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1
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Grasso EA, Pozzilli V, Tomassini V. Transverse myelitis in children and adults. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:101-117. [PMID: 37620065 DOI: 10.1016/b978-0-323-98817-9.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Transverse myelitis is a noncompressive myelopathy of inflammatory origin. The causes are broad, ranging from infective or toxic to immuno-mediated etiology. They can be manifestations of systemic diseases, such as sarcoidosis and systemic lupus erythematous, or phenotypes of neuroinflammation; in a portion of cases, the etiology remains unknown, leading to the designation idiopathic. The clinical presentation of transverse myelitis depends on the level of spinal cord damage and may include sensorimotor deficits and autonomic dysfunction. The age of onset of the disorder can impact the symptoms and outcomes of affected patients, with differences in manifestation and prognosis between children and adults. Spinal cord magnetic resonance imaging and cerebrospinal fluid examination are the main diagnostic tools that can guide clinicians in the diagnostic process, even though the search for antibodies that target the structural components of the neural tissue (anti-aquaporin4 antibodies and anti-myelin-oligodendrocyte antibodies) helps in the distinction among the immune-mediated phenotypes. Management and outcomes depend on the underlying cause, with different probabilities of relapse according to the phenotypes. Hence, immunosuppression is often recommended for the immune-mediated diseases that may have a higher risk of recurrence. Age at onset has implications for the choice of treatment.
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Affiliation(s)
- Eleonora Agata Grasso
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valeria Pozzilli
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Valentina Tomassini
- Department of Neurosciences, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies (ITAB), University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
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2
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Schwemberger R, Joe P. Upper Extremity Hypotonia in a 5-week-old Infant. Neoreviews 2022; 23:e692-e695. [PMID: 36180734 DOI: 10.1542/neo.23-10-e692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Rachel Schwemberger
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Priscilla Joe
- Department of Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA
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Safadi AL, Day D, Nagle B, Di Maria G, Malla P. Treatment Challenges in a Severe Case of Syphilitic Myelitis With a Longitudinally Extensive Spinal Cord Lesion. Neurohospitalist 2022; 12:400-403. [PMID: 35419144 PMCID: PMC8995592 DOI: 10.1177/19418744221075402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Syphilitic myelitis is an unusual manifestation of neurosyphilis, rarely reported in the literature. The best management approach remains unclear in severe cases with longitudinally extensive spinal cord lesions. We describe a 29-year-old man with a history of incompletely treated syphilis after a high-risk sexual encounter, who presented two years later with several weeks of progressive numbness and weakness in both legs. MRI spine showed significant cord expansion from the craniocervical junction to T6 with patchy cord enhancement. He was diagnosed with syphilitic myelitis given his history of inadequately treated syphilis, positive serum rapid plasma reagin at a high titer, and CSF pleocytosis with elevated protein along with a reactive CSF Venereal Disease Research Laboratory test. Alternative infectious or immunological etiologies were excluded. He was treated with IV penicillin and pulse steroid therapy with IV methylprednisolone 1 g daily for 3 days with improvement. However, he was soon readmitted with recurrent weakness requiring an additional course of pulse steroid therapy followed by a short prednisone taper. Afterward, his symptoms recurred with worsened cord expansion on imaging. He was re-treated with IV penicillin and pulse steroid therapy with a more prolonged prednisone taper. The patient subsequently improved and had no further recurrent symptoms on extended outpatient follow-up. This report illustrates the importance of keeping syphilitic myelitis on the differential as a treatable cause of longitudinally extensive myelopathy. The patient may have benefited from high-dose IV steroids with a prolonged taper while waiting for the full treatment effect of antibiotics.
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Affiliation(s)
- Amy Li Safadi
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Derek Day
- Department of Rehabilitation Medicine, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Brian Nagle
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Gianluca Di Maria
- Department of Neurology, MedStar Georgetown University
Hospital, Washington, DC, USA
| | - Prerna Malla
- Department of Neurology, MedStar Washington Hospital Center, Washington, DC, USA
- Prerna Malla, Department of Neurology, MedStar
Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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Dong H, Liu Z, Duan Y, Li D, Qiu Z, Liu Y, Huang J, Wang C. Syphilitic meningomyelitis misdiagnosed as spinal cord tumor: Case and review. J Spinal Cord Med 2021; 44:789-793. [PMID: 31603731 PMCID: PMC8477965 DOI: 10.1080/10790268.2019.1658283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Syphilitic meningomyelitis is a rare manifestation of neurosyphilis, not well described in the literature.Methods: We reported a rare case of a 29-year-old female with syphilitic meningomyelitis. Her clinical manifestations and imaging findings were discussed with the related literatures reviewed.Results: The patient presented with progressive bilateral lower extremities numbness and weakness for months. Laboratory tests revealed positive serum Treponema pallidum Hemagglutinin Test (TPHA) and rapid plasma reagin test (RPR). The cerebral spinal fluid (CSF) was positive with TPHA but negative for RPR with lymphocytic pleocytosis and elevated protein. Spinal MRI showed swelling and high-signal intensity of thoracic spinal cord except T6-7 level with associated gadolinium enhancement ("flip-flop sign") and peripheral strip-like enhancement on T1WI ("candle guttering appearance"). She was initially diagnosed as spinal cord tumor due to the chronic clinical onset and cord swelling with central enhancement found on thoracic MRI. After dramatic clinical and radiographic improvement with dexamethosone and serological tests of syphilis, she was diagnosed as probable syphilitic meningomyelitis. Till now, there are 12 cases of syphilitic myelitis reported with spinal cord MR images. Thoracic cord is the predominant involved segment (10/12), "candle guttering appearance" is the most common enhancing characteristics of the lesion (7/12), "flip-flop sign" may be seen in the stage with significant inflammation (3/12).Conclusion: Syphilitic meningomyelitis can occur at early or late stage of syphilis, the onset may be acute, subacute or chronic. The imaging findings suggested focal inflammation of the spinal cord. Prognosis is relatively good after proper treatment.
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Affiliation(s)
- Huiqing Dong
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zheng Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China,Correspondence to: Zheng Liu, Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing100053, People’s Republic of China; Ph: 008613910320552; 0086-10-83198899 ext 8701.
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dawei Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhandong Qiu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jing Huang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
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Ramrakhiani N, Sukhani PK, Dubey R. Neurosyphilis - A Forgotten Disease: Case Reports with Ten Years Follow-Up and Review of Literature. Neurol India 2020; 68:889-893. [PMID: 32859835 DOI: 10.4103/0028-3886.293488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Neurosyphilis is a rare disease. We describe two patients of neurosyphilis with their clinical course and long-term follow-up. Our first patient was a 47-year-old male who presented with ataxia, headache, papilledema, sensorineural hearing loss, and myelopathy. Investigations revealed pachymeningitis and cervicodorsal myelitis. Cerebrospinal fluid (CSF) was reactive with positive CSF Venereal Disease Research Laboratory (VDRL) and blood Treponema pallidum hemagglutination (TPHA). His clinical, laboratory, radiological findings, and follow-up of the last 10 years are discussed with serial imaging. Case 2 was a 61-year-old male, who presented with neuropsychiatric symptoms, which resolved with treatment. We have reviewed the Indian case reports of this disease. It is easy to confuse neurosyphilis with tubercular meningitis in an Indian setting. The role of steroids in myelitic form has also been discussed. Worldwide reported cases of syphilitic myelitis are tabulated with their outcomes.
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Affiliation(s)
- Neetu Ramrakhiani
- Department of Neurology, Fortis Escorts Hospital, Malviya Nagar, Jaipur, Rajasthan, India
| | - Paresh Kumar Sukhani
- Department of Radiodiagnosis, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Ramfal Dubey
- Department of Neurology, Fortis Escorts Hospital, Malviya Nagar, Jaipur, Rajasthan, India
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Yuan JL, Wang WX, Hu WL. Clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging. World J Clin Cases 2019; 7:1282-1290. [PMID: 31236392 PMCID: PMC6580337 DOI: 10.12998/wjcc.v7.i11.1282] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Syphilitic myelitis caused by Treponema pallidum is an extremely rare disease. However, symptomatic neurosyphilis, especially syphilitic myelitis, and its clinical features have been infrequently reported. Only a few cases of syphilitic myelitis have been documented. To the best of our knowledge, there are only 19 reported cases of syphilitic myelitis. However, the clinical features of syphilitic myelitis with longitudinally extensive myelopathy have been still not clear.
AIM To explore the clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging (MRI).
METHODS First, we report a patient who suffered from syphilitic myelitis with symptoms of sensory disturbance, with longitudinally extensive myelopathy with "flip-flop sign" on spinal MRI. Second, we performed a literature search to identify other reports (reviews, case reports, or case series) from January 1987 to December 2018, using the PubMed and Web of Science databases with the terms including "syphilis", "neurosyphilis", "syphilitic myelitis", "meningomyelitis", "central nervous system", and "spine". We also summarized the clinical features of syphilitic myelitis with longitudinally extensive myelopathy.
RESULTS A total of 16 articles of 20 cases were identified. Sixteen patients presented with the onset of sensory disturbance (80%), 15 with paraparesis (75%), and 9 with urinary retention (45%). Eleven patients had a high risk behavior (55%). Five patients had concomitant human immunodeficiency virus infection (25%). Serological data showed that 15 patients had positive venereal disease research laboratory test (VDRL)/treponema pallidum particle agglutination (TPHA), and 17 had positive VDRL/TPHA in cerebrospinal fluid (CSF). Seventeen patients were found to have elevated leukocytosis and protein in CSF. On MRI, 16 patients showed abnormal hyperintensities involved the thoracic spine, 6 involved the cervical spine, and 3 involved both the cervical and thoracic spine. There were 3 patients with the "flip-flop sign". All the patients were treated with penicillin, and 15 patients had a good prognosis.
CONCLUSION Our case further raises awareness of syphilitic myelitis as an important complication of neurosyphilis due to homosexuality, especially in developing countries such as China.
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Affiliation(s)
- Jun-Liang Yuan
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wei-Xue Wang
- Department of Oncology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wen-Li Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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7
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Elmouden H, Louhab N, Kissani N. Medullary involvement in neurosyphilis: a report of 12 cases and a review of the literature. Spinal Cord Ser Cases 2019; 5:38. [PMID: 31632699 PMCID: PMC6786502 DOI: 10.1038/s41394-019-0185-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/11/2019] [Accepted: 04/11/2019] [Indexed: 01/18/2023] Open
Abstract
Study design Retrospective case series. Objectives To describe the epidemiological, clinical, MRI and therapeutic features and the outcomes of patients with syphilitic myelitis in a third-level hospital in Marrakesh in southern Morocco. Setting The Neurology Department, University Hospital Mohamed VI Marrakesh, Morocco. Methods Twelve charts of persons with syphilitic myelitis over a period of 17 years were reviewed to determine demographics, presenting symptoms, clinical and radiological findings, biological features, treatment received and outcomes. Results There were 120 reports of neurosyphilis. Twelve patients (10%) had syphilitic myelitis. Eleven patients (92%) were male with mean age of 44 at presentation. Tabes dorsalis was the most common clinical form. Cerebrospinal fluid analysis showed lymphocytic meningitis in nine patients (75%). Spine MRI was abnormal in four patients (33%). All patients were treated with 30 million units of aqueous penicillin G IV per day for 10 days, every 3 months. In follow-up, two patients (17%) with clinical syphilitic meningomyelitis improved significantly, eight patients (66%) with tabes dorsalis and subacute transverse myelitis showed partial improvement but clinical status was stationary for two patients (17%) with Erb paraplegia. Conclusions All patients with myelopathy should undergo syphilitic serology because of nonspecific manifestations and curability of this disease.
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Affiliation(s)
- Hafida Elmouden
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
| | - Nisserine Louhab
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
| | - Najib Kissani
- Neurology Department, University Hospital Mohamed VI Marrakesh, Marrakesh, Morocco
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8
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Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
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Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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9
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Abstract
RATIONALE We report a rare case of syphilitic meningomyelitis presenting with visceral crisis and possessing characteristic imaging findings. PATIENT CONCERNS The patient, a 50-year-old woman, complained of pain in the upper abdomen and back. She then developed numbness in both lower extremities and weakness in the left lower limb. DIAGNOSIS Magnetic resonance imaging (MRI) of the spinal cord revealed the candle guttering sign and irregular enhancement at the T6 level. Rapid plasma reagin test of the cerebrospinal fluid yielded a titer of 1:8. Thus, the patient was diagnosed with syphilitic meningomyelitis. INTERVENTIONS She was treated with ceftriaxone and dexamethasone after the failure of penicillin treatment. OUTCOMES She could perform the activities of daily living, and her pain completely disappeared. LESSONS A patient with syphilitic meningomyelitis can present with visceral crisis caused by the involvement of the posterior nerve roots or the posterior horn, which usually occurs in patients with tabes dorsalis. Considering the non-specific symptoms and MRI features, we should be aware that abdominal pain may be a symptom of myelopathy, and syphilitic meningomyelitis ought to be taken into account in a patient with longitudinally extensive myelitis.
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Affiliation(s)
- Li Sun
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun
| | - Nannan Zheng
- Department of Neurology, Taiyuan Central Hospital, 5th lane of east Jiefang Road, Taiyuan, P.R China
| | - Yu Yang
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun
| | - Hai-Ning Zhang
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun
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10
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Tohge R, Shinoto Y, Takahashi M. Longitudinally Extensive Transverse Myelitis and Optic Neuropathy Associated with Syphilitic Meningomyelitis and Human Immunodeficiency Virus Infection: A Case Report and Review of the Literature. Intern Med 2017; 56:2067-2072. [PMID: 28768983 PMCID: PMC5577089 DOI: 10.2169/internalmedicine.56.8236] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of co-infection with Treponema pallidum and human immunodeficiency virus (HIV) is increasing in developing and developed countries. The neurological complications of both infections occasionally occur simultaneously during a clinical course. We herein report the case of an HIV carrier with syphilitic meningomyelitis and subclinical optic neuropathy. The patient presumably had latent syphilis and slowly developed longitudinally extensive transverse myelitis (LETM). A cerebrospinal fluid examination confirmed the diagnosis of active neurosyphilis based on an elevated T. pallidum hemagglutination assay index. A change in the patient's immune status, possibly due to HIV, might have converted the syphilis from latent to active, leading to LETM of the spinal cord.
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Affiliation(s)
- Rie Tohge
- Department of Neurology, Osaka Red Cross Hospital, Japan
| | - Yuya Shinoto
- Department of Neurology, Osaka Red Cross Hospital, Japan
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11
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Rovira A, Auger C. Spinal Cord in Multiple Sclerosis: Magnetic Resonance Imaging Features and Differential Diagnosis. Semin Ultrasound CT MR 2016; 37:396-410. [PMID: 27616313 DOI: 10.1053/j.sult.2016.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multiple sclerosis (MS) is an idiopathic inflammatory disorder of the central nervous system that affects not only the brain but also the spinal cord. In the diagnostic and monitoring process of MS, spinal cord magnetic resonance imaging (MRI) is not performed as commonly as brain MRI, mainly because of certain technical difficulties and the increase in total acquisition time. Nonetheless, spinal cord MRI findings are important to establish a prompt accurate diagnosis of MS, impart prognostic information, and provide valuable data for monitoring the disease course in certain cases. In this article, we discuss the technical aspects of spinal cord MRI, the typical MRI features of the spinal cord in MS, the clinical indications for this examination, and the differential diagnosis with other disorders that may produce similar clinical or MRI findings.
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Affiliation(s)
- Alex Rovira
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Cristina Auger
- Department of Radiology, Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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12
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Zhovtis Ryerson L, Herbert J, Howard J, Kister I. Adult-onset spastic paraparesis: an approach to diagnostic work-up. J Neurol Sci 2014; 346:43-50. [PMID: 25263600 DOI: 10.1016/j.jns.2014.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/20/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
Adult-onset, chronic progressive spastic paraparesis may be due to a large number of causes and poses a diagnostic challenge. There are no recent evidence-based guidelines or comprehensive reviews to help guide diagnostic work-up. We survey the literature on chronic progressive spastic paraparesis, with special emphasis on myelopathies, and propose a practical, MRI-based approach to facilitate the diagnostic process. Building on neuro-anatomic and radiographic conventions, we classify spinal MRI findings into six patterns: extradural; intradural/extramedullary; Intramedullary; Intramedullary-Tract specific; Spinal Cord Atrophy; and Normal Appearing Spinal Cord. A comprehensive differential diagnosis of chronic progressive myelopathy for each of the six patterns is generated. We highlight some of the more common and/or treatable causes of progressive spastic paraparesis and provide clinical pointers that may assist clinicians in arriving at the diagnosis. We outline a practical, comprehensive MRI-based algorithm to diagnosing adult-onset chronic progressive myelopathy.
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Affiliation(s)
| | - Joseph Herbert
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Jonathan Howard
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
| | - Ilya Kister
- NYU Langone Multiple Sclerosis Comprehensive Care Center, New York, NY, USA
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Nagappa M, Sinha S, Taly AB, Rao SL, Nagarathna S, Bindu PS, Bharath RD, Murthy P. Neurosyphilis: MRI features and their phenotypic correlation in a cohort of 35 patients from a tertiary care university hospital. Neuroradiology 2012; 55:379-88. [PMID: 23274762 DOI: 10.1007/s00234-012-1017-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/31/2012] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The clinical and MR imaging features of neurosyphilis are highly varied. In this study, we describe the spectrum of the imaging findings in patients with neurosyphilis. METHODS The MR imaging observations of 35 patients diagnosed to have neurosyphilis on the basis of cerebrospinal fluid reactive for the Venereal Disease Research Laboratory test were reviewed. RESULTS All the 35 patients, including four with human immunodeficiency virus coinfection, met the CDC diagnostic criteria for neurosyphilis. Patients were classified into three groups: (1) neuropsychiatric, (2) meningovascular, and (3) myelopathic, based on the dominant clinical manifestations. Fourteen patients with neuropsychiatric manifestations showed diffuse cerebral atrophy (14), parenchymal signal changes in the mesial temporal region (2) and temporal and basifrontal regions (1), infarcts (3), and nonspecific white matter changes (3). Eleven patients with meningovascular form showed infarcts (6), diffuse cerebral atrophy (3), signal changes in the mesial temporal region (3), sulcal exudates (1), progressive multifocal leukoencephalopathy (1), and a mass surrounding the carotid sheath (1). Spine imaging in ten patients with myelopathy showed long-segment signal changes (5), contrast enhancement (2), and dorsal column involvement (2). Three of these patients had normal spinal study. Six patients in the myelopathic group also underwent brain MRI that showed signal changes in the temporal region (2) and frontal region (1), multiple infarcts (1), and enhancing hypothalami (1). Three patients had normal study. CONCLUSION MRI abnormalities in neurosyphilis are protean and mimic of many other neurological disorders and thus require a high index of suspicion to reduce diagnostic omissions.
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Affiliation(s)
- M Nagappa
- Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560 029 Karnataka, India
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15
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Lee CB, Choi SM, Kim SJ, Chae BG, Kim JH, Jin SS, Joung MK. A Case of Acute Transverse Myelitis Associated with Neurosyphilis. Infect Chemother 2012. [DOI: 10.3947/ic.2012.44.6.446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Chan Bok Lee
- Department of Internal Medicine, Sam Anyang Hospital, Anyang, Gyeonggi-do, Korea
| | - Sang Myung Choi
- Department of Internal Medicine, Sam Anyang Hospital, Anyang, Gyeonggi-do, Korea
| | - Sung Jin Kim
- Department of Internal Medicine, Sam Anyang Hospital, Anyang, Gyeonggi-do, Korea
| | - Byoung Gy Chae
- Department of Internal Medicine, Sam Anyang Hospital, Anyang, Gyeonggi-do, Korea
| | - Jung-Hyun Kim
- Department of Public Health, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Su Sin Jin
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mi Kyong Joung
- Division of Infectious Diseases, Sam Anyang Hospital, Anyang, Gyeonggi-do, Korea
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16
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17
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Louhab N, Hajjaj I, Kissani N. Neurosyphilis : une cause rare de myélite. Presse Med 2010; 39:605-6. [DOI: 10.1016/j.lpm.2009.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 10/23/2009] [Accepted: 11/19/2009] [Indexed: 11/16/2022] Open
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18
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Affiliation(s)
- Diego Cadavid
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Charlestown, 02129, USA.
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19
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Pandit L. Differential diagnosis of white matter diseases in the tropics: An overview. Ann Indian Acad Neurol 2009; 12:12-21. [PMID: 20151003 PMCID: PMC2811971 DOI: 10.4103/0972-2327.48846] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2008] [Revised: 09/07/2008] [Accepted: 10/14/2008] [Indexed: 11/08/2022] Open
Abstract
In hospitals in the tropics, the availability of magnetic resonance imaging (MRI) facilities in urban areas and especially in teaching institutions have resulted in white matter diseases being frequently reported in a variety of clinical settings. Unlike the west where multiple sclerosis (MS) is the commonest white matter disease encountered, in the tropics, there are myriad causes for the same. Infectious and post infectious disorders probably account for the vast majority of these diseases. Human immunodeficiency virus (HIV) infection tops the list of infective conditions. Central nervous system (CNS) tuberculosis occasionally presents with patchy parenchymal lesions unaccompanied by meningeal involvement. Human T cell leukemia virus (HTLV) infection and cystic inflammatory lesions such as neurocysticercosis are important causes to be considered in the differential diagnosis. Diagnosing post infectious demyelinating disorders is equally challenging since more than a third of cases seen in the tropics do not present with history of past infection or vaccinations. Metabolic and deficiency disorders such as Wernicke's encephalopathy, osmotic demyelinating syndrome associated with extra pontine lesions and Vitamin B12 deficiency states can occassionaly cause confusion in diagnosis. This review considers a few important disorders which manifest with white matter changes on MRI and create diagnostic difficulties in a population in the tropics.
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Affiliation(s)
- Lekha Pandit
- Department of Neurology, KS Hegde Medical Academy, Mangalore-575018, Karnataka, India
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20
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Duncan MKJ, Howlett DC, Watson GMT. An unusual case of acute leg weakness. Br J Hosp Med (Lond) 2008; 69:356-7. [PMID: 18646423 DOI: 10.12968/hmed.2008.69.6.29629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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21
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Harzheim M, Schlegel U, Urbach H, Klockgether T, Schmidt S. Discriminatory features of acute transverse myelitis: a retrospective analysis of 45 patients. J Neurol Sci 2004; 217:217-23. [PMID: 14706227 DOI: 10.1016/j.jns.2003.10.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute transverse myelitis (ATM) is a pathogenetically heterogeneous inflammatory disorder of the spinal cord. Therefore, the identification of clinical and paraclinical features providing clues of the underlying etiologies is needed. The clinical presentation, blood and cerebrospinal fluid (CSF) findings as well as magnetic resonance imaging (MRI) and neurophysiological features were retrospectively analyzed in 45 unselected consecutive patients with ATM. Parainfectious ATM was diagnosed in 38% of patients. The underlying infectious agent, however, was identified only in a minority of patients. In 36% of patients, the etiology remained uncertain ("idiopathic" ATM) and in 22% ATM was the first manifestation of possible multiple sclerosis (ATM-MS) according to recently published diagnostic criteria. Spinal cord MRI showed signal alterations in 96% of the patients. In ATM-MS, monosegmental involvement of the spinal cord was most frequent while spinal cord involvement of two or more segments was more common in ATM of other etiologies. Of particular note, neurophysiological examinations showed evidence of peripheral nervous system (PNS) involvement in 27% of patients with ATM but not in patients with ATM-MS. Therefore, neurophysiological evidence of PNS involvement may provide additional discriminatory features between ATM-MS and ATM of other etiologies.
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Affiliation(s)
- Michael Harzheim
- Department of Neurology, University of Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany.
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22
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23
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Zifko U, Wimberger D, Lindner K, Zier G, Grisold W, Schindler E. MRI in patients with general paresis. Neuroradiology 1996; 38:120-3. [PMID: 8692419 DOI: 10.1007/bf00604794] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Few cases of MRI in neurosyphilis have been reported. We examined the value of MRI in patients with general paresis; MRI was performed on four HIV-negative patients with parenchymatous neurosyphilis. It demonstrated frontal and temporal atrophy, subcortical gliosis and, in one patient, increased ferritin in the basal ganglia. The progression of the lesions on MRI correlated well with the neuropsychiatric disturbances. The MRI findings correlated with the well-known neuropathological findings. This combination of pathological findings in neurosyphilis has not been described before and we suggest that MRI is of prognostic value in patients with general paresis.
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Affiliation(s)
- U Zifko
- Department of Neurology, Kaiser Franz Josef Spital, Vienna, Austria
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24
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Engelter S, Lyrer P, Radu EW, Steck AJ. Acute infectious disorders of the spinal cord and its roots with gadolinium-DTPA enhancement in magnetic resonance imaging. J Neurol 1996; 243:191-5. [PMID: 8750559 DOI: 10.1007/bf02444013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We studied three patients with myelomeningoradiculitis caused by Borrelia burgdorferi, herpes zoster virus or cytomegalovirus infection. All patients underwent MRI of the spinal cord with gadolinium-DTPA and showed enhancing lesions of the spinal cord or nerve roots that correlated with clinical signs. Gadolinium-DTPA enhancement may visualize lesions that suggest an inflammation associated with blood-brain-barrier alteration and indicate the diagnosis before serological results are available.
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Affiliation(s)
- S Engelter
- Department of Neurology, University Hospital, Basle, Switzerland
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