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Zhang Y, Chen H, Chen F. A case report of Immunoglobulin-G4-related hypertrophic sclerosing pachymeningitis. Radiol Case Rep 2024; 19:1758-1763. [PMID: 38390429 PMCID: PMC10883778 DOI: 10.1016/j.radcr.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/23/2024] [Accepted: 01/27/2024] [Indexed: 02/24/2024] Open
Abstract
IgG4-related diseases (IgG4-RD) are a group of chronic progressive autoimmune diseases of unknown etiology that are increasingly recognized as an important pathophysiological basis for a variety of systemic diseases. It is thought to involve almost any organ of the body, but the involvement of the central nervous system is relatively rare. We report the case of a 56-year-old male patient admitted to the hospital d recurrent dizziness and nausea for more than 3 months. The preoperative imaging was misdiagnosed as a meningioma, with this lesion demonstrated localized inhomogeneous thickening of the meninges in the left parietal region on T2-weighted and T2 fat suppression sequences with localized nodular changes. The patient's final pathologic diagnosis was IgG4-associated sclerosing thick encephalitis. The diagnosis of IgG4-associated hypertrophic pontine meningitis is challenging. Clinically, IgG4-associated sclerosing diseases usually present as mass-like lesions, which can be easily misdiagnosed as neoplastic lesions due to their similar appearance. These fundamentally recognized autoimmune disorders respond well to corticosteroid therapy. Therefore, accurate detection of IgG4-related disease is critical to prevent patients from undergoing unnecessary surgery.
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Affiliation(s)
- Yan Zhang
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), NO. 19, XIUHUA ST, XIUYING DIC, Haikou, Hainan 570311, P.R. China
| | - Huijuan Chen
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), NO. 19, XIUHUA ST, XIUYING DIC, Haikou, Hainan 570311, P.R. China
| | - Feng Chen
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), NO. 19, XIUHUA ST, XIUYING DIC, Haikou, Hainan 570311, P.R. China
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Peng Y, Lv ML, Feng H, Zhong JQ. Tuberculous hypertrophic pachymeningitis masquerading as meningioma: A case report. Asian J Surg 2024; 47:2313-2314. [PMID: 38336489 DOI: 10.1016/j.asjsur.2024.01.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Affiliation(s)
- Yu Peng
- Department of Radiology, Zigong First People's Hospital, 643000, Zigong, PR China
| | - Min-Li Lv
- Department of Radiology, Zigong First People's Hospital, 643000, Zigong, PR China
| | - Hao Feng
- Department of Radiology, Zigong First People's Hospital, 643000, Zigong, PR China
| | - Jian-Quan Zhong
- Department of Radiology, Zigong First People's Hospital, 643000, Zigong, PR China.
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Suezumi K, Uehara T, Taira A, Akamatsu N, Tanaka T, Hayashi Y, Komuta M, Shiomi T, Murai H. IgG4-related pachyleptomeningitis with inflammatory pseudotumor. eNeurologicalSci 2024; 34:100490. [PMID: 38229909 PMCID: PMC10789997 DOI: 10.1016/j.ensci.2023.100490] [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: 04/15/2023] [Revised: 06/23/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024] Open
Abstract
•We report the first case of IgG4-related pachyleptomeningitis.•Our case showed also an inflammatory pseudotumor on the side ipsilateral to the pachyleptomeningitis.•The pachyleptomeningitis is probably due to inflammation from the dural pseudotumor spreading along the adjacent meninges.
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Affiliation(s)
- Koki Suezumi
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Taira Uehara
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Akihiko Taira
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Naoki Akamatsu
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Yuichiro Hayashi
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Mina Komuta
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Takayuki Shiomi
- Department of Anatomic Pathology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita Hospital, Narita, Japan
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Abbas G, Karamchandani J, Ciarallo A, Durcan L. IgG4-Related Disease of the Central Nervous System: A Case Series. Can J Neurol Sci 2023; 50:907-913. [PMID: 36366774 DOI: 10.1017/cjn.2022.321] [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] [Indexed: 11/12/2022]
Abstract
IgG4-related disease (IgG4-RD) is a rare and often misdiagnosed disorder with limited literature that highlights the different neurological presentations of this treatable disease. The diagnosis of IgG4-RD could be challenging, while imaging is fundamental for the diagnosis, biopsy is considered the gold standard. Most cases respond well to steroids and immunosuppressive therapy. This is a case series study that illustrates the varied neurological presentations of IgG4-RD through three different patients that were followed at the Montreal Neurological Institute. This paper takes you through the diagnostic strategy that we followed to accurately diagnose and treat those patients.
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Affiliation(s)
- Ghada Abbas
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
- Department of Neurology, McGill University, Montreal, Quebec, Canada
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, Montreal, Quebec, Canada
| | - Jason Karamchandani
- Department of Pathology, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Anthony Ciarallo
- Department of Diagnostic Radiology, Nuclear Medicine, McGill University, Montreal, Quebec, Canada
| | - Liam Durcan
- Department of Neurology, McGill University, Montreal, Quebec, Canada
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, Montreal, Quebec, Canada
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Demas A, Labbé F, Vandendriessche A, Langlois V. Focal pachymeningitis in a returning traveler: Don't forget melioidosis. IDCases 2023; 33:e01834. [PMID: 37457812 PMCID: PMC10339118 DOI: 10.1016/j.idcr.2023.e01834] [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: 04/26/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
Background Melioidosis is an endemic disease in South-East Asia and Northern Australia caused by a Gram-negative bacillus, Burkholderia pseudomallei. Manifestations are wide and neurological involvement have rarely been described. Methods In this paper, we report a patient returning from Asia with an unusual infection including CNS involvement consistent with a melioidosis. Results This diagnosis was challenging and complex to carry out with multiple considerations, mainly because of the atypical nature of the germ. Burkholderia pseudomallei can be easily misidentified with Burkholderia thailandensis (rarely pathogenic to humans) during bacterial culture because of their phylogenetic proximity. The main pitfall of the management was that the responsible infectious agent was not referenced in the MALDI-TOF (considered as a bioterrorism agent) and led to a wrong strategy. Conclusions This case of melioidosis shows the difficulty regarding the diagnosis of this disease in a patient returning from an endemic zone and its frequent multiple organs involvement. Melioidosis is an emerging, potentially fatal disease which requires prolonged antibiotic treatment. Difficulties in clinical microbiology laboratories diagnosis of melioidosis, especially in non-endemic areas where clinical suspicion is low, may delay treatment and affect disease outcomes.
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Affiliation(s)
- Alexis Demas
- Neurology Unit, Hospital of Le Havre, Department of Neurology, Le Havre Hospital, 29 avenue Pierre Mendes, 76290, Le Havre Cedex, France
| | - Franck Labbé
- Biology Services, Hospital of Le Havre, Department of Biology Le Havre Hospital, 29 avenue Pierre Mendes, 76290, Le Havre Cedex, France
| | - Anne Vandendriessche
- Infectious Diseases Unit, Hospital of Le Havre, Department of Infectious Diseases, Le Havre Hospital, 29 avenue Pierre Mendes, 76290, Le Havre Cedex, France
| | - Vincent Langlois
- Department of Infectious Diseases and Internal Medicine, Le Havre Hospital, 29 avenue Pierre Mendes, 76290, Le Havre Cedex, France
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Gautier F, Neumann L, Adle-Biassete H, Rubenstein E, Bernat AL, Chimon A, Mouly S, Sène D, Comarmond C. Pachymeningitis associated with IgG4-related disease and ANCA positivity: Case report and review of the literature. Autoimmun Rev 2023; 22:103285. [PMID: 36738953 DOI: 10.1016/j.autrev.2023.103285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Hypertrophic pachymeningitis is a rare clinical disorder involving localized or diffuse thickening of the dura mater. Considering pachymeningitis is both in the clinical spectrum of IgG4-RD and ANCA vasculitis (specifically granulomatosis with polyangiitis), an overlap syndrome is discussed. METHODS We report a case of hypertrophic pachymeningitis revealed by headache and cranial nerve dysfunction, and coexistence of biopsy-proven IgG4-RD pachymeningitis and MPO-ANCA positivity. Furthermore, all cases previously reported in the literature of pachymeningitis with IgG4-RD and presence of ANCA were analyzed. RESULTS Thirteen patients with pachymeningitis, IgG4-RD and ANCA were analyzed. Patients with HP-related IgG4 and ANCA are mainly male (8, 62%). Median age at diagnosis was 64 years. Main clinical manifestations at diagnosis were localized to the head and neck with headaches (10, 77%), cranial nerve dysfunction (7, 54%), hearing impairment (6, 46%) and vertigo (4, 31%). Except 1 patient with diffuse aortitis, no other systemic manifestation was observed at diagnosis and during follow-up. Serum IgG4 was often elevated (11, 85%) and ANCA was mainly with myeloperoxidase specificity (11, 85%). Seven patients had cerebrospinal fluid analyse with lymphocytic pleocytosis in 5 cases (71%), elevated proteins in 4 cases (57%), positive oligoclonal bands in 3 cases (42%) and decreased glucose in one case (14%). On the MRI, the thickening of the dura mater concerned most often the posterior fossa, in 7 cases (54%). Among 10 cases with histological findings, all showed increased IgG4-positivity of plasma cells, 50% lymphocytic infiltrate but none presented the three major histological criteria of IgG4-related disease. Three (30%) showed histological signs of vasculitis with vascular wall damage and/or giant cells. Among the 12 patients treated with steroid therapy, a clinical improvement was noted in 11 cases (92%). Relapse occurred during tapering in 4 patients (33%). An immunosuppressive drug was added in 2nd line for 7 cases (54%), with a clinical improvement in all. CONCLUSION Pachymeningitis with IgG4 and ANCA seems a localized disease to the head and neck. Leptomeningeal biopsy commonly found IgG4 criteria and no vasculitis. All patients responded well to steroid therapy and immunosuppressive drugs, especially rituximab, with clinical and radiological improvement but relapse and/or sequelae are not uncommon.
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Affiliation(s)
- Félicien Gautier
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Lisa Neumann
- Department of Neurology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Homa Adle-Biassete
- Department of Pathology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Emma Rubenstein
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Alice Chimon
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Stéphane Mouly
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Damien Sène
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France
| | - Cloé Comarmond
- Department of Internal Medicine and Clinical Immunology, Lariboisière Hospital, Université Paris Cité, 75010 Paris, France.
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Zhang Y, Zhang X, Bhekharee AK, Du Z, Chu S. A case of Lymphoplasmacyte-rich meningioma mimicking pachymeningitis. BMC Neurol 2022; 22:283. [PMID: 35906535 PMCID: PMC9338539 DOI: 10.1186/s12883-022-02794-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lymphoplasmacyte-rich meningioma (LPRM) is a rare form of meningioma characterized by prominent lymphoplasmacytic infiltrates into the tumor. Report of flat growth of LPRM mimicking pachymeningitis is rare in the literature. CASE PRESENTATION A 55-year-old female who suffered from episodes of headache and seizures has been diagnosed with pachymeningitis for 4 years because post contrast brain MRI demonstrated enhanced carpet-like dura lesion in the left frontal lobe. The lesion kept unchanged on yearly follow-ups until a recent brain MRI found the lesion grew significantly into a mass. The lesion was resected and pathology suggested LPRM. CONCLUSION LPRM may present as carpet-like growth pattern on MRI. Long-term follow-up in patients with pachymeningitis is necessary.
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Affiliation(s)
- Yue Zhang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiang Zhang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Zunguo Du
- Department of Pathology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuguang Chu
- Department of Radiology, Pudong New District, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Shanghai, 200120, China.
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Esmaeilzadeh M, Dadak M, Atallah O, Möhn N, Skripuletz T, Hartmann C, Banan R, Krauss JK. IgG4-related hypertrophic pachymeningitis with tumor-like intracranial and intracerebral lesions. Acta Neurochir (Wien) 2022; 164:2781-7. [PMID: 35974231 DOI: 10.1007/s00701-022-05340-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/06/2022] [Accepted: 04/07/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE IgG4-related hypertrophic pachymeningitis is a rare fibroinflammatory disorder that may cause localized or diffused thickening of the dura mater. Misinterpretations of the clinical and imaging findings are common. Clinical manifestations depend on the location of the inflammatory lesion and on compression of neural structures leading to functional deficits. A dural biopsy is commonly needed for a definitive diagnosis. Immunomodulatory therapy is considered the therapy of choice. METHODS Four patients with IgG4-related hypertrophic pachymeningitis were identified over a 5-year period. Patient-related characteristics including age, preoperative workup, signs and symptoms of patients, and diagnostic procedures were evaluated. Furthermore, the surgical treatment and 5-year follow-up outcomes were analyzed. RESULTS There were two adults and two adolescents (mean age 32 years; range 15 to 67 years). Two patients were male, and two were female. No history of disease was known in any of the patients. Clinical symptoms were epilepsy (n = 2), ataxia and nausea (n = 1), and facial nerve palsy (n = 1). MR imaging studies showed contrast enhancing lesions in the temporal region in two patients, and in the cerebellar region in the other two patients. Subtotal resection was performed in two instances and a biopsy via a suboccipital retrosigmoid approach was obtained in the other two patients. Histochemical and immunohistochemical investigations revealed an IgG 4 disease in all of these patients. Immunomodulatorry therapy led to clinical stability during follow-up of 5 years in all four cases. CONCLUSION The diagnosis of IgG4-related hypertrophic pachymeningitis is challenging, but is of great relevance as treatment differs significantly from other forms of pachymeningitis and a specific therapeutic approach may avoid long-term neurological complications. Our series contributes to a better clinical characterization of this rare disease.
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Dutta P, Anand K. Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues. J Curr Ophthalmol 2021; 33:104-111. [PMID: 34409218 PMCID: PMC8365592 DOI: 10.4103/joco.joco_134_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.
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Affiliation(s)
- Paromita Dutta
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Kamlesh Anand
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
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10
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Dong LL, Sheikh IS, Huang AH, Wu XH, Chen EG, Ying KJ. Immunoglobulin G4-related disease: case report and literature review. Immunol Res 2021. [PMID: 34374950 DOI: 10.1007/s12026-021-09215-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a rare and chronic progressive clinical entity, characterized by elevated serum IgG4 along with tissue infiltration by IgG4 + plasma cells. It is an immune-mediated fibro-inflammatory condition that can affect virtually any organ and tissue. IgG4-related lung disease (IgG4-RLD) occupies 14% of all IgG4-RD, with nonspecific symptoms and various abnormal radiographic patterns. Published data on IgG4-related hypertrophic pachymeningitis (IgG4-RHP), an increasingly recognized central nervous system manifestation of IgG4-RD, is also limited. Both lung and cranial dura involvement have not yet been reported until now. We further entail a review of the literature on the clinicopathologic features and differential diagnosis of this uncommon disease. We herein report an interesting case of a 70-year-old male patient admitted due to headache and fever. A magnetic resonance imaging (MRI) of the brain revealed extensive dural thickening with marked enhancement. Chest computed tomography (CT) scan showed nodular or mass-like consolidation and focal interstitial change. Thoracoscopic lung biopsy and lumbar puncture were conducted. After careful histopathological observation and consideration of alternative differential diagnoses, he was diagnosed with IgG4-related disease with lung and cranial dural involvement based upon significant elevation of serum and cerebrospinal fluid (CSF) IgG4 concentration. The patient was started on oral prednisolone 60 mg/day (1.0 mg/kg/day) for 14 days, and a tapering dose of 5 mg every 2 weeks followed by maintenance therapy at low dose for 3 months. His clinical manifestations, and serologic and imaging findings improved with steroid treatment. Currently, the patient remains well without disease progression. IgG4-RD should be considered as a differential when diagnosing other similar multisystemic lesions. Clinical examination, careful histological observation, and immunostaining for appropriate markers are essential in establishing the diagnosis. Clinicians should become familiar with this alternative differential diagnosis.
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Yıldırım R, Cansu DÜ, Arık D, Saylısoy S, Korkmaz C. Aseptic meningitis in rheumatoid arthritis after anti-TNF administration: a case-based literature review. Rheumatol Int 2021; 41:1845-53. [PMID: 33751192 DOI: 10.1007/s00296-021-04822-6] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/22/2021] [Indexed: 12/17/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by articular and extra-articular manifestations. Among extra-articular involvement, rheumatoid meningitis (RM) is a rare condition, which may exhibit variable symptoms including headache, focal and/or generalized neurologic deficits. It may develop as the preceding manifestation of RA or occur at any time of the disease course. Some drugs used for the treatment of RA may give rise to aseptic meningitis or create a tendency to infectious meningitis due to their immunosuppressive effect. All these possibilities may lead to difficulties in the differential diagnosis. Achieving a diagnosis in a short time is crucial in terms of prognosis. Here, we would like to report a case with longstanding RA manifested by left-sided weakness and seizure shortly after initiating etanercept (ETA) therapy. ETA-induced meningitis was confirmed with appropriate diagnostic tools. Our aim with this case-based review is to attract the attention of this rare condition and discuss diagnostic challenges.
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Yazawa Y, Itabashi R. Hypertrophic Pachymeningitis Related Brain Infarction in Synovitis-Acne-Pustulosis-Hyperostosis Osteomyelitis Syndrome. J Stroke Cerebrovasc Dis 2020; 30:105522. [PMID: 33307288 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105522] [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: 09/19/2020] [Revised: 11/14/2020] [Accepted: 11/28/2020] [Indexed: 11/17/2022] Open
Abstract
A 50-year-old woman with a history of synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome was admitted for left unilateral neglect, dysarthria, and left hemiparesis. Brain MRI showed multiple infarctions in the territory of the right middle cerebral artery and gadolinium enhancement of the thickened frontotemporal dura mater on the right side. MR angiography showed significant narrowing of the cavernous segment of the right internal carotid artery. The right internal carotid artery stenosis was thought to originate from hypertrophic pachymeningitis associated with SAPHO syndrome. This is the first report of brain infarction due to internal carotid artery stenosis caused by hypertrophic pachymeningitis associated with SAPHO syndrome.
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Affiliation(s)
- Yukako Yazawa
- Department of Stroke Neurology, Kohnan Hospital, 4-20-1 Nagamachi-minami, Taihaku-ku, Sendai, Miyagi, 982-8523, Japan.
| | - Ryo Itabashi
- Stroke Center, Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Idaidori 2-1-1, Yahaba, Shiwa, Iwate, 028-3695, Japan
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Park JY, Choi I, Khil EK, Kim WJ, Shin IY. Idiopathic Hypertrophic Spinal Pachymeningitis with Spinal Cord Lesion: A Case Report. Korean J Neurotrauma 2020; 16:367-373. [PMID: 33163452 PMCID: PMC7607016 DOI: 10.13004/kjnt.2020.16.e17] [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: 10/24/2019] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/04/2022] Open
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare, diffuse inflammatory fibrosis of the dura mater that can lead to spinal cord compression. Though the optimal treatment is controversial, some reports recommend decompressive surgery and postoperative steroid therapy. However, we encountered a case of pachymeningitis that worsened after decompressive surgery. A 79-year-old woman presented with gait disturbance and bilateral lower extremity weakness that began 6 months prior. She had radiating pain on the C5 and T1 dermatomes and clumsiness in both hands. Magnetic resonance imaging (MRI) revealed diffuse thickening of the posterior longitudinal ligament of C6 to T4/5 and ligamentum flavum of C3/4 to T4/5, causing central canal stenosis and compressive myelopathy. She underwent posterior decompressive laminectomy from C4 to T1 total (T2 subtotal) and cervicothoracic screw fixation. During surgery, we found severe adhesion of the posterior longitudinal ligament and ligamentum flavum to the dura mater. Chronic inflammation with fibrosis and lymphoplasmacytic infiltration were present. After surgery, the patient's motor weakness worsened. Despite steroid treatment, her symptom severity fluctuated. Follow-up MRI obtained 3 months postoperation revealed high signal intensity from C5 to T2, possibly indicating aggravated compressive myelopathy. Thus, in this case, decompressive surgery and steroid therapy were detrimental.
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Affiliation(s)
- Jae yeon Park
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Il Choi
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Eun Kyung Khil
- Department of Radiology, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Wu Jae Kim
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
| | - Il Young Shin
- Department of Neurological Surgery, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong, Korea
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Elmaci I, Altinoz MA, Akdemir G, Sari R, Baskan O, Ozpinar A, Hacker E, Sav A. Neurosurgical and neuro-immunological management of IgG4-related hypertrophic sclerosing pachymeningitis. A literature survey and discussion of a unique index case. Clin Neurol Neurosurg 2020; 200:106342. [PMID: 33158629 DOI: 10.1016/j.clineuro.2020.106342] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/28/2020] [Accepted: 10/27/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Dural thickening is observed in lymphoma, dural carcinomatosis, meningioma, tuberculosis, and autoimmune diseases. We encountered a patient with dural thickening and complaints of neck and back pain, numbness and loss of strength in the hands. The patient also suffered from polychondritis and had previously received steroid and methotrexate treatment for this indication. The patients' serum was also positive for ANA, yet she did not have any other findings suggesting lupus. Our radiological and pathological analysis revealed IHSP (IgG4-related hypertrophic sclerosing pachymeningitis). In this review study, we provided a detailed literature survey to increase the awareness about IHSP in the neurosurgical community. METHODS MRI (magnetic resonance imaging)-based radiological analyses revealed a posterior extramedullary spinal mass extending from C2 to T2-T3 level. The dural mass was surgically excised and a broad panel of immunohistochemical markers including S100, EMA, CD246/ALK-1, CD45, CD20, CD79a, CD138, CD68, CD1a and CD34 was studied. Immunoglobulin heavy chain/kappa chain gene rearrangement analysis was performed which ruled out a lymphoproliferative disorder. RESULTS MRI and pathological findings suggested IHSP. As the disease relapsed with a new anterior extramedullary multilobulated lesion extending from C5 to T1 level, the patient is now closely monitored for further medical and surgical treatment. CONCLUSIONS IHSP is a relatively novel entity of hypertrophic pachymeningitis and should be included in the differential diagnosis of dural thickening. The fibrosis accompanying IHSP may not respond to medical treatment, which includes steroids and immunosuppressive agents. Additionally, neurological deficits, seizures, spinal decompression, hydrocephalus, or brainstem compression necessitate early surgical intervention. A continued vigilance is also necessary as the disease may relapse long-term following surgical treatment.
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Affiliation(s)
- Ilhan Elmaci
- Department of Neurosurgery, M.A.A. Acibadem University, Maslak Hospital, Istanbul, Turkey
| | - Meric A Altinoz
- Department of Medical Biochemistry, M.A.A. Acibadem University, Istanbul, Turkey.
| | | | - Ramazan Sari
- Department of Neurosurgery, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Ozdil Baskan
- Department of Radiology, Memorial Hospital, Istanbul, Turkey
| | - Alp Ozpinar
- Department of Neurosurgery, University of Pittsburgh, United States
| | - Emily Hacker
- Department of Neurosurgery, University of Pittsburgh, United States
| | - Aydin Sav
- Department of Pathology, Yeditepe University, Istanbul, Turkey
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15
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Sbeih I, Darwazeh R, Shehadeh M, Al-Kanash R, Abu-Farsakh H, Sbeih A. Immunoglobulin G4-Related Hypertrophic Pachymeningitis of the Spine: A Case Report and Systematic Review of the Literature. World Neurosurg 2020; 143:445-453. [PMID: 32777395 DOI: 10.1016/j.wneu.2020.07.227] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spinal immunoglobulin G4-related hypertrophic pachymeningitis (IgG4-HP) is a rare disease. Little information is known regarding the diagnosis, management, and prognosis of patients with spinal IgG4-HP. METHODS The authors present a case of spinal IgG4-HP with a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies (up to April 2020) that reported patients with spinal IgG4-HP, based on the criteria of Japan College of Rheumatology, were identified from the PubMed and Cochrane Library databases. RESULTS This systematic review identified 33 patients, including the present case, of whom 21 were male and 12 were female. The mean value of age was 51.2 (±12.6) years. Eight patients had systemic involvement. In addition, among 33 patients, 13 patients had an elevated serum IgG4. Surgery was performed in 31 patients. Steroid therapy alone and steroid therapy with immunosuppressants were effective in 94% and 100% of the cases, respectively. Furthermore, 31 of 33 patients reported improved outcomes, 1 patient died due to infection, and in 2 patients the data were not available. CONCLUSIONS Spinal IgG4-HP is a rare entity. In addition, it should be considered in the differential diagnosis of space-occupying lesions around the spinal cord. Histopathology with immunohistochemistry results provides the most reliable evidence for diagnosis. Steroid therapy is the first line of treatment. Surgical decompression may be required in patients presenting with nerve root and/or spinal cord compression. Long-term follow-up is necessary for patients with spinal IgG4-HP.
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Affiliation(s)
- Ibrahim Sbeih
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan.
| | - Rami Darwazeh
- Neurosurgery Department, Farah Medical Campus, Amman, Jordan
| | | | - Rasha Al-Kanash
- Endoscopic Spine Department, Razi Spine Clinic, Amman, Jordan
| | | | - Aseel Sbeih
- Neurosurgery Department, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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Akhaddar A, Rharrassi I. Hypertrophic cranial pachymeningitis coinfection with tuberculosis and actinomycosis. Surg Neurol Int 2020; 11:201. [PMID: 32754372 PMCID: PMC7395468 DOI: 10.25259/sni_383_2020] [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: 06/25/2020] [Accepted: 07/01/2020] [Indexed: 11/04/2022] Open
Abstract
This is a rare case report about hypertrophic cranial pachymeningitis coinfection with tuberculosis and actinomycosis in a 35-year-old male. The patient presented with progressive headache, paraesthesia, and blurred vision. Dural biopsy, histology, and cultures are imperative in pachymeningitis for establishing the diagnosis and guiding treatment.
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Affiliation(s)
- Ali Akhaddar
- Department of Neurosurgery, Avicenne Military Hospital, Mohammed V University, Rabat
| | - Issam Rharrassi
- Department of Pathology, Avicenne Military Hospital of Marrakech, Marrakech, Morocco
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17
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Amano E, Uchida K, Ishihara T, Otsu S, Machida A, Eishi Y. Propionibacterium acnes-associated chronic hypertrophic pachymeningitis followed by refractory otitis media: a case report. BMC Neurol 2020; 20:11. [PMID: 31918670 PMCID: PMC6953232 DOI: 10.1186/s12883-020-1600-3] [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: 06/27/2019] [Accepted: 01/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare disorder that involves localized or diffuse thickening of the dura mater. HP is associated with various inflammatory, infectious, and malignant diseases, such as rheumatic arthritis, sarcoidosis, anti-neutrophil cytoplasmic antibody-associated vasculitis, IgG4-related disorders, syphilis, tuberculosis, bacterial and fungal infections, cancer, and idiopathic diseases, when evaluation fails to reveal a cause. Among them, chronic infection with Propionibacterium acnes is a rare etiology of HP, and its pathology remains unclear. CASE PRESENTATION An 80-year-old man having refractory otitis media with effusion of the right ear presented with progressive right-sided headache and nausea. Post-contrast brain magnetic resonance imaging revealed right mastoiditis and remarkable thickening of the dura mater and enhancement of pia mater extending from the right middle cranial fossa to the temporal lobe. HP secondary to middle ear infection was suspected, and a biopsy of the right mastoid was performed. An anaerobic culture of the biopsied right mastoid showed the growth of P. acnes, and histopathological examination using P. acnes-specific monoclonal antibody (PAB antibody) revealed the infiltration of inflammatory cells with P. acnes. Moreover, using PAB antibody, P. acnes was detected in the biopsy specimen of the thickening dura mater. No granulomas were identified in either specimen. HP was resolved with long-term administration of antibiotics and steroids. CONCLUSION This is the first documentation of pathologically demonstrated chronic HP associated with P. acnes infection followed by refractory otitis media. This report showed that chronic latent P. acnes infection induces chronic inflammation.
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Affiliation(s)
- Eiichiro Amano
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan.
| | - Keisuke Uchida
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Tasuku Ishihara
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Shinichi Otsu
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Akira Machida
- Department of Neurology, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Yoshinobu Eishi
- Department of Human Pathology, Graduate School and Faculty of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
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18
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Ziff OJ, Hoskote C, Keddie S, D'Sa S, Davangnanam I, Lunn MPT. Frequent central nervous system, pachymeningeal and plexus MRI changes in POEMS syndrome. J Neurol 2019; 266:1067-1072. [PMID: 30756171 PMCID: PMC6469836 DOI: 10.1007/s00415-019-09233-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 11/22/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 11/24/2022]
Abstract
Objective Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes (POEMS) syndrome is a rare multisystem disease associated with a plasma-cell dyscrasia. Although pachymeningeal involvement has occasionally been described, MRI of the central nervous system (CNS) has not yet been extensively investigated. Methods We retrospectively evaluated CNS MRI in Europe’s largest single-center cohort of POEMS syndrome. Of 77 patients who have been formally diagnosed with POEMS, 41 had MRI brain and 29 had MRI spine. A control group of 33 patients with chronic inflammatory demyelinating polyneuropathy (CIDP) was used as this is the major differential diagnosis. Of these CIDP patients, 12 underwent both MRI brain and spine, 7 had solely MRI brain and 14 had MRI spine. Results In 41 POEMS patients with MRI brain, we identified frequent smooth, diffuse meningeal thickening of the cerebral convexities and falx (n = 29, 71%), of which 4 had meningeal collections. 17 (41%) had vascular abnormalities including white-matter disease, of which 4 had established infarcts. Of 29 patients with MRI spine, 17 (59%) had thickening of the brachial and lumbosacral plexus. Conversely in 19 CIDP patients with MRI brain, none had meningeal thickening (p < 0.0001); however, 8 (42%) had vascular abnormalities (p = 0.85). Of 26 patients with MRI spine, 9 (35%) had brachial or lumbosacral plexus thickening (p = 0.06). Conclusions In contrast to CIDP, POEMS patients frequently have pachymeningeal thickening. Vascular abnormalities and plexus thickening were also common but not statistically different to CIDP. Electronic supplementary material The online version of this article (10.1007/s00415-019-09233-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Oliver J Ziff
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Chandrashekar Hoskote
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Stephen Keddie
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Shirley D'Sa
- Cancer Division, Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Indran Davangnanam
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael P T Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK. .,Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK. .,Department of Neuroimmunology, The National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK.
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19
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Iaccarino I, Bozzetti F, Piccioni LO, Falcioni M. A case of external auditory canal osteoma complicated with cholesteatoma, mastoiditis, labyrinthitis and internal auditory canal pachymeningitis. ACTA ACUST UNITED AC 2019; 39:358-362. [PMID: 30745589 PMCID: PMC6843583 DOI: 10.14639/0392-100x-1547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 06/06/2017] [Indexed: 11/23/2022]
Abstract
The association between external auditory canal osteoma and external auditory canal cholesteatoma is rare, with only a few reports in the current literature. Intracranial complications are very rare in the external auditory canal cholesteatoma, especially with direct propagation through the internal auditory canal. A case of 27-year-old male presenting with external auditory canal osteoma with secondary external auditory canal cholesteatoma is described. Progression of the disease created in turn a mastoiditis, labyrinthitis and pachymeningitis confined to the internal auditory canal. The patient was treated by a subtotal petrosectomy, without entering the internal auditory canal. A control MRI after 3 months showed reduction of the internal auditory canal enhancement.
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Affiliation(s)
- I Iaccarino
- Otorhinolaryngology and Otoneurosurgery Department, University Hospital of Parma, Italy
| | - F Bozzetti
- Neuroradiology Department, University Hospital of Parma, Italy
| | - L O Piccioni
- Otorhinolaryngology Department, San Raffaele Scientific Institute, Milan, Italy
| | - M Falcioni
- Otorhinolaryngology and Otoneurosurgery Department, University Hospital of Parma, Italy
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20
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Parperis K, Abdulqader Y. Aortitis and pachymeningitis: an unusual combination in granulomatosis with polyangiitis (myeloperoxidase-associated vasculitis). BMJ Case Rep 2019; 12:12/1/e226795. [PMID: 30696638 DOI: 10.1136/bcr-2018-226795] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aortitis and pachymeningitis are uncommon manifestations of the antineutrophil cytoplasmic antibody-associated vasculitides, a group of systemic autoimmune diseases mainly affecting small vessels. We present a case of a 71-year-old woman with a remote history of idiopathic chronic granulomatous pachymeningitis complicated with aortic thickening due to autoimmune aortitis.
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Affiliation(s)
- Konstantinos Parperis
- Medicine, Maricopa Medical Center and University of Arizona College of Medicine, Phoenix, Arizona, USA.,Medicine, University of Cyprus Medical School, Nicosia, Cyprus
| | - Yasir Abdulqader
- Internal Medicine, Maricopa Integrated Health System, Phoenix, Arizona, USA
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21
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Abstract
OPINION STATEMENT IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. Early recognition of IgG4-RD is important to avoid permanent organ dysfunction and disability. Neurological involvement by IgG4-RD is relatively uncommon, but well recognised-hypertrophic pachymeningitis and hypophysitis are the most frequent manifestations. Although the nervous system may be involved in isolation, this more frequently occurs in conjunction with involvement of other systems. Elevated circulating levels of IgG4 are suggestive of the condition, but these are not pathognomonic and exclusion of other inflammatory disorders including vasculitis is required. Wherever possible, a tissue diagnosis should be established. The characteristic histopathological changes include a lymphoplasmacytoid infiltrate, storiform fibrosis and obliterative phlebitis. IgG4-RD typically responds well to treatment with glucocorticoids, although relapse is relatively common and treatment with a steroid-sparing agent or rituximab may be required. Improved understanding of the pathogenesis of IgG4-RD is likely to lead to the development of more specific disease treatments in the future.
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Affiliation(s)
| | - Alina Casian
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Harsha Gunawardena
- Department of Rheumatology, Brunel Building, Southmead Hospital, Bristol, UK
- Musculoskeletal Research Unit, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - David D'Cruz
- Louise Coote Unit, Guy's and St Thomas NHS Foundation Trust, London, UK
- Division of Immunology, Infection and Inflammatory Diseases, King's College London, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Claire M Rice
- School of Clinical Sciences, Level 1, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Department of Neurology, Brunel Building, Southmead Hospital, Bristol, UK.
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22
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Park TJ, Seo WD, Kim SY, Cho JH, Kim DH, Kim KH. Effective Response of Methotrexate for Recurrent Idiopathic Hypertrophic Spinal Pachymeningitis. Korean J Spine 2017; 13:200-203. [PMID: 28127378 PMCID: PMC5266097 DOI: 10.14245/kjs.2016.13.4.200] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/19/2022]
Abstract
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a chronic progressive and diffuse inflammatory fibrosis of the spinal dura mater. Though treatment of IHSP is surgical decompression with steroid therapy, treatment for recurrent IHSP is controversial. Our patient was diagnosed with IHSP based on magnetic resonance imaging (MRI) and underwent laminectomy for decompression following steroid pulse therapy. Despite maintenance of steroid therapy, the patient experienced 3 recurrences. As an alternative immunosuppressant medication, methotrexate was introduced with low-dose steroid. Fortunately, the symptom was resolved, and a decrease of dura thickening was revealed on MRI. We present the case and suggest that methotrexate might be an effective treatment modality for recurrent IHSP.
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Affiliation(s)
- Tae Joon Park
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | | | - Sang Young Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jae Hoon Cho
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hyun Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Hong Kim
- Department of Neurosurgery, Catholic University of Daegu School of Medicine, Daegu, Korea
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23
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Valenzuela RM, Keung B, Pula JH, Kattah JC. A Rare Case of Unilateral Progressive Vision Loss and Pachymeningitis. Neuroophthalmology 2016; 40:237-242. [PMID: 27928413 DOI: 10.1080/01658107.2016.1212079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022] Open
Abstract
We describe a 32-year-old man with presumed Vogt-Koyanagi Harada (VKH) syndrome, whose presenting symptoms were headache and progressive loss of vision in the right eye. Neuro-ophthalmic examination showed anterior and posterior uveitis, and retinal detachment in the right eye. Ocular coherence tomography (OCT) showed extensive submacular fluid in the right eye, while the fundus fluorescein angiogram (FFA) confirmed perifoveal retinal pigment epithelium (RPE) disruption and multifocal fluorescein leakage in the right eye. The brain MRI showed a small crescent of dependent fluid layering in the right posterior globe adjacent to the right optic nerve head, and pachymeningeal enhancement of the skull base dura along the clivus.This case demonstrates the utility of brain MRI and OCT findings in the early diagnosis of VKH syndrome, in the absence of prominent clinical signs of meningitis. Aggressive treatment is critical to preserve vision and prevent development of other systemic complications of the disease.
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Affiliation(s)
- Reuben Mari Valenzuela
- Department of Neurology, University of Illinois College of Medicine, Peoria, Peoria, Illinois, USA; Illinois Neurologic Institute, Peoria, Illinois, USA
| | - Bonnie Keung
- Illinois Neurologic Institute , Peoria, Illinois, USA
| | - John H Pula
- Department of Neurology, University of Illinois College of Medicine, Peoria, Peoria, Illinois, USA; North Shore University Health System, Glenview, Illinois, USA
| | - Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine, Peoria, Peoria, Illinois, USA; Illinois Neurologic Institute, Peoria, Illinois, USA
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Hisahara S, Yamada M, Matsuura Y, Tsuda E, Akiyama Y, Saitoh M, Kawamata J, Mikuni N, Shimohama S. ANCA-negative granulomatosis with polyangiitis presenting with orbital apex syndrome and recurrent pachymeningitis: A case report. J Neurol Sci 2016; 368:175-7. [PMID: 27538627 DOI: 10.1016/j.jns.2016.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/08/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Shin Hisahara
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Minoru Yamada
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Yousuke Matsuura
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Emiko Tsuda
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Yukinori Akiyama
- Department of Neurosurgery, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Masaki Saitoh
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Jun Kawamata
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Nobuhiro Mikuni
- Department of Neurosurgery, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
| | - Shun Shimohama
- Department of Neurology, School of Medicine, Sapporo Medical University, South 1, West 17, Chuo-ku, Sapporo 060-8543, Japan.
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25
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Yajima R, Toyoshima Y, Wada Y, Takahashi T, Arakawa H, Ito G, Kobayashi D, Yamada M, Kawachi I, Narita I, Takahashi H, Nishizawa M. A Fulminant Case of Granulomatosis with Polyangiitis with Meningeal and Parenchymal Involvement. Case Rep Neurol 2015; 7:101-4. [PMID: 26327907 PMCID: PMC4448053 DOI: 10.1159/000381942] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Central nervous system (CNS) involvement, such as pachymeningitis and/or cerebrovascular events, is rare in patients with granulomatosis with polyangiitis (GPA). Furthermore, the details of pathological examinations of cases have rarely been described. We describe a case of GPA that manifested as an isolated paranasal sinus disease that invaded the subarachnoid space and caused a hemorrhagic venous infarction. We also describe the pathological characteristics of the biopsied brain material from the successful decompressive craniectomy. In particular, granulomatous inflammation with geographic necrosis and multinucleated giant cells were observed in the perivascular area of the thickened dura mater and leptomeninges. Small vessels in the meninges were involved in the granulomatous lesions, and the lumens of the veins were often occluded. In the cerebral cortices and white matter in these areas, hemorrhagic infarction was widely observed. We suggest that our findings represent a novel mechanism of CNS involvement in GPA. Moreover, we believe that the emergency decompressive craniectomy and partial lobectomy for the cerebral infarction in this patient with GPA likely contributed to his survival.
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Affiliation(s)
- Ryuji Yajima
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yasuko Toyoshima
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yoko Wada
- The Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Tetsuya Takahashi
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Hiroyuki Arakawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Gaku Ito
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Daisuke Kobayashi
- The Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Mitsunori Yamada
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan ; Department of Clinical Research, Saigata Medical Center, National Hospital Organization, Niigata, Japan
| | - Izumi Kawachi
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Ichiei Narita
- The Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hitoshi Takahashi
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masatoyo Nishizawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
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George MM, Goswamy J, Solanki K, Bhalla R. Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum. Ann Med Surg (Lond) 2015; 4:103-6. [PMID: 25905016 PMCID: PMC4402385 DOI: 10.1016/j.amsu.2015.03.005] [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: 02/18/2015] [Accepted: 03/24/2015] [Indexed: 11/18/2022] Open
Abstract
Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures. Timely thorough investigation is critical to reduce the risk of irreversible damage. Prompt biopsy is essential to exclude both neoplasia and inflammatory conditions. Early corticosteroid administration is necessary to limit local infiltration.
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Affiliation(s)
- Manish M. George
- Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK
- Corresponding author. Tel.: +44 7737742817.
| | - Jay Goswamy
- Department of Otolaryngology-Head and Neck Surgery, Manchester Royal Infirmary, Oxford Road, M13 9WL, UK
| | - Kohmal Solanki
- Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton, Surrey, SM5 1AA, UK
| | - Rajiv Bhalla
- Manchester Academic Health Sciences Centre, Central Manchester University Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
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Li S, Tang H, Rong X, Huang X, Li Q. Pachymeningitis as a manifestation of ANCA-associated vasculitis: a care report and literature review. Int J Clin Exp Med 2015; 8:6352-6359. [PMID: 26131256 PMCID: PMC4483957] [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] [Received: 01/26/2015] [Accepted: 03/26/2015] [Indexed: 06/04/2023]
Abstract
Pachymeningitis is a rare cause of headache characterized by dura mater thickening with various origins. We present a 67-year-old male with cranial and spinal pachymeningitis and MPO-ANCA-associated vasculitis, which is considered as the cause of pachymeningitis of this patient. After revision of other 32 reported cases, our study suggested cranial and spinal pachymeningitis could be a manifestation of ANCA-associated vasculitis. Thus, it is important to screen other manifestations of ANCA-associated vasulitis as soon as pachymeningitis was suspected.
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Affiliation(s)
- Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
- Department of Rheumatology, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
| | - Honghu Tang
- Department of Rheumatology, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
| | - Xia Rong
- Department of Rheumatology, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
| | - Xiangyang Huang
- Department of Rheumatology, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
| | - Qianrui Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan UniversityChengdu, Sichuan, China
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Popkirov S, Kowalski T, Schlegel U, Skodda S. Immunoglobulin-G4-related hypertrophic pachymeningitis with antineutrophil cytoplasmatic antibodies effectively treated with rituximab. J Clin Neurosci 2015; 22:1038-40. [PMID: 25861887 DOI: 10.1016/j.jocn.2014.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/18/2014] [Accepted: 12/20/2014] [Indexed: 11/22/2022]
Abstract
We describe a 52-year-old man with hypertrophic pachymeningitis (HP) who was both seropositive for antineutrophil cytoplasmatic antibodies (ANCA) against myeloperoxidase, and had an immunoglobulin G4 (IgG4) positive fibroinflammatory response in meningeal biopsy. HP is a chronic inflammatory thickening of the dura mater which typically presents with headache, cranial nerve dysfunction and other neurological deficits. While first-line treatment with corticosteroids is recommended, many patients relapse and need additional immunosuppression. One recently described etiology is IgG4-related disease and in a subgroup of idiopathic patients, evidence suggests a crucial role of ANCA. To our knowledge, the simultaneous occurrence of IgG4-related disease and ANCA has not been reported so far. This man suffered life-threatening disease progression despite the administration of high dose steroids, cyclophosphamide and azathioprine. Treatment with rituximab was initiated which led to disappearance of clinical symptoms and decrease of dural thickening within weeks. This patient presents a possible disease overlap of IgG4-related and ANCA-associated HP and illustrates the effectiveness of rituximab in refractory IgG4-related HP.
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Takeuchi S, Osada H, Seno S, Nawashiro H. IgG4-Related Intracranial Hypertrophic Pachymeningitis : A Case Report and Review of the Literature. J Korean Neurosurg Soc 2014; 55:300-2. [PMID: 25132941 PMCID: PMC4130960 DOI: 10.3340/jkns.2014.55.5.300] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 07/25/2012] [Revised: 07/14/2013] [Accepted: 05/15/2014] [Indexed: 11/27/2022] Open
Abstract
Hypertrophic pachymeningitis is an uncommon disorder that causes a localized or diffuse thickening of the dura mater. Recently, the possibility that IgG4-related sclerosing disease may underlie some cases of intracranial hypertrophic pachymeningitis has been suggested. We herein report the tenth case of IgG4-related intracranial hypertrophic pachymeningitis and review the previous literature. A 45-year-old male presented with left-sided focal seizures with generalization. Magnetic resonance imaging (MRI) revealed a diffuse thickening and enhancement of the right convexity dura matter and falx with focal nodularity. The surgically resected specimens exhibited the proliferation of fibroblast-like spindle cells and an infiltration of mononuclear cells, including predominantly plasma cells. The ratio of IgG4-positive plasma cells to the overall IgG-positive cells was 45% in the area containing the highest infiltration of plasma cells. On the basis of the above findings, IgG4-related sclerosing disease arising from the dura mater was suspected. IgG4-related sclerosing disease should be added to the pachymeningitis spectrum.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hideo Osada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Soichiro Seno
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hiroshi Nawashiro
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
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Park IS, Kim H, Chung EY, Cho KW. Idiopathic hypertrophic cranial pachymeningitis misdiagnosed as acute subtentorial hematoma. J Korean Neurosurg Soc 2010; 48:181-4. [PMID: 20856672 DOI: 10.3340/jkns.2010.48.2.181] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/16/2010] [Accepted: 08/03/2010] [Indexed: 11/27/2022] Open
Abstract
A case of idiopathic hypertrophic cranial pachymeningitis (IHCP) misdiagnosed as an acute subdural hematoma is reported. A 37-year-old male patient presented with headache following head trauma 2 weeks earlier. Computerized tomography showed a diffuse high-density lesion along the left tentorium and falx cerebri. Initial chest X-rays revealed a small mass in the right upper lobe with right lower pleural thickening, which suggested lung cancer, such as an adenoma or mediastinal metastasis. During conservative treatment under the diagnosis of a subdural hematoma, left cranial nerve palsies were developed (3rd and 6th), followed by scleritis and uveitis involving both eyes. Magnetic resonance imaging (MRI) revealed an unusual tentorium-falx enhancement on gadolinium-enhanced T1-weighted images. Non-specific chronic inflammation of the pachymeninges was noticed on histopathologic examination following an open biopsy. Systemic steroid treatment was initiated, resulting in dramatic improvement of symptoms. A follow-up brain MRI showed total resolution of the lesion 2 months after steroid treatment. IHCP should be included in the differential diagnosis of subtentorial-enhancing lesions.
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Affiliation(s)
- Ik-Seong Park
- Department of Neurosurgery, St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
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