In neurological disorder related amyloidosis, several therapies have been developed in the recent decade. In AL and AA amyloidosis, novel chemotherapy and IL6 receptor antibody have been found to be effective, respectively. In addition to these amyloidosis, in transthyretin (TTR) related familial amyloidotic polyneuropathy (FAP), liver transplantation, tertial structure stabilizing drugs, and gene silencing drugs have been developing now. As neurological disorder related amyloidosis, systemic amyloidosis, such as AL amyloidosis, AA amyloidosis, dialysis related amyloidosis, FAP, senile systemic amyloidosis, and brain localized amyloidosis, such as Alzheimer’s disease, and prion disease are listed. In this review, we mentioned diagnosis, pathogenesis and therapies of systemic amyloidosis.
Anti-glutamic acid decarboxylase (GAD) antibodies are known to be associated with insulin-dependent diabetes mellitus (IDDM), stiff-person syndrome, and other neurological symptoms including temporal lobe epilepsy (TLE), known as autoimmune epilepsy. We treated four patients with TLE who had elevated titers of serum anti-GAD antibody (anti-GAD-Ab), higher than 100 U/ml. Three of the four patients started to have epileptic seizures in their 5th or 6th decade. Characteristic symptoms suggesting encephalitis or encephalopathy were absent at onset of these symptoms, which led to delayed diagnosis. All four patients developed two or three of cerebellar ataxia, neuropsychological impairment, and IDDM, by several years or decades after onset of TLE, even after seizure freedom in two patients. These abnormalities were indicators for suspecting the involvement of anti-GAD-Ab in the pathogenesis. Anti-GAD-Ab levels in the cerebrospinal fluid (CSF) were measured, which detected elevated CSF/serum anti-GAD-Ab ratio (≥ 1.0), suggesting intrathecal anti-GAD-Ab synthesis, in three of the four patients. The TLE symptoms were somewhat prolonged, but three of the four patients eventually achieved seizure freedom after immunotherapies with combinations of two or three anti-epileptic drugs. Serum anti-GAD Ab is recommended to be measured in patients with middle-aged onset TLE. Moreover, immune-modulating therapies including steroid pulse and intravenous immunoglobulin therapies could have ameliorated neurological complications, even in the chronic phase.
A 52-year-old woman was admitted to our hospital with muscle pain and an elevated creatine kinase level. She had experienced wrist pain at onset seven years ago. The initial possible diagnoses were rheumatoid arthritis and adult-onset Still disease. The patient received corticosteroid and immunosuppressant therapy but experienced deterioration of symptoms. The symptoms of muscle pain and mild creatine kinase elevation emerged four years prior to her visit. Further elevation of creatine kinase was observed for three months before her visit despite adjusting the immunosuppressant dose. On admission, she presented with muscle moderate weakness of the trunk and extremities and pain of the shoulder and medial thigh muscles. Elevation of muscle enzymes and inflammatory response were also detected, and the anti-PL7 antibody was positive. Muscle biopsy from biceps brachii revealed necrotizing myopathy with necrotic and regenerated muscle fibers. The final diagnosis was anti-PL7 antibody positive myositis. The patient was treated with a higher dose of prednisolone and an adequate dose of tacrolimus. Following this treatment, the symptoms were improved. Anti-ARS (aminoacyl t-RNA synthetase) antibodies such as anti-PL7 antibody are useful in diagnosis and for prognostic prediction. Further investigation of patients with anti-ARS antibodies positive myositis is required.
A 30-year old man was admitted with right hip pain and gait disturbances. Neurological findings revealed muscular weakness in the lower limbs, hyporeflexia, dysesthesia in the sacral region, and bowel and bladder disturbances. Cerebrospinal fluid (CSF) examination indicated a white blood cell count of 371/μl (lymphocyte:polymorphonuclear leukocyte = 97:3), protein levels of 463 mg/dl and sugar of 20 mg/dl. Although CSF culture was negative, tuberculous infection was presumed. Magnetic resonance imaging revealed areas of enhancement in the intramedullary region surrounding the spinal cord and cauda equina. Enhanced computed tomography (CT) of the abdomen revealed lymph node swelling around the head of the pancreas. Biopsy of the lymph node swelling was culture-positive for Mycobacterium tuberculosis. Hence, assuming a diagnosis of tuberculous lymphadenitis of the abdomen, antitubercular drugs were started. Since antitubercular therapy had beneficial effects on the neurological symptoms and CSF findings, we diagnosed the patient with tuberculous myeloradiculitis. Systematic examinations including lymph node biopsy and cultures were useful for the diagnosis of tuberculous myeloradiculitis.
A seventy-year-old man developed color change in his left toes and was treated for frostbite. Eight months later, he developed cognitive impairment and was admitted to our hospital. A remarkable increase of eosinophils was observed in peripheral blood. Brain MRI revealed abnormal lesions in the fornix, corpus callosum, basal ganglia and frontal lobe. Steroid therapy ameliorated his symptom temporarily, but he suddenly developed cardiopulmonary arrest. His autopsy revealed severe pulmonary hemorrhage with alveolar vasculitis and cholesterol crystals in the brain, kidneys, liver, and the other organs. It was possible that cholesterol embolization to multiple organs including the brain induced systemic vasculitis that caused pulmonary hemorrhage and his critical prognosis. Cholesterol embolization should be considered when we see a patient with brain lesions accompanied with eosinophilia.
An 85-year-old woman was first admitted to our hospital because of right ptosis and diplopia. Examinations showed right oculomotor paralysis and reduced vision in the right eye. Serological and neuroradiological examinations failed to reveal the etiology. Oral prednisolone was started for a presumptive diagnosis of idiopathic oculomotor nerve palsy, which resulted in little improvement. Approximately ten months after the first admission, left ptosis appeared and she was re-admitted to our hospital. One day after admission, external ophthalmoplegia and conjunctival injection on the left side appeared. MRI revealed abnormal flow void in the right cavernous sinus. Based on cerebral angiographic findings, dural arteriovenous fistula of the right cavernous sinus was diagnosed. Symptoms on the left side were considered to result from increased perfusion pressure due to venous drainage via the intercavernous sinus to the contralateral cavernous sinus. After transvenous embolization, symptoms and signs improved gradually. In a case of external ophthalmoplegia with unknown etiology, detailed neuroradiologyical examinations such as cerebral angiogram are advisable.
Cerebellar ataxia is most neurological sequelae in heat stroke. Heat stroke with cerebral cortical lesions is very rare. A 39-year-old man was admitted to our hospital because of coma, shock status and hyperthermia on arrival and developed disseminated intravascular coagulation (DIC). Hypotension was transient and all vital signs were resumed to normal within a week. Though normal vital sign, his coma state continued throughout. A diffusion weighted image (DWI) on MRI disclosed abnormal diffuse high intensity in the cerebral and cerebellar cortex without decreased apparent diffusion coefficient (ADC). These cortical changes were supported to the vasogenic edema induced by heat stroke. Four months later after the onset, the abnormal signal intensity in the cerebral and cerebellar cortex disappeared and cortical atrophy with ventricular enlargement developed. Electroencephalogram (EEG) of several times showed no electrical activities. The brain SPECT (123I-IMP) disclosed all over decreased blood flow. His vegetative state continued.
A 74-year-old woman was clinically diagnosed with possible amyotrophic lateral sclerosis (ALS) and was administered 100 mg/day of riluzole. After 2 months, she developed dyspnea and experienced gradual difficulty walking. Chest computed tomography revealed ground-glass opacity and consolidation in the lower lobes of both the lungs, thereby suggesting a diagnosis of interstitial pneumonia. Because the condition was suspected to be drug-induced, riluzole administration was discontinued and steroid (methylprednisolone) pulse therapy (1,000 mg/day, 3 days) was started. Her symptoms and radiological findings improved immediately. At 16 months later, she wanted to take riluzole again. She had the similar interstitial pneumonia on the 4th day of the re-administration. Drug (riluzole)-induced lymphocyte stimulation tests (DLST) were negative two times. The symptoms of interstitial pneumonia, a rare adverse effect of riluzole, are very similar to worsening symptoms of ALS; therefore, patients with ALS receiving riluzole therapy should be carefully monitored.
We report a 76-year-old male with ANCA-associated hypertrophic pachymeningitis, who presented with crescentic glomerulonephritis. At the initial visit, he had episodic frontal headache and multiple cranial nerve palsy, including double vision, right deafness, hoarseness, and dysphagia. Because proteinuria and hematuria were detected on urinalysis, we performed a kidney biopsy, leading to the diagnosis of crescentic glomerulonephritis. The presence of vascular inflammation in the kidney biopsy led us to consider that this patient may show progression to the systemic type of MPO-ANCA-positive hypertrophic pachymeningitis. This proved useful for prognostic and treatment determination. Based on the results of laboratory tests, imaging studies, and biopsies of the dura mater and kidney, the patient was diagnosed with ANCA-associated hypertrophic pachymeningitis.