Schilder's Disease

Primary Category

Neuroimmunology

P-Category

Secondary Category

S-Category

Authors:

Muhammad Tayyab Naeem MBBS,
Junaid Kalia MD

Introduction

A rare progressive myelinoclastic disorder of CNS affecting younger adulthood (between 7 and 12 years of age) and considered to be the variant of multiple sclerosis.

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Diagnostic Criteria

Diagnostic criteria for Schilder’s disease was presented by Poster in 1985[5]

1 to 2 cm large symmetrical plaques roughly greater than 2 cm in cerebral hemisphere mainly in centrum semiovale.

No adrenal gland dysfunction

No PNS Demyelination

No lesion on clinical, paraclinical, and imaging modalities.

Subacute and chronic myelinoclastic diffuse sclerosis

Serum VLCFA is normal that differentiates it from Adrenoleukodystrophy.

Etiology

Etiology is mainly unknown

Genetic abnormalities

Magnetic Resonance Spectroscopy has revealed metabolic abnormalities like

Increased lactate,
Increase choline to creatine ratio and
Decreased N-Acetyl aspartate to creatine ratio.

Viral Infections like Murine Virus (JHM)

Epidemiology

About 68 cases have been identified between 1960-2018.

Mainly affects the younger population between 5 -14 years of age.

Predominantly affects males.

Clinical Findings

Table 1: Features of Schilder’s Disease

History	Signs and Symptoms	Physical Findings
Which factors precipitated the disease? Have you experienced changes in bowel habits and urinary incontinence? Have you experienced psychiatric symptoms? Have you experienced headache and visual disturbances? Have you experienced intentional tremors and syncope? Have you experienced Dysarthria? Have you experienced weakness in your muscles on either side of the body?	Personality changes and loss of responsiveness, Changes in bowel and urinary symptoms, Papilledema and raised intracranial pressure, Dysarthria , Aphasia, Slowness of movement and Cerebellar changes	The most common symptoms encountered in Schilder’s disease include Pseudotumour symptoms, Babiniski sign positive, Deep tendon reflex positive, Aphasia, Flaccid paralysis, Optic neuritis/Atrophy Papillitis or stauungspapille, Bilateral optic neuritis, Demyelination in optic nerve and optic chiasm. Sensorineural hearing loss, Internuclear ophthalmoplegia, Raised intracranial pressure (Cushing Reflex Positive)

Differential Diagnosis

Multiple Sclerosis

Involves white matter
Has Oligoclonal bands in serum and CSF, unlike Schilder’s Disease.

Acute Multiple Sclerosis

Acute Disseminated Encephalomyelitis

Brain Abscess/Tumor

Neuromyelitis Optica/Balo concentric Sclerosis/Marburg MS

Astrocytoma/Glioblastoma multiforme

Adrenoleukodystrophy

Churg-Strauss syndrome

Granulomatosis with polyangiitis

Pathophysiology

Perivascular infiltration of CD45 positive T lymphocytes along with parenchymal Astrocytes and macrophages along with myelinolysis.

Astrocytes are Glial Fibrillary acid positive and macrophages have foamy long Fibrillary processes.

Microcytic degeneration and reactive gliosis is also observed.

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Areas most affected

Bifrontal lesions involving anterior Corpus Callosum and bilateral Parieto-occipital

Subcortical areas of genu and splenium of Corpus Callosum.

Pathognomic features

Large asymmetrical unmyelinated areas bilaterally along with alternation wavy pattern of preserved and unpreserved areas.

Both preserved and non preserved areas showed intact axons on neurofilament further strengthening the myelinoclastic and axon preserving nature of Schilder’s Disease.

These plaques usually spare U fibers on Luxol Fast Blue Stain and brain stem.

Table 2: Distinguishing features of Schilder’s disease from Multiple Sclerosis

Schilder’s disease	Multiple Sclerosis
Spinal cord involvement rarely occurs	Frequently affects the spinal cord in a primitive stage
Sparing of basal ganglia	Involvement of basal ganglia and thalamus
Cortex spared	Cortex involved
U-fibers spared	U-fiber lesion seen
Demyelination of optic chiasm	Optic chiasm spared

Source: Jarius S, Haas J, Paul F, Wildemann B.Myelinoclastic diffuse sclerosis (Schilder's disease) is immunologically distinct from multiple sclerosis: results from a retrospective analysis of 92 lumbar punctures .J Neuroinflammation. 2019;16(51):1-14

Investigations

MRI

1 to 2 large demyelinating plaques in the cerebral hemisphere appear hyperintense on T2 weighted scan and hypointense on T1 weighted images and these lesions are greater than 2 cm.

MRI also shows Wallerian degeneration.

CNS Myelin Basic Protein in Schilder’s disease is greater than 207ng/dl.

Incomplete ring enhancement, hyperintensity of enhanced regions, absence of mass effects, and absence of cortical disease.

Technetium Scan and cerebral angiograms

99 m Technetium pertechnetate brain imaging and flow, Cerebral angiograms, and Pneumoencephalogram.

Non-Contrast enhanced CT scan

Diagnostically more appropriate than an MRI scan.

CAT Scan

It may show hypointense lesions

CSF Analysis

Positive Wassermann reaction is found in Schilder’s disease patient and their mother.

CSF, Nasal and Oropharangeal swabs for viral cultures like Bartonella, EB virus, Cytomegalovirus, herpes 1, 2, and 7.

Findings

Four CSF samples were taken in 3 months and WBCs and opening pressure are measured at LP.

CSF WBCs were elevated on day 15 day of the symptoms and negative on day 70.

CSF opening pressure was 200mmHg at second puncture and 350mmHg at 3 puncture.

FLAIR

Fluid attenuated inversion recovery sequences is a sort of brain imaging modality used to nullify the hyperintense shadow of CSF to diagnose periventricular lesions.

FLAIR shows increase images in the periphery and low signals in the center.

Ultrastructural Studies

Ultrastructural studies of the stained tissue reveal

Myeloid bodies and
Zebra bodies

Perfusion weighted Scan

The lesion appears less perfused relative to areas of the brain not affected by myelinolysis.

Treatment

Palliative treatment

Palliative treatment like Occupation, physical and nutritional therapy is effective in the later stages of Schilder’s disease.

Maintaining Intravascular volume, ventilator support, electrolyte balance, and serial CBC to look for infection.

Pharmacological treatment

Methylprednisolone in a dose of 25-30mg/kg for 5 mornings followed by tapering steroid dose.

H2 receptor antagonists to deal with Cushing ulcers due to raised intracranial pressure.

Excellent response to steroids has been seen in patients with Schilder’s disease. Administration of steroids results in a decrease in size of lesions and improvement in the functionality of affected organs

Human-derived immunoglobulins are effective in Schilder’s disease.

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Fingolimod and Natalizumab should be avoided in tumefactive lesions of Schilder’s disease [19].

These drugs aggravate Neuromyelitis Optica.

Plasma exchange is also a rational treatment in patients nonresponsive to steroids.

Beta interferon and Rituximab has been used in the treatment of Schilder Disease.

Surgical Management

Surgical Decompression is effective in larger lesions to relieve the patient's symptoms.

Prognosis

Schilder’s disease is Monophasic in the majority of cases. Monophasic patterns may be progressive or static. However relapsing cases have been seen.

Factors affecting the prognosis

Degree of disease

Rate of Demyelination

<1 year: 40% cases

>10 years: 23% cases

Good prognosis in the prepubertal group when administered steroid intravenously and if the disease affects areas like deep gray nuclei or thalamus.

Complications

Pneumonia

Sepsis

Pulmonary embolism

Bed Sores due to chronic disease

Cerebral herniation

Bibliography

Karussis The diagnosis of multiple sclerosis and the various related demyelinating syndromes: a critical review. J Autoimmun. 2014; 48-49:134-42.

Miyamoto N, Kagohashi M, Nishioka K, Fujishima K, Kitada T, Tomita Y,.Mori K, Maeda M, Wada R, Matsumoto M, Mori H, Mizuno Y, Okuma Y. An Autopsy Case of Schilder’s Variant of Multiple Sclerosis (Schilder’s Disease). Eur Neurol 2006;55:103–107.

De Groot CJ, Bergers E, Kamphorst W, Ravid R, Polman CH, Barkhof F, van der Valk P: Post-mortem MRI-guided sampling of multiple sclerosis brain lesions. Increased yield of active Demyelination and (p)reactive lesions.Brain 2001;124:1635-1645

Garrido C, Levy-Gomes A, Teixeira J, Temudo T. Enfermedad de Schilder: dos nuevos casos y revision de la bibliografia[Schilder’s disease:two new cases and a review of the literature]. Rev Neurol.2004 Oct 16-31;39(8):734-8

Poser CM. Myelinoclastic diffuse sclerosis. In: Handbook of Clinical Neurology. V 3. New York, NY: American Elsevier; 1985:419-428.

Nejat, F. and Eflekhar,B. Decompressive aspiration in myelinoclastic diffuse sclerosis or Schilder disease. Case report. Journal of Neurosurgery(2002),97(6),1447-1449

Kraus D, Konen O, Straussberg R, et al. Schilder's disease: non-invasive diagnosis and successful treatment with human immunoglobulins. Eur J Paediatr Neurol. 2012;16(2):206-8. PMID: 21925910.

Pretorius ML, Loock DB, Ravenscroft A, Schoeman JF."Demyelinating disease of Schilder type in three young South African children: dramatic response to corticosteroids". J Child Neurol.1998; 13(5):197–201

Cobb SR, Mehringer Wallerian degeneration in a patient with Schilder disease: MR imaging demonstration. Published Online:Feb 1 1987https://doi.org/10.1148/radiology.162.2.3797667

Myelinoclastic diffuse sclerosis (Schilder's disease) Pragya Singh, Binit Sureka, Mahesh Kumar Mittal, Brij Bhushan Thukral

Kim DS, Na DG, Kim KH, Kim JH, Kim E, Yun BL, et al.Distinguishing tumefactive demyelinating lesions from glioma or central nervous system lymphoma: Added value of unenhanced CT compared with conventional contrast-enhanced MR imaging. Radiology. 2009;251:467-75.

Pretorius ML, Loock DB, Ravenscroft A, Schoeman JF. "Demyelinating disease of Schilder type in three young South African children: dramatic response to corticosteroids". Child Neurol. 199813(5): 197–201.

Kurdi M, Ramsay D. Balo’s Concentric lesions with concurrent features of Schilder’s disease in relapsing multiple sclerosis: neuropathological findings. Autopsy Case Rep[Internet]2016;6(4):21-26

Kraus D, Konen O, Straussberg R. Schilder’s disease:non-invasive diagnosisand successful treatment with human immunoglobulins.Europ J Paed Nurol. 2012;16(2):206-208.

15. Kurul SH, Çakmakçı H, Dirik E, Kovanlikaya A. Schilder's Disease: Case Study With Serial Neuroimaging. J Child Neurol. 2003;18:58-61.

Patricia H, Ellison, Barren KD. Clinical recovery from Schilder disease. 1979;29(2):244.

Jarius S, Haas J, Paul F, Wildemann B.Myelinoclastic diffuse sclerosis (Schilder's disease) is immunologically distinct from multiple sclerosis: results from retrospective analysis of 92 lumbar punctures.J Neuroinflammation. 2019;16(51):1-14

Lin Wei-Sheng, Kuo Meng-Fai, Peng S Shinn-Forng, Fan Pi-Chuan. Long-term Outcome of Schilder Disease Treated With Interferon-β. Pediatrics. 2019;144 (5): e20190505

Algahtani H, Shirah B, Alassiri A.Tumefactive demyelinating lesions:a comprehensive review. Mult Scler Relat Disord.2017;14:72-79

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