other causes of LETM.
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Sharma K, Tolaymat S, Yu H, Elkhooly M, Jaiswal S, Jena A, Kakara M, Sriwastava S. Progressive multifocal leukoencephalopathy in anti-CD20 and other monoclonal antibody (mAb) therapies used in multiple sclerosis: A review. J Neurol Sci 2022; 443:120459. [PMID: 36283150 DOI: 10.1016/j.jns.2022.120459] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 11/27/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a subacute CNS inflammatory disease seen primarily among immunocompromised patients. It is caused by the JC virus (JCV), a polyomavirus that otherwise induces an insidious, latent infection in the general population. This reactivated disease is characterized by cognitive and behavioral changes, language disturbances, motor weakness, or visual deficits. Median survival in patients with AIDS is approximately 2-4 months, and mortality is high (around 4% in untreated AIDS). Recent scientific developments indicate that PML can also be associated with the increased utilization of monoclonal antibody (mAb) immunotherapy. In fact, PML has been witnessed with several mAbs, including natalizumab in multiple sclerosis, rituximab for lymphoma or lupus, efalizumab for psoriasis, and ofatumumab in leukemia; this leads us to the risk reassessment of PML due to treatment-induced immunosuppression. The range of clinical presentations of JCV-related disease has transformed over time and can pose significant challenges to the current diagnostic criteria. Most cases with PML suffer from persistent and irreversible neurological conditions, and some with chronic, low-level viral replication in the CNS. With the expanded use of mAbs for various autoimmune and lymphoproliferative disorders, we are now seeing this infection in non-HIV patients on drugs such as natalizumab, rituximab, and other recently approved therapies. This article aims to review the relationship between the incidence of PML and all four mAbs used in the treatment of MS. Currently, at least 18 FDA-approved medications carry label warnings for PML;to this date, no treatment has been convincingly effective.
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Affiliation(s)
- Kanika Sharma
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Sarah Tolaymat
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Hongxuyang Yu
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | | | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States of America
| | - Anek Jena
- Calcutta Medical College, Calcutta, India
| | - Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, United States of America
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America; West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States of America; School of Medicine, West Virginia University, Morgantown, WV, United States of America; Division of Multiple Sclerosis and Neuroimmunology Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, United States of America.
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Peterson S, Jalil A, Beard K, Kakara M, Sriwastava S. Updates on efficacy and safety outcomes of new and emerging disease modifying therapies and stem cell therapy for Multiple Sclerosis: A review. Mult Scler Relat Disord 2022; 68:104125. [PMID: 36057173 DOI: 10.1016/j.msard.2022.104125] [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] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
Multiple Sclerosis (MS) is a chronic neurodegenerative autoimmune disorder of the central nervous system (CNS) and the most common cause of serious physical disability in working-age adults. Drug development and research in this field have rapidly evolved over the past two decades, leading to the broad array of treatment options available today. These disease-modifying therapies (DMTs) work through distinct mechanisms of action and exhibit varying safety and efficacy profiles to help manage symptoms and reduce exacerbations in MS patients. Our extensive understanding of this condition has also led to novel approaches, such as the discovery of specific biomarkers that allow us to monitor the therapeutic response towards DMTs. The development of new DMTs continues to progress quickly today, and it can be difficult for clinicians to remain up to date on the most recent advancements and new treatment options for their patients. In this comprehensive review, we provide an outline of current MS medications in the pipeline including emerging DMTs and stem cell therapy, as well as the unique characteristics of these medications, including their indications, pharmacokinetic effects, and the relevant advancements.
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Affiliation(s)
- Sarah Peterson
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amaris Jalil
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Katherine Beard
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Mihir Kakara
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, PA, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA
| | - Shitiz Sriwastava
- West Virginia University, School of Medicine, Morgantown, WV, USA; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA; Depratment of Neurology, Wayne State University, Detroit, MI, USA; West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA; Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, McGovern Medical School (UT Health), University of Texas Health Science Center at Houston, Houston, TX, USA.
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10
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Feizi P, Sharma K, Pasham SR, Nirwan L, Joseph J, Jaiswal S, Sriwastava S. Central nervous system (CNS) inflammatory demyelinating diseases (IDDs) associated with COVID-19: A case series and review. J Neuroimmunol 2022; 371:577939. [PMID: 35939945 PMCID: PMC9343076 DOI: 10.1016/j.jneuroim.2022.577939] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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] [Received: 05/26/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Over the past two years, SARS-CoV-2 has frequently been documented with various post and para-infectious complications, including cerebrovascular, neuromuscular, and some demyelinating conditions such as acute disseminated encephalomyelitis (ADEM). We report two rare neurological manifestations post-COVID-19 infection; multiple sclerosis (MS) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). Further, we reviewed other CNS inflammatory demyelinating diseases (IDDs) associated with SARS-CoV-2, including optic neuritis (ON) and neuromyelitis optica spectrum disorders (NMOSD). METHODS A descriptive analysis and literature search of Google Scholar and PubMed was conducted by two independent reviewers from December 1st, 2019, to March 30th, 2022, and included all the case studies of MS, MOGAD, NMOSD, and ON associated with COVID-19 infection. CASE PRESENTATIONS Case 1 (MS) was a 24-year-old female with paresthesia and bilateral weakness one week after COVID-19 symptom onset who showed demyelinating plaques and 12 isolated oligoclonal bands (OCBs). Case 2 (MOGAD) was a 41-year-old male with encephalomyelitis 16 days after COVID-19, who later developed MOG-antibody-associated optic neuritis. RESULTS Out of 18 cases, NMOSD was the most common post-COVID manifestation (7, 39%), followed by MOGAD (5, 28%), MS (4, 22%), and isolated ON (2, 11%). The median duration between the onset of COVID-19 symptom onset and neurological symptoms was 14 days. 61% of these were male, with a mean age of 35 years. IVMP was the treatment of choice, and nearly all patients made a full recovery, with zero fatalities. CONCLUSIONS Although these neurological sequelae are few, physicians must be cognizant of their underlying pathophysiology and associated clinical and neuro-diagnostic findings when treating COVID-19 patients with atypical presentations.
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Affiliation(s)
- Parissa Feizi
- Department of Neuroradiology, West Virginia University, Morgantown, WV, USA
| | - Kanika Sharma
- Department of Neurology, West Virginia University, Morgantown, WV, USA
| | - Shreya R Pasham
- Malla Reddy Institute of Medical Sciences (MRIMS), Hyderabad, India
| | - Lalit Nirwan
- Meditrina Institute of Medical Sciences, Nagpur, India
| | - Joe Joseph
- Department of Neuroradiology, West Virginia University, Morgantown, WV, USA
| | - Shruti Jaiswal
- West Virginia Clinical Translational Science, Morgantown, WV, USA
| | - Shitiz Sriwastava
- Department of Neurology, West Virginia University, Morgantown, WV, USA; West Virginia Clinical Translational Science, Morgantown, WV, USA.
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11
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Liberio R, Kramer E, Memon AB, Reinbeau R, Feizi P, Joseph J, Wu J, Sriwastava S. Relevance of Medullary Vein Sign in Neurosarcoidosis. Neurol Int 2022; 14:638-647. [PMID: 35997361 PMCID: PMC9397064 DOI: 10.3390/neurolint14030052] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Central nervous system involvement is uncommon in patients with sarcoidosis. It remains a diagnostic challenge for clinicians, as there is a broad differential diagnosis that matches the presenting neurological signs. Often, the imaging findings also overlap with other disease entities. One understudied finding in patients with neurosarcoidosis is the presence of medullary vein engorgement on SWI imaging, termed the “medullary vein sign”, which has been postulated to be a specific sign for neurosarcoidosis. This study aims to provide an understanding of the diagnostic potential of the medullary vein sign. Methods: Thirty-two patients who presented with neurologic signs concerning for possible neurosarcoidosis were analyzed retrospectively for the presence of the medullary vein sign. Results: Out of these cases, 7 cases of definitive neurosarcoidosis cases were found based on other imaging signs, biopsy and CSF analysis; the remaining were classified into groups as possible (16), probable (5) and (4) cases of other infectious meningoencephalitis including 2 cases of autoimmune encephalitis. Seven patients among all of these cases were found to have the medullary vein sign on imaging, with five cases with confirmed and two cases from possible neurosarcoidosis. The sensitivity of the medullary vein sign in this study was 71.4%, and the specificity was 92.3%. Discussion: The benefits of improving diagnostic criteria for neurosarcoidosis include more rapid diagnosis leading to more prompt treatment, less exposure to potentially harmful antibiotics or antifungals, and less long-term neurological effects. Our results support that the medullary vein sign will potentially fill in the diagnostic gaps that have challenged the timely diagnosis of neurosarcoidosis. Conclusions: Our findings support that the medullary vein sign has a high specificity and should be included in the diagnostic criteria for neurosarcoidosis.
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Affiliation(s)
- Richard Liberio
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Emily Kramer
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Anza B. Memon
- Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Ryan Reinbeau
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Parissa Feizi
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Joe Joseph
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Janet Wu
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Shitiz Sriwastava
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26506, USA
- Correspondence: ; Tel.: +1-304-581-1903
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12
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Colantonio MA, Nwafor DC, Jaiswal S, Shrestha AK, Elkhooly M, Rollins S, Wen S, Sriwastava S. Myelin oligodendrocyte glycoprotein antibody-associated optic neuritis and myelitis in COVID-19: a case report and a review of the literature. Egypt J Neurol Psychiatr Neurosurg 2022; 58:62. [PMID: 35668818 PMCID: PMC9152836 DOI: 10.1186/s41983-022-00496-4] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background Our case explored the spectrum of autoimmune and infectious neurological complications of Coronavirus Disease 2019. In addition, we also reviewed and discussed clinical features, neuroimaging, CSF findings, and outcomes in patients with COVID-19-associated Myelin Oligodendrocyte Glycoprotein Antibody Disorder (MOGAD) CNS inflammatory disorder. Case presentation Here we presented a case of post-Coronavirus Disease 2019 infection Myelin Oligodendrocyte Glycoprotein Antibody Disorder in a 41-year-old male who presented with gait instability, urinary retention, and confusion. Workup done in hospital showed transverse myelitis in cervical spine region and left optic neuritis. Laboratory findings showed Myelin Oligodendrocyte Glycoprotein-IgG antibodies were positive in serum (1:100), suggestive of post-COVID Myelin Oligodendrocyte Glycoprotein Antibody Disorder. Conclusion To our knowledge, this is the first comprehensive case report and the literature review that includes the clinical features, neuroimaging, CSF findings, and outcomes in COVID-19-associated Myelin Oligodendrocyte Glycoprotein Antibody Disorder.
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Affiliation(s)
| | - Divine C. Nwafor
- School of Medicine, West Virginia University, Morgantown, WV USA
| | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, Morgantown, WV USA
| | | | | | - Steven Rollins
- Department of Biostatistics, West Virginia University, Morgantown, WV USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV USA
| | - Shitiz Sriwastava
- School of Medicine, West Virginia University, Morgantown, WV USA
- West Virginia Clinical and Translational Science Institute, Morgantown, WV USA
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, One Medical Center Dr., Suite 1310, Morgantown, WV 26506-9180 USA
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13
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Yu H, Wu H, Subapriya R, Kaur A, Pasham SR, Upadhaya R, Sriwastava S. Single-Center Experience on Progressive Multifocal Leukoencephalopathy (PML) cases, neuroimaging relevance, and management at West Virginia University (WVU). J Med Virol 2022; 94:4015-4022. [PMID: 35451090 DOI: 10.1002/jmv.27804] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/07/2022]
Abstract
Progressive Multifocal Leukoencephalopathy (PML) is an increasingly common and rapidly fatal demyelinating infection of CNS caused by the highly prevalent JCV in immunocompromised individuals belonging to all age groups and genders. HIV is the most common predisposing factor among other immunodeficient conditions leading to reactivation and multiple neurological symptoms. It has varied findings on MRI and diagnosis is confirmed by positive JC virus in CSF. We report 12 confirmed cases of PML from a single academic center. We comprehensively described clinical presentations, risk factors, CSF and neuroimaging findings, treatment and outcome for these cases of PML, a rare disease. The cases were almost equivalently distributed among young and old age groups and both genders. Positive JC virus on CSF was present in the majority of cases along with mild to severe reduction in lymphocyte counts. Significant MRI changes were present in all cases ranging from T2 hypertense signals to white matter lesions in various regions. Treatment with the reversion of immune-modulators, optimization of antiviral therapy (ART), plasmapheresis (PLEX), IVIG, Mirtazapine, oral steroids, and others was started as soon as the diagnosis was made in the majority of the cases. However, PML is a rapidly fatal illness and hence, survival was only seen in 4 cases in our study. The objective of this article is to highlight the importance of early diagnosis of PML with CSF findings and neuroimaging, early reversion of immunosuppressive medications, and careful monitoring and treatment of HIV cases with goals to reduce mortality, long-term morbidity, and deficits. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hongxuyang Yu
- Department of Neurology, West Virginia University, Morgantown, WV
| | - Hongyan Wu
- Department of Neurology, West Virginia University, Morgantown, WV
| | - R Subapriya
- Department of Neurology, West Virginia University, Morgantown, WV
| | - Arshdeep Kaur
- Department of Neurology, Wayne State University, Detroit, MI
| | - Shreya R Pasham
- Malla Reddy Institute of Medical Sciences (MRIMS), Hyderabad, India
| | | | - Shitiz Sriwastava
- Department of Neurology, West Virginia University, Morgantown, WV.,West Virginia Clinical Transitional Science, Morgantown, WV, USA
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14
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Khan E, Shrestha AK, Elkhooly M, Wilson H, Ebbert M, Srivastava S, Wen S, Rollins S, Sriwastava S. CNS and PNS manifestation in immune checkpoint inhibitors: A systematic review. J Neurol Sci 2022; 432:120089. [PMID: 34942546 DOI: 10.1016/j.jns.2021.120089] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 09/04/2021] [Revised: 12/02/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Immunomodulatory therapies, including the use of immune checkpoint inhibitors (ICIs), have made a profound impact on treatment of advanced cancers in recent decades. Neurologic immune-related adverse events (irAEs) related to use of these agents are rare but potentially fatal sequelae. This systematic reviewed aimed to describe onset, clinical features, treatment, and outcome of neurological irAEs following ICI usage. METHODS A systematic literature search was conducted to identify all case reports (n = 168) and case series (n = 29) describing neurological irAEs (n = 255 patients). Patient demographics, clinical features, and clinical courses were extracted and used to assess statistical relationships between reported variables. RESULTS Of reports describing neurological irAEs related to ICI use, the majority of cases were in men (66%) and patients above the age of fifty (85%). Disorders of the peripheral nervous system (PNS, 83%) were more common than central nervous system involvement. Neuromuscular disorders were the most common type of neurological irAE (e.g. myasthenia gravis, 36%), followed by peripheral neuropathies (16%), followed by all CNS disorders combined (15%). Most cases presented within the first 5 doses of ICI treatment. Most patients improved clinically, but 24% of cases were fatal. Mortality was highest in patients with neuromuscular irAEs, such as myasthenia gravis and myositis. CONCLUSION This systematic literature review describes the largest collection of neurological irAEs to date including both CNS and PNS manifestations of ICIs. The information described herein can be used to better inform monitoring and treatment of patients undergoing treatment with ICIs.
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Affiliation(s)
- Erum Khan
- B.J. Medical College and Civil Hospital, Ahmedabad, India
| | | | | | - Hannah Wilson
- West Virginia University, School of Medicine, Morgantown, WV, United States of America
| | - Michael Ebbert
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | | | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, United States of America
| | - Steven Rollins
- Department of Biostatistics, West Virginia University, Morgantown, WV, United States of America
| | - Shitiz Sriwastava
- West Virginia University, School of Medicine, Morgantown, WV, United States of America; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America; Depratment of Neurology, Wayne State University, United States of America; West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States of America.
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15
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Sriwastava S, Khan E, Khalid SH, Kaur A, Feizi P. Progressive multifocal leukoencephalopathy in an immunocompetent patient: A case report and review of literature. J Med Virol 2021; 94:2860-2869. [PMID: 34854099 DOI: 10.1002/jmv.27493] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
Progressive multifocal leukoencephalopathy (PML), a demyelinating disease of the brain, caused by the John Cunningham virus (JCV) is usually seen in patients who are immunocompromised. Here, we describe a case of an immunocompetent patient diagnosed with PML and a comprehensive literature review. A 64-year-old Caucasian male presented with acute worsening of progressive neurological decline with difficulty in vision and reading. Based on history, examination, cerebrospinal fluid markers, histopathology, and magnetic resonance imaging brain at the time of presentation diagnosed the patient with PML in a setting of no immunosuppression disorder. The patient was started on Pelfilgrastim with significant systematic improvement. In our literature review, it was seen that the average age of symptom presentation was 57.5 with predominance in males. Most of the patients presented with progressive neurological deficits with symptomology ranging from mild confusion, aphasia, anxiety to sensory disturbances with numbness, hemiparesis, and hemianopsia. Out of the 21 cases, patients responded to mirtazapine and intravenous pulse methylprednisolone (IVMP). The mortality rate was close to 50% with 11 fatal cases and 10 nonfatal cases. Our case and literature review demonstrate the possibility that PML may very rarely occur in patients that are immunocompetent. Furthermore, our review showed that patients responded well to mirtazapine and IVMP. We also want to highlight that the mortality rate was lower in this review and was only compared to mortality in PML associated with immunocompromised status.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,Department of Neurology, Wayne State University, Detroit, Michigan, USA.,Department of Clinical Research, West Virginia Clinical and Translational Science Institute, Morgantown, West Virginia, USA.,Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Erum Khan
- Department of Medicine, B.J. Medical College and Civil Hospital, Ahmedabad, India
| | - Syed H Khalid
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Arshdeep Kaur
- Department of Neurology, Wayne State University, Detroit, Michigan, USA
| | - Parissa Feizi
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
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16
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Sriwastava S, Chaudhary D, Srivastava S, Beard K, Bai X, Wen S, Khalid SH, Lisak RP. Progressive multifocal leukoencephalopathy and sphingosine 1-phosphate receptor modulators used in multiple sclerosis: an updated review of literature. J Neurol 2021; 269:1678-1687. [PMID: 34800168 DOI: 10.1007/s00415-021-10910-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/04/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Progressive multifocal leukoencephalopathy (PML) is a serious viral infection associated with disease-modifying therapies (DMT) for multiple sclerosis (MS) including sphingosine 1-phosphate receptor (S1PR) modulators. The objective of this review was to investigate the characteristics of PML in MS patients associated with drugs of the S1PR modulator. METHODS We conducted a literature review and analysis of 24 patients from 12 publications in PubMed, SCOPUS and EMBASE. This is a descriptive analysis and study of characteristics of PML associated fingolimod and related S1PR modulator group of DMT. RESULTS A total of 24 cases of PML in MS patients treated with fingolimod were identified. Of these, 21 cases contained data regarding changes in the expanded disability status scale (EDSS). One case of PML in association with ozanimod treatment in a clinical trial was also identified. In PML cases associated with fingolimod, the mean age at the time of PML diagnosis was 50.91 ± 11.5 years. All patients were treated with fingolimod for more than 24 months. Compared to patients who improved or were stable, in terms of EDSS, after symptomatic management of PML, the non-improved groups were significantly older. There were no fatalities in either group during the reported follow-up period. CONCLUSION The incidence of PML appears to be extremely low in MS patients treated with S1PR modulators. Risk of PML increases with increase in duration of treatment with S1PR modulators like fingolimod, and increased age at the time of PML diagnosis is associated with worse prognosis.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, 26506, USA.
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA.
- Department of Neurology, Wayne State University, Detroit, MI, USA.
- School of Medicine, West Virginia University, Morgantown, WV, USA.
| | | | | | - Katherine Beard
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Xue Bai
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Syed Hassan Khalid
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Robert P Lisak
- Department of Neurology, Wayne State University, Detroit, MI, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA
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17
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Sriwastava S, Shrestha AK, Khalid SH, Colantonio MA, Nwafor D, Srivastava S. Spectrum of Neuroimaging Findings in Post-COVID-19 Vaccination: A Case Series and Review of Literature. Neurol Int 2021; 13:622-639. [PMID: 34842783 PMCID: PMC8628885 DOI: 10.3390/neurolint13040061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first detected in Wuhan, China in December 2019. Symptoms range from mild flu-like symptoms to more severe presentations, including pneumonia, acute respiratory distress syndrome (ARDS), and even death. In response to the COVID-19 pandemic, the Emergency Use Authorization (EUA) approved the use of several vaccines. Because vaccines have been fast-tracked for emergency use, the short and long-term safety profile has been an area of concern. The aim of this paper is to extensively review published literature regarding post-COVID-19 vaccination neurological complications and characterize neuroimaging findings from three case presentations for early diagnosis and treatment. Methods: The analysis includes data from PubMed and Google Scholar. Articles included were retrieved from database inception beginning December 2020 with no language restrictions. Terms used include "SARS-CoV-2", "post Covid vaccination", "neurological complications", "Guillain-barre Syndrome", "Transverse-myelitis", "Cerebral Venous Sinus thrombosis", and "Cerebral hemorrhage". Results: The literature review yielded several neurological complications post vaccination, including cerebral sinus venous thrombosis, transverse myelitis, Guillain-Barré Syndrome and optic neuritis, to name a few. Patient case presentation findings were consistent with documented results in published literature. Conclusions: We present a case series with a thorough literature review documenting adverse neurological affects following COVID-19 vaccination. Our case presentations and literature review highlight the importance of neuroimaging when diagnosing post-COVID-19 vaccination adverse effects. MRI imaging study is an important tool to be considered in patients presenting with post-COVID-19 vaccination-related unexplained neurological symptoms for accurate diagnosis.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA;
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA; (M.A.C.); (D.N.)
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26506, USA
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA;
- Correspondence:
| | | | - Syed Hassan Khalid
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA;
| | - Mark A. Colantonio
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA; (M.A.C.); (D.N.)
| | - Divine Nwafor
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA; (M.A.C.); (D.N.)
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18
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Beard K, Sriwastava S. Insight in booster COVID-19 vaccine and disease modifying therapy in multiple sclerosis. J Neurol Sci 2021; 430:120034. [PMID: 34688988 PMCID: PMC8523307 DOI: 10.1016/j.jns.2021.120034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Beard
- School of Medicine, West Virginia University, United States of America,Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Shitiz Sriwastava
- School of Medicine, West Virginia University, United States of America,Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America,West Virginia Clinical and Translational Science Institute, United States of America,Corresponding author at: Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
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19
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Sriwastava S, Lisak RP. Acetylcholine receptor antibodies in a patient with sensory neuropathy. J Neuroimmunol 2021; 359:577692. [PMID: 34403864 DOI: 10.1016/j.jneuroim.2021.577692] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 07/30/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Antibodies to acetylcholine receptor (AChR) are detected in the vast majority of patients with generalized myasthenia gravis (MG) and are rarely detected in significant titer in other autoimmune diseases. We report a patient with an axonal predominately sensory neuropathy for over 12 years with persistent binding and modulating AChR antibodies as well as striational muscle antibodies with no evidence of MG or any neoplastic disease.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, West Virginia University, USA; Department of Neurology, Wayne State University and Detroit Medical Center, USA.
| | - Robert P Lisak
- Department of Neurology, Wayne State University and Detroit Medical Center, USA; Department of Biochemistry, Microbiology and Immunology, Wayne State University, USA
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20
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Kelsey A, Casinelli G, Tandon M, Sriwastava S. Breast Carcinoma After Ocrelizumab Therapy in Multiple Sclerosis Patients: A Case Series and Literature Review. J Cent Nerv Syst Dis 2021; 13:11795735211037785. [PMID: 34497472 PMCID: PMC8419566 DOI: 10.1177/11795735211037785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ocrelizumab is a humanized CD20 monoclonal antibody which was approved for management of Relapsing Remitting Multiple Sclerosis (RRMS) and Primary Progressive Multiple Sclerosis (PPMS) in 2017. We present 2 patients, a 67-year-old woman with history of PPMS and a 42-year-old woman with RRMS, who were started on ocrelizumab and were diagnosed with invasive ductal cell breast carcinoma after 2 years of ocrelizumab infusion followed by discontinuation of the drug. Large trials conducted for ocrelizumab showed malignancies in a total of 4 cases with RRMS in OPERA 1 trial conducted over 2 years from 2011 to 2013 (breast cancer, renal cell carcinoma, and melanomas) and in 11 cases with PPMS seen in ORATORIO trial conducted in 2017. There are currently no other published case reports of breast cancer in setting of ocrelizumab use for MS outside of large trials on literature review.
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Affiliation(s)
- Andrew Kelsey
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Gabriella Casinelli
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Medha Tandon
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA.,West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA
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21
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Khan E, Shrestha AK, Colantonio MA, Liberio RN, Sriwastava S. Acute transverse myelitis following SARS-CoV-2 vaccination: a case report and review of literature. J Neurol 2021; 269:1121-1132. [PMID: 34482455 PMCID: PMC8418691 DOI: 10.1007/s00415-021-10785-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
Objective To report a unique case and literature review of post COVID-19 vaccination associated transverse myelitis and with abnormal MRI findings. Background Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only a few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2). Here, we identify a post COVID-19 vaccination patient diagnosed with acute transverse myelitis. Method A retrospective chart review of a patient diagnosed with post SARS-CoV-2 vaccination acute transverse myelitis, and a review of literature of all the reported cases of other post vaccination and transverse myelitis, from December 1st, 2010 till July 15th, 2021, was performed. Conclusion To our knowledge, this is the one of early reported case of transverse myelitis and with post SARS-CoV-2 vaccination, who responded well to plasmapheresis. Further studies would be recommended to identify the underlying correlation between COVID-19 vaccination and transverse myelitis.
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Affiliation(s)
- Erum Khan
- B.J. Medical College and Civil Hospital, Ahmedabad, India.,Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | - Mark A Colantonio
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Richard N Liberio
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, USA. .,West Virginia Clinical Transitional Science, Morgantown, WV, USA.
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22
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Prasad A, Hurlburt G, Podury S, Tandon M, Kingree S, Sriwastava S. A Novel Case of Bifacial Diplegia Variant of Guillain-Barré Syndrome Following Janssen COVID-19 Vaccination. Neurol Int 2021; 13:404-409. [PMID: 34449715 PMCID: PMC8395825 DOI: 10.3390/neurolint13030040] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 04/16/2021] [Revised: 06/30/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated demyelinating disorder which attacks the peripheral nervous system. Antecedent infection or vaccine administration are known to precipitate the onset of this disorder. Its typical presentation leads to a symmetric, rapidly progressive, ascending paresis with associated sensory deficits and impaired reflexes. We present a rare case of a bi-facial diplegia variant of GBS, within four weeks of the COVID-19 vaccination. Due to its chronology, clinical manifestations, and cerebrospinal fluid (CSF) findings, we propose this case to be a rare complication of the COVID-19 vaccination.
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Affiliation(s)
- Apoorv Prasad
- Department of Neurology, Berkeley Medical Center, West Virginia University, Martinsburg, WV 25401, USA; (A.P.); (G.H.); (S.K.)
| | - Gage Hurlburt
- Department of Neurology, Berkeley Medical Center, West Virginia University, Martinsburg, WV 25401, USA; (A.P.); (G.H.); (S.K.)
| | - Sanjiti Podury
- Army College of Medical Sciences, New Delhi 110010, India;
| | - Medha Tandon
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA;
| | - Seth Kingree
- Department of Neurology, Berkeley Medical Center, West Virginia University, Martinsburg, WV 25401, USA; (A.P.); (G.H.); (S.K.)
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26505, USA
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26505, USA
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA
- Correspondence: ; Tel.: +1-304-581-1903
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Prasad A, Hurlburt G, Van Antwerp E, Srivastava S, Sriwastava S. A rare case of gliomatosis cerebri lurking beneath the shadows of a stroke mimic. Radiol Case Rep 2021; 16:2701-2705. [PMID: 34345333 PMCID: PMC8319009 DOI: 10.1016/j.radcr.2021.06.060] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 11/18/2022] Open
Abstract
Gliomatosis cerebri (GC) is a diffuse infiltrative neoplastic glial process with a devastating prognosis. Considering its rarity, unpredictable clinical manifestations, and lack of characteristic radiographic features, GC is a difficult diagnosis that is quite often delayed. In this report, we present a case of a 61-year-old man with a history of chronic alcohol abuse and atrial fibrillation who presented with right arm weakness initially presumed to be from an acute ischemic stroke. GC was not diagnosed until six months after initial symptoms and diagnosis was indicated when considering the neurocognitive findings in conjunction with suggestive radiographic findings. The presence of a rapid, expansile lesion in the cortex, corpus callosum, and infratentorial structures with mild parenchymal enlargement, as shown in our case, is more revealing of an invasive entity typical of GC rather than an ischemic process and other pathologies. This case demonstrates the fatal challenges of its prompt recognition and the therapeutic limitations for those patients presenting with advanced symptoms at the time of diagnosis. Recognizing GC in cases with such rapid multilobe clinical features with similar diffusely invasive patterns of growth on imaging can avoid a delay in diagnosis and improve patient quality of life.
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Affiliation(s)
- Apoorv Prasad
- Department of Neurology, Berkeley Medical Center, West Virginia University, Morgantown, WV
| | - Gage Hurlburt
- West Virginia School of Osteopathic Medicine, Lewisburg, WV
| | | | | | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
- West Virginia Clinical and Translational Science Institute
- Corresponding author.
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24
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Moreno-Escobar MC, Feizi P, Podury S, Tandon M, Munir B, Alvi M, Adcock A, Sriwastava S. Acute cerebellitis following SARS-CoV-2 infection: A case report and review of the literature. J Med Virol 2021; 93:6818-6821. [PMID: 34314031 PMCID: PMC8427025 DOI: 10.1002/jmv.27232] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/24/2021] [Indexed: 12/13/2022]
Abstract
Novel coronavirus disease (COVID‐19) first described in Wuhan, China in December 2019, has rapidly spread across the world and become a global public health emergency. Literature on the neurological manifestations of COVID‐19 is limited. We report a 24‐year‐old male, who presented with vertigo, dysarthria, and bradyphrenia 3 weeks after being diagnosed with COVID‐19 on nasopharyngeal reverse transcription polymerase chain reaction. The patient was diagnosed with acute cerebellitis based on magnetic resonance imaging features and showed improvement posttreatment with intravenous methylprednisone for 5 days. The scope of this article is to highlight the importance of early identification of neurological symptoms and timely management as the outcomes may be catastrophic.
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Affiliation(s)
- Maria Camila Moreno-Escobar
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Parissa Feizi
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | | | - Medha Tandon
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Badria Munir
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Muhammad Alvi
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Amelia Adcock
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,West Virginia Clinical and Translational Science Institute, Morgantown, West Virginia, USA
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.,West Virginia Clinical and Translational Science Institute, Morgantown, West Virginia, USA
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25
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Podury S, Khan E, Tandon M, Jaiswal S, Sriwastava S. Evolution of our understanding of MS-COVID-19 interactions and concerns for vaccination. J Clin Neurosci 2021; 90:132-134. [PMID: 34275536 PMCID: PMC8166521 DOI: 10.1016/j.jocn.2021.05.063] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/12/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022]
Abstract
As the news of approval of COVID-19 vaccination emerge, neurologists across the globe ponder upon whether to use immunotherapies in patients with Multiple Sclerosis (MS). This paper highlights the mechanism of various disease modifying therapies (DMTs) as well as the recently approved Pfizer and Moderna vaccines for COVID-19 as well as guidelines as introduced by National Multiple Sclerosis Society. As their mechanisms counteract each other at the molecular level, we believe further evidence and data might lay the foundation to formulate much needed recommendations for the usage of these medications while vaccinating MS patients on DMTs.
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Affiliation(s)
| | - Erum Khan
- B.J. Medical College and Civil Hospital, Ahmedabad, India
| | - Medha Tandon
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States; West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States.
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26
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Sriwastava S, Tandon M, Podury S, Prasad A, Wen S, Guthrie G, Kakara M, Jaiswal S, Subedi R, Elkhooly M, Lisak RP. COVID-19 and neuroinflammation: a literature review of relevant neuroimaging and CSF markers in central nervous system inflammatory disorders from SARS-COV2. J Neurol 2021; 268:4448-4478. [PMID: 34009454 PMCID: PMC8131883 DOI: 10.1007/s00415-021-10611-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The literature on neurological manifestations in COVID-19 patients has been rapidly increasing with the pandemic. However, data on CNS inflammatory disorders in COVID-19 are still evolving. We performed a literature review of CNS inflammatory disorders associated with coronavirus disease-2019 (COVID-19). METHODS We screened all articles resulting from a search of PubMed, Google Scholar and Scopus, using the keywords; "SARS-CoV-2 and neurological complication", "SARS-CoV-2 and CNS Complication" looking for reports of transverse myelitis, longitudinally extensive transverse myelitis, neuromyelitis optica, myelitis, Myelin Oligodendrocyte Glycoprotein Antibody Disorder (MOGAD), Acute Disseminated Encephalomyelitis (ADEM), Acute Hemorrhagic Necrotizing Encephalitis/Acute Hemorrhagic Leukoencephalitis (AHNE/AHLE), Cytotoxic lesion of the Corpus Callosum/Mild Encephalopathy Reversible Splenium Lesion(CLOCC/MERS) and Optic neuritis published between December 01, 2019 and March 15, 2021. RESULTS Our literature search revealed 43 patients meeting the diagnosis of myelitis, including Transverse Myelitis, ADEM, AHNE/AHLE or CLOCC/MERS and Optic neuritis. Acute myelitis was most commonly associated with non-severe COVID-19 and all reported cases of AHNE/AHLE had severe COVID-19 infection. Based on IDSA/ATS criteria of either requiring vasopressor for septic shock or mechanical ventilation, 49% (n = 18) patients were considered to have a severe COVID infection. There were 7 (n = 19%) fatalities. CONCLUSION To our knowledge, this is among the first reviews that includes the clinical features, neuroimaging, CSF findings and outcomes in COVID-19-associated CNS inflammatory disorders. Our observational review study reveals that although rare, myelitis, ADEM, AHNE and CLOCC can be associated with COVID-19 infection. Further studies using MRI imaging and CSF analysis in early diagnosis and intervention of these disorders are warranted.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV, 26506, USA. .,West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA. .,Department of Neurology, Wayne State University, Detroit, MI, USA.
| | - Medha Tandon
- Deaprtment of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Apoorv Prasad
- Department of Neurology, Berkeley Medical Center, West Virginia University, Martinsburg, WV, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Garret Guthrie
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Mihir Kakara
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, USA
| | | | | | - Robert P Lisak
- Department of Neurology, Wayne State University, Detroit, MI, USA.,Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI, USA
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27
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Wen S, Prasad A, Freeland K, Podury S, Patel J, Subedi R, Khan E, Tandon M, Kataria S, Kimble W, Sriwastava S. Clinical Characteristics and Outcomes of COVID-19 in West Virginia. Viruses 2021; 13:v13050835. [PMID: 34063160 PMCID: PMC8148202 DOI: 10.3390/v13050835] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 01/08/2023] Open
Abstract
This study examines the clinical characteristics, outcomes and types of management in SARS-CoV-2 infected patients, in the hospitals affiliated with West Virginia University. We included patients from West Virginia with SARS-CoV-2 infection between 15 April to 30 December 2020. Descriptive analysis was performed to summarize the characteristics of patients. Regression analyses were performed to assess the association between baseline characteristics and outcomes. Of 1742 patients, the mean age was 47.5 years (±22.7) and 54% of patients were female. Only 459 patients (26.3%) reported at least one baseline symptom, of which shortness of breath was most common. More than half had at least one comorbidity, with hypertension being the most common. There were 131 severe cases (7.5%), and 84 patients (4.8%) died despite treatment. The mean overall length of hospital stay was 2.6 days (±6.9). Age, male sex, and comorbidities were independent predictors of outcomes. In this study of patients with SARS-CoV-2 infection from West Virginia, older patients with underlying co-morbidities had poor outcomes, and the in-hospital mortality was similar to the national average.
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Affiliation(s)
- Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV 26505, USA; (S.W.); (K.F.)
| | - Apoorv Prasad
- Berkeley Medical Center, Department of Neurology, West Virginia University, Morgantown, WV 25401, USA;
| | - Kerri Freeland
- Department of Biostatistics, West Virginia University, Morgantown, WV 26505, USA; (S.W.); (K.F.)
| | - Sanjiti Podury
- Department of Medicine, Army College of Medical Sciences, New Delhi 110010, Delhi, India;
| | - Jenil Patel
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX 75235, USA;
| | - Roshan Subedi
- Research Section, Nepal Health Research Council, Kathmandu 44600, Nepal;
| | - Erum Khan
- Department of Medicine, B.J. Medical College and Civil Hospital, Ahmedabad 380016, Gujarat, India;
| | - Medha Tandon
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15215, USA;
| | - Saurabh Kataria
- Department of Neurology, Louisiana State University, Health Sciences Center, Shreveport, LA 71130, USA;
| | - Wesley Kimble
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26505, USA;
| | - Shitiz Sriwastava
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26505, USA;
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26505, USA
- Correspondence:
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Frey J, Kramer J, Castellani R, Sriwastava S. Clinical Reasoning: A 47-Year-Old With Headache, Vertigo, and Double Vision. Neurology 2021; 97:e535-e539. [PMID: 33931540 DOI: 10.1212/wnl.0000000000012138] [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)
- Jessica Frey
- From the Departments of Neurology (J.F., J.K., S.S.) and Pathology, Anatomy, & Laboratory Medicine (R.C.), West Virginia University, Morgantown.
| | - Joshua Kramer
- From the Departments of Neurology (J.F., J.K., S.S.) and Pathology, Anatomy, & Laboratory Medicine (R.C.), West Virginia University, Morgantown
| | - Rudolph Castellani
- From the Departments of Neurology (J.F., J.K., S.S.) and Pathology, Anatomy, & Laboratory Medicine (R.C.), West Virginia University, Morgantown
| | - Shitiz Sriwastava
- From the Departments of Neurology (J.F., J.K., S.S.) and Pathology, Anatomy, & Laboratory Medicine (R.C.), West Virginia University, Morgantown
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29
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Tandon M, Kataria S, Patel J, Mehta TR, Daimee M, Patel V, Prasad A, Chowdhary AA, Jaiswal S, Sriwastava S. A Comprehensive Systematic Review of CSF analysis that defines Neurological Manifestations of COVID-19. Int J Infect Dis 2021; 104:390-397. [PMID: 33434662 PMCID: PMC7837002 DOI: 10.1016/j.ijid.2021.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Received: 11/21/2020] [Revised: 12/28/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Limited literature exists on Cerebrospinal fluid (CSF) findings in COVID-19 patients with neurological symptoms. In this review, we conducted a descriptive analysis of CSF findings in patients with COVID-19 to understand prognosis and explore therapeutic options. METHODS We searched PubMed, Google Scholar, and Scopus databases using the keywords "SARS-CoV-2 in cerebrospinal fluid" and "SARS-CoV-2 and CNS Complications"" for reports of CSF findings in COVID-19 related neurological manifestations. Descriptive analyses were conducted to observe the CSF protein and cell counts based on age, gender, severity, fatality of COVID-19, and whether central (CNS) or peripheral nervous system (PNS) was associated. RESULTS A total of 113 patients were identified from 67 studies. Of these, 7 patients (6.2%) were fatal COVID-19 cases and 35 patients (31%) were considered severe COVID-19 cases. CSF protein was elevated in 100% (7/7) of the fatal cases with an average of 61.28 mg/dl and in 65.0% (52/80) in non-fatal cases with an average 56.73 mg/dl. CSF protein levels were elevated in 74.5% (38/51) patients with non-severe COVID-19 and 68.6% (24/35) in those with a severe COVID-19 infection. CSF cell count was increased in 43% of fatal cases, 25.7% severe cases, and 29.4% of non-severe cases. CONCLUSION Our analysis showed that the most common CSF findings situation in COVID-19 infection is elevated protein with, very occasionally, mild lymphocyte predominant pleocytosis. Further studies to elucidate the pathophysiology of neurological complications in COVID-19 are recommended.
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Affiliation(s)
| | - Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare at Columbia, MO, United States
| | - Jenil Patel
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas Medical Sciences at Little Rock, AR, United States
| | - Tejas R Mehta
- Department of Neurology, University of Missouri Healthcare at Columbia, MO, United States
| | - Maha Daimee
- Department of Neurology, MedStar Georgetown University, Washington, DC, United States
| | - Viral Patel
- Jefferson Medical Center, West Virginia University, United States
| | - Apoorv Prasad
- Berkley Medical Center, West Virginia University, School of Medicine, Morgantown, WV, United States
| | | | - Shruti Jaiswal
- West Virginia Clinical and Translational Science Institute, United States
| | - Shitiz Sriwastava
- West Virginia Clinical and Translational Science Institute, United States; Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States; Department of Neurology, Wayne State University, Detroit, MI, United States.
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30
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Moreno-Escobar MC, Kataria S, Khan E, Subedi R, Tandon M, Peshwe K, Kramer J, Niaze F, Sriwastava S. Acute transverse myelitis with Dysautonomia following SARS-CoV-2 infection: A case report and review of literature. J Neuroimmunol 2021; 353:577523. [PMID: 33640717 PMCID: PMC7895682 DOI: 10.1016/j.jneuroim.2021.577523] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/20/2021] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
Objective To report a unique case and literature review of post COVID-19 associated transverse myelitis and dysautonomia with abnormal MRI and CSF findings. Background Coronavirus disease have been reported to be associated with several neurological manifestations such as stroke, Guillain-Barré syndrome, meningoencephalitis amongst others. There are only few reported cases of transverse myelitis with the novel coronavirus (n-CoV-2) and only one reported case identifying dysautonomia in COVID-19 patient. Here, we identify a COVID-19 patient diagnosed with acute transverse myelitis in addition to dysautonomia following with complete resolution of symptoms. Method A retrospective chart review of a patient diagnosed with post SARS-CoV-2 infection acute transverse myelitis and dysautonomia, and a review of literature of all the reported cases of transverse myelitis and COVID-19, from December 1st, 2019 till December 25th, 2020, was performed. Conclusion To our knowledge, this is the first reported case of transverse myelitis and dysautonomia in a patient with SARS-CoV-2 infection, who responded to intravenous methyl prednisone and bromocriptine. Follow-up imaging of the spine showed complete resolution of the lesion. Further studies would be recommended to identify the underlying correlation between COVID-19 and transverse myelitis.
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Affiliation(s)
| | - Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare, Columbia, MO, USA
| | - Erum Khan
- B.J. Medical College and Civil hospital, Ahmedabad, India
| | | | | | - Krithika Peshwe
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Joshua Kramer
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Faraze Niaze
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Shitiz Sriwastava
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, USA; West Virginia Clinical Transitional Science, Morgantown, WV, USA.
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31
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Sriwastava S, Kataria S, Tandon M, Patel J, Patel R, Jowkar A, Daimee M, Bernitsas E, Jaiswal P, Lisak RP. Guillain Barré Syndrome and its variants as a manifestation of COVID-19: A systematic review of case reports and case series. J Neurol Sci 2021; 420:117263. [PMID: 33321326 PMCID: PMC7725056 DOI: 10.1016/j.jns.2020.117263] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [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: 10/13/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND The COVID-19 pandemic caused by SARS-COV-2 began in Wuhan, China in December 2019. Reports of COVID-19 with central (CNS) and peripheral nervous (PNS) system manifestations are emerging. In this systematic review, we compared and summarized the demographics, clinical features, Brighton criteria, immunological and laboratory findings with a focus on modified Erasmus GBS Outcome Score (mEGOS) in SARS-CoV-2 patients with GBS and its variants. METHODS Based on PRISMA guidelines, we searched three databases (PubMed, Scopus, and Google Scholar) for studies on COVID-19 and GBS between December 1, 2019 to July 15, 2020. For descriptive analysis, we studied two groups with: 1) acute inflammatory demyelinating polyradiculoneuropathy (AIDP) variant, and 2) Non-AIDP/Other variants. We compared mEGOS scores for patients in both groups along with other key clinical features. RESULTS Of the 50 GBS cases identified from 37 studies, 33 (66%) had acute inflammatory demyelinating polyradiculopolyneuropathy (AIDP) while 17 (34%) were of other (non-AIDP) variants. There mEGOS scores did not differ between AIDP patients and AMAN/AMSAN patients. Majority of the AIDP (66.7%) and AMAN/AMSAN (57.2%) patients belonged to Brighton level 1 indicating maximum diagnostic certainty. CONCLUSION To our knowledge, this is among the first reviews that includes GBS variants and the clinical prediction tool mEGOS for prognostication in COVID-19 patients. Further research is needed to assess whether IVIG is preferable over plasmapheresis in this population of GBS patients. It would also be crucial to follow these patients over time to identify the long-term disability as well as treatment outcomes.
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Affiliation(s)
- Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America.
| | - Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare at Columbia, MO, United States of America
| | | | - Jenil Patel
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Riddhi Patel
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, TX, USA
| | - Abbas Jowkar
- Department of Neurology, Mercy Health, Michigan State University, Grand Rapids, MI, United States of America
| | - Maha Daimee
- Department of Neurology, MedStar Georgetown University, Washington, DC, United States of America
| | - Evanthia Bernitsas
- Department of Neurology, Wayne State University, Detroit, MI, United States of America
| | - Preeti Jaiswal
- Department of Public Health, Walden University, Minneapolis, MN, United States of America
| | - Robert P Lisak
- Department of Neurology, Wayne State University, Detroit, MI, United States of America; Department of Biochemistry, Microbiology and Immunology, Detroit, MI, United States of America
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32
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Chowdhary A, Subedi R, Tandon M, Wen S, Patel J, Kataria S, Peterson S, Gwinn R, Elkhooly M, Prasad A, Nirwan L, Adcock A, Sriwastava S. Relevance and Clinical Significance of Magnetic Resonance Imaging of Neurological Manifestations in COVID-19: A Systematic Review of Case Reports and Case Series. Brain Sci 2020; 10:E1017. [PMID: 33371260 PMCID: PMC7766893 DOI: 10.3390/brainsci10121017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 11/04/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
We performed a systematic literature review of neuroimaging, predominantly focusing on magnetic resonance imaging (MRI) findings associated with neurological manifestations of coronavirus disease-2019 (COVID-19). We screened articles from PubMed, Google Scholar and Scopus, looking for reports that would potentially have neuroimaging findings in patients with COVID-19. Data analysis was performed with patient-based data based on the availability of clinical characteristics and outcomes for each individual patient from the studies. Chi square and Wilcoxon rank-sum tests were used to report COVID-19 severity and outcomes based on neurological imaging indicators and pathophysiology. A total of 171 patients with COVID-19 having neurological complications, from 134 studies, were identified in our review. The most common neuroimaging finding was ischemic stroke (62, 36.2%) cases, followed by CNS inflammatory disorder (44, 25.7%), and hemorrhagic stroke (41, 24.0%). Around 51% of all the fatal COVID-19 cases had an ischemic stroke. Among patients with ischemic stroke, the mean age of those who suffered from COVID-19 infection was 57.5 years (SD = 15.4) whereas it was 50.7 years (SD = 15.1) among those without stroke/other diagnosis. Fatality was more common in patients with ischemic stroke compared to those with other diagnosis (40% vs. 22%, p = 0.011). The most frequently published neuroimaging findings in patients with COVID-19 were ischemic stroke, CNS inflammatory disorder, and hemorrhagic disorder. In those studies, ischemic stroke was associated with fatality, and was more frequently seen in older patients. Based on our findings, early usage of MRI in COVID-19 patients may be recommended.
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Affiliation(s)
- Anisa Chowdhary
- Institute of Nuclear Medicine and Allied Sciences, New Delhi 110054, India;
| | - Roshan Subedi
- Institute of Medicine, Kathmandu P.O.BOX 1524, Nepal;
| | | | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV 26506, USA;
| | - Jenil Patel
- Department of Epidemiology, Fay W. Boozman, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare, Columbia, MO 65212, USA;
| | - Sarah Peterson
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA; (S.P.); (R.G.)
| | - Ronald Gwinn
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA; (S.P.); (R.G.)
| | - Mahmoud Elkhooly
- Department of Neuropsychiatry, Minia University, Minia 61519, Egypt;
| | - Apoorv Prasad
- Department of Neurology, Berkeley Medical Center, West Virginia University, Morgantown, WV 26506, USA;
| | - Lalit Nirwan
- Meditrina Institute of Medical Sciences, Nagpur, Maharashtra 440012, India;
| | - Amelia Adcock
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA;
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA;
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA
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Kataria S, Tandon M, Melnic V, Sriwastava S. A case series and literature review of multiple sclerosis and COVID-19: Clinical characteristics, outcomes and a brief review of immunotherapies. eNeurologicalSci 2020; 21:100287. [PMID: 33163634 PMCID: PMC7605741 DOI: 10.1016/j.ensci.2020.100287] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/04/2020] [Accepted: 10/27/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In view of the emerging coronavirus pandemic, the demand for knowledge about the impact of SARS-CoV-2 on people with Multiple Sclerosis (MS) continues to grow. Patients receiving disease modifying therapy (DMT) for MS have a higher background risk of infection-related health care utilization when compared to the general population. Therefore, there is a need of evidence-based recommendations to reduce the risk of infection and also managing MS patients with SARS-CoV-2. CASE DESCRIPTION We present three patients with history of Multiple Sclerosis (MS) on DMTs presenting with worsening MS symptoms likely pseudo exacerbation who were diagnosed with COVID-19. DISCUSSION An extensive review of 7 articles was performed, in addition to a brief review on DMTs use in MS patients with COVID-19. In our cases, all patients were on DMT and severe course of disease was noted in 2 cases. No fatality was observed. CONCLUSIONS This review provides a base on the clinical characteristics, outcomes and the roles of DMTs in MS patients suffering from n-cov-2. Physicians need to be vigilant about considering COVID-19 infection related relapse in the MS patients, especially in this COVID-19 pandemic era and look for pseudo-exacerbation. As most cases are found to have mild course and full recovery on DMTs, further research is needed to formulate evidence-based guidelines. This review will particularly be helpful for the researchers and registries to collect future data on MS and COVID-19.
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Key Words
- ALT, Alanine Transaminase
- AST, Aspartate Transaminase
- ATS/IDSA, American Thoracic Society and Infectious Disease Society of America
- Antigen presenting cells, (APCs)
- BUN, Blood Urea Nitrogen
- COVID-19
- COVID-19, Coronavirus Disease 2019
- CRP, C-Reactive Protein
- CSF, Cerebrospinal fluid
- CT, Computed Tomography
- DMT, Disease Modifying Therapy
- EDSS, Expanded Disability Status Score
- IV, Intravenous
- Immunotherapies
- JCV, John Cunnigham virus
- L, Liters
- MS, Multiple Sclerosis
- Multiple sclerosis
- NK cells, Natural Killer Cells
- Novel coronavirus
- Ocrelizumab
- PPMS, Primary Progressive Multiple Sclerosis
- Progressive multifocal leukoencephalopathy, (PML).
- RRMS, Relapsing Remitting Multiple Sclerosis
- RT PCR, Reverse Transcription Polymerase Chain Reaction
- SARS-CoV-2
- SARS-CoV-2, Severe Acute Respiratory Syndrome Coronavirus 2
- Terminally differentiated late effector memory T cells, (TEMRA)
- n-Cov2, Novel coronavirus 2
- ul, Microliters
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Affiliation(s)
- Saurabh Kataria
- Department of Neurology, University of Missouri Healthcare at Columbia, MO
| | | | - Violina Melnic
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, United States of America
| | - Shitiz Sriwastava
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, United States of America
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Prasad A, Kataria S, Srivastava S, Lakhani DA, Sriwastava S. Multiple embolic stroke on magnetic resonance imaging of the brain in a COVID-19 case with persistent encephalopathy. Clin Imaging 2020; 69:285-288. [PMID: 33038618 PMCID: PMC7536517 DOI: 10.1016/j.clinimag.2020.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 12/12/2022]
Abstract
The pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or coronavirus disease 2019 (COVID-19) are well known. The literature on neurological manifestations and complications in patients with COVID-19 has been increasing but is still sparse. At present, there are only a few reported case reports and clinical studies on neurological manifestations of COVID-19, of which ischemic stroke is one of the most common ones. Coagulopathy and vascular endothelial dysfunction have been proposed as the complications of COVID-19 which can ultimately lead to ischemic stroke. In this case report, we present a case of multifocal ischemic stroke in a patient with COVID-19. This patient had persistent encephalopathy and dysarthria after recovering from hypoxic respiratory failure and subsequently developed ischemic stroke in multiple vascular territories during hospital admission. Hypercoagulopathy and vascular endothelial dysfunction have been proposed as complications of COVID 19 which can lead to stroke. Diagnoses of stroke in critically ill patients hospitalized with COVID-19 using MRI brain can be challenging due to multiple factors. Patient with COVID-19 with stroke in multiple vascular territories after he had persistent encephalopathy and dysarthria. MRI brain is more sensitive and specific modality to detect brain tissue that has been damaged by an ischemic stroke than a CT head.
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Affiliation(s)
- Apoorv Prasad
- Department of Neurology, Berkley Medical Center, West Virginia University, School of Medicine, Morgantown, WV, United States of America.
| | - Saurabh Kataria
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America
| | - Samiksha Srivastava
- School of Medicine, Chongqing Medical University, Chongqing, Yuzhong District, China
| | - Dhairya A Lakhani
- Department of Radiology, West Virginia University, School of Medicine, WV, United States of America.
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States of America.
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Feizi P, Lakhani DA, Kataria S, Srivastava S, Tarabishy AR, Deib G, Sriwastava S. Multiple cerebral cavernous hemangiomas masquerading as hemorrhagic brain metastases. Radiol Case Rep 2020; 15:1973-1977. [PMID: 32874394 PMCID: PMC7452062 DOI: 10.1016/j.radcr.2020.07.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 11/19/2022] Open
Abstract
Intracranial hemorrhagic metastases are a relatively common finding in patients with thyroid carcinoma. Consequently, more unusual vascular lesions may be overlooked in contemplating a differential diagnosis in this patient group. A 50-year-old female with previously treated papillary thyroid carcinoma presented to the emergency department following new onset seizures. Her work up revealed multiple intraparenchymal brain lesions, hyperdense on computed tomography and demonstrating susceptibility effect, T1 shortening and contrast enhancement on magnetic resonance imaging, suggestive of metastases. Subsequent studies revealed lesional architecture consistent with multiple cavernous malformations, made evident by resolution of edema and evolution of blood products. Clinicians should be aware of the possibility of unusual intracranial hemorrhagic lesions in oncology patients which may only become evident on serial imaging evaluation. Cavernous hemangioma has typical MRI characteristic features which includes “mulberry” appearance on T2-weighted and fluid attenuation inversion recovery images with varying internal signal intensity which indicates multiple stages of blood products within the cavernous hemangioma. The lesions commonly have a typical T2-weighted dark hemosiderin rim. Blood sensitive demonstrates prominent surrounding hypointensity representing blooming secondary to internal blood products and/or calcification, if present. Cavernous hemangioma may rarely demonstrate some degree of contrast enhancement. Perfusion imaging may show alteration in capillary permeability involving cavernous malformations which has been previously described in the literature.
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Affiliation(s)
- Parissa Feizi
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
| | - Dhairya A. Lakhani
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
- Department of Radiology, West Virginia University, Morgantown, WV
| | - Saurabh Kataria
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
| | - Samiksha Srivastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
| | - Abdul R. Tarabishy
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
| | - Gerard Deib
- Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV
- Corresponding author.
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36
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Bailey C, Mach J, Kataria S, Tandon M, Lakhani DA, Sriwastava S. West Nile virus encephalitis: A report of two cases and review of neuroradiological features. Radiol Case Rep 2020; 15:2422-2426. [PMID: 33005280 PMCID: PMC7519252 DOI: 10.1016/j.radcr.2020.09.023] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 01/27/2023] Open
Abstract
West Nile virus (WNV) is a single-stranded RNA arbovirus of Flavivirus genus that is endemic to the United States and known to cause neuroinvasive disease. Diagnosis is confirmed by the presence of WNV-specific IgM antibodies within serum or cerebrospinal fluid (CSF). Radiologically, it presents as hyperintense T2 signal within deep brain structures (ie, thalami and mid-brain) with or without cerebral peduncle and substantia nigra involvement. On diffusion-weighted imaging, restricted diffusion is reported in basal ganglia and disseminated throughout the white matter. In this report, we describe the imaging findings for 2 cases of WNV from our institution; a 56-year-old female and a 34-year-old female. Increased vigilance for WNV is warranted, particularly in immunosuppressed patients presenting with a clinical picture of viral meningoencephalitis despite initial negative magnetic resonance imaging or CSF analysis. A high suspicion for WNV disease should prompt repeat imaging or laboratory workup.
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Affiliation(s)
- Christopher Bailey
- Department of Radiology, Detroit Medical Center, Wayne State University, Detroit, MI
| | - John Mach
- Department of Radiology, Detroit Medical Center, Wayne State University, Detroit, MI
| | - Saurabh Kataria
- Department of Neurology, Rockefeller Neuroscience Institute, School of Medicine, West Virginia University, Morgantown, WV
| | - Medha Tandon
- Army College of Medical Sciences, Base Hospital, New Delhi, India
| | - Dhairya A Lakhani
- Department of Radiology, School of Medicine, West Virginia University, Morgantown, WV
| | - Shitiz Sriwastava
- Department of Neurology, Rockefeller Neuroscience Institute, School of Medicine, West Virginia University, Morgantown, WV
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Sriwastava S, Yarraguntla K, Zutshi D, Basha MM, Bernitsas E, Marawar R. Relevance of cerebrospinal fluid findings in patients with multiple sclerosis and seizures. J Neurol Sci 2019; 406:116482. [PMID: 31622901 DOI: 10.1016/j.jns.2019.116482] [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] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 08/29/2019] [Accepted: 09/15/2019] [Indexed: 10/26/2022]
Abstract
Seizures occur 2-3 times more frequently in Multiple Sclerosis (MS) patients compared to the general population. The prevalence of seizures is reported to be 1.5-7.8% in MS population. However, it is unclear if seizure is an indirect symptom of neuroinflammation in MS. In our study, we explored the relevance of cerebrospinal fluid (CSF) findings in this unique patient cohort with MS and seizures. We retrospectively reviewed the charts of 32 MS patients with subsequent seizures (MSSS) and 12 patients with seizures followed by MS (SFMS). These two study groups were compared with two control groups - MS without seizures (MSNOS) and seizures without MS (SNOMS). Clinical characteristics and CSF findings between these groups were compared using boot strapped independent t-test. The CSF lymphocyte percentage of the SFMS group (95.6 ± 3) was significantly higher compared to MSNOS (66.0 ± 36.9, p = .04) and SNOMS (81.7 ± 10.0, p = .03). The CSF IgG index was significantly higher in SFMS group (1.9 ± 1.2, p = .02) as compared to MSSS group (0.99 ± 0.4). Patients with seizures as initial symptom of MS may have higher degree of CNS inflammation. Nonspecific clinical symptoms and atypical imaging findings in patients presenting with seizures may warrant close monitoring for development of MS.
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Affiliation(s)
- S Sriwastava
- Multiple Sclerosis Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - K Yarraguntla
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - D Zutshi
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - M M Basha
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - E Bernitsas
- Multiple Sclerosis Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America
| | - R Marawar
- Comprehensive Epilepsy Center, Department of Neurology, Wayne State School of Medicine, Detroit Medical Center, United States of America.
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Sriwastava S, Srinivas M, Kanna A, Yarraguntla K, Jowkar A, George E. Anti-glutamic acid decarboxylase antibody (GAD) syndromes may have more aggressive disease course in African Americans and early onset of presentation compare to Caucasians group. eNeurologicalSci 2019; 17:100208. [PMID: 31646204 PMCID: PMC6804399 DOI: 10.1016/j.ensci.2019.100208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/07/2019] [Indexed: 01/06/2023] Open
Abstract
Anti-Glutamic acid decarboxylase antibodies (GAD) are increasingly diagnosed in the clinic and this antibody related syndromes can manifest commonly as autoimmune encephalitis, Stiff person syndrome and cerebellar ataxia. However, it is unclear if the race has role in age of incidence, presentation and severity of symptoms of anti-GAD associated conditions. In our cohort of 40 patients who were anti-GAD positive, we observed that the age at which the anti-GAD titers turned out to be positive was significantly lower in African Americans (AA) compared to Caucasians (Cau) irrespective of the type of conditions. However, the age at symptoms onset didn't differ significantly different between these groups. Furthermore, AA anti-GAD positive patients had seizures as their initial presentation that was significantly higher in incidence compared to Cau indicating that AA have more aggressive form of autoimmune phenomenon for reasons unknown. Future studies to explore the variations in autoimmune process and their phenotypes may aid in understanding anti-GAD syndromes differently between these racial groups.
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Sriwastava S, Kanna A, Basha O, Xu J, Yarraguntla K, George E. Varicella zoster encephalitis in an immunocompromised patient presented with migraine type headache: A case report. eNeurologicalSci 2019; 16:100205. [PMID: 31497657 PMCID: PMC6718817 DOI: 10.1016/j.ensci.2019.100205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 01/24/2023] Open
Abstract
Varicella zoster virus (VZV) has been increasingly linked with encephalitis and atypical presentations in immunosuppressed patients. We present a patient with history of immunosuppressant intake for polymyositis who initially presented with throbbing frontal headache that raised the suspicion of migraine. She did not respond to anti-migraine medication and later developed stimulus induced myoclonus. She then had significant neurological decline and eventually became encephalopathic. Her initial imaging of brain was unremarkable which warranted further investigations. She was then diagnosed to be VZV positive in the cerebrospinal fluid (CSF) sample that confirmed VZV encephalitis. She responded well to IV Acyclovir treatment and her neurological function improved significantly. In this case, there was delay in diagnosis of VZV in the setting of immunosuppression and non-specific clinical presentation. Therefore, we encourage to strongly consider early VZV diagnostic work up and treatment in immunocompromised patients who can present with non-specific symptoms without a typical cutaneous rash.
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Affiliation(s)
- Shitiz Sriwastava
- Division of Neurology, Detroit Medical Center, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
| | - Anila Kanna
- Division of Neurology, Children's Hospital of Michigan, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Carman and Ann Adams Department of Pediatrics Children's Hospital of Michigan, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
| | - Omar Basha
- Division of Neurology, Detroit Medical Center, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
| | - Jian Xu
- Division of Neurology, Detroit Medical Center, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
| | - Kalyan Yarraguntla
- Division of Neurology, Detroit Medical Center, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
| | - Edwin George
- Division of Neurology, Detroit Medical Center, 4201 St. Antoine street, Detroit, MI 48201, United States of America.,Wayne State University School of Medicine, 4201 St. Antoine street, Detroit, MI 48201, United States of America
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40
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Sriwastava S, Desai A, Yuliati A, Watson CR, Sivaswamy L. A Child With a Hoarse Cry and Intracranial Calcification. Pediatr Neurol 2018; 87:78-79. [PMID: 30501889 DOI: 10.1016/j.pediatrneurol.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/19/2018] [Accepted: 08/07/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Shitiz Sriwastava
- Dept. of Neurology, Detroit Medical Center, Wayne State University, Detroit, Michigan.
| | - Aaron Desai
- Dept. of Neurology, Detroit Medical Center, Wayne State University, Detroit, Michigan
| | - Asri Yuliati
- Dept. of Pediatric Neurology, Childrens Hospital of Michigan, Wayne State University, Detroit, Michigan
| | - Carla R Watson
- Dept. of Pediatric Neurology, Childrens Hospital of Michigan, Wayne State University, Detroit, Michigan
| | - Lalitha Sivaswamy
- Dept. of Pediatric Neurology, Childrens Hospital of Michigan, Wayne State University, Detroit, Michigan
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Yarraguntla K, Seraji-Bozorgzad N, Lichtman-Mikol S, Razmjou S, Bao F, Sriwastava S, Santiago-Martinez C, Khan O, Bernitsas E. Multiple Sclerosis Fatigue: A Longitudinal Structural MRI and Diffusion Tensor Imaging Study. J Neuroimaging 2018; 28:650-655. [DOI: 10.1111/jon.12548] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- K. Yarraguntla
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
| | - N. Seraji-Bozorgzad
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
| | - S. Lichtman-Mikol
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
| | - S. Razmjou
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
| | - F. Bao
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
| | - S. Sriwastava
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - C. Santiago-Martinez
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - O. Khan
- Sastry Foundation Advanced Imaging Laboratory; Wayne State School of Medicine; Detroit MI
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
| | - E. Bernitsas
- Multiple Sclerosis Center, Department of Neurology; Wayne State University School of Medicine; Detroit MI
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Desai A, Sriwastava S, Gadgeel SM, Lisak RP. New onset myasthenia gravis in a patient with non small cell lung cancer treated with lorlatinib a novel anti-cancer agent. J Neurol Sci 2018; 392:100-101. [PMID: 30031992 DOI: 10.1016/j.jns.2018.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Aaron Desai
- Department of Neurology, Wayne State University/Detroit Medical Center, United States.
| | - Shitiz Sriwastava
- Department of Neurology, Wayne State University/Detroit Medical Center, United States
| | - Shirish M Gadgeel
- Karmanos Cancer Institute, Department of Oncology, Wayne State University, United States
| | - Robert P Lisak
- Department of Neurology, Wayne State University/Detroit Medical Center, United States; Department of Microbiology, Immunology and Biochemistry, Wayne State University, United States
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Anand CS, Gupta SK, Sriwastava S. Rhinosporidiosis. J Indian Med Assoc 1975; 64:40-2. [PMID: 1133466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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