Infectious CNS disease as a differential diagnosis in systemic rheumatic diseases: three case reports and a review of the literature.

BACKGROUND: Immunosuppressive treatment of rheumatic diseases may be associated with several opportunistic infections of the brain. The differentiation between primary central nervous system (CNS) involvement and CNS infection may be difficult, leading to delayed diagnosis. OBJECTIVE: To differentiate between CNS involvement and CNS infection in systemic rheumatic diseases. METHODS AND RESULTS: Three patients with either longstanding or suspected systemic rheumatic diseases (systemic lupus erythematodes, Wegener's granulomatosis, and cerebral vasculitis) who presented with various neuropsychiatric symptoms are described. All three patients were pretreated with different immunosuppressive drugs (leflunomide, methotrexate, cyclophosphamide) in combination with corticosteroids. Magnetic resonance imaging of the brain was suggestive of infectious disease, which was confirmed by cerebrospinal fluid analysis or stereotactic brain biopsy (progressive multifocal leucoencephalopathy (PML) in two and nocardiosis in one patient). DISCUSSION: More than 20 cases of PML or cerebral nocardiosis in patients receiving corticosteroids and cytotoxic drugs for rheumatic disease have been reported. The clinical aspects of opportunistic CNS infections and the role of brain imaging, cerebrospinal fluid analysis and stereotactic brain biopsy in the differential diagnosis are reviewed.

["Catastrophic systemic lupus erythematosus" with Rosai-Dorfman sinus histiocytosis. Successful treatment with anti-CD20/rutuximab]. / "Katastrophaler SLE" mit Rosai-Dorfman-Sinushistiozytose. Erfolgreiche Behandlung mit Anti-CD20/Rituximab.

HISTORY AND ADMISSION FINDINGS: A 59-year old woman was admitted with a four-month history of polyarthritis, myalgias and photosensitivity insufficiently responsive to methotrexate, corticosteroids and azathioprin. On physical examination she presented with symmetric ankle edema, polyserositis, petechial bleeding and swelling of cervical, axillary and inguinal lymph nodes. INVESTIGATIONS: Laboratory analysis revealed a trilinear cytopenia without signs of hemolysis. Acute phase proteins were elevated. Furthermore antinuclear antibodies, anti-phospholipid IgM antibodies, hypocomplementemia, a spurious IgGkappa paraprotein were noted. CT scans confirmed lymphadenopathy and revealed a pleural and pericardial effusion. Bone marrow biopsy showed marked hypercellularity and polyclonal plasmocytosis. Based on these findings systemic lupus erythematosus was initially suspected. However when abdominal MRI showed a retroperitoneal mass, an extensive histological workup, which also included lymph nodes and spleen, revealed numerous plasma cells and histiocytes in dilated sinuses, diagnostic of Rosai-Dorfman sinus histiocytosis. TREATMENT AND COURSE: High dose corticosteroids, intravenous gamma-globulin and repeated courses of cyclophosphamide failed to improve the pancytopenia, as did splenectomy. The patient was given the anti-CD20 monoclonal antibody Rituximab and all signs and symptoms improved dramatically. 18 months after the last treatment, the patient is in complete clinical and hematological remission. CONCLUSIONS: Sinus histiocytosis of Rosai/Dorfman can be associated with or mimic severe SLE. Rituximab, an anti-CD20 monoclonal antibody, may improve the antibody-mediated pathogenetic mechanism underlying both entities.

Constitutive expression of Bcl-xL or Bcl-2 prevents peptide antigen-induced T cell deletion but does not influence T cell homeostasis after a viral infection.

We examined the CD8+ T cell response to lymphocytic choriomeningitis virus (LCMV) in mice doubly transgenic for an LCMV-specific TCR and for either bcl-xL or bcl-2. Clonal down-sizing of the anti-viral CD8+ T cell response and the generation of T cell memory was not influenced by constitutive expression of these anti-apoptotic proteins in T cells. Expression of Bcl-xL or Bcl-2 did, however, prevent LCMV peptide-induced peripheral deletion of mature CD8+ T cells in vivo and apoptosis of activated LCMV-specific effector T cells in vitro. The CD8+ T cells "rescued" by Bcl-xL or Bcl-2 from peptide antigen-induced cell death were anergic and this could not be reversed by addition of IL-2 in vitro or by adoptive transfer into antigen-free recipient mice followed by LCMV infection in vivo. Taken together, we show here that 1) Bcl-xL or Bcl-2 are functionally equivalent in their ability to modulate CD8+ T cell survival in vivo, 2) distinct apoptosis signaling pathways exist in CD8+ T cells, one that can be inhibited by Bcl-2 or Bcl-xL and one that cannot be blocked, and 3) apoptosis of CD8+ effector T cells during the declining phase of an immune response is not prevented by constitutive expression of the anti-apoptotic proteins Bcl-xL and Bcl-2.