Multiple neurological manifestations in a patient with systemic lupus erythematosus and anti-NXP2-positive myositis: A case report

RATIONALE

Systemic lupus erythematosus (SLE) is a complex autoimmune inflammatory disease that frequently affects various organs. Neuropsychiatric manifestations in SLE patients, known as neuropsychiatric SLE, are clinically common. However, the principal manifestation of cranial neuropathy in patients with SLE and comorbidities is relatively rare.

PATIENT CONCERNS

In this report, we describe a 51-year-old Chinese woman who was admitted with a chief complaint of chronic-onset facial paresthesia, dysphagia, and choking cough when drinking water, accompanied by slurred speech, salivation, and limb weakness. The blood autoantibody test results showed that many SLE-associated antibodies were positive. Meanwhile, anti-nuclear matrix protein 2 (NXP2) antibody was strongly positive in the idiopathic inflammatory myopathy (IIM) spectrum test from the serum. Muscle biopsy indicated inflammatory infiltration of the muscle fiber stroma.

DIAGNOSES

Taking into account the clinical manifestations and laboratory tests of the present case, the diagnosis of SLE and probable IIM was established.

INTERVENTIONS

Corticosteroids and additional gamma globulin were administered and the clinical symptoms were relieved during the treatment process.

OUTCOMES

Unfortunately, the patient experienced sudden cardiac and respiratory arrest. Multiple system dysfunctions exacerbated disease progression, but in the present case, we speculated that myocardial damage resulting from SLE could explain why she suddenly died.

LESSONS

To our knowledge, multiple neurological manifestations in patients with SLE and anti-NXP2-positive myositis are rare. Note that SLE is still a life-threatening disease that causes multiple system dysfunctions, which requires increasing attention.

Caveats and truths in genetic, clinical, autoimmune and autoinflammatory issues in Blau syndrome and early onset sarcoidosis

Blau syndrome (BS) and early onset sarcoidosis (EOS) are, respectively, the familial and sporadic forms of the pediatric granulomatous autoinflammatory disease, which belong to the group of monogenic autoinflammatory syndromes. Both of these conditions are caused by mutations in the NOD2 gene, which encodes the cytosolic NOD2 protein, one of the pivotal molecules in the regulation of innate immunity, primarily expressed in the antigen-presenting cells. Clinical onset of BS and EOS is usually in the first years of life with noncaseating epithelioid granulomas mainly affecting joints, skin, and uveal tract, variably associated with heterogeneous systemic features. The dividing line between autoinflammatory and autoimmune mechanisms is probably not so clear-cut, and the relationship existing between BS or EOS and autoimmune phenomena remains unclear. There is no established therapy for the management of BS and EOS, and the main treatment aim is to prevent ocular manifestations entailing the risk of potential blindness and to avoid joint deformities. Nonsteroidal anti-inflammatory drugs, corticosteroids and immunosuppressive drugs, such as methotrexate or azathioprine, may be helpful; when patients are unresponsive to the combination of corticosteroids and immunosuppressant agents, the tumor necrosis factor-α inhibitor infliximab should be considered. Data on anti-interleukin-1 inhibition with anakinra and canakinumab is still limited and further corroboration is required. The aim of this paper is to describe BS and EOS, focusing on their genetic, clinical, and therapeutic issues, with the ultimate goal of increasing clinicians' awareness of both of these rare but serious disorders.

Varicella-zoster meningoencephaloradiculoneuropathy in an immunocompetent young woman

The clinical manifestations of varicella-zoster virus infections can be divided into primary infection with chickenpox and reactivated infection with dermatomal shingles, disseminated herpes zoster, zoster sine herpete and varicella-zoster virus encephalitis, meningitis and vasculopathy. We present a case of zoster sine herpete leading to meningitis with cranial and peripheral nerve palsies. A 17-year-old woman was admitted to hospital with intermittent fever, drowsiness, slowness and subsequent frontal headache and horizontal diplopia. Cerebrospinal fluid examination revealed lymphocytic pleocytosis and PCR amplified varicella-zoster virus DNA. Laboratory and clinical findings were suggestive of meningoencephaloradiculoneuropathy, stemming from varicella-zoster virus and affecting cranial and peripheral nerves. Only 5% of patients with zoster develop cranial and peripheral nerve palsies. Diagnosis is imperative in order to initiate prompt antiviral therapy so as to minimize morbidity and the risk of death.

[The present and the prospect of study on Blau syndrome/early-onset sarcoidosis]

Blau syndrome (BS) and early-onset sarcoidosis (EOS) are both systemic granulomatous disease evoked by the mutated NOD2. It occurs in children younger than 4 years of age and is characterized by a distinct triad of skin, joint, and eye disorders without apparent pulmonary involvement. NOD2 encodes an intracellular receptor for muramyl dipeptide (MDP), the common component of bacterial cell wall peptidoglycan, and is expressed in cytoplasm of monocytic cells and epithelial cells. While its loss-of-function mutations are recognized in Crohn's disease, the mutations observed in BS/EOS are gain-of-function, and induced MDP-independent basal NF-kappaB activation. But we still do not know the precious molecular mechanism how the activation of NOD2 induces granuloma formation in the skin, joints and eyes.

[Presence of antibodies against gangliosides among patients with Lyme borreliosis--preliminary study]

THE AIM of the study was the evaluation of autoantibody reaction against endogenous gangliosides in the course of Lyme borreliosis.

MATERIAL AND METHODS

Antibodies against profile of gangliosides composed of GM1, GM2, GM3, GD1a,GD1b,GT1b, GQ1b were evaluated in serum patients with early disseminated (neuroborreliosis) Lyme disease (n = 16), patients with long lasting serologic response against Borrelia burgdorferi (n = 32) and in healthy subjects (n = 16). Immunoblot test for IgG was used.

RESULTS

Antibodies were detected in all evaluated groups. In group of neuroborreliosis (lymphocytic meningitis with cranial nerve invoIvement) there was no essential difference with control group. It was stated in group of forestry workers with serological features of infection B. burgdorferi lasting for years.

CONCLUSIONS

Results of the study do not support the thesis of participation of IgG autoantibodies against gangliosides in pathogenesis early disseminated Lyme borreliosis in form of lymphocytic meningitis with cranial nerves paresis. Antibodies against endogenous glicosfingolipides in Lyme borreliosis probably can lead to affecting nervous system (demielinisation and polineuropathy) but probably require long-term immunization, what is suggested by results of examined group of patients with the multi-annual serological features of infection.

Anti-Ku autoantibodies: series of 5 cases

Autoantibodies directed against nuclear protein Ku are infrequently detected. If present, they are found in high titers in patients with connective tissue overlap syndromes. This article describes 5 patients with anti-Ku antibodies in whom systemic lupus erythematosus, Sjögren's syndrome, idiopathic lung fibrosis or scleroderma - polymyositis overlap syndrome were diagnosed. Interestingly, signs and symptoms of transient cranial neuropathy involving trigeminal and facial nerves were reported by 3 patients. Cranial nerve neuropathy has not been described in patients with anti-Ku autoantibodies previously.

Sarcoidosis of the nervous system

Although sarcoidosis is rarely confined to the nervous system, any neurological features that do occur frequently happen early in the course of the disease. The most common neurological presentation is with cranial neuropathies, but seizures, chronic meningitis and the effects of mass lesions are also frequent. The diagnostic process should first confirm nervous system involvement and then provide supportive evidence for the underlying disease; in the absence of any positive tissue biopsy, the most useful diagnostic tests are gadolinium enhanced MRI of the brain and CSF analysis, although both are non-specific. The mainstay of treatment is corticosteroids, but these often have to be combined with other immunosuppressants such as methotrexate, hydroxychloroquine or cyclophosphamide. There is increasing evidence that infliximab is a safe treatment with good steroid sparing capacity.

Microscopic polyangitis presenting with temporal arteritis and multiple cranial neuropathies

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis affects vessels of various diameters in various tissues or organs, sometimes associated with neurological complications. A 77-year-old man developed dysphagia, hoarseness, dysgeusia, gait unsteadiness, and right temporalgia; neurological examination revealed multiple cranial neuropathies. Laboratory studies demonstrated severe inflammatory responses, elevation of perinuclear ANCA, and mild proteinuria. Magnetic resonance imaging of the brain showed dural enhancement in the cerebellar tentorium. Biopsy revealed necrotizing glomerulonephritis in the kidney, and temporal arteritis without giant cells in the temporal artery. The patient was diagnosed with microscopic polyangitis presenting with temporal arteritis and multiple cranial nerve involvement, and was treated with predonisolone, after which the symptoms and laboratory data showed improvement. This is the first case of ANCA-associated vasculitis with pathologically verified lesions in the temporal artery as well as in the kidney. Thus, ANCA-associated vasculitis may simultaneously affect large vessels such as temporal artery, as well as microvessels in the kidney, nerves and other organs.

Severe cranial nerve involvement in a patient with monoclonal anti-MAG/SGPG IgM antibody and localized hard palate amyloidosis

We report a patient with severe cranial polyneuropathy as well as sensory limb neuropathy. Biclonal serum IgM-kappa/IgM-lambda gammopathy was found and serum anti-myelin-associated glycoprotein (MAG)/sulfoglucuronyl paragloboside (SGPG) IgM antibody was also detected. Immunofluorescence analysis of a sural nerve biopsy specimen revealed binding of IgM and lambda-light chain on myelin sheaths. No amyloid deposition was detected in biopsied tissues except for the hard palate, suggesting that the amyloidosis was of the localized type and had no relation to the pathogenesis of cranial neuropathy. Our observations indicate that the anti-MAG/SGPG IgM antibody may be responsible for this patient's cranial polyneuropathy, which is a rare manifestation in anti-MAG/SGPG-associated neuropathy.

Paraneoplastic rhombencephalitis and brachial plexopathy in two cases of amphiphysin auto-immunity

Amphiphysin, a synaptic vesicle protein, is an auto-immune target in rare cases of paraneoplastic neurological disorders. We report two additional cases with distinct neurological syndromes and paraneoplastic anti-amphiphysin antibodies. The first patient, a 59-year-old man, presented with cerebellar and cranial nerve dysfunction and small cell lung carcinoma. The second, a 77-year- old woman, presented with left brachial plexopathy followed by sensorimotor neuropathy and breast carcinoma.

Isolated cranial neuropathy associated with anti-glycolipid antibodies

We describe seven patients with isolated cranial neuropathy in whom serum anti-glycolipid antibodies were detected. Trigeminal sensory neuropathy was found in four patients, who had exhibited symptoms for 2 months to 4 years. The other three patients showed facial nerve palsy with or without ophthalmoparesis. Temporal profile analysis of anti-glycolipid antibodies revealed that titers of anti-glycolipid IgM antibodies against GM2 and LM1 gradually decreased in patients having chronic trigeminal sensory neuropathy. In patients with acute trigeminal sensory neuropathy, elevation of anti-LM1 antibody titers continued over 12 months although anti-GalNAc-GD1a antibody disappeared. On the other hand, titers of anti-glycolipid antibodies rapidly decreased in patients with acute facial nerve palsy with or without ophthalmoparesis. We conclude that anti-glycolipid antibodies may play an important role in the development of isolated cranial neuropathy in some patients.

A clinicopathological study of a patient with anti-Hu-associated paraneoplastic sensory neuronopathy with multiple cranial nerve palsies

Only a few cases of paraneoplastic neurologic syndrome with multiple cranial palsies have been reported. This is the case report of a patient with small-cell lung cancer and a high titer of anti-Hu antibodies who developed a tonic left pupil and multiple cranial nerve palsies, including palsies of the left fifth through tenth nerves and both twelfth nerves, as in Garcin syndrome showing at least more than seven ipsilateral cranial nerve palsies, in the course of paraneoplastic sensory neuronopathy (PSN). Pathologic examination revealed no metastasis or direct invasion of malignancy with gliosis and perivascular inflammation throughout the brainstem, indicating paraneoplastic encephalomyelitis (PEM). The numbers of EBM11+ cells (probably reactive microglia), CD8+ cells, and CD4+ cells increased. Intracellular adhesion molecule-1 and lymphocyte function associated molecule-1 were expressed intensely on the endothelia of microvessels and were found to have infiltrated mononuclear cells around microvessels in the brainstem. Multiple cranial nerve palsies and their effects including the tonic pupil are likely due to the paraneoplastic effect of the primary systemic malignancy.

Intravenous immunoglobulin for cranial polyneuropathy associated with Campylobacter jejuni infection

This study reports the efficacy of i.v. immunoglobulin in a patient with cranial polyneuropathy resulting from Campylobacter jejuni infection who had high titers of serum IgG antibodies against gangliosides GD1a and GT1b in the acute phase. Treatment with i.v. immunoglobulin (400 mg/kg/day x 5 days) led to rapid partial resolution of his neurologic manifestations, but complete recovery was not obtained until 6 months later. The present case suggests that i.v. immunoglobulin therapy prevents further progression of the disease but that it may not shorten the clinical course of cranial polyneuropathy in some cases associated with Campylobacter jejuni infection.

Three patients with ophthalmoplegia associated with Campylobacter jejuni

Cranial polyneuropathy is idiopathic in most patients. Idiopathic cranial polyneuropathy is an acute postinfectious syndrome, along with Guillain-Barré syndrome and Miller Fisher syndrome, in which the common preceding pathogen is Campylobacter jejuni. Serum anti-GQ1b antibodies are elevated in Miller Fisher syndrome and Guillain-Barré syndrome with ophthalmoplegia. Three patients with idiopathic cranial polyneuropathy with predominant ocular involvement are presented. C. jejuni isolated from stool specimens belonged to Penner serotypes O:4, O:23, and O:33. Serum anti-GQ1b antibodies were elevated in all patients but demonstrated rapid reduction concomitant with clinical recovery. All patients recovered completely. Because both preceding C. jejuni infection and elevated anti-GQ1b antibodies decreasing with time were seen in all patients, the pathogenesis of idiopathic cranial polyneuropathy with ophthalmoplegia may be similar to that of Miller Fisher syndrome.

Hypocomplementemic urticarial vasculitis and lower cranial nerve palsies

A 55 years post menopausal lady presented with puffiness of face, and a pruritic urticarial rash over face and upper trunk of one week duration with accompanying dysphagia. Clinical examination revealed an urticarial rash over face and upper trunk, two small ulcers over floor of mouth and evidence of bilateral VIII, IX and Xth cranial nerve palsies. Hypocomplementemia, negative immune profile and evidence of vasculitis on skin biopsy suggested a diagnosis of hypocomplementemic urticarial vasculitis. The patient responded to a course of steroids.

P-ANCA-positive Wegener's granulomatosis presenting with hypertrophic pachymeningitis and multiple cranial neuropathies: case report and review of literature

An autopsy case of hypertrophic pachymeningitis and multiple cranial neuropathies is reported. A 53-year-old woman with paraplegia and various neurological signs which developed over a 2 year period was diagnosed as having an epidural mass with thickened dura mater extending from the lower cervical to the thoracic spinal cord. In addition, bilateral episcleritis, blephaloptosis, and blindness of the right eye with various cranial nerve deficits were found to be caused by the mass lesions involving the paranasal sinuses, orbit, and the cavernous sinus. Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) was positive, but cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) was negative by enzyme-linked immunosorbent assay. The partially removed epidural mass with hypertrophied dura mater and biopsy of the paranasal lesions showed chronic granulomatous inflammation with vasculitis. The remaining lesions resolved with steroid therapy with remarkable neurological improvement. The positive p-ANCA test, paranasal involvement, the report of a similar histopathological case and a review of the literature on granulomatous pachymeningitis suggest the presence of p-ANCA-positive Wegener's granulomatosis with central nervous system involvement characterized by hypertrophic pachymeningitis and/or multiple cranial neuropathies.

Antibodies to GD3, GT3, and O-acetylated species in Guillain-Barré and Fisher's syndromes: their association with cranial nerve dysfunction

We examined serum antibodies to the four fetal antigens GD3, O-acetyl GD3, GT3, and O-acetyl GT3 ganglioside in patients with Guillain-Barré syndrome (GBS) or its variant Fisher's syndrome (FS). The patients with FS more often had significant IgG antibodies against GD3, GT3, and O-acetyl GT3 than did the healthy controls. Furthermore, anti-GD3 and anti-GT3 IgG antibodies were more often significantly present in the patients with FS than in those with GBS. IgG antibody to GD3, GT3, and O-acetyl GT3 had a significant association with the presence of ophthalmoparesis. These antibodies, however, cross-reacted with GQ1b and we detected no antibodies which specifically reacted with fetal gangliosides. In addition, oculomotor involvement was more closely related to IgG antibodies to GQ1b than to those to fetal gangliosides. No evidence was obtained that the serum antibodies to these fetal gangliosides are associated with specific neurologic signs of cranial nerves.

Cranial polyneuropathy with elevated serum antiganglioside antibody

We report a 6-year-old girl with cranial polyneuropathy with elevated serum levels of antiganglioside antibodies. She manifested herpetic vesicles around the right upper eyelid and mouth without antecedent infection. She developed facial asymmetry and double vision 5 days after the first appearance of the vesicles. Neurological examination on admission disclosed palsies of the bilateral sixth and twelfth cranial nerves and right third and seventh cranial nerves, but limb muscle weakness, ataxia, and areflexia were not observed. Cerebrospinal fluid examination and MRI of the brain showed no abnormalities. Serum antibodies to gangliosides GQ1b and GT1b, but not GM1, and those to Campylobacter jejuni were significantly increased on admission and on the hospital day 14. These observations suggest that the present case is a variant form of Miller Fisher syndrome or Bickerstaff's brainstem encephalitis subsequent to asymptomatic C. jejuni infection. We treated her with intravenous administration of high-dose methylprednisolone and acyclovir, but almost no effect was observed. All cranial nerve palsies, however, had resolved completely approximately 4 months later. This may be the first pediatric case in which cranial polyneuropathy and antiganglioside antibodies were associated.

[A study of acute infection of herpes simplex virus in mouse trigeminal ganglia]

We investigated the shift to latency and protective reaction in mice trigeminal ganglia after inoculation of herpes simplex virus type 1 (HSV-1) onto the cornea. BALB/c mice were inoculated and the trigeminal ganglia were removed periodically. Lymphocytes in the ganglia were observed using immunocytochemical techniques. The results obtained were as follows: (1) HSV-1 positive neuronal cells were recognized at 3 days after inoculation but not at 14 days. (2) The relative proportion of T cells in lymphocytes was greater than that of B cells at 3 days, but B cells were more numerous at 5 days. Then T cells become more numerous again at 7 days. (3) Among the subsets in T cells, the ratio of CD4+ and CD8+ cells was almost equal at 3 days, but then CD4+ cells increased and CD8+ cells had disappeared at 14 days after inoculation. These results show that HSV-1 that reached the trigeminal ganglion from the cornea by axonal transport infected neuronal cells, multiplied there and then disappeared resulting in latency. Cellular immunity, especially the function of CD4+ cells, played a main role in this protective reaction by suppressing the viral growth.

Immunohistological study of encephalomalacia in pigs infected with Aujeszky's disease virus

Seven hysterectomy-derived colostrum-deprived pigs aged 4 weeks were inoculated intranasally with 10(3) plaque-forming units (1 ml) of the Yamagata YS-81 strain of Aujeszky's disease virus. One pig died and five developed encephalomyelitis and trigeminal ganglionitis. Three pigs killed on days 12-16 showed prominent malacic degeneration. Associated with the malacic foci were many lysosome-positive cells. IgG- and IgM-containing cells in the perivascular cuffs and glial nodules were first detected on day 7, after which they increased in number. They were thought to be closely associated with the presence of neutralizing antibody. These findings suggest that inflammatory cells in the brain are of haematogenous origin.

Trigeminal sensory neuropathy. A study of 22 cases

The clinical and electrophysiological findings in 22 patients with chronic trigeminal sensory neuropathy are described. The main clinical feature was slowly evolving unilateral or bilateral facial numbness sometimes associated with pain and paraesthesiae and commonly with disturbed taste. Nine patients had either systemic sclerosis or mixed connective tissue disease. Of the 13 other patients, 9 had either organ or nonorgan specific serum autoantibodies. Blink reflex latencies were recorded in 17 patients, the commonest abnormality being an 'afferent' defect with modest prolongation of latency. Trigeminal sensory evoked responses were recorded in 14 cases, 6 showing mild prolongation of latencies. It is suggested that the lesion in this type of trigeminal neuropathy is in the trigeminal ganglion or in the proximal part of the main trigeminal divisions. This conclusion is supported by limited pathological data.

Genetics of natural resistance to herpes simplex virus type 1 latent infection of the peripheral nervous system in mice

The genetics of natural resistance to the development of latent infection in the trigeminal ganglia of mice inoculated in the lip with herpes simplex virus type 1 (HSV-1) was examined. Based on coefficients of a logistic regression relating latency to strain and HSV-1 concentration, inbred strains of mice formed a continuum of resistance ranging from most resistant (C57BL/6J) to most susceptible (PL/J). When these results were analysed along with latency data derived from studies employing a non-fatal concentration of HSV-1, three subpopulations were identified among these strains: resistant (C57BL/10J, BALB/cByJ, C57BL/6J), moderately resistant (DBA/2J, SWR/J, A/J, AKR/J, DBA/1J) and susceptible (PL/J, LP/J, CBA/J). Results from F1 hybrids between resistant and moderately resistant strains (B6D2F1/J, B6AF1/J) and between resistant and susceptible strains [(C57BL/6J X CBA/J)F1, (C57BL/6J X LP/J)F1)] indicated that resistance is dominant. Data from both inbred and congenic strains failed to show an association between H-2 and resistance to the development of a latent infection. Studies of mortality also indicated that a continuum was present, with C57BL/10J, C57BL/6J and DBA/1J being most resistant and PL/J mice most susceptible. When inbred strains were categorized on the basis of resistance to the development of latent infection and mortality, five groups could be identified. Group A are strains resistant to both mortality and latency (C57BL/6J, C57BL/10J, DBA/1J) while group B consists of one strain (BALB/cByJ) intermediate in resistance to mortality but resistant to latency. Group C are strains intermediate in resistance to mortality and susceptible to latency (LP/J, CBA/J) while Group D are strains susceptible to mortality and intermediate in susceptibility to latency (AKR/J, SWR/J, DBA/2J). Group E consists of one strain (PL/J) susceptible to both mortality and latency. These results indicate that host factors play an important role in the establishment of latent infection in vivo.

Herpes simplex virus latency in the rabbit trigeminal ganglia: ganglionic superinfection

It has been confirmed and further documented that infection of the rabbit cornea with the E-43 strain of HSV-1 precludes superinfection of the corresponding trigeminal ganglia by another HSV strain, i.e., the challenging virus does not establish latency and can not be recovered from the ganglia. It was shown that after primary infection, a state of resistance is established in the neuronal cells of the ganglia, and although the challenging strain reaches the ganglia, it does not cause discernible acute infection, and does not displace the resident virus in the ganglia. This protection was present 6 months after primary infection, was independent of immune factors such as circulating or secretory antibodies, and was localized to the point of entry of the primary infecting strain and the sensory neurons that innervate that site. The smallest inoculum that provided protection from ganglionic superinfection was that which produced overt disease in the eye, although different degrees of disease resulted from varying inocula above this minimum. Asymptomatic primary infections produced by subminimal inocula of the E-43 strain or by the HSV recombinant strain, F(MP)F, which is avirulent for the rabbit eye, protected against severe disease and death, but the degree of protection against ganglionic superinfection was variable and depended on the time of challenge. These findings suggest that susceptible neurons in the trigeminal ganglion, when "occupied" by an infecting strain, cannot be superinfected by a second strain.