Recommendations by the Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and the Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) on vaccination in general and specifically against SARS-CoV-2 for patients with demyelinating diseases of the central nervous system.

The Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) provide recommendations in this document for vaccination of the population with demyelinating diseases of the central nervous system (CNS) against infections in general and against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. We emphasize the seriousness of the current situation in view of the spread of COVID-19 in our country. Therefore, reference guides on vaccination for clinicians, patients, and public health authorities are particularly important to prevent some infectious diseases. The DCNI/ABN and BCTRIMS recommend that patients with CNS demyelinating diseases (e.g., MS and NMOSD) be continually monitored for updates to their vaccination schedule, especially at the beginning or before a change in treatment with a disease modifying drug (DMD). It is also important to note that vaccines are safe, and physicians should encourage their use in all patients. Clearly, special care should be taken when live attenuated viruses are involved. Finally, it is important for physicians to verify which DMD the patient is receiving and when the last dose was taken, as each drug may affect the induction of immune response differently.

Recommendations by the Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and the Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) on vaccination in general and specifically against SARS-CoV-2 for patients with demyelinating diseases of the central nervous system / Recomendações do Departamento Científico de Neuroimunologia da Academia Brasileira de Neurologia (DCNI/ABN) e do Comitê Brasileiro de Tratamento e Pesquisa em Esclerose Múltipla e Doenças Neuroimunológicas (BCTRIMS) sobre vacinação em geral e contra a SARS-CoV-2 para pacientes com doenças desmielinizantes do sistema nervoso central

ABSTRACT The Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) provide recommendations in this document for vaccination of the population with demyelinating diseases of the central nervous system (CNS) against infections in general and against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. We emphasize the seriousness of the current situation in view of the spread of COVID-19 in our country. Therefore, reference guides on vaccination for clinicians, patients, and public health authorities are particularly important to prevent some infectious diseases. The DCNI/ABN and BCTRIMS recommend that patients with CNS demyelinating diseases (e.g., MS and NMOSD) be continually monitored for updates to their vaccination schedule, especially at the beginning or before a change in treatment with a disease modifying drug (DMD). It is also important to note that vaccines are safe, and physicians should encourage their use in all patients. Clearly, special care should be taken when live attenuated viruses are involved. Finally, it is important for physicians to verify which DMD the patient is receiving and when the last dose was taken, as each drug may affect the induction of immune response differently.

RESUMO O DC de Neuroimunologia da ABN e o BCTRIMS trazem, nesse documento, as recomendações sobre vacinação da população com doenças desmielinizantes do sistema nervoso central (SNC) contra infecções em geral e contra o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2), causador da COVID-19. Destaca-se a gravidade do atual momento frente ao avanço da COVID-19 em nosso País, o que torna mais evidente e importante a criação de guia de referência para orientação aos médicos, pacientes e autoridades de saúde pública quanto à vacinação, meio efetivo e seguro no controle de determinadas doenças infecciosa. O DCNI/ABN e o BCTRIMS recomendam que os pacientes com doenças desmielinizantes do SNC (ex., EM e NMOSD) sejam constantemente monitorados, quanto a atualização do seu calendário vacinal, especialmente, no início ou antes da mudança do tratamento com uma droga modificadora de doença (DMD). É importante também salientar que as vacinas são seguras e os médicos devem estimular o seu uso em todos os pacientes. Evidentemente, deve ser dada especial atenção às vacinas com vírus vivos atenuados. Por fim, é importante que os médicos verifiquem qual DMD o paciente está em uso e quando foi feita a sua última dose, pois cada fármaco pode interagir de forma diferente com a indução da resposta imune.

Spectrum of ocular manifestations and visual outcomes of neurosyphilis among 53 patients.

BACKGROUND: In the era of the re-emergence of syphilis, ocular syphilis has gained attention because its prevalence has increased and it can cause blindness and disability. OBJECTIVES: To investigate the clinical presentation and prognosis of ocular syphilis. METHODS: Prospective study on 53 patients (90 eyes) with ocular syphilis diagnosed at the Santa Casa of Belo Horizonte, Brazil. The diagnosis was based on clinical manifestations of the disease and on serological markers (positive serum treponemal and non-treponemal tests or two positive treponemal tests). RESULTS: Thirty-five eyes (66%) were from men and the mean age was 45.3 ± 12.0 years. HIV coinfection was confirmed in 10 patients (18.9%). Forty-four (84.9%) had VDRL titers ≥ 1:32. Bilateral ocular involvement occurred in 68%. Optic neuritis was diagnosed in 51.7% of the eyes and uveitis in 48.2%. Regarding visual acuity, the median baseline logarithm of the minimum angle of resolution (logMAR) was 1 (20/200 Snellen), while after antibiotic therapy, the median was 0.2 (20/30 Snellen). Poor visual acuity after treatment, defined as the best-corrected visual acuity (BCVA; logMAR 1; 20/200 Snellen) or worse, was associated with severe BCVA at presentation (below logMAR 1.3; 20/400 Snellen) (p = 0.001) and age over 50 years (p = 0.001). CONCLUSIONS: This study confirms the wide spectrum of clinical manifestations of ocular syphilis. The most frequent form was optic neuritis, an important differential diagnosis from other causes of inflammatory neuritis. Early diagnosis is essential, given that this is a treatable condition with excellent visual recovery in most cases.

Evaluation of diagnosis and treatment practices of Brazilian neurologists among patients with multiple sclerosis.

BACKGROUND: Recent changes to the diagnostic criteria for multiple sclerosis (MS) and new medications have had a major impact on the way in which specialists manage the disease. OBJECTIVE: To investigate factors considered by Brazilian neurologists in managing MS, and to identify how these contribute to diagnosis and treatment. METHODS: Potential participants were selected by a steering committee (MS experts who developed this survey). Only MS specialists were included in the study (neurologists who had completed a neuroimmunology fellowship or who were treating more than 30 MS patients). Links to the online questionnaire were distributed between March 2019 and January 2020. This questionnaire was composed of sections with hypothetical MS scenarios. RESULTS: Neurologists from 13 Brazilian states responded to the survey (n = 94). In the clinically isolated syndrome (CIS) scenario, the respondents agreed to treat patients with a high risk of MS diagnosis, whereas in the radiologically isolated syndrome (RIS) half of the respondents opted not to treat, even among high-risk patients. In cases of low-activity relapsing-remitting MS (RRMS), the choice of treatment was distributed among interferon beta, glatiramer acetate and teriflunomide, which were changed to fingolimod and natalizumab, as RRMS severity increased. The topics in which disagreement was found included practices regarding use of disease-modifying therapy (DMT) for pregnant patients and the washout period required for some DMTs. CONCLUSIONS: This study enabled identification of areas of agreement and disagreement about MS treatment among Brazilian neurologists, which can be used to update future protocols and improve patient management.

Central Nervous System Idiopathic Inflammatory Demyelinating Disorders in South Americans: A Descriptive, Multicenter, Cross-Sectional Study.

The idiopathic inflammatory demyelinating disease (IIDD) spectrum has been investigated among different populations, and the results have indicated a low relative frequency of neuromyelitis optica (NMO) among multiple sclerosis (MS) cases in whites (1.2%-1.5%), increasing in Mestizos (8%) and Africans (15.4%-27.5%) living in areas of low MS prevalence. South America (SA) was colonized by Europeans from the Iberian Peninsula, and their miscegenation with natives and Africans slaves resulted in significant racial mixing. The current study analyzed the IIDD spectrum in SA after accounting for the ethnic heterogeneity of its population. A cross-sectional multicenter study was performed. Only individuals followed in 2011 with a confirmed diagnosis of IIDD using new diagnostic criteria were considered eligible. Patients' demographic, clinical and laboratory data were collected. In all, 1,917 individuals from 22 MS centers were included (73.7% female, 63.0% white, 28.0% African, 7.0% Mestizo, and 0.2% Asian). The main disease categories and their associated frequencies were MS (76.9%), NMO (11.8%), other NMO syndromes (6.5%), CIS (3.5%), ADEM (1.0%), and acute encephalopathy (0.4%). Females predominated in all main categories. The white ethnicity also predominated, except in NMO. Except in ADEM, the disease onset occurred between 20 and 39 years old, early onset in 8.2% of all cases, and late onset occurred in 8.9%. The long-term morbidity after a mean disease time of 9.28±7.7 years was characterized by mild disability in all categories except in NMO, which was scored as moderate. Disease time among those with MS was positively correlated with the expanded disability status scale (EDSS) score (r=0.374; p=<0.001). This correlation was not observed in people with NMO or those with other NMO spectrum disorders (NMOSDs). Among patients with NMO, 83.2% showed a relapsing-remitting course, and 16.8% showed a monophasic course. The NMO-IgG antibody tested using indirect immunofluorescence (IIF) with a composite substrate of mouse tissues in 200 NMOSD cases was positive in people with NMO (95/162; 58.6%), longitudinally extensive transverse myelitis (10/30; 33.3%) and bilateral or recurrent optic neuritis (8/8; 100%). No association of NMO-IgG antibody positivity was found with gender, age at onset, ethnicity, early or late onset forms, disease course, or long-term severe disability. The relative frequency of NMO among relapsing-remitting MS (RRMS) + NMO cases in SA was 14.0%. Despite the high degree of miscegenation found in SA, MS affects three quarters of all patients with IIDD, mainly white young women who share similar clinical characteristics to those in Western populations in the northern hemisphere, with the exception of ethnicity; approximately one-third of all cases occur among non-white individuals. At the last assessment, the majority of RRMS patients showed mild disability, and the risk for secondary progression was significantly superior among those of African ethnicity. NMO comprises 11.8% of all IIDD cases in SA, affecting mostly young African-Brazilian women, evolving with a recurrent course and causing moderate or severe disability in both ethnic groups. The South-North gradient with increasing NMO and non-white individuals from Argentina, Paraguay, Brazil and Venezuela confirmed previous studies showing a higher frequency of NMO among non-white populations.

Open-ring enhancement in pseudotumoral multiple sclerosis: important radiological aspect.

Introduction. Observation of open-ring enhancement in magnetic resonance imaging (MRI) is considered a specificity marker for diagnosing pseudotumoral multiple sclerosis (MS). This finding is of great value in the differential diagnosis of tumefactive lesions. Case Report. We describe a 55-year-old white woman, with previous history of ovarian cancer and recent history of fatigue and bilateral retroorbital pain. Important bilateral visual impairment evolved over one month. Physical examination detected the presence of right homonymous hemianopia. Cranial MRI showed an expanding lesion with open-ring enhancement. Given the range of diagnostic possibilities, a stereotactic biopsy was performed, and histopathological examination was consistent with an active demyelinating disease. The patient was treated with 1 g of methylprednisolone and symptoms improved following a significant reduction in the lesion. Conclusions. We highlight the MRI results suggestive of pseudotumoral MS, especially open-ring enhancement, which is an important radiologic aspect to diagnosis and can assist in avoiding unnecessary biopsies.

Vitamin B12 extensive thoracic myelopathy: clinical, radiological and prognostic aspects. Two cases report and literature review.

The myelopathy caused by vitamin B12 deficiency is known as subacute combined degeneration. It is rare, but a well known cause of demyelination of the dorsal columns of the spinal cord. The magnetic resonance imaging is characterized by an increased signal on T2-weighted images involving the posterior columns of cervical and thoracic cord. There have been few cases in literature with extensive lesions (more than seven levels) of the thoracic spinal cord. The clinical and radiological improvements are possible if the replacement of vitamin B12 is initiated precocious. We present two rare cases of extensive thoracic myelopathy due to vitamin B12 deficiency. The first is a young woman with complete clinical recovery and important radiologic improvement after early treatment. In addition, the second case is an older man with partial response to the treatment. Those cases illustrate the importance of considering vitamin B12 deficiency in any patient, who presents with myelopathy.

[Cerebral venous thrombosis: study of fifteen cases and review of literature].

OBJECTIVE: To analyze a series of 15 patients with cerebral venous thrombosis (CVT) who had follow-ups at the neurology service of Santa Casa de Belo Horizonte Hospital from April, 2007 to December, 2008. These results were compared with data in literature. METHODS: Cases were evaluated by retrospective study of the epidemiologic characteristics, signs and symptoms, risk factors and prognosis of 15 patients with cerebral venous thrombosis. RESULTS: Diagnoses were reached through magnetic resonance imaging of the brain in 14 cases and through an angiography in one. The main risk factors identified were use of birth control pills (40%) and history of family member with deep venous thrombosis. Thrombophilia was found in two patients (13%). The veins more affected were the transverse sinus (73%) followed by the upper sagital sinus (53%). Four patients had strokes and five had only headaches as isolated symptoms. Twelve patients were treated with heparin and oral anticoagulant. CONCLUSION: Treatment with heparin in the acute phase followed by an oral anticoagulant was shown as safe and efficient to prevent worsening of the disease, recurrence and for quick improvement of neurological symptoms of all treated patients. CVT is one of the possible diagnoses of secondary headache even in patients with no signs and symptoms.

Trombose de seios venosos cerebrais: estudo de 15 casos e revisão de literatura / Cerebral venous thrombosis: study of fifteen cases and review of literature

OBJETIVO: Analisar uma série de 15 pacientes com trombose venosa cerebral (TVC) e comparar os resultados com dados da literatura. MÉTODOS: Foram avaliados, por meio de estudo retrospectivo, transversal e descritivo, as características epidemiológicas, o quadro clínico, os fatores de risco e o prognóstico de 15 pacientes com TVC admitidos no serviço de Neurologia da Santa Casa de Belo Horizonte no período de abril de 2007 a Dezembro de 2008. RESULTADOS: O diagnóstico de TVC foi confirmado por exame de ressonância nuclear magnética de encéfalo em 14 casos e por angiografia cerebral em um caso. Os principais fatores de risco identificados foram o uso do anticoncepcional oral (40 por cento) e uma história prévia ou familiar de trombose venosa profunda. Trombofilia foi encontrada em dois pacientes (13 por cento). O seio mais acometido foi o transverso (73 por cento), seguido pelo sagital superior, em 53 por cento. Quatro pacientes apresentaram acidente vascular cerebral e outros 5 apresentaram-se apenas com cefaleia isolada. Doze pacientes foram tratados com heparina e anticoagulação oral sequencial. CONCLUSÃO: A terapêutica com heparina na fase aguda seguida do anticoagulante oral demonstrou-se segura e eficaz na prevenção da progressão da doença, de sua recidiva e na rápida recuperação do quadro neurológico de todos os pacientes tratados. A TVC deve ser considerada no diagnóstico de cefaleia secundária mesmo em pacientes com ausência de outros sinais ou sintomas.

OBJECTIVE: To analyze a series of 15 patients with cerebral venous thrombosis (CVT) who had follow-ups at the neurology service of Santa Casa de Belo Horizonte Hospital from April, 2007 to December, 2008. These results were compared with data in literature. METHODS: Cases were evaluated by retrospective study of the epidemiologic characteristics, signs and symptoms, risk factors and prognosis of 15 patients with cerebral venous thrombosis. RESULTS: Diagnoses were reached through magnetic resonance imaging of the brain in 14 cases and through an angiography in one. The main risk factors identified were use of birth control pills (40 percent) and history of family member with deep venous thrombosis. Thrombophilia was found in two patients (13 percent). The veins more affected were the transverse sinus (73 percent) followed by the upper sagital sinus (53 percent). Four patients had strokes and five had only headaches as isolated symptoms. Twelve patients were treated with heparin and oral anticoagulant. CONCLUSION: Treatment with heparin in the acute phase followed by an oral anticoagulant was shown as safe and efficient to prevent worsening of the disease, recurrence and for quick improvement of neurological symptoms of all treated patients. CVT is one of the possible diagnoses of headaches as an isolated symptom.

Cisto enterogênico intra-espinhal: relato de caso / Intraspinal enterogenous cyst: report of case

Os autores apresentam um caso de Cisto Enterogênico intradural cervical operado, com ótimo resultado. Discutem a embriogénese, quadro clínico, diagnóstico neurorradiológico e terapêutica desta patologia a partir de revisäo da literatura