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Yoshikawa S, Ueda T. The visualization of hypertrophic pachymeningitis in antineutrophil cytoplasmic antibody-associated granulomatosis with polyangiitis on contrast-enhanced FLAIR. Radiol Case Rep 2024; 19:418-423. [PMID: 38028296 PMCID: PMC10679861 DOI: 10.1016/j.radcr.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Hypertrophic pachymeningitis is a rare inflammatory condition that leads to the thickening of the dura mater, either due to unknown or identifiable secondary causes. Granulomatosis with polyangiitis is a notable causative agent, and hypertrophic pachymeningitis is the initial presentation in certain cases. The diagnosis of hypertrophic pachymeningitis is aided by contrast-enhanced MRI, although distinguishing between normal and abnormal dural enhancement can be challenging using contrast-enhanced T1WI. This study highlights the case of an 80-year-old woman diagnosed with hypertrophic pachymeningitis secondary to antineutrophil cytoplasmic antibody-associated granulomatosis with polyangiitis, where contrast-enhanced FLAIR played a crucial role in distinctly identifying abnormal dural enhancement and differentiating it from normal dura. In conclusion, although contrast-enhanced T1WI remains indispensable, contrast-enhanced FLAIR can serve as a valuable complementary tool in MRI study sequences for the diagnosis of hypertrophic pachymeningitis.
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Affiliation(s)
- Satoshi Yoshikawa
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, 9-7 Jurakumawari-Matsushita-cho, Nakagyo-ku, Kyoto 604-8401, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, 9-7 Jurakumawari-Matsushita-cho, Nakagyo-ku, Kyoto 604-8401, Japan
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Yeo J, Yee GT, Seo J, Seo MR, Baek HJ, Choi HJ. Immunoglobulin G4-related hypertrophic pachymeningitis with an isolated scalp mass mimicking a brain tumor: a case report and literature review. J Rheum Dis 2024; 31:54-58. [PMID: 38130960 PMCID: PMC10730807 DOI: 10.4078/jrd.2023.0023] [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: 04/16/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 12/23/2023]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune disorder associated with fibroinflammatory conditions that can affect multiple organs. Hallmark histopathological findings of IgG4-RD include lymphocytic infiltration of IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. However, little is known about central nervous system involvement of IgG4-RD. Hypertrophic pachymeningitis (HP) has recently been reported as a manifestation of IgG4-RD, which may have previously been demonstrated in a significant percentage of idiopathic cases. Herein, we report a rare case of a 63-year-old male who presented with a scalp mass that mimicked a brain tumor. He was diagnosed with IgG4-related HP (IgG4-RP) after surgery. This case suggests that awareness of a possibility of IgG4-RP in patients with isolated scalp masses, even in the absence of systemic symptoms, is crucial. A combination of careful history taking, evaluation of serum IgG4-levels and imaging as an initial work-up, followed by tissue biopsy, is important for the differential diagnosis of IgG4-RP, malignancy, and other infectious diseases.
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Affiliation(s)
- Jina Yeo
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Gi Taek Yee
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jaedeok Seo
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Mi Ryoung Seo
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyo-Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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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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Ikeda J, Shimojima Y, Yamada A, Sekijima Y. Quantitative evaluation of the thickened dura mater impacting clinical signs in immune-mediated hypertrophic pachymeningitis. J Neurol Sci 2023; 453:120780. [PMID: 37689000 DOI: 10.1016/j.jns.2023.120780] [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: 05/06/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE This study evaluated the volume of thickened dura mater lesions and their impact on clinical findings in immune-mediated hypertrophic pachymeningitis (HP). METHODS The volume of contrast-enhanced dura mater on magnetic resonance imaging was evaluated using the imaging feature quantification system in 19 patients with immune-mediated HP, including 12 with antineutrophil cytoplasmic antibody-related, 4 with IgG4-related, and 3 with idiopathic HP, as well as 10 with multiple sclerosis (MS) as controls. The implications of HP volume on neurological manifestations and cerebrospinal fluid (CSF) laboratory markers were statistically analyzed in patients with immune-mediated HP. RESULTS The volumes of the contrast-enhanced dura mater in the convexity, cranial fossa, and tentorium cerebelli were significantly higher in patients with immune-mediated HP than in those with MS. Among patients with immune-mediated HP, those with cranial nerve (CN) VIII neuropathy had a significantly higher volume of the contrast-enhanced dura mater in the cranial fossa than those without CN VIII neuropathy. The volume of the contrast-enhanced dura mater in the tentorium cerebelli was positively correlated with CSF protein levels. CONCLUSION Quantification of the thickened dura mater is useful for elucidating the relationship with the clinical findings in immune-mediated HP. Thickened dura mater lesions in the cranial fossa may be implicated in the development of CN VIII neuropathy. The enlargement of HP lesions in the tentorium cerebelli can increase CSF protein levels.
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Affiliation(s)
- Junji Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Akira Yamada
- Department of Radiology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Yu H, Lu C, Duan W, Dong Y, Wang Z, Wang X, Jian F. A selected case series of idiopathic hypertrophic pachymeningitis in a single center: Pathological characteristics and case-oriented review. J Neuroimmunol 2023; 383:578191. [PMID: 37660537 DOI: 10.1016/j.jneuroim.2023.578191] [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: 05/12/2023] [Revised: 07/06/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a relatively rare disease of the central nervous system characterized by local or diffuse fibrous thickening of the dura mater. At present, there is still insufficient research on the pathogenesis and treatment strategies of this disease. We reported a continuous case series of seven patients with idiopathic HP (IHP), and also details one case of immunoglobulin G4-related HP requiring surgical intervention. Early diagnosis and appropriate surgical intervention for IHP could prevent the progression of permanent neurological damage and spinal cord paraplegia.
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Affiliation(s)
- Huaxiao Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Chunli Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Yachao Dong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Zuowei Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China.
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, PR China; Neurospine Center, China International Neuroscience Institute (China-INI), PR China; Research Center of Spine and Spinal Cord, Beijing Institute of Brain Disorders, Capital Medical University, PR China; National Center for Neurological Disorders, PR China.
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Das S, Ray BK. The Spectrum of Intracranial Hypertrophic Pachymeningitis at an Eastern Indian Tertiary Care Center. Ann Indian Acad Neurol 2023; 26:678-689. [PMID: 38022439 PMCID: PMC10666889 DOI: 10.4103/aian.aian_561_23] [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: 06/25/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Hypertrophic pachymeningitis (HP) is a treatable, rare inflammatory disease, either primary or secondary to systemic causes. Aims To characterize the etiology, clinical manifestations, and treatment outcomes of HP patients and determine the factors influencing the radiological resolution of the pachymeningeal enhancement and recurrence of symptoms within the follow-up period. Materials and Methods We collected data for this prospective observational study between March 1, 2021 and May 31, 2022, at the Bangur Institute of Neurosciences, Kolkata, and the patients were followed for a 6-month period. Demographic, clinical, laboratory, and treatment-related data were collected. A univariate logistic regression model was used for comparison between patients with and without radiological resolution of pachymeningitis and between patients with and without symptom recurrence. Results Among 44 patients, the male: female ratio was 1.2:1. The median age at disease onset was 35.5 (28.5-49.5) years. The etiologies were idiopathic (56.8%), tuberculosis (22.8%), immunoglobulin G subtype 4 (IgG4) disease (9.2%), other infections (6.8%), and neoplastic (4.4%). Headache was the most common presentation (95.4%), followed by cranial neuropathies (68.2%). Optic and oculomotor neuropathies were the most common. In terms of radiological features, 27.27, 29.54, and 43.18% of patients had diffuse, focal regular, and focal irregular enhancement, respectively. Temporal (50%), followed by cavernous sinus (38.63%) enhancement, was the most common. Recurrence occurred in 36 and 50% of idiopathic and IgG4-related HP cases, respectively. Mycophenolate mofetil was added to their steroid regimen with no further recurrences. Conclusion The cohort had a marked absence of (antineutrophil cytoplasmic antibodies) ANCA-associated HP. The severity of clinical manifestations or distribution of pachymeningitis did not differ significantly among the etiological groups. The presence of idiopathic etiology and focal regular enhancement had a significantly higher chance of radiological resolution. The response to therapy was satisfactory. Recurrence was significantly related to shorter steroid courses (
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Affiliation(s)
- Suman Das
- Department of Neuromedicine, North Bengal Medical College, Darjeeling District, West Bengal, India
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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Sergio P, Alejandro R, Cristian F. Hypertrophic pachymeningitis due to IgG4-related disease (RD-IgG4). A case report. Reumatol Clin (Engl Ed) 2023:S2173-5743(23)00090-4. [PMID: 37179159 DOI: 10.1016/j.reumae.2023.05.001] [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] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 11/22/2022] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Hypertrophic pachymeningitis (HP) is a clinico-radiological entity characterized by a thickening of the dura mater that may be focal or diffuse and manifested by a variety of neurological syndromes. Aetiologically, it is classified as infectious, neoplastic, autoimmune, and idiopathic. Many of these formerly idiopathic cases have been shown to fall into the spectrum of IgG4-related disease. OBJECTIVE To describe the case of a patient attended for neurological involvement due to hypertrophic pachymeningitis with initial diagnosis of inflammatory myofibroblastic tumour and final diagnosis of IgG4-related disease. CASE A 25-year-old woman with neurological symptoms of 3 years' evolution characterized initially by right hypoacusis, evolving with headache and diplopia. Magnetic resonance imaging (MRI) of the encephalon showed pachymeningeal thickening with involvement of vasculo-nervous structures in the tip of the cerebellum, cavernous sinus, ragged foramen, and optic chiasm. The patient presented for consultation with the result of an incisional biopsy that reported a proliferative lesion combining fibrous elements of fascicular or swirling arrangement with collagenized streaks with dense, lymphoplasmacytic infiltrate and some macrophages, with negative staining for ALK 1, with a diagnosis of inflammatory myofibroblastic tumour. Due to suspicion of IgG4-related disease (IgG4-RD) the biopsy was sent for review and pertinent complementary studies were requested. BIOPSY REVIEW Non storiform fibrosis, predominantly lymphoplasmacytic infiltrate, histiocytes, and polymorphonuclear infiltrate in sectors, without granulomas or atypia. Staining for germs negative. Immunohistochemistry with 50-60 IgG4+/HPF cells and range of 15%-20%, CD68+ in histiocytes, CD1a-, S100-. The patient presented deterioration of visual acuity due to ophthalmic nerve involvement, so glucocorticoid treatment was started in pulses and rituximab with regression of symptoms and imaging improvement of the lesions. CONCLUSION HP is a clinical imaging syndrome with variable symptoms and aetiologies that poses a diagnostic challenge. In this case the initial diagnosis was inflammatory myofibroblastic tumour, which is a neoplasm of variable behaviour, locally aggressive, and can metastasize; it is one of the main differential diagnoses of IgG4-related disease because they share anatomopathological features, including storiform fibrosis. IgG4-RD is an immune-mediated condition that can have single or multiple involvement. Its diagnosis is complex when it presents with single organ involvement or in non-typical organs (CNS, meninges) in which data are scarce, as in the case of our patient with single organ involvement of the CNS. Although there are classification criteria to guide non-specialists in the diagnosis, the sum of the clinical picture, imaging, laboratory, pathological anatomy, and immunohistochemistry will always be evaluated together for a definitive diagnosis.
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Affiliation(s)
- Paira Sergio
- Servicio de Reumatología, Hospital José María Cullen, Santa Fe, Argentina
| | - Reibaldi Alejandro
- Servicio de Reumatología, Hospital José María Cullen, Santa Fe, Argentina.
| | - Froullet Cristian
- Servicio de Diagnóstico por Imágenes, Hospital José María Cullen, Santa Fe, Argentina
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Shimojima Y, Sekijima Y. Hypertrophic pachymeningitis in ANCA-associated vasculitis: Clinical and immunopathological features and insights. Autoimmun Rev 2023; 22:103338. [PMID: 37062439 DOI: 10.1016/j.autrev.2023.103338] [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: 03/21/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
Hypertrophic pachymeningitis (HP) is an inflammatory disorder characterized by intracranial and spinal thickened dura mater, leading to several neurological manifestations including headaches, cranial neuropathies, seizures, and sensorimotor disorders. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a crucial disease that is implicated in the development of immune-mediated HP. HP is observed throughout the clinical course of AAV, and 3%-4% of patients with AAV experience HP as the initial clinical episode. However, patients with ANCA-related HP are unclassifiable in the classification criteria of AAV when HP is the only manifestation, suggesting that ANCA-related HP can be identified as a central nervous system-limited type of AAV. Among patients with AAV, those who develop HP have predominantly been classified as having granulomatosis with polyangiitis (GPA). Myeloperoxidase-ANCA positivity has been more frequently demonstrated than proteinase 3-ANCA positivity in patients with ANCA-related HP. The ear, nose, and throat manifestations, such as otitis media, sinusitis, and mastoiditis, as well as mucous membranes/eyes manifestations including sudden visual loss, are robustly associated with HP in AAV. The histology of thickened dura mater tissues includes fibrotic changes and infiltration of several immunocompetent cells, but the typical findings of GPA, such as granulomatous inflammation with necrotizing vasculitis, are not observed in all patients with ANCA-related HP. Corticosteroids are the first-line therapy for ANCA-related HP, while the concomitant use of immunosuppressive agents including cyclophosphamide, methotrexate, and mycophenolate mofetil, is an ideal strategy for achieving remission. Rituximab is a useful agent in refractory ANCA-related HP.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Senda M, Ueda A, Ito M, Shima S, Mizutani Y, Mutoh T, Watanabe H. Long-term response to immunotherapy in patients with hypertrophic pachymeningitis. Fujita Med J 2023; 9:35-40. [PMID: 36789128 PMCID: PMC9923450 DOI: 10.20407/fmj.2021-026] [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] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/05/2022] [Indexed: 02/16/2023]
Abstract
Objective In this study, we aimed to clarify the relationship between initial treatment response, prednisolone (PSL) dosage, clinical type, and recurrence in patients with hypertrophic pachymeningitis (HP). Methods The study cohort comprised eight patients with HP who had been admitted to our hospital from April 2015 to June 2020. Diagnostic criteria for HP included neurological abnormalities and dural thickening on magnetic resonance gadolinium-enhanced T1-weighted images. Results Relevant characteristics of the eight study patients are as follows. There were two men and six women. The average age at onset was 58.3 (range: 29-79) years. Three of them had myeloperoxidase-antineutrophil cytoplasmic antibody-related vasculitis, one immunoglobulin G4-related disease, and one ulcerative colitis. The remaining three patients had idiopathic HP. The average maximum dosage of PSL was 0.79 mg/kg/day, and the average daily maintenance dosage 0.18 mg/kg/day. Three patients needed additional immunosuppressive drugs. Both idiopathic and secondary HP initially responded well to PSL, with improvement in activities of daily living. Six patients had some sequelae related to cranial nerve involvement. No relapses occurred while the patients were taking moderate doses of PSL; however, all patients with idiopathic HP had recurrences when their PSL dosage was reduced. Conclusions Patients with idiopathic HP and HP associated with immune disorders respond to steroids and immunosuppressive drugs and recover well. However, there is a high rate of relapse after reduction of PSL dosage, mainly in those with idiopathic HP.
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Affiliation(s)
- Mayumi Senda
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan,Department of Neurology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Akihiro Ueda
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Mizuki Ito
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan,Department of Neurology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Sayuri Shima
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Yasuaki Mizutani
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Hirohisa Watanabe
- Department of Neurology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
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Luísa de Almeida Marcelino A, Streit S, Homeyer MA, Bauknecht HC, Radbruch H, Ruprecht K, Prüss H. Hypertrophic Pachymeningitis with Persistent Intrathecal Inflammation Secondary to Neurosarcoidosis Treated with Intraventricular Chemotherapy: A Case Report. Case Rep Neurol 2023; 15:87-94. [PMID: 37384037 PMCID: PMC10294282 DOI: 10.1159/000531229] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023] Open
Abstract
Hypertrophic pachymeningitis (HP) is a rare immune-mediated disease characterized by thickening of the dura mater with consecutive cranial neuropathy. While HP is usually treated with systemic immunotherapies, response to therapy is variable and may be limited by insufficient drug concentrations in the brain. We report on a 57-year-old patient with HP manifesting with vision and hearing loss who had sustained clinical progression despite various systemic immunotherapies. Intraventricular chemotherapy with methotrexate, cytarabine, and dexamethasone was initiated. We present clinical, imaging and cerebrospinal fluid (CSF) findings, including cytokine levels before and after intraventricular treatment: rapid decrease of cell count, lactate and profibrotic cytokine levels in the CSF following intraventricular chemotherapy was paralleled by a mild reduction of dura thickness in MRI. The already severely impaired visual acuity and hearing loss did not progress further. Treatment was complicated by exacerbation of previously subtle psychiatric symptoms. Follow-up was terminated after 6 months as the patient suffered from a fatal ischemic stroke. Autopsy revealed neurosarcoidosis as the underlying cause of HP. This case report suggests that intrathecal chemotherapy can reduce the inflammatory milieu in the CNS and should be considered for treatment-refractory HP before irreversible damage of cranial nerves has occurred.
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Affiliation(s)
- Ana Luísa de Almeida Marcelino
- Department of Neurology with Experimental Neurology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Streit
- Department of Neuropathology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marie Alice Homeyer
- Department of Neurology with Experimental Neurology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
| | - Hans-Christian Bauknecht
- Department of Neuroradiology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Helena Radbruch
- Department of Neuropathology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology with Experimental Neurology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Harald Prüss
- Department of Neurology with Experimental Neurology, Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Neurodegenerative Diseases (DZNE) Berlin, Berlin, Germany
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Shimojima Y, Kishida D, Ichikawa T, Kida T, Yajima N, Omura S, Nakagomi D, Abe Y, Kadoya M, Takizawa N, Nomura A, Kukida Y, Kondo N, Yamano Y, Yanagida T, Endo K, Hirata S, Matsui K, Takeuchi T, Ichinose K, Kato M, Yanai R, Matsuo Y, Nishioka R, Okazaki R, Takata T, Ito T, Moriyama M, Takatani A, Miyawaki Y, Ito-Ihara T, Kawaguchi T, Kawahito Y, Sekijima Y. Hypertrophic pachymeningitis in ANCA-associated vasculitis: a cross-sectional and multi-institutional study in Japan (J-CANVAS). Arthritis Res Ther 2022; 24:204. [PMID: 35999568 PMCID: PMC9396769 DOI: 10.1186/s13075-022-02898-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 05/12/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study investigated the characteristics of hypertrophic pachymeningitis (HP) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), using information from a multicenter study in Japan. METHODS We analyzed the clinical information of 663 Asian patients with AAV (total AAV), including 558 patients with newly diagnosed AAV and 105 with relapsed AAV. Clinical findings were compared between patients with and without HP. To elucidate the relevant manifestations for HP development, multivariable logistic regression analyses were additionally performed. RESULTS Of the patients with AAV (mean age, 70.2 ± 13.5 years), HP was noted in 30 (4.52%), including 20 (3.58%) with newly diagnosed AAV and 10 (9.52%) with relapsed AAV. Granulomatosis with polyangiitis (GPA) was classified in 50% of patients with HP. A higher prevalence of GPA was significantly observed in patients with HP than in those without HP in total AAV and newly diagnosed AAV (p < 0.001). In newly diagnosed AAV, serum proteinase 3 (PR3)-ANCA positivity was significantly higher in patients with HP than in those without HP (p = 0.030). Patients with HP significantly had ear, nose, and throat (ENT) (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.03-2.14, p = 0.033) and mucous membrane/eye manifestations (OR 5.99, 95% CI 2.59-13.86, p < 0.0001) in total AAV. Moreover, they significantly had conductive hearing loss (OR 11.6, 95% CI 4.51-29.57, p < 0.0001) and sudden visual loss (OR 20.9, 95% CI 5.24-85.03, p < 0.0001). CONCLUSION GPA was predominantly observed in patients with HP. Furthermore, in newly diagnosed AAV, patients with HP showed significantly higher PR3-ANCA positivity than those without HP. The ear and eye manifestations may be implicated in HP development.
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Affiliation(s)
- Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Takanori Ichikawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Takashi Kida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Omura
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University, Tokyo, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Naoya Kondo
- Department of Nephrology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Takuya Yanagida
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoshi Matsui
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo Medical University School of Medicine, Nishinomiya, Hyogo, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Matsuo
- Department of Rheumatology, Tokyo Kyosai Hospital, Tokyo, Japan.,Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University, Yonago, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Hospital, Izumo, Shimane, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Ayuko Takatani
- Rheumatic Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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12
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Yu Y, Lv L, Yin SL, Chen C, Jiang S, Zhou PZ. Clivus-involved immunoglobulin G4 related hypertrophic pachymeningitis mimicking meningioma: A case report. World J Clin Cases 2022; 10:6269-6276. [PMID: 35949844 PMCID: PMC9254204 DOI: 10.12998/wjcc.v10.i18.6269] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/23/2022] [Accepted: 04/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immunoglobulin G4 related disease (IgG4-RD) is a fibroinflammatory disease with markedly elevated serum IgG4 levels and fibrous tissue proliferation, accompanied by numerous plasma cells. IgG4 related hypertrophic pachymeningitis (IgG4-RHP) is relatively rare and indistinguishable from other phymatoid diseases before the operation. The risk of long-term immunosuppression needs to be balanced with disease activity.
CASE SUMMARY A 40-year-old man presented with headache and bilateral abducent paralysis. He was also diagnosed with pulmonary tuberculosis 10 years ago and was on regular treatment for the same. Before the operation and steroid therapy, the patient was suspected of having tubercular meningitis at a local hospital. A clivus lesion was found via brain magnetic resonance imaging (MRI) at this presentation. He was preliminarily diagnosed with meningioma and underwent Gamma Knife Surgery. Transnasal endoscopic resection was performed to treat deterioration of nerve function. Postoperative pathologic examination suggested IgG4-RD. Moreover, the serum IgG4 was elevated at 1.90 g/L (reference range: 0.035-1.500 g/L). After steroid therapy for 2 mo, the lesion size diminished on MRI, and the function of bilateral abducent nerves recovered.
CONCLUSION IgG4-RHP is relatively rare and indistinguishable before the operation. Elevated serum IgG4 levels and imaging examination help in the diagnosis of IgG4-RHP. Surgery is necessary when lesions progress and patients start to develop cranial nerve function deficit.
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Affiliation(s)
- Yang Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Liang Lv
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Sen-Lin Yin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Cheng Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Pei-Zhi Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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13
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Kramer DE, Kerolus MG, Furlan K, Nag S, O'Toole JE. Recurrent IgG4-Related Meningeal Disease of the Cervicothoracic Spine: A Case Report and Review of the Literature. Neurol India 2022; 70:1180-1186. [PMID: 35864660 DOI: 10.4103/0028-3886.349607] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND IgG4-related disease is a rare, recently recognized chronic inflammatory disease. IgG4-related hypertrophic pachymeningitis (IgG4-RHP) of the central nervous system predominantly involves the cranial meninges. Spinal involvement remains rare. OBJECTIVE We report a case of recurrent cervicothoracic IgG4-RHP and review the surgical literature. METHODS AND MATERIALS A 35-year-old woman presented with a 6-month history of neck and right shoulder pain, progressive right triceps weakness and paresthesias in the right C8 and T1 dermatomes. MRI demonstrated a T2 hypointense epidural soft tissue mass extending from C6-T1. The patient underwent C6-T1 laminoforaminotomy and partial resection with near complete symptom resolution. Histopathology was consistent with diagnosis of IgG4-RHP. Eighteen months postoperatively, she experienced symptom recurrence necessitating re-operation and adjuvant postoperative prednisone with complete resolution at 40-months' follow-up. RESULTS AND CONCLUSIONS Of the now nineteen confirmed cases of IgG4-RHP, fifteen underwent surgery. A majority achieved partial resection. Three surgical patients did not receive adjuvant therapy with symptomatic recurrence between 2 and 18 months.
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Affiliation(s)
- Dallas E Kramer
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Mena G Kerolus
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Karina Furlan
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - Sukriti Nag
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - John E O'Toole
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
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14
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Sato-Akushichi M, Kinouchi R, Kawai N, Nomura K. Optic neuropathy secondary to granulomatosis with polyangiitis in a patient with Graves' disease: a case report. J Med Case Rep 2021; 15:618. [PMID: 34963497 PMCID: PMC8715570 DOI: 10.1186/s13256-021-03207-4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 11/26/2021] [Indexed: 11/21/2022] Open
Abstract
Background Dysthyroid optic neuropathy is the most commonly suspected diagnosis of optic neuropathy in Graves’ patients; however, other causes need to be ruled out. We present a unique case of optic neuropathy secondary to hypertrophic pachymeningitis with antineutrophil cytoplasmic antibody-associated vasculitis, which was suspected to be antithyroid drug related.
Case presentation A 79-year-old Japanese male presented with acute visual loss in the left eye. He had a 24-year history of Graves’ disease and was taking methimazole. Best-corrected visual acuity was 0.8 in the right eye and light perception in the left eye, and relative afferent pupillary defect in the left eye was seen. Ocular movement was normal, and there were no findings explaining visual loss in intermediate optic media and fundus in the left eye. Contrast-enhanced magnetic resonance imaging demonstrated thickened dura mater. Tests for myeloperoxidase-antineutrophil cytoplasmic antibody, proteinuria, and hematuria were positive; pulmonary nodule lesions and a blood clot in the left lower leg were also found. After excluding the presence of diseases that could lead to hypertrophic pachymeningitis, we diagnosed optic neuropathy due to hypertrophic pachymeningitis with granulomatosis with polyangiitis—a subtype of antineutrophil cytoplasmic antibody-associated vasculitis. Since he had history of using methimazole, antineutrophil cytoplasmic antibody-associated vasculitis was considered as drug related. We started high-dosage steroid pulse therapy followed by 1 mg/kg body weight daily of oral prednisolone, and subsequently tapered. Methimazole was stopped. Best-corrected visual acuity recovered to 0.9, 2 weeks after starting treatment. Though myeloperoxidase-antineutrophil cytoplasmic antibody remained negative, the symptom relapsed 6 months after treatment initiation. We gave a second high-dose steroid pulse therapy followed by prednisolone tapered together with methotrexate. Remission remained, and using 4 mg/week methotrexate without prednisolone, myeloperoxidase-antineutrophil cytoplasmic antibody was kept within the normal limit until now, 4 years after onset. Conclusion We present a case of optic neuropathy with hypertrophic pachymeningitis related to antineutrophil cytoplasmic antibody-associated vasculitis, which was suspected to be drug related. The patient had good visual recovery after quitting the drug and receiving immunosuppressive therapy with systemic steroids. Hypertrophic pachymeningitis with antineutrophil cytoplasmic antibody-associated vasculitis related to antithyroid drugs should be considered as a differential diagnosis for optic neuropathy in Graves’ patients in whom optic nerve compression is not obvious. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-021-03207-4.
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Affiliation(s)
- Miki Sato-Akushichi
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Reiko Kinouchi
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan. .,Medicine and Engineering Combined Research Institute, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Naoko Kawai
- Department of Ophthalmology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kenichiro Nomura
- Department of Otolaryngology Head and Neck Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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15
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Hoshino R, Furuta M, Shibata M, Wakamatsu I, Nagashima K, Yamaguchi R, Ikeda Y. Vanishing tumefactive ANCA-associated hypertrophic pachymeningitis: A case report. Clin Neurol Neurosurg 2021; 212:107070. [PMID: 34894573 DOI: 10.1016/j.clineuro.2021.107070] [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: 09/23/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
We report a case of a 59-year-old man with hypertrophic pachymeningitis (HP), initially presenting as a tumefactive lesion that disappeared spontaneously. He developed headache and left abducens nerve palsy 2 years before admission, and cerebral magnetic resonance imaging (MRI) revealed a round mass lesion. Meningioma was initially considered, but the lesion disappeared spontaneously along with the symptoms. However, 6 months before admission, left abducens nerve palsy reappeared. Repeated MRI revealed multiple intracranial tumefactive lesions. HP was diagnosed based on the pathological analysis of the biopsied specimen. HP can appear as a vanishing tumor, and pathological evaluation is essential for a precise diagnosis. If spontaneous disappearance of tumefactive intracranial lesions is encountered, the possibility of HP should be considered.
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Affiliation(s)
- Reona Hoshino
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Minori Furuta
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Makoto Shibata
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ikuo Wakamatsu
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazuaki Nagashima
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Japan.
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16
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López-Simón E, Corriols-Noval P, Castillo-Ledesma N, Rodríguez-Martín M, Morales-Angulo C. Audiovestibular Symptoms in Patients With Idiopathic Hypertrophic Pachymeningitis: Systematic Literature Review. Acta Otorrinolaringol Esp (Engl Ed) 2021; 72:387-393. [PMID: 34844678 DOI: 10.1016/j.otoeng.2020.08.006] [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: 05/06/2020] [Accepted: 08/18/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypertrophic pachymeningitis is an infrequent inflammatory disease resulting in thickening and fibrosis of the dura mater. In most cases, the cause in unknown and is called idiopathic hypertrophic pachymeningitis (IHP). Audiovestibular symptoms are infrequent and the pathogenesis is still unclear. MATERIALS AND METHODS A systematic literature review of cases with IHP and vestibular symptoms from 2000 to February 2020 was performed. PRISMA Checklist was followed and PubMED database, Web of Science and Cochrane library were searched. We report a case of an adolescent with a diagnosis of vestibular neuritis in the context of IHP attended in our clinic. RESULTS We reviewed 5 articles related to IHP and vestibular disorders. A total of 7 cases (5 women and 2 men), with ages between 27 and 68 years with IHP were found. They all had audiovestibular symptoms. In contrast to our patient, uni or bilateral neurosensorial hearing loss was reported in all cases. Furthermore, there is no other case report published describing the association between IHP and vestibular neuritis. High dose steroids improved symptoms in 85.7% of the patients. CONCLUSION Vestibular symptoms in IHP are uncommon and the pathogenesis is still debatable. Entrapment of nerves in the internal auditory canal and secondary neuronal damage could be suspected as the main cause of hearing and vestibular loss.
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Affiliation(s)
- Eugenia López-Simón
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain.
| | - Patricia Corriols-Noval
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain
| | - Nathalia Castillo-Ledesma
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain
| | - Minerva Rodríguez-Martín
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain
| | - Carmelo Morales-Angulo
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), Spain
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17
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Kitagawa T, Komatsu T, Omoto S, Sato T, Takatsu H, Sakai K, Umehara T, Murakami H, Mitsumura H, Iguchi Y. A case of idiopathic hypertrophic pachymeningitis with high adenosine deaminase in cerebrospinal fluid. Clin Neurol Neurosurg 2021; 211:107056. [PMID: 34837821 DOI: 10.1016/j.clineuro.2021.107056] [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: 10/23/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
Adenosine deaminase (ADA) in cerebrospinal fluid (CSF) has been reported as useful to diagnose tuberculous meningitis and hypertrophic pachymeningitis (HP). The case of a 59-year-old woman with impaired vision and an auditory disturbance due to massive intracranial HP is presented. Although acid-fast bacillus cultures and polymerase chain reaction tests for Mycobacterium tuberculosis in the CSF were negative, tuberculous HP was diagnosed clinically because of the high ADA in CSF, and anti-tuberculosis drugs were administered with prednisolone because idiopathic HP (IHP) could not be ruled out. Since the impaired vision worsened with prednisolone reduction despite the continuation of anti-tuberculosis drugs, a dural biopsy was performed, and the patient was diagnosed with IHP. ADA is associated with lymphocyte proliferation and differentiation and increased by activation of cell-mediated immunity. Elevated CSF-ADA might be caused by lymphocyte infiltration in the thickened dura mater.
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Affiliation(s)
- Tomomichi Kitagawa
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan.
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Shusaku Omoto
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Tadashi Umehara
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hidetomo Murakami
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
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18
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Sharma R, Kaur K, Sasidharan A, Gupta R, Laythalling RK. IgG4-Related Disease in Intradural Extramedullary Location- Detailed Case Illustration and Literature Review with Special Emphasis on Role of Surgery in its Management. Neurol India 2021; 69:1176-1183. [PMID: 34747781 DOI: 10.4103/0028-3886.329549] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background IgG4-related disease (IgG4RD) is a multisystemic progressive fibroinflammatory and lymphoproliferative autoimmune disorder of unknown etiopathogenesis; and its occurrence in intradural extramedullary (IDEM) location is extremely rare. Aim and Objective The aim of this study was to review all IDEM IgG4RD cases described in English literature and to signify the role of surgery in its management at this rare location along with the surgical technique and intraoperative findings. Methods An Internet-based search (PubMed) for the published reports describing spinal cases of IgG4RD with IDEM involvement was done using the keyword: spinal IgG4-related disease. An illustration of a case of cranial IgG4-related disease in a young man who developed metachronous cervical involvement in intradural extramedullary (IDEM) location is also presented. Results Amongst 45 spinal IgG4RD cases reported in English Literature, only 3 cases were IDEM IgG4RD. In the illustrated case, portion of the cervical lesion causing cervical cord encasement was intradural but extraarachnoidal- located between arachnoid and dura, without any pial involvement. All these 4 cases improved following surgery. Conclusion Timely meticulous resection of mass lesion in situations of medical treatment failure or progressive neurological decline can lead to reversibility of mass effect-associated neurological manifestations of IgG4RD.
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Affiliation(s)
| | - Kavneet Kaur
- Department of Pathology, AIIMS, New Delhi, India
| | | | - Ranjan Gupta
- Department of Rheumatology, AIIMS, New Delhi, India
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19
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Nomura S, Shimojima Y, Kondo Y, Kishida D, Sekijima Y. Hypertrophic pachymeningitis in polyarteritis nodosa: a case-based review. Clin Rheumatol 2021; 41:567-572. [PMID: 34725743 DOI: 10.1007/s10067-021-05971-6] [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: 09/24/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 11/29/2022]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurological disorder with focal or diffuse thickening of the dura mater, which usually causes headache, cranial neuropathies, seizures, and motor or sensory impairments. The development of HP is attributed to an immune-mediated mechanism, and some autoimmune diseases have been implicated in the development of HP. Herein, we describe the case of a 73-year-old woman with persistent headache ascribable to HP, which developed approximately 3 years after a diagnosis of polyarteritis nodosa (PAN). She was treated with high-dose corticosteroid and cyclophosphamide that resulted in immediate disappearance of headache and improved radiological findings of thickened dura mater. In addition, she was subsequently administered methotrexate, ultimately resulting in maintenance of remission and regular reduction of prednisolone. In our review of published English articles, only two cases of HP in patients with PAN have been reported to date, suggesting that HP is a rare complication in PAN. However, it should be recognized that HP may develop as a neurological involvement related to PAN.
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Affiliation(s)
- Shun Nomura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Yasufumi Kondo
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Dai Kishida
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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Abstract
PURPOSE OF REVIEW IgG4-related disease (IgG4-RD) is emerging as a fibro-inflammatory entity affecting multiple organs, including manifold neurologic manifestations. This review discusses general characteristics of IgG4-RD neurologic disease including epidemiology, histology, clinical picture and treatment approaches. RECENT FINDINGS IgG4-RD is increasingly recognized as an important underlying pathophysiology in multiple disorders of neurologic interest, including orbital inflammation, infundibulo-hypophysitis, hypertrophic pachymeningitis, and even in rare cases CNS parenchymal disease and cranial vascular involvement. These were previously considered idiopathic and unrelated to any systemic disease but now known to share a common histopathology. New knowledge regarding the pathogenesis, clinical features and epidemiology of IgG4 is emerging, and new neurological manifestations continue to be described. Diagnostic progress includes CT-PET imaging, the use of flow cytometry for plasmablast quantification, and the use of reverse passive latex agglutination aiming to overcome the prozone phenomenon. Histopathologic confirmation of IgG4-RD remains the gold standard method of diagnosis but new diagnostic criteria for systemic and organ-specific disease are being proposed. Though glucorticoids remain the mainstay of therapy, relapses and incomplete recovery are frequent. Rituximab is a promising treatment in IgG4-RD that is severe, refractory or glucocorticoid dependent. Initiation of immunosuppression at an early stage of disease should be considered in order to avoid development of refractory fibrosis. SUMMARY The current review emphasizes the neurologic manifestations of IgG4-RD.
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Affiliation(s)
- G Saitakis
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA
| | - B K Chwalisz
- Division of Neuro-Ophthalmology, Department of Ophthalmology, Massachusetts Eye & Ear Infirmary/Harvard Medical School, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
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López-Simón E, Corriols-Noval P, Castillo-Ledesma N, Rodríguez-Martín M, Morales-Angulo C. Audiovestibular symptoms in patients with idiopathic hypertrophic pachymeningitis: Systematic literature review. Acta Otorrinolaringol Esp (Engl Ed) 2021; 72:S0001-6519(20)30171-0. [PMID: 33648724 DOI: 10.1016/j.otorri.2020.08.008] [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: 05/06/2020] [Revised: 08/15/2020] [Accepted: 08/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypertrophic pachymeningitis is an infrequent inflammatory disease resulting in thickening and fibrosis of the dura mater. In most cases, the cause in unknown and is called idiopathic hypertrophic pachymeningitis (IHP). Audiovestibular symptoms are infrequent and the pathogenesis is still unclear. MATERIALS AND METHODS A systematic literature review of cases with IHP and vestibular symptoms from 2000 to February 2020 was performed. PRISMA Checklist was followed and PubMED database, Web of Science and Cochrane library were searched. We report a case of an adolescent with a diagnosis of vestibular neuritis in the context of IHP attended in our clinic. RESULTS We reviewed 5 articles related to IHP and vestibular disorders. A total of 7 cases (5 women and 2 men), with ages between 27 and 68 years with IHP were found. They all had audiovestibular symptoms. In contrast to our patient, uni or bilateral neurosensorial hearing loss was reported in all cases. Furthermore, there is no other case report published describing the association between IHP and vestibular neuritis. High dose steroids improved symptoms in 85.7% of the patients. CONCLUSION Vestibular symptoms in IHP are uncommon and the pathogenesis is still debatable. Entrapment of nerves in the internal auditory canal and secondary neuronal damage could be suspected as the main cause of hearing and vestibular loss.
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Affiliation(s)
- Eugenia López-Simón
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España.
| | - Patricia Corriols-Noval
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Nathalia Castillo-Ledesma
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Minerva Rodríguez-Martín
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
| | - Carmelo Morales-Angulo
- Unidad de Otoneurología, Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander (Cantabria), España
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Woo PYM, Ng BCF, Wong JHM, Ng OKS, Chan TSK, Kwok NF, Chan KY. The protean manifestations of central nervous system IgG4-related hypertrophic pachymeningitis: a report of two cases. Chin Neurosurg J 2021; 7:13. [PMID: 33536053 DOI: 10.1186/s41016-021-00233-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 01/07/2021] [Indexed: 01/13/2023] Open
Abstract
Background IgG4-related hypertrophic pachymeningitis is a relative newly recognized and rare manifestation of IgG4-related disease, an immune-mediated fibroinflammatory tumefactive disorder. Fewer than 80 patients have been reported in the literature, and it can mimic common neurosurgical conditions. We describe the clinical presentation of two patients that were initially considered to have a subdural collection, tuberculous meningitis, and a cervical spinal meningioma, but were eventually diagnosed with this disease. Case presentation Two ethnic Chinese men, 86 and 62 years old, experienced a 4-week history of headache. Both patients had a history of autoimmune disease, namely glomerulonephritis and Grave’s disease, respectively. Magnetic resonance brain imaging revealed diffuse dural thickening with the latter patient exhibiting homogeneous and intense gadolinium-contrast enhancement. Since the 86-year-old patient also had progressive bilateral visual loss, giant cell arteritis was suspected and a 2-week course of glucocorticoid therapy was prescribed, but his symptoms failed to improve. The 62-year-old patient also had accompanying low-grade fever and was treated empirically as having tuberculous meningitis although there were no confirmatory microbiological findings. This patient further developed right hemiparesis, and additional imaging revealed a C4/5 intradural-extramedullary contrast-enhancing lesion resembling a meningioma causing cord compression. Both patients underwent neurosurgical intervention with the former undergoing a dural biopsy and the latter having the cervical lesion resected. The final diagnosis was IgG4-related hypertrophic pachymeningitis with the hallmark histological features of lymphoplasmacytic infiltration of IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. In addition, their serum IgG4 levels were elevated (i.e., > 135 mg/dL). Both patients received at least 6 months of glucocorticoid therapy while the latter also had azathioprine. Their symptoms improved significantly and recurrent lesions were not detected on follow-up imaging. Conclusions A high index of suspicion for this condition is suggested when a male patient with a history of autoimmune disease and compatible radiological findings, experiences subacute headache that is disproportionate to the degree of dural involvement. Neurosurgeons should consider early meningeal biopsy to establish a definitive histological diagnosis in order for early effective immunosuppressive treatment to be initiated and to avoid unnecessary morbidity.
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Machida M, Nakamura I, Sato A, Nakamura S, Miyazaki Y, Watanabe H. Hypertrophic pachymeningitis caused by Schizophyllum sp.: a novel case report. Infection 2020; 49:775-779. [PMID: 33156492 DOI: 10.1007/s15010-020-01544-y] [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: 08/10/2020] [Accepted: 10/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The pathogenic fungus Schizophyllum sp. can cause allergic fungal rhinosinusitis and allergic bronchopulmonary mycosis in humans. Sinus and lung infections due to Schizophyllum sp. have been reported globally; however, no case of hypertrophic pachymeningitis due to this pathogen has been reported yet. Herein, we describe for the first time, a case of hypertrophic pachymeningitis due to Schizophyllum sp. CASE PRESENTATION A 69-year-old woman visited the hospital with chief complaints of headache, right trigeminal neuralgia (third branch), ataxic gait, and deafness in the right ear. Magnetic resonance imaging revealed a tumor in the right sphenoidal sinus and thickening of the dura mater surrounding the right porus acusticus internus. Endoscopic sinus surgery and neuroendoscopic biopsy were performed to remove sinus lesions and intracranial lesions, respectively. Both pathological specimens showed findings indicative of filamentous fungi on Grocott's staining. DNA sequencing with the sinus specimen revealed Schizophyllum sp. as the causative pathogen, consistent with the diagnosis of fungal sinusitis and hypertrophic pachymeningitis. Intravenous liposomal amphotericin B was started, but owing to lack of improvement, the treatment was switched to intravenous voriconazole. We observed improvements in both radiological findings and symptoms. However, the symptoms exacerbated again when the trough level of voriconazole decreased. Upon increasing the voriconazole dose, a higher trough level was obtained and the symptoms improved. CONCLUSION Our study suggests that when symptoms of central nervous system infection due to Schizophyllum sp. do not improve with liposomal amphotericin B, voriconazole can be administered at high trough levels to improve the symptoms.
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Affiliation(s)
- Masaki Machida
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.,Tokyo Medical University, Department of Preventive Medicine and Public Health, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Itaru Nakamura
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Akihiro Sato
- KARADA Internal Medicine Clinic, 1-2-8-10 Nishigotanda, Shinagawa-ku, Tokyo, 141-0031, Japan
| | - Shigeki Nakamura
- Tokyo Medical University, Department of Microbiology, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo, 160-8402, Japan
| | - Yoshitsugu Miyazaki
- National Institute of Infectious Diseases, Department of Chemotherapy and Mycoses, 1-23-1Shinjuku-ku, Toyama, 162-8640, Japan
| | - Hidehiro Watanabe
- Tokyo Medical University Hospital, Department of Infection Prevention and Control, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Li HX, Zuo L, Peng XX, Zong Q, Zhang K, Liu YZ, Wang H, Han GL. Immunoglobulin G4-related hypertrophic pachymeningitis with spinal cord compression: A case report. J Neuroimmunol 2020; 347:577325. [PMID: 32731049 DOI: 10.1016/j.jneuroim.2020.577325] [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: 05/08/2020] [Revised: 05/22/2020] [Accepted: 07/09/2020] [Indexed: 01/03/2023]
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized inflammatory condition that can be found in many organs. However, spinal involvement is rare and has been described only in case reports and series. Here, we report a rare case of spinal IgG4-RD that resulted in hypertrophic pachymeningitis with spinal cord compression. This case expands the phenotypic presentation for the neurological sequelae of IgG4-RD. Our case hints that spinal IgG4-RD may be misdiagnosed, and IgG4-RD in patients should be considered when the patient has a dural mass. Although early surgery, steroids, and/or immunosuppressive therapy may prevent neurological complications, the side effects should receive more attention during treatment.
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Affiliation(s)
- Hong-Xing Li
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China.
| | - Lin Zuo
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Xiao-Xiao Peng
- Department of stomatology, Dongying District People's Hospital, 333 Jinan Road, Dongying, Shandong 257000, China
| | - Qiang Zong
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Kai Zhang
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Yi-Zhe Liu
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Han Wang
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China
| | - Guang-Liang Han
- Department of Neurosurgery, Shengli Oilfield Central Hospital, 31 Jinan Road, Dongying, Shandong 257000, China.
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Harabuchi Y, Kishibe K, Tateyama K, Morita Y, Yoshida N, Okada M, Kunimoto Y, Watanabe T, Inagaki A, Yoshida T, Imaizumi M, Nakamura T, Matsunobu T, Kobayashi S, Iino Y, Murakami S, Takahashi H, Tono T. Clinical characteristics, the diagnostic criteria and management recommendation of otitis media with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV) proposed by Japan Otological Society. Auris Nasus Larynx 2020; 48:2-14. [PMID: 32768313 DOI: 10.1016/j.anl.2020.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 02/06/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a form of necrotizing vasculitis with few or no immune deposits. It primarily affects small and medium blood vessels. AAV is classified into three categories, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangitis (EGPA), and two major ANCAs, proteinase 3 (PR3)-ANCA or myeloperoxidase (MPO)-ANCA are involved in their pathogenesis. Intractable otitis media frequently occurs in patients with GPA, MPA or EGPA, although all patients show similar clinical features, regardless of the type of AAV. Furthermore, approximately 15% patients with otitis media caused by AAV do not show ANCA positivity, histopathological evidence, or any other AAV-related lesions at the initial visit; therefore, these patients do not fulfill the ordinary diagnostic criteria for systemic AAV. Thus, we first proposed that this condition could be categorized as "otitis media with AAV (OMAAV)". Subsequently, the Japanese Otological Society (JOS) conducted a nationwide survey between December 2013 and February 2014 and identified 297 patients with OMAAV. The survey revealed that OMAAV is a disease that initially occurs in the middle ear and subsequently spreads to other organs such as the lungs and kidneys, with eventual involvement of all body organs. Severe sequelae such as facial palsy, hypertrophic pachymeningitis, complete deafness, and subarachnoid hemorrhage resulting in death can also occur. In this review, we introduce the clinical features, diagnostic criteria, and treatment strategies recommended by JOS for early diagnosis and treatment of OMAAV.
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Affiliation(s)
- Yasuaki Harabuchi
- Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical University, , Midorigaoka-Higashi 2-1-1-1, Asahikawa, 078-8510 Hokkaido, Japan.
| | - Kan Kishibe
- Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical University, , Midorigaoka-Higashi 2-1-1-1, Asahikawa, 078-8510 Hokkaido, Japan
| | - Kaori Tateyama
- Department of Otolaryngology, Oita University Faculty of Medicine, Oita, Japan
| | - Yuka Morita
- Department of Otolaryngology, Niigata University Faculty of Medicine, Niigata, Japan
| | - Naohiro Yoshida
- Department of Otolaryngology, Jichi Medical University Saitama Medical Center, Omiya, Japan
| | - Masahiro Okada
- Department of Otolaryngology, Ehime University Faculty of Medicine, Toon, Japan
| | - Yasuomi Kunimoto
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Tottori, Japan
| | - Takeshi Watanabe
- Department of Otolaryngology, Nagasaki University Faculty of Medicine, Nagasaki, Japan
| | - Akira Inagaki
- Department of Neuro-otolaryngology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tadao Yoshida
- Department of Otorhinolaryngology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuyoshi Imaizumi
- Department of Otolaryngology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Nakamura
- Department of Otolaryngology, Miyazaki University Faculty of Medicine, Miyazaki, Japan
| | | | - Shigeto Kobayashi
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Koshigaya, Japan
| | - Yukiko Iino
- Department of Otolaryngology, Jichi Medical University Saitama Medical Center, Omiya, Japan
| | - Shingo Murakami
- Department of Neuro-otolaryngology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Haruo Takahashi
- Department of Otolaryngology, Nagasaki University Faculty of Medicine, Nagasaki, Japan
| | - Tetsuya Tono
- Department of Otolaryngology, Miyazaki University Faculty of Medicine, Miyazaki, Japan
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Papathanasiou A, Yeo JM, Humberstone M, Hosseini AA. MOG-antibody-associated hypertrophic pachymeningitis. Mult Scler Relat Disord 2020; 42:102074. [PMID: 32361264 DOI: 10.1016/j.msard.2020.102074] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/22/2020] [Accepted: 03/25/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The clinical spectrum of myelin oligodendrocyte glycoprotein (MOG)-antibody-associated disease is expanding. OBJECTIVE To describe an unusual case of MOG-antibody-associated hypertrophic pachymeningitis (HP). METHODS Case study. RESULTS A 57-year-old female presented with a generalised seizure on a background of 3 months history of progressive cognitive decline and behavioural changes. Brain Magnetic Resonance Imaging (MRI) revealed widespread pachymeningeal enhancement and hyperintense signal in both hippocampi. Cerebrospinal Fluid (CSF) examination was normal. The patient was found positive for MOG-antibody. She clinically improved with steroids and the MRI abnormalities completely resolved. CONCLUSIONS Clinicians might consider testing for MOG-antibody in cases with HP.
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Affiliation(s)
- Athanasios Papathanasiou
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Jing-Ming Yeo
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Miles Humberstone
- Department of Neurology, Queen's Medical Centre, United Lincolnshire Hospitals NHS Trust, Nottingham, UK
| | - Akram A Hosseini
- Department of Neurology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
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Pensato U, Benini M, Fabbri VP, Avoni P, Foschini MP, Rizzo G, Liguori R. Headache and Dural Enhancement: Two Case Studies of Different Treatable Pathologies. World Neurosurg 2020; 141:306-310. [PMID: 32593763 DOI: 10.1016/j.wneu.2020.06.126] [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: 05/23/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) and spontaneous intracranial hypotension are different treatable diseases, which should promptly be recognized and treated to prevent neurologic sequelae. Headache and dural enhancement are the main features of both diseases, thus differentiating between these 2 conditions can be difficult. CASES DESCRIPTION We present 2 cases with headache and dural enhancement, in which the differential diagnosis was challenging at presentation because, in both cases, clear positional pain modification was not reported. Each patient was referred to us with the suspicion of a diagnosis actually affecting the other one. Based on further findings, which supported diagnosis of spontaneous intracranial hypotension in the first case and of HP in the second one, we briefly review clinical, radiologic, and laboratory features, which can help in the differential diagnosis. CONCLUSIONS An accurate diagnostic workup is mandatory to distinguish among HP and intracranial hypotension.
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Affiliation(s)
- Umberto Pensato
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Matteo Benini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Viscardo Paolo Fabbri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Patrizia Avoni
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Maria Pia Foschini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giovanni Rizzo
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Ota K, Nakazato Y, Okuda R, Yokoyama R, Kawasaki H, Tamura N, Yamamoto T. Polycystic subdural hygroma associated with immunoglobulin G4-related intracranial hypertrophic pachymeningitis: a case report. BMC Neurol 2020; 20:228. [PMID: 32498716 PMCID: PMC7271496 DOI: 10.1186/s12883-020-01815-z] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
Background Recent studies have examined hypertrophic pachymeningitis as an IgG4-RD. However, there are no reports of immunoglobulin G4 (IgG4)-related hypertrophic pachymeningitis with polycystic subdural hygroma. Case presentation A 56-year-old man presented to the hospital with complaints of a persistent, pulsatile, occipital headache and general malaise. Magnetic resonance imaging of the brain revealed hypertrophic pachymeningitis with polycystic subdural hygroma and hematoma. Based on the dural biopsy findings and exclusion of other diseases, the patient was diagnosed with immunoglobulin G4 (IgG4)-related hypertrophic pachymeningitis. IgG4-related diseases may cause subdural hygroma more commonly than other diseases that cause hypertrophic pachymeningitis. Conclusions This is the first case report discussing polycystic subdural hygroma and hematoma with IgG4-related hypertrophic pachymeningitis.
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Affiliation(s)
- Kazumichi Ota
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan.
| | - Yoshihiko Nakazato
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Risa Okuda
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Ryu Yokoyama
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Hitoshi Kawasaki
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Naotoshi Tamura
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Toshimasa Yamamoto
- Department of Neurology, Saitama Medical University, 38 Morohongo Moroyama, Iruma-gun, Saitama, 350-0495, Japan
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Ikeda J, Shimojima Y, Usami Y, Ueno KI, Kishida D, Sekijima Y. Cerebrospinal fluid biomarkers implicated in the pathogenesis of anti-neutrophil cytoplasmic antibody-related hypertrophic pachymeningitis. Clin Rheumatol 2020; 39:1803-11. [PMID: 32036585 DOI: 10.1007/s10067-020-04971-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Hypertrophic pachymeningitis (HP) related to anti-neutrophil cytoplasmic antibody (ANCA) is the most frequently seen immune-mediated HP. We investigated cerebrospinal fluid (CSF) biomarkers related to the pathogenesis of ANCA-related HP (ANCA-HP). METHODS The levels of B cell activation factor of the tumor necrosis factor family (BAFF), a proliferation-inducing ligand (APRIL), and transforming growth factor beta 1 (TGF-β1) in the CSF were compared between patients with ANCA-HP (n = 12), other types of immune-mediated HP (other HP; n = 12), multiple sclerosis (MS; n = 14), and non-inflammatory neurological disorders (NIND; n = 10). In addition, we evaluated whether ANCA would be detected in CSF. RESULTS CSF levels of BAFF, APRIL, and TGF-β1 were significantly increased in ANCA-HP and other HP. In particular, BAFF and APRIL levels were significantly correlated with the IgG index in ANCA-HP. In other HP, BAFF and APRIL levels were significantly correlated with cell counts and protein levels in CSF. Of 12 patients with ANCA-HP, the CSF of 7 patients (58%) tested positive for myeloperoxidase (MPO)- or proteinase 3 (PR3)-ANCA, while none of the CSF samples from other HP, MS, or NIND patients tested positive. CONCLUSION The levels of BAFF, APRIL, and TGF-β1 may serve as useful CSF biomarkers for assessing the disease activity of immune-mediated HP. Moreover, BAFF and APRIL in the CSF may be implicated in the pathogenesis of ANCA-HP via promoting autoreactive B cells, while detecting MPO- or PR3-ANCA in the CSF may be found in some patients with ANCA-HP.Key Points• CSF BAFF, APRIL, and TGF-β1 levels increase significantly in immune-mediated HP.• CSF BAFF and APRIL levels are significantly correlated with IgG index in ANCA-HP.• Detection of MPO- or PR3-ANCA in the CSF is found in some patients with ANCA-HP.• BAFF, APRIL, and ANCA in the CSF may be implicated in the pathogenesis of ANCA-HP.
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Wyrostek S, Chakrabarti S, Baldwin K, Avila JD. A Case of Hypertrophic Pachymeningitis Associated with Immunoglobulin-G4 and c-ANCA. Case Rep Neurol 2019; 11:290-294. [PMID: 31762760 PMCID: PMC6872998 DOI: 10.1159/000502569] [Citation(s) in RCA: 5] [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: 06/23/2019] [Accepted: 08/06/2019] [Indexed: 11/26/2022] Open
Abstract
Hypertrophic pachymeningitis (HP) is characterized by inflammation of the dura mater. It has been described in the setting of numerous systemic inflammatory diseases including immunoglobulin G4 (IgG4)-related disease as well as granulomatosis with polyangiitis (GPA). In this case report, we describe a 48-year-old man presenting with headache who was found to have HP and had systemic features of both GPA and IgG4-related disease as well as seropositivity for both cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and IgG4. He was treated with prednisone and rituximab with improvement in his symptoms. Co-occurrence of IgG4 and ANCA against myeloperoxidase has been reported in other cases of HP. The overlap between IgG4 and ANCA has also been described in other systemic manifestations of the diseases. These reports suggest a clinical overlap between ANCA and IgG4-related disease, and the case presented herein suggests an overlap between GPA and IgG4-related disease.
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Affiliation(s)
- Stephanie Wyrostek
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Satabdi Chakrabarti
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Kelly Baldwin
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - J David Avila
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, USA
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Kuribayashi T, Manabe Y, Fujiwara S, Omote Y, Narai H, Abe K. Combined Hypertrophic Pachymeningitis and Cerebral Venous Thrombosis in a Case of Granulomatosis with Polyangiitis. Case Rep Neurol 2019; 11:252-255. [PMID: 31572162 PMCID: PMC6751471 DOI: 10.1159/000502284] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 11/21/2022] Open
Abstract
We report a rare case of hypertrophic pachymeningitis (HP) and cerebral venous thrombosis associated with proteinase-3-antineutrophil cytoplasmic antibody (PR3-ANCA)-positive granulomatosis with polyangiitis (GPA). A 58-year-old male developed left headache after exudative otitis media. The laboratory data were positive for PR3-ANCA. Brain magnetic resonance imaging revealed bilateral paranasal sinusitis, left frontal lobe edema, and a thick dura mater with abnormal enhancement in the frontotemporal lobe. Magnetic resonance venography detected stenosis of the superior sagittal sinus. The patient was successfully treated with glucocorticoid, cyclophosphamide, and apixaban. Contrast neuroimaging should be performed for patients who present with unexplained headache, especially with middle ear and paranasal inflammation. These symptoms should be considered as GPA-related HP and cerebral venous thrombosis.
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Affiliation(s)
- Tadahiro Kuribayashi
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yasuhiro Manabe
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shunya Fujiwara
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yoshio Omote
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hisashi Narai
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine and Dentistry, Okayama University, Okayama, Japan
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Nambirajan A, Sharma MC, Garg K, Sriram S, Boorgula MT, Suri V. Large dural-based mass with bony hyperostosis in a 16-year-old male: IgG4-related disease mimicking lymphoplasmacyte-rich meningioma. Childs Nerv Syst 2019; 35:1423-1427. [PMID: 31073682 DOI: 10.1007/s00381-019-04187-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND IgG4-related disease is an autoimmune process that presents with tumefactive lesions characterized by storiform fibrosis, a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, obliterative phlebitis, and often elevated serum IgG4 levels. Central nervous system IgG4-related disease is very rare and usually occurs in the form of hypertrophic pachymeningitis or hypophysitis. Presentation as a large solitary meningioma-like mass with overlying hyperostosis in a young adult has not been reported before. CASE SUMMARY A 16-year-old male presented with focal seizures for 5 months. Imaging showed a large, extra-axial, and contrast-enhancing mass lesion in the left frontoparietal region with focal calvarial thickening. Histopathology revealed a fibrosclerotic lesion involving dura with a polymorphic infiltrate of plasma cells, mature lymphocytes, histiocytes, and occasional eosinophils. Immunohistochemical workup excluded the possibilities of meningioma, lymphoproliferative neoplasms, and histiocytic lesions. Majority of plasma cells were IgG4+ rendering a diagnosis of IgG4-related disease. Further serological and imaging workup did not reveal any evidence of systemic involvement. His serum IgG4 levels were normal. Considering a gross total resection of the lesion, no further treatment was given and the patient has been asymptomatic since. CONCLUSION IgG4-related lesions of the CNS are under-recognized and accurate diagnosis, especially in those with isolated CNS disease and normal serum IgG4 levels, necessitates robust histopathological and laboratory workup to exclude mimics. They may occur as large dural masses with hyperostosis and differentiation from lymphoplasmacyte-rich meningiomas, in particular, can be challenging. While steroids are the mainstay of treatment in IgG4-related disease, surgical resection may be curative in solitary lesions presenting with compressive symptoms.
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Affiliation(s)
- A Nambirajan
- Department of Pathology, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India
| | - M Chand Sharma
- Department of Pathology, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India
| | - K Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India
| | - S Sriram
- Department of Pathology, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India
| | - M Thej Boorgula
- Department of Neurosurgery, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India
| | - V Suri
- Department of Pathology, All India Institute of Medical Sciences, First Floor, Teaching Block, AIIMS, New Delhi, 110029, India.
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Nardone R, Brigo F, Covi M, Carnicelli L, Caleri F, Tischler H, Hauer L, Sellner J. Hypertrophic chronic pachymeningitis associated with Epstein-Barr virus reactivation: a case report. J Neurovirol 2019; 25:426-428. [PMID: 30747332 DOI: 10.1007/s13365-019-00731-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 12/17/2018] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
Hypertrophic pachymeningitis is a rare inflammatory condition characterized by the thickening of the dura mater. We describe a patient who presented with intractable headache and complex cranial nerve palsy. Hypertrophy of the frontal dura was accompanied by pleocytosis and detection of Epstein-Barr virus (EBV) by PCR in cerebrospinal fluid. Clinical symptoms gradually improved after acyclovir and corticosteroid treatment, whereas dural pathology remained unchanged on neuroimaging. This case points at an expansion of the spectrum of neurological manifestations for EBV.
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Affiliation(s)
- Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy. .,Department of Neurology, Christian Doppler Medical Center, Salzburg, Austria.
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Markus Covi
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Luca Carnicelli
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Francesca Caleri
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Hannes Tischler
- Department of Neurology, Franz Tappeiner Hospital, Via Rossini 5, I-39012, Merano (BZ), Italy
| | - Larissa Hauer
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Christian Doppler Medical Center, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Salzburg, Austria.,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Zhang X, Fujii T, Ogata H, Yamasaki R, Masaki K, Cui Y, Matsushita T, Isobe N, Kira JI. Cerebrospinal fluid cytokine/chemokine/growth factor profiles in idiopathic hypertrophic pachymeningitis. J Neuroimmunol 2019; 330:38-43. [PMID: 30784775 DOI: 10.1016/j.jneuroim.2019.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 11/12/2018] [Revised: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Hypertrophic pachymeningitis (HP) is a rare neurologic disease causing inflammatory fibrous thickening of the brain and spinal dura mater. We investigated the cerebrospinal fluid cytokine profile of HP by measuring 28 cytokines/chemokines/growth factors with a multiplexed fluorescent immunoassay in 8 patients with HP (6 idiopathic, 1 IgG4-related, 1 anti-neutrophil cytoplasmic antibody-related), and 11 with other non-inflammatory neurologic diseases (OND). Interleukin (IL)-4, IL-5, IL-9, IL-10, TNF-α, and CXCL8/IL-8 levels were significantly higher in idiopathic HP (IHP) than OND. Cluster analyses disclosed two major clusters: one mainly consisted of IHP and the other of OND, suggesting a unique cytokine profile in IHP.
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Affiliation(s)
- Xu Zhang
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China. shu-@neuro.med.kyushu-u.ac.jp
| | - Takayuki Fujii
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Katsuhisa Masaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yiwen Cui
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noriko Isobe
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Abstract
Hypertrophic pachymeningitis (HP) is a chronic, progressive diffuse inflammatory condition that leads to thickening of the dura mater and can be idiopathic or associated with sarcoidosis among other disorders. In this case report, we present a rare case of cervical spine HP in a 29-year-old woman in the post-partum period, who had a history of pituitary adenoma and juvenile rheumatoid arthritis. Magnetic resonance imaging (MRI) of the spine revealed a soft tissue mass and moderate cord compression. The patient underwent C3-C7 laminectomy. Pathological analysis of the cervical epidural mass demonstrated a reactive inflammatory cell process. Recurrence of symptoms and worsening of pachymeningitis on imaging studies warranted further work-up which revealed mediastinal/hilar lymphadenopathy. Transbronchial biopsy revealed non-caseating granulomatous disease consistent with sarcoidosis. The patient was started on oral steroids and eventually methotrexate with significant clinical and radiographic improvement. Follow-up imaging studies showed minimal dural thickening in the thoracic spine and eventually complete resolution. HP should be considered in a patient with spinal cord compression, myelopathy, and radicular pain of unclear etiology, and sarcoidosis should be considered in idiopathic cases.
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Affiliation(s)
- Hussam A Yacoub
- a Departments of Medicine (Division of Neurology) , Lehigh Valley Health Network , Allentown , PA , USA
| | - P Mark Li
- b Surgery (Division of Neurological/Spine Surgery) , Lehigh Valley Health Network , Allentown , PA , USA
| | | | - Dmitry Khaitov
- a Departments of Medicine (Division of Neurology) , Lehigh Valley Health Network , Allentown , PA , USA
| | - Daniel F Brown
- d Pathology , Lehigh Valley Health Network , Allentown , PA , USA
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Cação G, Calejo M, Alves JE, Medeiros PB, Vila-Cha N, Mendonça T, Taipa R, Silva AM, Damásio J. Clinical features of hypertrophic pachymeningitis in a center survey. Neurol Sci 2018; 40:543-551. [PMID: 30588552 DOI: 10.1007/s10072-018-3689-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 06/29/2018] [Accepted: 12/17/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is characterized by cranial and/or spinal thickening of the dura mater with or without associated inflammation. Neuroimaging studies reveal dura mater thickening and focal or diffuse contrast enhancement. It is described in association with trauma, infections, tumors, autoimmune/inflammatory diseases, and cerebrospinal fluid hypotension syndrome, with some cases remaining idiopathic. METHODS A retrospective study was conducted with patients' identification through a key terms search within MRI reports in the period of July 2008 to September 2015. Clinical files, MRI, laboratory, and pathology data were reviewed. RESULTS Fifty-three patients were identified and 20 were excluded because they did not meet the inclusion criteria. Of the 33 included, 19 were female, with a mean age at symptoms onset of 51.2 ± 17.6 years. The most common presenting symptoms were headache and cranial nerves palsy, followed by seizures, delirium, lumbar pain, cognitive decline, motor deficit, and language impairment. In 17 patients, a neoplastic etiology was identified; in eight, inflammatory/autoimmune; in six, infectious; and two were classified as idiopathic. Of the eight patients with inflammatory/autoimmune etiology, four had possible IgG4-related disease (IgG4-RD) and the remaining had granulomatosis with polyangiitis, sarcoidosis, rheumatoid arthritis, and Tolosa-Hunt syndrome. Treatment was directed according to the underlying etiology. DISCUSSION In the described series, a female predominance was identified, with symptoms' onset in the 5th decade. Although headache was the most common symptom, clinical presentation was varied, emphasizing the role of MRI in HP diagnosis. The underlying etiologies were diverse, with only a few cases remaining idiopathic, also reflecting the contribution of the recently described IgG4-RD.
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Affiliation(s)
- Gonçalo Cação
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Margarida Calejo
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - José Eduardo Alves
- Neuroradiology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | | | - Nuno Vila-Cha
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Teresa Mendonça
- Internal Medicine Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Taipa
- Neuropathology Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Joana Damásio
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
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Imafuku A, Sawa N, Kawada M, Hiramatsu R, Hasegawa E, Yamanouchi M, Hoshino J, Ubara Y, Takaichi K. Incidence and risk factors of new-onset hypertrophic pachymeningitis in patients with anti-neutrophil antibody-associated vasculitis: using logistic regression and classification tree analysis. Clin Rheumatol 2018; 38:1039-1046. [PMID: 30483978 DOI: 10.1007/s10067-018-4372-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 09/28/2018] [Revised: 11/11/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Hypertrophic pachymeningitis (HP) is a rare complication in patients with anti-neutrophil antibody-associated vasculitis (AAV); its clinical features, incidence, and risk factors remain unknown. We aimed to clarify the prevalence, clinical features, and factors associated with new-onset HP in patients with AAV. METHOD A retrospective cohort study involving 93 patients with AAV was conducted. HP incidence between patients with granulomatosis with polyangiitis (GPA) and those with microscopic polyangiitis (MPA) was compared to investigate risk factors associated with HP. We performed only univariate analysis using logistic regression and classification tree (CART) analysis due to the small number of HP cases. RESULTS Among the 93 patients (76 with MPA and 17 with GPA), only 6 patients developed HP (1 with MPA, 5 with GPA) over an average observation period of 4 years; all patients who developed HP were positive for myeloperoxidase anti-neutrophil antibody. HP incidence was significantly higher in patients with GPA than in those with MPA (60.2 versus 3.3 persons per 1000 person-years, respectively, P = 0.002). The univariate analysis revealed that otitis media (P < 0.001) and sinusitis (P = 0.014) were associated with new-onset HP. Univariate CART analysis grouped the patients into patients with HP who have otitis media (33%) and patients with HP who have sinusitis (21%). The odds ratio of otitis media adjusted by age and first diagnosis of AAV was 38.1 (95% confidence interval, 3.08-331.4; P = 0.004). CONCLUSIONS Although only in the univariate analysis, otitis media was the most discriminating factor to predict new-onset HP in patients with AAV.
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Affiliation(s)
- Aya Imafuku
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan. .,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan.
| | - Masahiro Kawada
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Rikako Hiramatsu
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Eiko Hasegawa
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Masayuki Yamanouchi
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Junichi Hoshino
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Yoshihumi Ubara
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
| | - Kenmei Takaichi
- Department of Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minatoku, 105-8470, Japan
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Peng A, Yang X, Wu W, Xiao Z, Xie D, Ge S. Anti-neutrophil cytoplasmic antibody-associated hypertrophic cranial pachymeningitis and otitis media: a review of literature. Eur Arch Otorhinolaryngol 2018; 275:2915-2923. [PMID: 30328500 PMCID: PMC6244657 DOI: 10.1007/s00405-018-5172-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 08/24/2018] [Accepted: 10/11/2018] [Indexed: 12/24/2022]
Abstract
Background and objective It has been recognized that anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides may lead to hypertrophic pachymeningitis (HP) or intractable otitis media (OM). To our knowledge, few cases of coexistent ANCA-related HP and OM have been described previously. To increase awareness of this disease, we reviewed the literature describing patients with HP and intractable OM in a population with AAV to guide clinical decision making for otolaryngologists. Methods PubMed was searched with the following terms: ANCA-associated vasculitis, otitis media, and hypertrophic pachymeningitis. Only patients with concomitant AAV, OM and HP were considered and included in this review. Results A total of 243 articles were reviewed, and of these, 6 met inclusion criteria. Headache, cranial polyneuropathy, and intractable OM with effusion or granulation were common. Serum MPO–ANCA positivity was most common in Asian patients. Almost all patients had dural mater thickening on gadolinium-enhanced magnetic resonance imaging of the brain. Corticosteroids plus an immunosuppressant was more effective and most patients had improved hearing after treatment, but approximately 50% of subjects had disease relapse. Conclusion In this review, we summarized the current knowledge on the clinical features, diagnosis, treatment, and pathogenesis of this disease. We should carefully detect the potential cases of ANCA-related HP and OM in patients with intractable OM, HP, or AAV, and make the optimal treatment plan to avoid long-term neurological complications and irreversible hearing loss. Furthermore, due to an increased possibility of relapse, close follow-up, including a hearing test, ANCA titers, imaging examination, and detection of toxic and side effects of immunosuppressive therapy, are necessary.
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Affiliation(s)
- Anquan Peng
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Xinming Yang
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Weijing Wu
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Zian Xiao
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Dinghua Xie
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Shenglei Ge
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, People's Republic of China.
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Winkel M, Lawton CD, Sanusi OR, Horbinski CM, Dahdaleh NS, Smith ZA. Neuro-surgical considerations for treating IgG4-related disease with rare spinal epidural compression. Surg Neurol Int 2018; 9:209. [PMID: 30488007 PMCID: PMC6213809 DOI: 10.4103/sni.sni_156_18] [Citation(s) in RCA: 10] [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: 05/28/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a group of distinct autoimmune disorders affecting nearly every organ system in the body. Although central nervous system involvement is quite rare, it may present as hypertrophic pachymeningitis more frequently affecting the brain than the spine. In this study, we provide a case of spinal IgG4-RD pseudotumor resulting in cord compression, and a comprehensive review of the literature. Case Description: A patient presented with an extradural mass causing spinal cord compression at the L2-L3 level. Pathologically this proved to be an IgG4-RD pseudotumor. The patient was treated with thecal sac decompression and post-operative steroids that resulted in complete resolution of his symptoms. Conclusion: IgG4-RD is typically under-recognized and under-reported in the spinal literature. The clinical spinal presentation and non-surgical vs. surgical treatment are relatively straightforward. Although most cases can be managed with a course of steroids, surgical decompression may be required in patients presenting with spinal cord and/or nerve root compression. The differential diagnoses for these spinal tumors or pseudotumors should include IgG4-RD. Early detection and appropriate treatment can lead to satisfactory outcomes.
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Affiliation(s)
- Maia Winkel
- Department of Neurological Surgery, Chicago Medical School At Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Cort D Lawton
- Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Olabisi R Sanusi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Craig M Horbinski
- Department of Neurological Surgery and Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Tsuchida K, Fukumura S, Yamamoto A, Akiyama Y, Hirano H, Tsutsumi H. Rapidly progressive fatal idiopathic hypertrophic pachymeningitis with brainstem involvement in a child. Childs Nerv Syst 2018; 34:1795-8. [PMID: 29730790 DOI: 10.1007/s00381-018-3819-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare disorder characterized by diffuse thickening of the dura mater with resultant neurologic deficits. HP develops secondary to various conditions or idiopathically usually in adults but rarely in children. CASE REPORT We describe a 3-year-old female child with idiopathic HP. Her HP involved the entire central nervous system with progression into the brainstem. The lesion responded poorly to pulsed steroids or any immunosuppressants. The brainstem lesion grew rapidly and formed various nodules that ultimately resulted in brain death. This is the first fatal case of HP in a child.
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Barbieri FR, Novegno F, Iaquinandi A, Lunardi P. Hypertrophic Pachymeningitis and Hydrocephalus-The Role of Neuroendoscopy: Case Report and Review of the Literature. World Neurosurg 2018; 119:183-188. [PMID: 30075265 DOI: 10.1016/j.wneu.2018.07.194] [Citation(s) in RCA: 3] [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: 05/02/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare primary or secondary inflammatory disorder that manifests with thickening of dura mater involving predominantly the tentorium and falx in the focal form. Hydrocephalus has not been reported in association with secondary HP. CASE DESCRIPTION A 61-year-old woman presented with intracranial HP of the posterior fossa secondary to Wegener granulomatosis not responsive to corticosteroid therapy. Owing to the association of noncommunicating hydrocephalus, endoscopic third ventriculostomy was performed. There was immediate improvement of neurologic symptoms and no postoperative complications. The patient had very good clinical and radiologic outcome at 1-year follow-up. CONCLUSIONS In a case of noncommunicating hydrocephalus related to focal HP of the posterior fossa, endoscopic third ventriculostomy was effective in resolving symptoms related to increased intracranial pressure. The physiopathogenetic mechanisms and therapeutic strategies were discussed along with a review of the most relevant literature.
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Affiliation(s)
| | - Federica Novegno
- Department of Neurosurgery, Policlinico Tor Vergata, Rome, Italy
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Ueno T, Hikichi H, Kon T, Nunomura JI, Tomiyama M. Bacterial meningitis due to Streptococcus pneumoniae following untreated idiopathic hypertrophic pachymeningitis. J Neurol Sci 2017; 380:44-45. [PMID: 28870586 DOI: 10.1016/j.jns.2017.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Hiroki Hikichi
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Tomoya Kon
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Jin-Ichi Nunomura
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
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Tang R, Li F, Chen Q. A case report of atypical long segmental thoracic hypertrophic pachymeningitis with ossification of ligamentum flavum and literature review. Eur Spine J 2017; 26:202-206. [PMID: 28365857 DOI: 10.1007/s00586-017-5030-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 03/02/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Thoracic spinal stenosis caused by ossification of ligamentum flavum (OLF) is frequently seen, but long segmental thoracic spinal cord compressed by consequent thickened ligament posteriorly was rarely reported. OBJECT To report a case of thoracic spinal cord compression caused by atypical long segmental thoracic hypertrophic pachymeningitis (HP) with OLF. METHODS A 55-year-old woman presenting with weakness and numbness in lower extremities was admitted to our department. Combined with physical examination and MRI results, diagnosis of HP with OLF was considered. Due to progressive neurological symptoms, thoracic decompression with internal fixation was performed. RESULTS The patient felt a reduced numbness and improvement in motor functions 5 days after surgery. Pathological examination suggested the diagnosis of HP with OLF. CONCLUSIONS HP is a rare condition characterized as thickening and enhancement of the dura mater on contrast-enhanced MRI and chronic inflammatory hyperplasia changes on biopsy. A case of atypical HP complicated with OLF is described. Chondrocytes infiltration in histological examination indicates the potential of ossification in HP.
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Affiliation(s)
- Ruofu Tang
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Street N88, Hangzhou, Zhejiang, China.
| | - Fangcai Li
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Street N88, Hangzhou, Zhejiang, China
| | - Qixin Chen
- Department of Orthopedics, The Second Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Street N88, Hangzhou, Zhejiang, China
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Harsch IA, Schiffer A, Konturek PC. Hypertrophic Pachymeningitis and the Syndrome of Inappropriate Antidiuretic Hormone Secretion: Coincidence or Cause? Med Princ Pract 2017; 26:289-291. [PMID: 28245481 PMCID: PMC5588415 DOI: 10.1159/000466697] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/28/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate a potential cause of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). CLINICAL PRESENTATION AND INTERVENTION A 70-year-old female patient had nausea and collapsed. Although euvolemic, pathological laboratory findings showed hyponatremia and hypoosmolality, and cerebral magnetic resonance imaging showed hypertrophic pachymeningitis. Secondary hypertrophic pachymeningitis was excluded. Other nonneurological reasons for SIADH were also excluded. Moderate fluid restriction restored an almost normal serum osmolality and sodium. CONCLUSION This case of SIADH was conservatively treated with moderate fluid restriction that almost restored normal serum osmolality and sodium levels.
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Affiliation(s)
- Igor Alexander Harsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine II, Thuringia Clinic Saalfeld, Saalfeld, Germany
- *Prof. Dr. Igor Alexander Harsch, MD, Thuringia Clinic Saalfeld “Georgius Agricola”, Rainweg 68, DE-07318 Saalfeld/Saale (Germany), E-Mail
| | - Anne Schiffer
- Division of Neurology, Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Thuringia Clinic Saalfeld, Saalfeld, Germany
| | - Peter C. Konturek
- Division of Gastroenterology, Department of Internal Medicine II, Thuringia Clinic Saalfeld, Saalfeld, Germany
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Ushiyama S, Kinoshita T, Shimojima Y, Ohashi N, Kishida D, Miyazaki D, Nakamura K, Sekijima Y, Ikeda SI. Hypertrophic Pachymeningitis as an Early Manifestation of Relapsing Polychondritis: Case Report and Review of the Literature. Case Rep Neurol 2016; 8:211-217. [PMID: 27920712 PMCID: PMC5121543 DOI: 10.1159/000450850] [Citation(s) in RCA: 8] [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: 08/09/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022] Open
Abstract
Neurological involvement in relapsing polychondritis (RP) is relatively rare. We describe the case of an 80-year-old man who presented with hypertrophic pachymeningitis (HP) together with arthritis as the first manifestation of RP. Auricular chondritis, which subsequently determined the diagnosis of RP, occurred a few weeks after the detection of HP. The neurological symptoms, as well as arthritis, were promptly improved by treatment with corticosteroids. It is generally difficult to diagnose RP in the absence of typical cartilaginous involvement; however, the present case suggests that HP may occur as an early clinical manifestation of RP.
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Affiliation(s)
- Satoru Ushiyama
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomomi Kinoshita
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuhiko Ohashi
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Dai Kishida
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Daigo Miyazaki
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Katsuya Nakamura
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Shu-Ichi Ikeda
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
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Kon T, Nishijima H, Haga R, Funamizu Y, Ueno T, Arai A, Suzuki C, Nunomura JI, Baba M, Takahashi T, Tomiyama M. Hypertrophic pachymeningitis accompanying neuromyelitis optica spectrum disorder: A case report. J Neuroimmunol 2015; 287:27-8. [PMID: 26439957 DOI: 10.1016/j.jneuroim.2015.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 07/10/2015] [Revised: 07/28/2015] [Accepted: 08/04/2015] [Indexed: 11/29/2022]
Abstract
We report a case of idiopathic cerebral hypertrophic pachymeningitis accompanying neuromyelitis optica spectrum disorder. No other identifiable cause of pachymeningitis was detected. Corticosteroid therapy was effective for both diseases. Hypertrophic pachymeningitis is closely related to autoimmune inflammatory disease of the central nervous system. This case supports the hypothesis that hypertrophic pachymeningitis can be a rare comorbidity of neuromyelitis optica spectrum disorder.
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Affiliation(s)
- Tomoya Kon
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Haruo Nishijima
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Rie Haga
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yukihisa Funamizu
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Chieko Suzuki
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Jin-ichi Nunomura
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masayuki Baba
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Toshiyuki Takahashi
- Department of Neurology, Tohoku University School of Medicine, Sendai, Japan; Department of Neurology, Yonezawa National Hospital, Yonezawa, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
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Yoon BN, Kim SJ, Lim MJ, Han JY, Lee KW, Sung JJ, Ha CK, Choi SH. Neuro-Behçet's Disease Presenting as Hypertrophic Pachymeningitis. Exp Neurobiol 2015; 24:252-5. [PMID: 26412975 PMCID: PMC4580753 DOI: 10.5607/en.2015.24.3.252] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 06/02/2015] [Revised: 08/22/2015] [Accepted: 09/08/2015] [Indexed: 11/19/2022] Open
Abstract
A 25-year-old man presented with blurred vision and chronic headache. His brain MRI revealed bilateral frontal pachymeningeal enhancement with leptomeningeal enhancement. The patient had experienced recurrent oral ulcer and had anterior uveitis and papulopustules skin lesion. We diagnosed him with hypertrophic pachymeningitis (HP) associated with neuro-Behçet's disease (NBD). There have been few reports describing HP in patients with NBD. We report a case of NBD presenting as HP.
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Affiliation(s)
- Byung-Nam Yoon
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
| | - Soo-Jung Kim
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
| | - Mi-Jin Lim
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon 22332, Korea
| | - Jee-Young Han
- Department of Neurology, Seoul National University Hospital, College of Medicine, Seoul 03080, Korea
| | - Kwang-Woo Lee
- Department of Neurology, Seoul National University Hospital, College of Medicine, Seoul 03080, Korea
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University Hospital, College of Medicine, Seoul 03080, Korea
| | - Choong Kun Ha
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
| | - Seong Hye Choi
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
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Dash GK, Thomas B, Nair M, Radhakrishnan A. Clinico-radiological spectrum and outcome in idiopathic hypertrophic pachymeningitis. J Neurol Sci 2015; 350:51-60. [PMID: 25703277 DOI: 10.1016/j.jns.2015.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [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: 10/31/2014] [Revised: 01/25/2015] [Accepted: 02/05/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To elucidate the clinico-radiological features, treatment response and outcome of a large cohort of patients (n=20) with idiopathic hypertrophic pachymeningitis (IHP) and to examine if any of these features could differentiate between IHP and secondary causes of hypertrophic pachymeningitis (SHP). METHODS 20 patients with IHP diagnosed between 1998 and 2009 formed the study cohort. We adopted a validated clinical score to quantitatively assess and document their neurological disability and to compare their pre- and post-treatment outcomes. Appropriate statistical analysis was done to look for any clinical and/or radiological features to differentiate IHP from SHP. RESULTS Out of the twenty eight consecutive patients with pachymeningitis, 20 were having IHP and 8 were having SHP (Tuberculosis-5, Sarcoidosis-2, Wegener's granulomatosis-1). In IHP, headache and visual symptoms dominated the clinical symptomatology (80% and 75%). In MRI, the peripheral pattern of contrast enhancement was more common with IHP (p=0.03). The posterior falx and tentorium showing a hypointense center ("fibrosis") and enhancing periphery ("active inflammation") together mimicking "Eiffel-by-night" sign was found to be more commonly associated with IHP (60% vs 12.5%, p=0.03). Biopsy was done in 9 patients. At a mean follow-up of 51 months (range 24-144 months), the mean pretreatment clinical score improved from 6.55 to 1.80 in 20 patients with IHP (p<0.001). CONCLUSIONS Our data on the largest cohort of patients with IHP would shed light into its clinico-radiological spectrum, treatment and outcome. The prognosis is satisfactory if managed appropriately. We have highlighted the role of MRI in differentiating between IHP and other causes of SHP.
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Affiliation(s)
- Gopal Krishna Dash
- Department of Neurology and Imaging & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Bejoy Thomas
- Department of Neurology and Imaging & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Muralidharan Nair
- Department of Neurology and Imaging & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Ashalatha Radhakrishnan
- Department of Neurology and Imaging & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
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Shiraishi W, Hayashi S, Iwanaga Y, Murai H, Yamamoto A, Kira JI. A case of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome presenting with hypertrophic pachymeningitis. J Neurol Sci 2014; 349:229-31. [PMID: 25549534 DOI: 10.1016/j.jns.2014.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 06/11/2014] [Revised: 11/04/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
A 43-year-old woman with a 3-year history of headache, fever, and swelling of the forehead, presented to our hospital. A general examination revealed palmar and plantar pustules. Blood analyses showed an elevated white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate. Brain MRI revealed a partially thickened cranial bone with gadolinium enhancement, and also abnormally enhanced dura mater. Bone scintigraphy showed involvement of the cranial bone and bilateral sternoclavicular joints. Palmar skin biopsy indicated palmoplantar pustulosis. From these results, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome with associated hypertrophic pachymeningitis was diagnosed. After corticosteroid therapy and tonsillectomy, the clinical symptoms and radiological abnormalities were improved. Clinicians should be aware of SAPHO as a potential unusual cause of hypertrophic pachymeningitis.
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Affiliation(s)
- Wataru Shiraishi
- Department of Neurology, JCHO Kyushu Hospital, 8-1 kishinoura, Yahatanishi-ku, Kitakyushu City, Fukuoka 806-8501, Japan; Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Shintaro Hayashi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yasutaka Iwanaga
- Department of Neurology, JCHO Kyushu Hospital, 8-1 kishinoura, Yahatanishi-ku, Kitakyushu City, Fukuoka 806-8501, Japan
| | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Akifumi Yamamoto
- Department of Neurology, JCHO Kyushu Hospital, 8-1 kishinoura, Yahatanishi-ku, Kitakyushu City, Fukuoka 806-8501, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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Takahashi H, Yamashita H, Morooka M, Kubota K, Takahashi Y, Kaneko H, Kano T, Mimori A. The utility of FDG-PET/CT and other imaging techniques in the evaluation of IgG4-related disease. Joint Bone Spine 2014; 81:331-6. [PMID: 24568886 DOI: 10.1016/j.jbspin.2014.01.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [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: 11/07/2013] [Accepted: 01/15/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVES This study aimed to evaluate the utility of imaging techniques, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), in immunoglobulin (IgG)4-related disease (IgG4-RD). METHODS We reviewed eight IgG4-RD patients who were referred to our hospital between August 2006 and April 2012. All cases underwent FDG-PET/CT and brain magnetic resonance imaging (MRI) and endobronchial ultrasonography (EBUS) were also performed in five cases and one case, respectively. RESULTS Although nearly all patients with IgG4-RD in this study were negative for CRP (mean 0.22 mg/dL), various organ involvement sites were detected by FDG-PET/CT. In the active phase in two autoimmune pancreatitis (AIP) cases, FDG-PET/CT showed longitudinal and heterogeneous FDG accumulation in the pancreas with FDG uptake in the hilar or mediastinal lymph nodes. Follow-up FDG-PET/CT after therapy in one case revealed that the abnormal FDG uptake in all affected lesions had completely disappeared. In two cases, brain MRI revealed asymptomatic hypertrophic pachymeningitis. In one case, EBUS imaging of mediastinal lymph node swelling was consistent with tortuous vessels with high Doppler signals and hyperechoic strands between lymph nodes. CONCLUSIONS When FDG-PET/CT shows FDG accumulation, characteristic of IgG4-RD in organs, without evidence of an associated inflammatory reaction, a diagnosis of IgG4-RD can be made. Treatment effects can be assessed by the disappearance of FDG uptake. A routine brain MRI is useful for detecting asymptomatic hypertrophic pachymeningitis. EBUS may also be useful for differentiating among the etiologies of lymphadenopathy with characteristic sonographic imaging findings.
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Affiliation(s)
- Hiroyuki Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan.
| | - Miyako Morooka
- Department of Radiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Kazuo Kubota
- Department of Radiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Yuko Takahashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Toshikazu Kano
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
| | - Akio Mimori
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655 Japan
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