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Treatment of CNS sarcoidosis with infliximab and mycophenolate mofetil

From the Department of Neurobiology and Anatomy (M.M.) and the Departments of Neurology, Microbiology, and Immunology and the Cancer Center (B.M.S.), University of Rochester School of Medicine and Dentistry, NY.

Address correspondence and reprint requests to Dr. Benjamin M. Segal, Dept. of Neurology, Holtom-Garrett Program in Neuroimmunology, University of Michigan, 4009 BSRB, 109 Zina Pitcher Place, SPC 2200, Ann Arbor, MI 48109-2200 bmsegal{at}umich.edu

Objective: To describe the effects of the anti–tumor necrosis factor neutralizing antibody, infliximab, and the antiproliferative immunosuppressant, mycophenolate mofetil, in refractory neurosarcoidosis.

Methods: We treated patients with biopsy-proven sarcoidosis and CNS involvement, who had failed treatment with steroids, with infliximab (5 mg/kg on weeks 0, 2, and 6, and then every 6–8 weeks thereafter). Six out of seven patients were co-treated with mycophenolate mofetil (1,000 mg PO BID). Patients underwent a review of symptoms and complete neurologic examination every 3 months and MRI scanning before and after 3–4 infusions of infliximab.

Results: All patients reported significant symptomatic improvement by the fourth infusion of infliximab, including relief of headache and neuropathic pain, reversal of motor, sensory, or coordination deficits, and control of seizure activity. Furthermore, infliximab therapy was universally associated with a decrease in lesion size or suppression of gadolinium enhancement as documented by MRI. A positive treatment response was attained irrespective of location or distribution of CNS involvement by sarcoidosis (dural/leptomeningeal based vs intraparenchymal; cord vs brain; single lesion vs multifocal). There were no serious adverse effects in a follow-up period spanning 6–18 months.

Conclusions: Combination treatment with mycophenolate mofetil and infliximab is a promising therapeutic approach for neurosarcoidosis.

A = azathioprine; AA = African American; Cy = cyclophosphamide; E = etanercept; EDSS = Expanded Disability Status Scale; MMF = mycophenolate mofetil; MMSE = Mini-Mental State Examination; N = neurologic; O = ophthalmologic; P = pulmonary; Pq = Plaquenil; R = rheumatologic; Si = sinuses; S = steroids; TNF = tumor necrosis factor; VPS = ventriculoperitoneal shunt; W = white.

Received December 23, 2006. Accepted in final form October 15, 2008.

Supplemental data at www.neurology.org

B.M.S. is supported by grants from NINDS (NS047687-01) and NIAID (U19 AI056390; Project 2) of the National Institutes of Health, and the National Multiple Sclerosis Society.

Disclosure: Dr. Segal has received honoraria and grant support from Centocor for lectures, consultation, and research activities unrelated to the subject of this manuscript. He has also served as a consultant for Biogen, Serono, and TEVA.

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				S. Pawate, H. Moses, and S. Sriram Presentations and outcomes of neurosarcoidosis: a study of 54 cases QJM, July 1, 2009; 102(7): 449 - 460. [Abstract] [Full Text] [PDF]