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Keh RYS, Selby DA, Jones S, Gosal D, Lavin T, Lilleker JB, Carr AS, Lunn MP. Predicting long-term trends in inflammatory neuropathy outcome measures using latent class modelling. J Peripher Nerv Syst 2021; 27:84-93. [PMID: 34936164 DOI: 10.1111/jns.12481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunoglobulin (Ig) is used to treat chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy with conduction block (MMNCB). Regular infusions may be used for symptom control. Disease activity is monitored with clinical outcome measurements. We examined outcome measure variation during clinically stable periods in Ig-treated CIDP and MMNCB patients. We explored utility of serial outcome measurement in long-term outcome prediction. METHODS Retrospective longitudinal analysis of a single neuroscience centre's Ig-treated CIDP and MMNCB patients, 2009-2020, was performed. Mean and percentage change for grip strength, Rasch-built overall disability scales (RODS) and MRC sum scores (MRC-SS) during periods of clinical stability were compared to score-specific minimal clinically important differences (MCID). Latent class mixed modelling (LCMM) was used to identify longitudinal trends and factors influencing long-term outcome. RESULTS We identified 85 CIDP and 23 MMNCB patients (1,423 datapoints; 5635 treatment-months). Group-averaged outcome measures varied little over time. Intra-individual variation exceeded MCID for RODS in 44.2% CIDP and 16.7% MMNCB datapoints, grip strength in 10.6% (CIDP) and 8.8%/27.2% (MMNCB right/left hand) and MRC-SS in 43.5% (CIDP) and 20% (MMNCB). Multivariate LCMM identified subclinical trends toward improvement (32 patients) and deterioration (73 patients) in both cohorts. At baseline, CIDP 'deteriorators' were older than 'improvers' (66.2 versus 57 years, p=0.025). No other individual factors predicted categorisation. The best model for 'deteriorator' identification was contiguous sub-MCID decline in more than one outcome measure (CIDP: sensitivity 74%, specificity 59%; MMNCB: sensitivity 73%, specificity 88%). DISCUSSION Outcome measure interpretation determines therapeutic decision-making in Ig-dependent neuropathy patients, but intra-individual variation is common, often exceeding MCID. Here we show sub-MCID contiguous changes in more than one outcome measurement are a better predictor of long-term outcome. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ryan Yann Shern Keh
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Antony Selby
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Sam Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - David Gosal
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Timothy Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Aisling S Carr
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK.,Institute of Neurology, University College London, London, UK
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Zhu J, Zhang Y, Li R, Lin Y, Fu Y, Yan Y, Zhu W, Wang N, Zhang Z, Xu G. Anti-ganglioside Antibodies in Guillain-Barre Syndrome: A Novel Immunoblotting-Panel Assay. Front Neurol 2021; 12:760889. [PMID: 34899578 PMCID: PMC8654804 DOI: 10.3389/fneur.2021.760889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to determine the diagnostic efficiency of a novel immunoblotting detection assay for anti-ganglioside antibodies (AGAs) in the Guillain–Barre syndrome (GBS). Method: Serum immunoglobulin (IgG and IgM) of AGAs were measured in 121 participants from a registered cohort study of immune-mediated neuropathies and 29 healthy controls by immunoblotting panel assay. Sensitivity, specificity, and positive predictive value (PPV) of the assay were compared to calculate the diagnostic accuracy. Result: In our cohort, any of the AGAs were positive in 42.4% of the GBS patients. The sensitivity and specificity of AGAs (both IgG and IgM) in the diagnosis of GSB were 42 and 76% while for IgG-AGAs were 35 and 87%. AGAs positivity had a significant association with the AMAN subtype (P = 0.0004), and the sensitivity, specificity of AGAs in AMAN were 86, 69%, respectively with high (AUC = 0.78, p = 0.002) discriminative powers. GM1-IgG AGA was more common and specific to AMAN patients than other GBS forms (p = 0.008). Conclusion: Our novel immunoblotting detection assay could complement GBS diagnosis. IgG-AGAs were more likely to be detected in GBS, and GM1-IgG AGA could assist AMAN diagnosis.
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Affiliation(s)
- Jiting Zhu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuanyuan Zhang
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Runyun Li
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yi Lin
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ying Fu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yaping Yan
- National Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an, China
| | - Wenli Zhu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ning Wang
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zaiqiang Zhang
- Department of Neurology, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guorong Xu
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Stikvoort García DJL, Kovalchuk MO, Goedee HS, van Schelven LJ, van den Berg LH, Franssen H, Sleutjes BTHM. Motor unit integrity in multifocal motor neuropathy: A systematic evaluation with CMAP scans. Muscle Nerve 2021; 65:317-325. [PMID: 34854491 PMCID: PMC9300115 DOI: 10.1002/mus.27469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/18/2021] [Accepted: 11/23/2021] [Indexed: 11/09/2022]
Abstract
Introduction/Aims Progressive axonal loss in multifocal motor neuropathy (MMN) is often assessed with nerve conduction studies (NCS), by recording maximum compound muscle action potentials (CMAPs). However, reinnervation maintains the CMAP amplitude until a significant portion of the motor unit (MU) pool is lost. Therefore, we performed more informative CMAP scans to study MU characteristics in a large cohort of patients with MMN. Methods We derived the maximum CMAP amplitude (CMAPmax), an MU number estimate (MUNE), and the largest MU amplitude stimulus current required to elicit 5%, 50%, and 95% of CMAPmax (S5, S50, S95) and relative ranges ([S95 − S5] × 100 / S50) from the scans. These metrics were compared with clinical, laboratory, and NCS results. Results Forty MMN patients and 24 healthy controls were included in the study. CMAPmax and MUNE were reduced in MMN patients (both P < .001). Largest MU amplitude as a percentage of CMAPmax was increased in MMN patients (P < .001). Disease duration and treatment duration were not associated with MUNE. Relative range was larger in patients with anti‐GM1 antibodies than in those without anti‐GM1 antibodies (P = .016) and controls (P < .001). The largest MU amplitudes were larger in patients without anti‐GM1 antibodies than in patients with anti‐GM1 antibodies (P = .037) and controls (P = .044). Discussion We found that MU loss is common in MMN and accompanied by enlarged MUs. Presence of anti‐GM1 antibodies was associated with increased relative range of MU thresholds and reduction in largest MU amplitude. Our findings indicate that CMAP scans complement routine NCS, and may have potential for practical monitoring of treatment efficacy and disease progression.
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Affiliation(s)
| | - Maria O Kovalchuk
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leonard J van Schelven
- Department of Medical Technology and Clinical Physics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hessel Franssen
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Boudewijn T H M Sleutjes
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
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Bocci S, Giannini F, Volpi N, Rossi A, Ginanneschi F. Multifocal motor neuropathy occurring after acute motor axonal neuropathy: two stages of the same disease? Neurol Sci 2021; 43:1463-1465. [PMID: 34800200 DOI: 10.1007/s10072-021-05725-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Silvia Bocci
- Department of Medical, Surgery and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy
| | - Fabio Giannini
- Department of Medical, Surgery and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy
| | - Nila Volpi
- Department of Medical, Surgery and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy
| | - Alessandro Rossi
- Department of Medical, Surgery and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy
| | - Federica Ginanneschi
- Department of Medical, Surgery and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy.
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Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
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Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
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Shelly S, Klein C, Dyck PJB, Paul P, Mauermann ML, Berini SE, Howe B, Fryer JP, Basal E, Bakri HM, Laughlin RS, McKeon A, Pittock SJ, Mills J, Dubey D. Neurofascin-155 Immunoglobulin Subtypes: Clinicopathologic Associations and Neurologic Outcomes. Neurology 2021; 97:e2392-e2403. [PMID: 34635556 PMCID: PMC8673722 DOI: 10.1212/wnl.0000000000012932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/01/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Multiple studies highlighting diagnostic utility of neurofascin 155 (NF155)-IgG4 in chronic demyelinating inflammatory polyradiculoneuropathy (CIDP) have been published. However, few studies comprehensively address the long-term outcomes, or clinical utility of NF155-IgM or NF155-IgG, in the absence of NF155-IgG4. In this study we evaluate phenotypic and histopathological specificity, and differences in outcomes between these NF155 antibody isotypes or IgG subclasses. We also compare NF155-IgG4 seropositive cases to other seropositive demyelinating neuropathies. METHODS In this study, neuropathy patient sera seen at Mayo Clinic were tested for NF155-IgG4, NF155-IgG and NF155-IgM autoantibodies. Demographic and clinical data of all seropositive cases were reviewed. RESULTS We identified 32 NF155 patients (25 NF155-IgG positive [20 NF155-IgG4 positive], 7 NF155-IgM seropositive). NF155-IgG4 seropositive patients clinically presented with distal more than proximal muscle weakness, positive sensory symptoms (prickling, asymmetric paresthesia, neuropathic pain) and gait ataxia. Cranial nerve involvement (11/20, 55%) and papilledema (4/12, 33%) occurred in many. Electrodiagnostic testing (EDX) demonstrated demyelinating polyradiculoneuropathy (19/20, 95%). Autonomic involvement occurred in 45% (n=9, median CASS score 3.5, range 1-7). Nerve biopsies from the NF155-IgG4 patients (n=11) demonstrated grouped segmental demyelination (50%), myelin reduplication (45%) and paranodal swellings (50%). Most patients needed 2nd and 3rd line immunosuppression but had favorable long-term outcomes (n=18). Among 14 patients with serial EDX over 2 years, all except one demonstrated improvement after treatment. NF155-IgG positive NF155-IgG4 negative (NF155-IgG positive) and NF155-IgM positive patients were phenotypically different from NF155-IgG4 seropositive patients. Sensory ataxia, neuropathic pain, cerebellar dysfunction and root/plexus MRI abnormalities were significantly more common in NF155-IgG4 positive compared to MAG-IgM neuropathy. Chronic immune sensory polyradiculopathy (CISP)/CISP-plus phenotype was more common among Contactin-1 neuropathies compared to NF155-IgG4 positive cases. NF155-IgG4 positive cases responded favorably to immunotherapy compared to MAG-IgM seropositive cases with distal acquired demyelinating symmetric neuropathy (p<0.001) and had better long-term clinical outcomes compared to contactin-1 IgG (p=0.04). DISCUSSION We report long-term follow-up and clinical outcome of NF155-IgG4 patients. NF155-IgG4 but not IgM or IgG patients have unique clinical-electrodiagnostic signature. We demonstrate NF155-IgG4 positive patients, unlike classical CIDP with neuropathic pain and dysautonomia common at presentation. Long-term outcomes were favorable. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that NF155-IgG4 seropositive patients, compared to typical CIDP patients, present with distal more than proximal muscle weakness, positive sensory symptoms, and gait ataxia.
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Affiliation(s)
- Shahar Shelly
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota
| | - Christopher Klein
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - P James B Dyck
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota
| | - Pritikanta Paul
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago
| | | | - Sarah E Berini
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota
| | - Benjamin Howe
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota.,Department of radiology. Mayo Clinic Foundation, Rochester, Minnesota
| | - James P Fryer
- Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - Eati Basal
- Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - Hammami M Bakri
- Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - Ruple S Laughlin
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota
| | - Andrew McKeon
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - Sean J Pittock
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - John Mills
- Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
| | - Divyanshu Dubey
- Department of Neurology Mayo Clinic Foundation, Rochester, Minnesota .,Department of Laboratory Medicine and Pathology Mayo Clinic Foundation, Rochester, Minnesota
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Abstract
This article focuses on principles of nerve conduction studies and needle electromyography applied to the electrodiagnosis of polyneuropathy. The components of the electrodiagnostic evaluation of polyneuropathy and the electrophysiological characteristics of axonal and demyelinating neuropathies and nodo-paranodopathies are reviewed.
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Affiliation(s)
- Rocio Vazquez Do Campo
- Department of Neurology, University of Alabama at Birmingham, 260 Sparks Center, 1720 7th Avenue S, Birmingham, AL 35294, USA.
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58
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Beecher G, Shelly S, Dyck PJB, Mauermann ML, Martinez-Thompson JM, Berini SE, Naddaf E, Shouman K, Taylor BV, Dyck PJ, Engelstad J, Howe BM, Mills JR, Dubey D, Spinner RJ, Klein CJ. Pure Motor Onset and IgM-Gammopathy Occurrence in Multifocal Acquired Demyelinating Sensory and Motor Neuropathy. Neurology 2021; 97:e1392-e1403. [PMID: 34376509 DOI: 10.1212/wnl.0000000000012618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To longitudinally investigate patients with multifocal acquired demyelinating sensory and motor neuropathy (MADSAM), quantifying timing and location of sensory involvements in motor onset patients, along with clinicohistopathologic and electrophysiologic findings to ascertain differences in patients with and without monoclonal gammopathy of uncertain significance (MGUS). METHODS Patients with MADSAM seen at Mayo Clinic and tested for monoclonal gammopathy and ganglioside antibodies were retrospectively reviewed (January 1, 2007-December 31, 2018). RESULTS Of 76 patients with MADSAM, 53% had pure motor, 16% pure sensory, 30% sensorimotor, and 1% cranial nerve onsets. Motor-onset patients were initially diagnosed with multifocal motor neuropathy (MMN). MGUS occurred in 25% (89% immunoglobulin M [IgM] subtype), associating with ganglioside autoantibodies (p < 0.001) and higher IgM titers (p < 0.04). Median time to sensory involvements (confirmed by electrophysiology) in motor onset patients was 18 months (range 6-180). Compared to initial motor nerve involvements, subsequent sensory findings were within the same territory in 35% (14/40), outside in 20% (8/40), or both in 45% (18/40). Brachial and lumbosacral plexus MRI was abnormal in 87% (34/39) and 84% (21/25), respectively, identifying hypertrophy and increased T2 signal predominantly in brachial plexus trunks (64%), divisions (69%), and cords (69%), and intrapelvic sciatic (64%) and femoral (44%) nerves. Proximal fascicular nerve biopsies (n = 9) more frequently demonstrated onion-bulb pathology (p = 0.001) and endoneurial inflammation (p = 0.01) than distal biopsies (n = 17). MRI and biopsy findings were similar among patient subgroups. Initial Inflammatory Neuropathy Cause and Treatment (INCAT) disability scores were higher in patients with MGUS relative to without (p = 0.02). Long-term treatment responsiveness by INCAT score reduction ≥1 or motor Neuropathy Impairment Score (mNIS) >8-point reduction occurred in 75% (49/65) irrespective of MGUS or motor onsets. Most required ongoing immunotherapy (86%). Patients with MGUS more commonly required dual-agent immunotherapy for stability (p = 0.02). DISCUSSION Pure motor onsets are the most common MADSAM presentation. Long-term follow-up, repeat electrophysiology, and nerve pathology help distinguish motor onset MADSAM from MMN. Better long-term immunotherapy responsiveness occurs in motor onset MADSAM compared to MMN reports. Patients with MGUS commonly require dual immunotherapy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that most clinical, electrophysiologic, and histopathologic findings were similar between patients with MADSAM with and without MGUS.
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Affiliation(s)
- Grayson Beecher
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Shahar Shelly
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - P James B Dyck
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Michelle L Mauermann
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Jennifer M Martinez-Thompson
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Sarah E Berini
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Elie Naddaf
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Kamal Shouman
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Bruce V Taylor
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Peter James Dyck
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - JaNean Engelstad
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Benjamin M Howe
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - John R Mills
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Divyanshu Dubey
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Robert J Spinner
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Christopher J Klein
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia.
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Pro S, Ursitti F, Pruneddu GL, Di Capua M, Valeriani M. Childhood-Onset Multifocal Motor Neuropathy with IgM Antibodies to Gangliosides GM1: A Case Report with Poor Outcome. Neuropediatrics 2021; 52:406-409. [PMID: 33511596 DOI: 10.1055/s-0040-1722677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Multifocal motor neuropathy (MMN) is a slowly progressive motor neuropathy characterized by asymmetric muscle weakness without sensory involvement. Typically, MMN respond completely to treatment with intravenous immunoglobulin (IVIg). MMN is even rarer in the pediatric population, where only five patients have been reported up to now. CASE REPORT We discuss the 3-year follow-up of a 13-year-old girl with MMN who was positive for IgM antibodies to gangliosides GM1. She was diagnosed with MMN in accordance with the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria. Serological studies revealed that she tested positive for IgM antibodies to GM1. She underwent intravenous methylprednisolone followed by an oral prednisone taper, intravenous immunoglobulin (IVIg), plasma exchange followed by IVIG and prednisone and Rituximab. No improvement was referred. At the present, she shows flaccid tetraplegia, facial diplegia, and bulbar cranial nerve palsy. CONCLUSION Although childhood onset MMN is rare, most patients reported in literature respond to IVIg treatment. In a few cases, however, IVIg can be ineffective. In our patient, IVIg as well as treatment with prednisolone, plasma exchange and rituximab have failed.
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Affiliation(s)
- Stefano Pro
- Neurophysiology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabiana Ursitti
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gian Luca Pruneddu
- Paediatric Neurorehabilitation Units Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matteo Di Capua
- Neurophysiology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimiliano Valeriani
- Child Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Pacoureau L, Labeyrie C, Catalan P, Echaniz-Laguna A, Henriquez S, Laparra A, Cauquil C, Chrétien P, Hacein-Bey-Abina S, Goujard C, Adam C, Lambotte O, Adams D, Noël N. Neuropathies périphériques associées aux syndromes lymphoprolifératifs : spectre clinique et démarche diagnostique. Rev Med Interne 2021; 42:844-854. [PMID: 34373143 DOI: 10.1016/j.revmed.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
Lymphoproliferative syndromes (multiple myeloma, Waldenström's disease, chronic lymphocytic leukemia, lymphomas) may be associated with peripheral neuropathies. The mechanism can be dysimmune, associated or not with monoclonal gammopathies; paraneoplastic; infiltrative; or more commonly, iatrogenic or due to vitamin deficiency. The diagnosis can be complex, especially when the neuropathy is the presenting manifestation, requiring a close cooperation between internists and neurologists. The positive diagnosis of the neuropathy is based on a systematic electro-clinical investigation, which specifies the topography and the mechanism of the nerve damage, sometimes reinforced by imaging examinations, in particular, nerve and/or plexus MRI. The imputability of the neuropathy to a lymphoproliferative syndrome is based on a set of arguments including the clinical context (B signs, tumour syndrome), first-line laboratory tests (hemogram, protein electrophoresis, viral serologies, complement), auto-antibodies discussed according to the neuropathy (anti-MAG, anti-gangliosides) and sometimes more invasive examinations (bone marrow or neuro-muscular biopsies).
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Affiliation(s)
- L Pacoureau
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - C Labeyrie
- Service de neurologie, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Centre de référence neuropathies amyloïdes familiales et autres neuropathies rares (NNERF), Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - P Catalan
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France
| | - A Echaniz-Laguna
- Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France; Service de neurologie, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Centre de référence neuropathies amyloïdes familiales et autres neuropathies rares (NNERF), Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - S Henriquez
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France
| | - A Laparra
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France
| | - C Cauquil
- Service de neurologie, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Centre de référence neuropathies amyloïdes familiales et autres neuropathies rares (NNERF), Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - P Chrétien
- INSERM, UTCBS, Unité des technologies chimiques et biologiques pour la Santé, Université de Paris, CNRS, 75006 Paris, France; Service d'immunologie biologique, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - S Hacein-Bey-Abina
- INSERM, UTCBS, Unité des technologies chimiques et biologiques pour la Santé, Université de Paris, CNRS, 75006 Paris, France; Service d'immunologie biologique, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - C Goujard
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France
| | - C Adam
- Service d'anatomie pathologique et neuropathologie, Assistance publique-Hôpitaux de Paris, Groupe Hospitalier Universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - O Lambotte
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France; Inserm UMR 1184, Immunologie des maladies virales et auto-immunes (IMVA), Université Paris Saclay, 94275 Le Kremlin-Bicêtre cedex, France; CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Université Paris Saclay, 94275 Le Kremlin-Bicêtre cedex, France
| | - D Adams
- Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France; Service de neurologie, Assistance publique-Hôpitaux de Paris, Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Centre de référence neuropathies amyloïdes familiales et autres neuropathies rares (NNERF), Groupe hospitalier universitaire Paris Sud, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - N Noël
- Service de médecine interne et immunologie clinique, Assistance publique-Hôpitaux Paris Saclay, Hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris Saclay, Faculté de médecine, Le Kremlin Bicêtre, France; Inserm UMR 1184, Immunologie des maladies virales et auto-immunes (IMVA), Université Paris Saclay, 94275 Le Kremlin-Bicêtre cedex, France; CEA, DSV/iMETI, Division of Immuno-Virology, IDMIT, Université Paris Saclay, 94275 Le Kremlin-Bicêtre cedex, France.
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van Rosmalen MHJ, Goedee HS, Derks R, Asselman F, Verhamme C, de Luca A, Hendrikse J, van der Pol WL, Froeling M. Quantitative magnetic resonance imaging of the brachial plexus shows specific changes in nerve architecture in chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy and motor neuron disease. Eur J Neurol 2021; 28:2716-2726. [PMID: 33934438 PMCID: PMC8362016 DOI: 10.1111/ene.14896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The immunological pathophysiologies of chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) differ considerably, but neither has been elucidated completely. Quantitative magnetic resonance imaging (MRI) techniques such as diffusion tensor imaging, T2 mapping, and fat fraction analysis may indicate in vivo pathophysiological changes in nerve architecture. Our study aimed to systematically study nerve architecture of the brachial plexus in patients with CIDP, MMN, motor neuron disease (MND) and healthy controls using these quantitative MRI techniques. METHODS We enrolled patients with CIDP (n = 47), MMN (n = 29), MND (n = 40) and healthy controls (n = 10). All patients underwent MRI of the brachial plexus and we obtained diffusion parameters, T2 relaxation times and fat fraction using an automated processing pipeline. We compared these parameters between groups using a univariate general linear model. RESULTS Fractional anisotropy was lower in patients with CIDP compared to healthy controls (p < 0.001), patients with MND (p = 0.010) and MMN (p < 0.001). Radial diffusivity was higher in patients with CIDP compared to healthy controls (p = 0.015) and patients with MND (p = 0.001) and MMN (p < 0.001). T2 relaxation time was elevated in patients with CIDP compared to patients with MND (p = 0.023). Fat fraction was lower in patients with CIDP and MMN compared to patients with MND (both p < 0.001). CONCLUSION Our results show that quantitative MRI parameters differ between CIDP, MMN and MND, which may reflect differences in underlying pathophysiological mechanisms.
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Affiliation(s)
- Marieke H. J. van Rosmalen
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - H. Stephan Goedee
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Rosina Derks
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Fay‐Lynn Asselman
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Camiel Verhamme
- Department of NeurologyAmsterdam NeuroscienceAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alberto de Luca
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - J. Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - W. Ludo van der Pol
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Martijn Froeling
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. Eur J Neurol 2021; 28:3556-3583. [PMID: 34327760 DOI: 10.1111/ene.14959] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). RESULTS Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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Longinetti E, Sveinsson O, Press R, Ye W, Ingre C, Piehl F, Fang F. ALS patients with concurrent neuroinflammatory disorders; a nationwide clinical records study. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:209-219. [PMID: 34852680 DOI: 10.1080/21678421.2021.1946084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective:To determine if inflammation in proximity of the motor unit may contribute to neurodegeneration in amyotrophic lateral sclerosis (ALS). Methods: We identified all patients diagnosed in Sweden with concurrent ALS and multiple sclerosis (MS), myasthenia gravis (MG), inflammatory polyneuropathies (IP), or dermatopolymyositis (DMPM) during 1991-2014 according to the Swedish Patient Register (N = 263). We validated medical records for 92% of these patients (18 records were not retrieved and three did not contain enough information) and compared patients with a confirmed overlap (N = 28) with an independent sample of patients with solely ALS (N = 271). Results: Ninety-one patients were deemed as not having ALS (34.6%). Among the remaining 151 with validated ALS, 12 had also a confirmed MS diagnosis, nine a confirmed MG diagnosis, four a confirmed IP diagnosis, and three a confirmed DMPM diagnosis. Seventeen of the patients were women and 11 were men. Seventy-nine percent of the patients with a confirmed overlap had MS, MG, IP, or DMPM diagnosed prior to ALS. Compared to patients with only ALS, the concurrent patients were significantly older at symptoms onset, had higher prevalence of bulbar onset, but used Riluzole and noninvasive ventilation less frequently. Conclusions: We found that a high concurrence of ALS and MS/MG/IP/DMPM diagnoses is largely due to diagnostic uncertainty. A minority of patients had a true concurrence, where MS, MG, IP, and DMPM preceded the ALS diagnosis, which might be due to chance alone. Four patients were diagnosed with MG shortly after onset of ALS, suggesting that neurodegeneration might trigger autoimmunity.
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Affiliation(s)
- Elisa Longinetti
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Olafur Sveinsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rayomand Press
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Weimin Ye
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Ingre
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fang Fang
- Fang Fang, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Bos JW, Groen EJN, Wadman RI, Curial CAD, Molleman NN, Zegers M, van Vught PWJ, Snetselaar R, Vijzelaar R, van der Pol WL, van den Berg LH. SMN1 Duplications Are Associated With Progressive Muscular Atrophy, but Not With Multifocal Motor Neuropathy and Primary Lateral Sclerosis. NEUROLOGY-GENETICS 2021; 7:e598. [PMID: 34169148 PMCID: PMC8220964 DOI: 10.1212/nxg.0000000000000598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/02/2021] [Indexed: 11/30/2022]
Abstract
Objective To assess the association between copy number (CN) variation in the survival motor neuron (SMN) locus and multifocal motor neuropathy (MMN), progressive muscular atrophy (PMA), and primary lateral sclerosis (PLS) susceptibility and to determine the association of SMN1 and SMN2 CN with MMN, PMA, and PLS disease course. Methods In this monocenter study, we used multiplex ligation-dependent probe amplification to determine SMN1 and SMN2 CN in Dutch patients with MMN, PMA, and PLS and controls. We stratified clinical parameters for SMN1 and SMN2 CN. We analyzed SMN1 and SMN2 exons 1–6, intron 6, and exon 8 CN to study the genetic architecture of SMN1 duplications. Results SMN1 and SMN2 CN were determined in 132 patients with MMN, 150 patients with PMA, 104 patients with PLS, and 956 control subjects. MMN and PLS were not associated with CN variation in SMN1 or SMN2. By contrast, patients with PMA more often than controls carried SMN1 duplications (≥3 SMN1 copies, 12.0% vs 5.0%, odds ratio 2.69 (1.43–4.91), p 0.0020). SMN1 and SMN2 CN status was not associated with MMN, PLS, or PMA disease course. In case of SMN1 exon 7 duplications, exons 1–6, exon 8, and introns 6 and 7 were also duplicated, suggesting full SMN1 duplications. Conclusions SMN1 duplications are associated with PMA, but not with PLS and MMN. SMN1 duplications in PMA are balanced duplications. The results of this study highlight the primary effect of altered SMN CN on lower motor neurons.
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Affiliation(s)
- Jeroen W Bos
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Ewout J N Groen
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Renske I Wadman
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Chantall A D Curial
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Naomi N Molleman
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Marinka Zegers
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Paul W J van Vught
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Reinier Snetselaar
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Raymon Vijzelaar
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery (J.W.B., E.J.N.G., R.I.W., C.A.D.C., W.L.v.d.P., L.H.v.d.B.), UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands; and MRC Holland (N.N.M., M.Z., P.W.J.v.V., R.S., R.V.), Amsterdam, the Netherlands
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Tanemoto M, Hisahara S, Ikeda K, Yokokawa K, Manabe T, Tsuda R, Yamamoto D, Matsushita T, Matsumura A, Suzuki S, Shimohama S. Sporadic Amyotrophic Lateral Sclerosis Due to a FUS P525L Mutation with Asymmetric Muscle Weakness and Anti-ganglioside Antibodies. Intern Med 2021; 60:1949-1953. [PMID: 33518565 PMCID: PMC8263198 DOI: 10.2169/internalmedicine.6168-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) due to a fused in sarcoma (FUS) P525L mutation is characterized by a rapidly progressive course. Multifocal motor neuropathy (MMN) may resemble ALS in early stage and is associated with anti-ganglioside antibodies. A 38-year-old woman was admitted to our hospital because of progressive muscle weakness in the right limbs. She had mild mental retardation and minor deformities. Initially, we suspected MMN given the asymmetric muscle weakness and detection of anti-ganglioside antibodies. However, physical and electrophysiological tests did not support MMN, instead suggesting ALS. We confirmed a heterozygous P525L mutation and finally diagnosed this case as ALS due to an FUS mutation.
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Affiliation(s)
- Masanobu Tanemoto
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Shin Hisahara
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Kazuna Ikeda
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Kazuki Yokokawa
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Tatsuo Manabe
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Reiko Tsuda
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Daisuke Yamamoto
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Takashi Matsushita
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Akihiro Matsumura
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Syuuichirou Suzuki
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
| | - Shun Shimohama
- Department of Neurology, Sapporo Medical University, School of Medicine, Japan
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66
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst 2021; 26:242-268. [PMID: 34085743 DOI: 10.1111/jns.12455] [Citation(s) in RCA: 166] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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Telleman JA, Herraets IJT, Goedee HS, van Eijk RPA, Verhamme C, Eftimov F, Lieba-Samal D, Asseldonk JTV, van den Berg LH, van der Pol WL, Visser LH. Prognostic value of nerve ultrasonography: A prospective multicenter study on the natural history of chronic inflammatory neuropathies. Eur J Neurol 2021; 28:2327-2338. [PMID: 33909329 DOI: 10.1111/ene.14885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Nerve ultrasound is a promising new tool in chronic inflammatory neuropathies. The aim of this study was to determine its prognostic value in a prospective multicenter cohort study including incident and prevalent patients with CIDP and MMN. METHODS We enrolled 126 patients with CIDP, and 72 with MMN; 71 were treatment-naive. Patients with chronic idiopathic axonal polyneuropathy (CIAP; n = 35) were considered as disease controls. Standardized neurological examination, questionnaires, and nerve ultrasonography were obtained at time of inclusion and 1-year follow-up. Nerve size development over time and correlation between nerve size and clinical outcome measures were determined using linear mixed effects models. RESULTS Nerve size development over time was heterogeneous. Only in MMN was there a correlation between C5 nerve root size and deterioration of grip strength (-1.3 kPa/mm2 (95% confidence interval [CI] -2.3 to -0.2). No other significant correlations between nerve size and clinical outcome measures were found. In MMN, presence of nerve enlargement at inclusion predicted deterioration of grip strength, and MMN patients with enlargement confined to the brachial plexus seemed to have more favorable outcomes. No other predictive effects of sonographic nerve size were found. CONCLUSIONS The present study indicates that the natural course of nerve size development in CIDP and MMN is heterogeneous, and that the prognostic value of sonographic nerve enlargement is limited. It had some predictive effect in patients with MMN. Further research in specific subgroups of chronic inflammatory neuropathy is necessary to determine the usefulness of nerve ultrasonography after the diagnostic phase.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands
| | - Ingrid J T Herraets
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands
| | - Hendrik Stephan Goedee
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands.,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Camiel Verhamme
- Amsterdam University Medical Center, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Filip Eftimov
- Amsterdam University Medical Center, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, The Netherlands
| | - Doris Lieba-Samal
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Jan Thies van Asseldonk
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands
| | - Willem Ludo van der Pol
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Utrecht, Utrecht, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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68
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Safety and efficacy of CAR T cells in a patient with lymphoma and a coexisting autoimmune neuropathy. Blood Adv 2021; 4:6019-6022. [PMID: 33284942 DOI: 10.1182/bloodadvances.2020003176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022] Open
Abstract
Key Points
CAR T-cell therapy was safe and effective in a DLBCL patient with coexisting autoimmune neuropathy. CD19 CAR T-cell therapy may control refractory autoantibodies and monoclonal gammopathies.
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69
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Long-term treatment with subcutaneous immunoglobulin in multifocal motor neuropathy. Sci Rep 2021; 11:9216. [PMID: 33911162 PMCID: PMC8080704 DOI: 10.1038/s41598-021-88711-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/16/2021] [Indexed: 12/03/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is a rare disease with a prevalence of less than 1 per 100,000 people. Intravenous immunoglobulin (IVIG) therapy, performed for a long-term period, has been demonstrated able to improve the clinical picture of MMN patients, ameliorating motor symptoms and/or preventing disease progression. Treatment with subcutaneous immunoglobulin (SCIg) has been shown to be as effective as IVIG. However, previously published data showed that follow-up of MMN patients in treatment with SCIg lasted no more than 56 months. We report herein the results of a long-term SCIg treatment follow up (up to 96 months) in a group of 8 MMN patients (6 M; 2F), previously stabilized with IVIG therapy. Clinical follow-up included the administration of Medical Research Council (MRC) sum-score, the Overall Neuropathy Limitation Scale (ONLS) and the Life Quality Index questionnaire (LQI) at baseline and then every 6 months. Once converted to SCIg, patients’ responsiveness was quite good. Strength and motor functions remained stable or even improved during this long-term follow-up with benefits on walking capability, resistance to physical efforts and ability in hand fine movements.
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70
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Urbain F, Labeyrie C, Castilla-Llorente C, Cintas P, Puma A, Maubeuge N, Puyade M, Farge D. [Autologous hematopoietic stem cell transplantation for chronic inflammatory demyelinating polyneuropathy]. Rev Med Interne 2021; 42:639-649. [PMID: 33773849 DOI: 10.1016/j.revmed.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/02/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a dysimmune neuropathy with sensory and/or motor symptoms due to destruction of the myelin sheat secondary to an auto-immune attack. A quarter to a third of patients do not respond to immunomodulatory first line recommended therapies. No second line treatment has shown its effectiveness with a sufficient level of evidence. Autologous hematopoietic stem cell transplantation (AHSCT) is a promising therapy for autoimmune disease, especially for CIDP in recent works. We present in this article an update on the diagnosis of CIDP, its conventional treatments as well as the results of AHSCT in this indication, which was the subject of French recommendations under the aegis of the SFGMTC and neuromuscular disease french faculty (FILNEMUS) as a third line therapy after failure of two first-line and one second-line treatments.
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Affiliation(s)
- F Urbain
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, service de medecine interne, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France.
| | - C Labeyrie
- Assistance Publique-Hôpitaux de Paris, centre de reference maladies rares neuropathies amyloïdes familiales et autres neuropathies peripheriques rares, service de neurologie, groupe hospitalier universitaire Paris Sud, hôpital Bicêtre, 94275 Le Kremlin-Bicêtre cedex, France
| | - C Castilla-Llorente
- Institut Gustave-Roussy, service d'hématologie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - P Cintas
- Explorations neurophysiologiques, centre SLA, centre de référence de pathologie neuromusculaire, CHU Toulouse, hôpital Pierre-Paul-Riquet, 31059 Toulouse Cedex, France
| | - A Puma
- Maladies du systeme nerveux peripherique et du muscle, Centre SLA, hôpital Pasteur 2-Zone C, CS 51069, 06001 Nice cedex 1, France
| | - N Maubeuge
- CHU de Poitiers, service de neurologie, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - M Puyade
- CHU de Poitiers, service de médecine interne et maladies infectieuses, 2, rue de la Milétrie, 86021 Poitiers cedex, France; CHU de Poitiers, CIC-1402, 2, rue de la Milétrie, 86021 Poitiers cedex, France
| | - D Farge
- Unité de médecine interne, maladies auto-immunes et pathologie vasculaire UF04, Centre de référence des maladies auto-immunes systémiques rares d'Île-de-France MATHEC Hôpital Saint-Louis, UF04, Filière 'FAI2R', 1, avenue Claude-Vellefaux, 75475 Paris, France; Université de Paris, EA 3518, Paris, France; Département de Médecine, Université McGill, Montreal, QC, Canada
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71
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Babatin MA, AlJohani A. Demyelinating polyneuropathy associated with chronic inactive hepatitis B infection. BMJ Case Rep 2021; 14:14/3/e237070. [PMID: 33766960 PMCID: PMC7996366 DOI: 10.1136/bcr-2020-237070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is a case report of a 42-year-old female patient with chronic inactive hepatitis B virus (HBV) infection who presented with relapsing chronic inflammatory demyelinating polyneuropathy (CIDP). Her initial attack was of acute onset (ie, acute CIDP) resembling Guillain-Barré syndrome that responded well to intravenous immunoglobulin (IVIG) therapy. The second episode was chronic and refractory to IVIG. She was managed with plasma exchange, long-term corticosteroids, immunosuppressants and HBV antiviral therapy. She showed both clinical and electromyographic improvement, with no recurrence after 2 years of follow-up.
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Abstract
Peripheral nerve imaging is a helpful and sometimes essential adjunct to clinical history, physical examination, and electrodiagnostic studies. Advances in imaging technology have allowed the visualization of nerve structures and their surrounding tissues. The clinical applications of ultrasound and magnetic resonance imaging (MRI) in the evaluation of peripheral nerve disorders are growing exponentially. This article reviews basics of ultrasound and MRI as they relate to nerve imaging, reviews advantages and limitations of each imaging modality, reviews the applications of ultrasound and MRI in disorders of peripheral nerve, and discusses emerging advances in the field.
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Affiliation(s)
- Natalia L Gonzalez
- Department of Neurology, Neuromuscular Division, Duke University, Duke University Hospital, 3403 DUMC, Duke South Clinic 1L, Durham, NC 27710, USA.
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University, Duke University Hospital, 3403 DUMC, Duke South Clinic 1L, Durham, NC 27710, USA
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Davalos L, London ZN, Stino AM, Gallagher GW, Callaghan BC, Wieland CM, Nowacek DG. Patients who meet electrodiagnostic criteria for CIDP rarely present with a sensory predominant DSP phenotype. Muscle Nerve 2021; 63:881-884. [PMID: 33745140 DOI: 10.1002/mus.27235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION It is unknown how often patients with electrodiagnostic evidence of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), a potentially treatable condition, present with a distal symmetric polyneuropathy (DSP) phenotype. METHODS We reviewed the records of patients who presented to our electrodiagnostic laboratory between January 1, 2011, to December 31, 2019, and fulfilled electrodiagnostic criteria for CIDP to identify those who presented with a sensory predominant DSP phenotype. RESULTS One hundred sixty-two patients had a chronic acquired demyelinating neuropathy, of whom 138 met criteria for typical or atypical CIDP. Nine of these patients presented with a sensory predominant DSP phenotype, among whom six were eventually diagnosed with distal acquired demyelinating symmetric (DADS) neuropathy; one with Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin changes (POEMS) syndrome; and two with idiopathic DSP. The prevalence of acquired chronic demyelinating neuropathies among all patients presenting with a DSP phenotype was estimated to be 0.34%. DISCUSSION Patients who meet electrodiagnostic criteria for CIDP rarely present with a sensory predominant DSP phenotype, and electrodiagnostic testing rarely identifies treatable demyelinating neuropathies in patients who present with a DSP phenotype.
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Affiliation(s)
- Long Davalos
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Zachary N London
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Amro M Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Gary W Gallagher
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Brian C Callaghan
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Clare M Wieland
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Dustin G Nowacek
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Kapoor M, Keh R, Compton L, Morrow S, Gosal D, Manji H, Reilly MM, Lunn MP, Lavin TM, Carr AS. Subcutaneous immunoglobulin dose titration to clinical response in inflammatory neuropathy. J Neurol 2021; 268:1485-1490. [PMID: 33608795 DOI: 10.1007/s00415-020-10318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/28/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Individualized dosing is an established approach in intravenous immunoglobulin (IVIg) treatment for inflammatory neuropathies. There is less experience in effective dosing strategies for subcutaneous (SC) immunoglobulin. METHODS We conducted a retrospective cohort study of patients with inflammatory neuropathies transferring from IVIg to SCIg in two UK peripheral nerve services. I-RODS and grip strength were used to measure outcome. Dose and clinical progress were documented at 1 year and at last review. RESULTS 44/56 patients remained on maintenance SCIg beyond 1 year (mean 3.3 years, range 1-9 years) with stable clinical outcomes. Clinical deteriorations were corrected by small increases in SCIg dose in 20 patients at 1 year, a further 9 requiring subsequent further up-titrations. Sixteen tolerated dose reduction. Mean dose change was + 2.4% from baseline. Two patients required IVIg bolus rescue (2 g/kg). Three patients successfully discontinued Ig therapy. Nine patients returned to IVIg due to clinical relapse or patient preference. Overall tolerance was good. DISCUSSION Dose titration to clinical response is an effective approach in SCIg maintenance therapy.
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Affiliation(s)
- Mahima Kapoor
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Ryan Keh
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital Trust, Stott Lane, Salford, UK
| | - Laura Compton
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Sarah Morrow
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital Trust, Stott Lane, Salford, UK
| | - David Gosal
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital Trust, Stott Lane, Salford, UK
| | - Hadi Manji
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Tim M Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital Trust, Stott Lane, Salford, UK
| | - Aisling S Carr
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
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75
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Telleman JA, Herraets IJT, Goedee HS, van Asseldonk JT, Visser LH. Ultrasound scanning in the diagnosis of peripheral neuropathies. Pract Neurol 2021; 21:186-195. [DOI: 10.1136/practneurol-2020-002645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/13/2022]
Abstract
Nerve ultrasound scanning has become a valuable diagnostic tool in the routine workup of peripheral nerve disorders, effectively complementing conventional electrodiagnostic studies. The most relevant sonographic features are nerve size and structural integrity. Several peripheral neuropathies show characteristic and distinct patterns of nerve enlargement, allowing their early and accurate identification, and reducing test-burden and diagnostic delay for patients. In mononeuropathies such as carpal tunnel syndrome and ulnar neuropathy at the elbow, nerve enlargement develops only at specific sites of entrapment, while in polyneuropathy the nerve enlargement may be multifocal, regional or even diffuse. Nerve ultrasound scanning can reliably identify chronic inflammatory neuropathies, even when extensive electrodiagnostic studies fail, and it should therefore be embedded in routine diagnostic workup of peripheral neuropathies. In this paper we describe a potential diagnostic strategy to achieve this.
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Nerve Ultrasound as Helpful Tool in Polyneuropathies. Diagnostics (Basel) 2021; 11:diagnostics11020211. [PMID: 33572591 PMCID: PMC7910962 DOI: 10.3390/diagnostics11020211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Polyneuropathies (PNP) are a broad field of diseases affecting millions of people. While the symptoms presented are mostly similar, underlying causes are abundant. Thus, early identification of treatable causes is often difficult. Besides clinical data and basic laboratory findings, nerve conduction studies are crucial for etiological classification, yet limited. Besides Magnetic Resonance Imaging (MRI), high-resolution nerve ultrasound (HRUS) has become a noninvasive, fast, economic and available tool to help distinguish different types of nerve alterations in neuropathies. Methods: We aim to describe typical ultrasound findings in PNP and patterns of morphological changes in hereditary, immune-mediated, diabetic, metabolic and neurodegenerative PNP. Literature research was performed in PubMed using the terms ‘nerve ultrasound’, neuromuscular ultrasound, high-resolution nerve ultrasound, peripheral nerves, nerve enlargement, demyelinating, hereditary, polyneuropathies, hypertrophy’. Results: Plenty of studies over the past 20 years investigated the value of nerve ultrasound in different neuropathies. Next to nerve enlargement, patterns of nerve enlargement, echointensity, vascularization and elastography have been evaluated for diagnostic terms. Furthermore, different scores have been developed to distinguish different etiologies of PNP. Conclusions: Where morphological alterations of the nerves reflect underlying pathologies, early nerve ultrasound might enable a timely start of available treatment and also facilitate follow up of therapy success.
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Bakers JNE, van Eijk RPA, van den Berg LH, Visser-Meily JMA, Beelen A. Pattern of muscle strength improvement after intravenous immunoglobulin therapy in multifocal motor neuropathy. Muscle Nerve 2021; 63:678-682. [PMID: 33501670 PMCID: PMC8247955 DOI: 10.1002/mus.27185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/10/2022]
Abstract
Introduction In multifocal motor neuropathy (MMN), knowledge about the pattern of treatment response in a wide spectrum of muscle groups, distal as well as proximal, after intravenous immunoglobulin (IVIg) initiation is lacking. Methods Hand‐held dynamometry data of 11 upper and lower limb muscles, from 47 patients with MMN was reviewed. Linear mixed models were used to determine the treatment response after IVIg initiation and its relationship with initial muscle weakness. Results All muscle groups showed a positive treatment response after IVIg initiation. Changes in SD scores ranged from +0.1 to +0.95. A strong association between weakness at baseline and the magnitude of the treatment response was found. Discussion Improved muscle strength in response to IVIg appears not only in distal, but to a similar degree also in proximal muscle groups in MMN, with the largest response in muscle groups that show the greatest initial weakness.
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Affiliation(s)
- Jaap N E Bakers
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anita Beelen
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.,Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
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78
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High-resolution mapping identifies HLA class II associations with multifocal motor neuropathy. Neurobiol Aging 2021; 101:79-84. [PMID: 33582569 DOI: 10.1016/j.neurobiolaging.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To gain further insight in the immunopathology underlying multifocal motor neuropathy (MMN) by exploring the association between MMN and the human leukocyte antigen (HLA) class II DRB1, DQB1, and DQA loci in depth and by correlating associated haplotypes to detailed clinical and anti-ganglioside antibody data. METHODS We performed high-resolution HLA-class II typing for the DRB1, DQB1, and DQA1 loci in 126 well-characterized MMN patients and assessed disease associations with haplotypes. We used a cohort of 1305 random individuals as a reference for haplotype distribution in the Dutch population. RESULTS The DRB1*15:01-DQB1*06:02 haplotype (OR 1.6 [95% CI 1.1-2.2], p < 0.05) and the DRB1*12:01-DQB1*03:01 haplotype (OR 2.7 [95% CI 1.2-5.5], p < 0.05) were more frequent in patients with MMN than in controls. These haplotypes were not associated with disease course, response to treatment or anti-ganglioside antibodies. CONCLUSIONS MMN is associated with the DRB1*15:01-DQB1*06:02 and DRB1*12:01-DQB1*03:01 haplotypes. These HLA molecules or gene variants in their immediate vicinity may promote the specific inflammatory processes underlying MMN.
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79
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Ballegaard M, Nelson LM, Gimsing P. Comparing neuropathy in multiple myeloma and AL amyloidosis. J Peripher Nerv Syst 2020; 26:75-82. [PMID: 33368817 DOI: 10.1111/jns.12428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/05/2020] [Accepted: 12/16/2020] [Indexed: 01/01/2023]
Abstract
Peripheral neuropathy (PN) is frequent in patients with monoclonal gammopathy due to plasma cell dyscrasia, but little is known about the comparative impact of nerve dysfunction in different disorders. We compared clinical and laboratory results between two diagnostic groups. We recruited 76 untreated multiple myeloma (MM) and 27 AL amyloidosis (ALA) patients for evaluation of symptoms, clinical findings and nerve conduction studies (NCS). We diagnosed significant PN using total neuropathy scores (TNS > 7) in 17.6% of MM and 48.1% of ALA patients and in 27.7% of MM and 35.7% of ALA patients using NCS findings. TNS score grades were significantly higher in the AL amyloidosis patients (Fisher's exact test: P = .02) but a NCS based PN diagnosis was not significantly different (Fisher's exact test: P = .13). A significantly higher TNS vibration (P = .04) and pin (P = .02) sensory sign and TNS reflex (P = .04) sign score was found in amyloidosis patients. Likewise, quantitative sensory thresholds for vibration was higher in amyloidosis patients (Welsh ANOVA: P = .01). NCS revealed signs of more frequent axonal tibial neuropathy with significantly lower motor response amplitudes (P = .02) and resulting higher TNS scores (P = .002), while sural nerve sensory response amplitudes were without significant difference (P = .86). We found more severe TNS grades of PN in AL amyloidosis patients compared with MM patients. We also found higher sensory symptoms scores and higher thresholds for vibration but similar sensory involvement using NCS. The NCS exclusively showed signs of an axonal neuropathy.
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Affiliation(s)
- Martin Ballegaard
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | | | - Peter Gimsing
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Haematology, Rigshospitalet, Copenhagen, Denmark
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80
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Mantero V, Basilico P, Borelli P, Cappello A, Salmaggi A, Rigamonti A. A case of monofocal motor neuropathy with GM1 and GD1b antibodies improved with intravenous immunoglobulin. J Neuroimmunol 2020; 350:577452. [PMID: 33279873 DOI: 10.1016/j.jneuroim.2020.577452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022]
Abstract
Multifocal motor neuropathy is a purely motor neuropathy with a probably dysimmune pathogenesis, supported by the presence of anti-GM1 IgM antibodies in about half of the cases. Single nerve involvement allows for diagnosis of possible multifocal motor neuropathy. We present the case of a middle age man presenting with progressive weakness and hypotrophy in the left leg and difficulty in walking, in which we have diagnosed a dysimmune mononeuropathy. Treatment with IVIg was performed with substantial improvement. Although only one nerve is involved, early diagnosis of dysimmune mononeuropathy is important to start IVIg treatment that is often decisive.
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Affiliation(s)
- Vittorio Mantero
- Neurology Unit, "A. Manzoni" Hospital - ASST Lecco, Lecco, Italy.
| | - Paola Basilico
- Neurology Unit, "A. Manzoni" Hospital - ASST Lecco, Lecco, Italy
| | - Paolo Borelli
- Neurology Unit, "A. Manzoni" Hospital - ASST Lecco, Lecco, Italy
| | - Antonio Cappello
- Radiological Department, "A. Manzoni" Hospital - ASST, Lecco, Lecco, Italy
| | - Andrea Salmaggi
- Neurology Unit, "A. Manzoni" Hospital - ASST Lecco, Lecco, Italy
| | - Andrea Rigamonti
- Neurology Unit, "A. Manzoni" Hospital - ASST Lecco, Lecco, Italy
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81
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Yield of the PMP22 deletion analysis in patients with compression neuropathies. J Neurol 2020; 267:3617-3623. [DOI: 10.1007/s00415-020-10052-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
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82
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hATTR Pathology: Nerve Biopsy Results from Italian Referral Centers. Brain Sci 2020; 10:brainsci10110780. [PMID: 33114611 PMCID: PMC7692609 DOI: 10.3390/brainsci10110780] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/11/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Pathological evidence of amyloid on nerve biopsy has been the gold standard for diagnosis in hereditary transthyretin amyloidosis polyneuropathy (hATTR-PN) for a long time. In this article, we reviewed the pathological findings of a large series of sural nerve biopsies from a cohort of hATTR-PN patients, collected by different Italian referral centers. Patients and Methods: We reviewed clinical and pathological data from hATTR-PN patients, diagnosed and followed in five Italian referral centers for peripheral neuropathies. Diagnosis was formulated after a positive genetic test for transthyretin (TTR) mutations. Sural nerve biopsy was performed according to standard protocols. Results: Sixty-nine sural nerve biopsies from hATTR-PN patients were examined. Congo red positive deposits were found in 73% of cases. Only the Phe64Leu mutation failed to show amyloid deposits in a high percentage of biopsies (54%), as already described. Unusual pathological findings, such as myelin abnormalities or inflammatory infiltrates, were detected in occasional cases. Conclusions: Even if no longer indicated to confirm hATTR-PN clinical suspicion, nerve biopsy remains, in expert hands, a rapid and inexpensive tool to detect amyloid deposition. In Italy, clinicians should be aware that a negative biopsy does not exclude hATTR-PN, particularly for Phe64Leu, one of the most frequent mutations in this country.
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83
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Topakian R, Müller P, Ciovica-Oel IC, Trenkler J. In the borderland of multifocal motor neuropathy and chronic inflammatory demyelinating polyradiculopathy. Neurol Sci 2020; 42:1131-1134. [PMID: 33074453 DOI: 10.1007/s10072-020-04804-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy (CIDP) and multifocal motor neuropathy (MMN) are seen as distinct entities with marked differences in pathophysiology and clinical, laboratory, and imaging features. We report a patient with an immune-mediated neuropathy in the borderland of CIDP and MMN, whose magnetic resonance imaging and cerebrospinal fluid (CSF) features strongly resembled CIDP, while the clinical course and treatment response suggested the diagnosis of MMN without conduction blocks. There is strong evidence that MMN is not a variant of CIDP and that these conditions can be separated pathologically. Our case report widens the spectrum of MMN presentations, indicating the existence of a clinical overlap syndrome of MMN and CIDP, and emphasizing the need for more precise criteria regarding CSF and nerve root imaging abnormalities in the differentiation of chronic immune-mediated neuropathies.
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Affiliation(s)
- Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Grieskirchner Str. 42, 4600, Wels, Austria.
| | - Petra Müller
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Grieskirchner Str. 42, 4600, Wels, Austria
| | | | - Johannes Trenkler
- Institute of Neuroradiology, Kepler University Hospital, Linz, Austria
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Luigetti M, Giovannini S, Romano A, Bisogni G, Barbato F, Di Paolantonio A, Servidei S, Granata G, Sabatelli M. Small Fibre Involvement in Multifocal Motor Neuropathy Explored with Sudoscan: A Single-Centre Experience. Diagnostics (Basel) 2020; 10:diagnostics10100755. [PMID: 32993111 PMCID: PMC7599533 DOI: 10.3390/diagnostics10100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 11/20/2022] Open
Abstract
Objective: Multifocal motor neuropathy (MMN) is a rare inflammatory neuropathy, clinically characterized by exclusive motor involvement. We wished to evaluate the possible presence of sensory dysfunction, including the evaluation of small fibres, after a long-term disease course. Patients and methods: seven MMN patients, regularly followed in our Neurology Department, underwent clinical evaluation, neurophysiological examination by nerve conduction studies (NCSs), and Sudoscan. We compared neurophysiological data with a group of patients with other disorders of the peripheral nervous system. Results: NCSs showed a reduction of sensory nerve action potential amplitude in 2/7 MMN patients. Sudoscan showed borderline electrochemical skin conductance (ESC) values in 3/7 MMN patients (two of them with abnormal sensory NCSs). Conclusions: Our results confirm that sensory involvement may be found in some MMN after a long-term disease course, and it could also involve the small fibres.
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Affiliation(s)
- Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Correspondence: ; Tel.: +39-063-0154-435
| | - Silvia Giovannini
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Riabilitazione, 00168 Rome, Italy
| | - Angela Romano
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Centro Clinico NEMO adulti, 00168 Rome, Italy;
| | | | - Francesco Barbato
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
| | - Andrea Di Paolantonio
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
| | - Serenella Servidei
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurofisiopatologia, 00168 Rome, Italy
| | - Giuseppe Granata
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurofisiopatologia, 00168 Rome, Italy
| | - Mario Sabatelli
- Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (S.G.); (A.R.); (F.B.); (A.D.P.); (S.S.); (G.G.); (M.S.)
- Centro Clinico NEMO adulti, 00168 Rome, Italy;
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85
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Excitability of motor and sensory axons in multifocal motor neuropathy. Clin Neurophysiol 2020; 131:2641-2650. [PMID: 32947198 DOI: 10.1016/j.clinph.2020.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 07/18/2020] [Accepted: 08/14/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess excitability differences between motor and sensory axons of affected nerves in patients with multifocal motor neuropathy (MMN). METHODS We performed motor and sensory excitability tests in affected median nerves of 20 MMN patients and in 20 age-matched normal subjects. CMAPs were recorded from the thenar and SNAPs from the 3rd digit. Clinical tests included assessment of muscle strength, two-point discrimination and joint position. RESULTS All MMN patients had weakness of the thenar muscle and normal sensory tests. Motor excitability testing in MMN showed an increased threshold for a 50% CMAP, increased rheobase, decreased stimulus-response slope, fanning-out of threshold electrotonus, decreased resting I/V slope, shortened refractory period, and more pronounced superexcitability. Sensory excitability testing in MMN revealed decreased accommodation half-time and S2-accommodation and less pronounced subexcitability. Mathematical modeling indicated increased Barrett-Barrett conductance for motor fibers and increase in internodal fast potassium conductance for sensory fibers. CONCLUSIONS Excitability findings in MMN suggest myelin sheath or paranodal seal involvement in motor fibers and, possibly, paranodal detachment in sensory fibers. SIGNIFICANCE Excitability properties of affected nerves in MMN differ between motor and sensory nerve fibers.
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86
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Different distributions of nerve demyelination in chronic acquired multifocal polyneuropathies. Chin Med J (Engl) 2020; 133:2558-2564. [PMID: 32947359 PMCID: PMC7722580 DOI: 10.1097/cm9.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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87
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Impaired conduction of Ia sensory fibers in multifocal motor neuropathy: An electrophysiological demonstration. Clin Neurophysiol Pract 2020; 5:152-156. [PMID: 32913936 PMCID: PMC7473831 DOI: 10.1016/j.cnp.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives To report the clinical and electrophysiological findings in two patients with multifocal motor neuropathy (MMN) and bilateral absent patellar and Achilles tendon reflexes despite normal strength of quadriceps and calf muscles. Methods The medical history and clinical evaluation were completed by electrophysiological tests: sensory and motor nerve conduction studies, needle electromyography, motor-evoked potentials (MEPs) after transcranial magnetic stimulation, patellar T (tendon) responses, quadriceps and soleus H (Hoffman) reflex recordings. Results In the two patients, history, clinical evaluation, nerve conduction studies, favorable response to intravenous immunoglobulins, and positive anti-GM1 antibodies fulfilled the diagnosis of MMN. The lower limbs were asymptomatic, except for a unilateral weakness of foot dorsiflexion. The patellar and Achilles tendon reflexes disappeared during the course of the disease. The sensory nerve conduction studies were normal or minimally modified, M-wave and MEP/M amplitude ratio to the quadriceps were normal, patellar T (tendon) responses were virtually absent, and H-reflex to the quadriceps and soleus muscles were absent. Conclusions These observations, which show the interruption of the reflex afferent pathway, raise the question of Ia afferent involvement in the lower limbs of these two patients with MMN. Further investigations should determine the frequency and significance of these findings in this disorder.
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88
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Herraets I, van Rosmalen M, Bos J, van Eijk R, Cats E, Jongbloed B, Vlam L, Piepers S, van Asseldonk JT, Goedee HS, van den Berg L, van der Pol WL. Clinical outcomes in multifocal motor neuropathy: A combined cross-sectional and follow-up study. Neurology 2020; 95:e1979-e1987. [PMID: 32732293 DOI: 10.1212/wnl.0000000000010538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/17/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the clinical course of multifocal motor neuropathy (MMN) in a large cohort of patients and to identify predictive factors of a progressive disease course. METHODS Between May 2015 and February 2016, we collected clinical data from 100 patients with MMN, of whom 60 had participated in a nationwide cross-sectional cohort study in 2007. We documented clinical characteristics using standardized questionnaires and performed a standardized neurologic examination. We used multiple linear regression analysis to identify factors that correlated with worse outcome. RESULTS We found that age at diagnosis (45.2 vs 48.6 years, p < 0.02) was significantly increased between 2007 and 2015-2016, whereas diagnostic delay decreased by 15 months. Seven out of 10 outcome measures deteriorated over time (all p < 0.01). Patients who had a lower Medical Research Council (MRC) sumscore and absence of 1 or more reflexes at the baseline visit showed a greater functional loss at follow-up (p = 0.007 and p = 0.016). CONCLUSIONS Our study shows that MMN is a progressive disease. Although 87% of patients received maintenance treatment, muscle strength, reflexes, vibration sense, and the Self-Evaluation Scale score significantly deteriorated over time. Lower MRC sumscore and absence of reflexes predicted a more progressive disease course. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that lower MRC sumscore and the absence of reflexes predict a more progressive disease course in patients with MMN.
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Affiliation(s)
- Ingrid Herraets
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Marieke van Rosmalen
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Jeroen Bos
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Ruben van Eijk
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Elies Cats
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Bas Jongbloed
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Lotte Vlam
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Sanne Piepers
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Jan-Thies van Asseldonk
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - Leonard van den Berg
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands
| | - W Ludo van der Pol
- From the Department of Neurology and Neurosurgery (I.H., M.v.R., J.B., R.v.E., H.S.G., L.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.v.E.), University Medical Center Utrecht; Department of Neurology (E.C.), Gelre Hospital, Apeldoorn; Department of Neurology (B.J.), Admiraal de Ruyter Hospital, Goes; Department of Neurology (L.V.), Erasmus Medical Center, Rotterdam; Department of Neurology (S.P.), Meander Medical Center, Amersfoort; and Department of Neurology and Clinical Neurophysiology (J.-T.v.A.), Elisabeth-Tweesteden Hospital Tilburg, the Netherlands.
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Dörner M, Schreiber F, Stephanik H, Tempelmann C, Winter N, Stahl JH, Wittlinger J, Willikens S, Kramer M, Heinze HJ, Vielhaber S, Schelle T, Grimm A, Schreiber S. Peripheral Nerve Imaging Aids in the Diagnosis of Immune-Mediated Neuropathies-A Case Series. Diagnostics (Basel) 2020; 10:E535. [PMID: 32751486 PMCID: PMC7459443 DOI: 10.3390/diagnostics10080535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diagnosis of immune-mediated neuropathies and their differentiation from amyotrophic lateral sclerosis (ALS) can be challenging, especially at early disease stages. Accurate diagnosis is, however, important due to the different prognosis and available treatment options. We present one patient with a left-sided dorsal flexor paresis and initial suspicion of ALS and another with multifocal sensory deficits. In both, peripheral nerve imaging was the key for diagnosis. METHODS We performed high-resolution nerve ultrasound (HRUS) and 7T or 3T magnetic resonance neurography (MRN). RESULTS In both patients, HRUS revealed mild to severe, segmental or inhomogeneous, nerve enlargement at multiple sites, as well as an area increase of isolated fascicles. MRN depicted T2 hyperintense nerves with additional contrast-enhancement. DISCUSSION Peripheral nerve imaging was compatible with the respective diagnosis of an immune-mediated neuropathy, i.e., multifocal motor neuropathy (MMN) in patient 1 and multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) in patient 2. Peripheral nerve imaging, especially HRUS, should play an important role in the diagnostic work-up for immune-mediated neuropathies and their differentiation from ALS.
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Affiliation(s)
- Marc Dörner
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Frank Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
| | - Heike Stephanik
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Claus Tempelmann
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Natalie Winter
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Jan-Hendrik Stahl
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Julia Wittlinger
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Sophia Willikens
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Magdalena Kramer
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
- Leibniz Institue for Neurobiology (LIN), 39120 Magdeburg, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, 06847 Dessau, Germany;
| | - Alexander Grimm
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
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90
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Tichy EM, Prosser B, Doyle D. Expanding the Role of the Pharmacist: Immunoglobulin Therapy and Disease Management in Neuromuscular Disorders. J Pharm Pract 2020; 35:106-119. [PMID: 32677504 PMCID: PMC8822190 DOI: 10.1177/0897190020938212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immunoglobulin G (IgG) is a commonly used treatment for chronic neuromuscular
disorders (NMDs), such as chronic inflammatory demyelinating polyneuropathy and
multifocal motor neuropathy. IgG therapy has also shown promise in treating
other NMDs including myasthenia gravis, polymyositis, and dermatomyositis. IgG
is administered as either intravenous immunoglobulin (IVIg) or subcutaneous
immunoglobulin (SCIg), with SCIg use becoming more popular due to the treatment
burden associated with IVIg. IVIg requires regular venous access; long infusions
(typically 4-6 hours); and can result in systemic adverse events (AEs) for some
patients. In contrast, SCIg can be self-administered at home with shorter
infusions (approximately 1 hour) and fewer systemic AEs. As patient care shifts
toward home-based settings, the role of the pharmacist is paramount in providing
a continuation of care and acting as the bridge between patient and clinic.
Pharmacists with a good understanding of current recommendations, dosing
strategies, and administration routes for IgG therapy are best placed to support
patients. The aims of this review are to highlight the evidence supporting IgG
therapy in the treatment of NMDs and provide practical information on patient
management and IVIg/SCIg dosing in order to guide pharmacists on optimizing
clinical outcomes and patient care.
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Affiliation(s)
- Eric M Tichy
- Pharmacy Supply Solutions, Supply Chain Management, Mayo Clinic, Rochester, MN, USA
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91
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Herraets IJT, Goedee HS, Telleman JA, van Eijk RPA, Verhamme C, Saris CGJ, Eftimov F, van Alfen N, van Asseldonk JT, Visser LH, van den Berg LH, van der Pol LW. Nerve ultrasound for diagnosing chronic inflammatory neuropathy: A multicenter validation study. Neurology 2020; 95:e1745-e1753. [PMID: 32675082 DOI: 10.1212/wnl.0000000000010369] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/06/2020] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To validate the diagnostic accuracy of a previously described short sonographic protocol to identify chronic inflammatory neuropathy (CIN), including chronic inflammatory demyelinating polyneuropathy (CIDP), Lewis Sumner syndrome, and multifocal motor neuropathy (MMN), and to determine the added value of nerve ultrasound to detect treatment-responsive patients compared to nerve conduction studies (NCS) in a prospective multicenter study. METHODS We included 100 consecutive patients clinically suspected of CIN in 3 centers. The study protocol consisted of neurologic examination, laboratory tests, NCS, and nerve ultrasound. We validated a short sonographic protocol (median nerve at forearm, upper arm, and C5 nerve root) and determined its diagnostic accuracy using the European Federation of Neurological Societies/Peripheral Nerve Society criteria of CIDP/MMN (reference standard). In addition, to determine the added value of nerve ultrasound in detecting treatment-responsive patients, we used previously published diagnostic criteria based on clinical, NCS, and sonographic findings and treatment response (alternative reference standard). RESULTS Sensitivity and specificity of the sonographic protocol for CIN according to the reference standard were 87.4% and 67.3%, respectively. Sensitivity and specificity of this protocol according to the alternative reference standard were 84.6% and 72.8%, respectively, and of NCS 76.1% and 93.4%. With addition of nerve ultrasound, 44 diagnoses of CIN were established compared to 33 diagnoses with NCS alone. CONCLUSIONS A short sonographic protocol shows high diagnostic accuracy for detecting CIN. Nerve ultrasound is able to detect up to 25% more patients who respond to treatment. CLASSIFICATION OF EVIDENCE This multicenter study provides Class IV evidence that nerve ultrasound improves diagnosis of CIN.
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Affiliation(s)
- Ingrid J T Herraets
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johan A Telleman
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Verhamme
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Christiaan G J Saris
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Filip Eftimov
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nens van Alfen
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J Thies van Asseldonk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Leo H Visser
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ludo W van der Pol
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., L.W.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care (R.P.A.v.E.), University Medical Center Utrecht; Amsterdam Neuroscience (C.V., F.E.), Amsterdam University Medical Center, University of Amsterdam; and Department of Neurology (C.G.J.S., N.v.A.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
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Electrodiagnostic Testing of Large Fiber Polyneuropathies: A Review of Existing Guidelines. J Clin Neurophysiol 2020; 37:277-287. [DOI: 10.1097/wnp.0000000000000674] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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93
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Doneddu PE, Mandia D, Gentile F, Gallia F, Liberatore G, Terenghi F, Ruiz M, Nobile-Orazio E. Home monitoring of maintenance intravenous immunoglobulin therapy in patients with chronic inflammatory neuropathy. J Peripher Nerv Syst 2020; 25:238-246. [PMID: 32470190 DOI: 10.1111/jns.12396] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/30/2022]
Abstract
To evaluate the utility of different outcome measures to monitor dose adjustment of intravenous immunoglobulin (IVIg) therapy in patients with chronic inflammatory neuropathy (CIN). We assessed the adjustment of IVIg maintenance therapy in 20 patients (10 CIDP and 10 MMN) by regularly monitoring grip strength (GS) using a Martin Vigorimeter, RODS, and quality of life using the SF-36 questionnaire. These measures were regularly performed by the patient at home. We also assessed the extended MRC sumscore (eMRC sumscore) at each outpatient visit for IVIg infusion. We also enrolled 30 healthy controls to measure any possible training effect of GS with time and to analyze random fluctuation of GS. Clinically relevant change was detected by eMRC sumscore in 14 (93%) patients, by RODS in 11 (73%) patients, and by GS in 8 (53%) patients. Early sensitivity was greatest for RODS (73%), followed by GS (53%), and eMRC sumscore (27%). This differed from CIDP, with an early change in RODS in 100% of patients, and MMN with an early change in GS in 75%. None of the outcome measures alone was sufficient to detect clinically significant changes in all patients. Home monitoring of outcome measures objectively assisted clinical decision during individualization of IVIg treatment. We recommend a multimodal approach using different outcome measures to monitor the individual patient with CIN.
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Affiliation(s)
| | | | | | | | | | | | - Marta Ruiz
- Humanitas Clinical and Research Institute, Milan, Italy
| | - Eduardo Nobile-Orazio
- Humanitas Clinical and Research Institute, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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Pegat A, Boisseau W, Maisonobe T, Debs R, Lenglet T, Psimaras D, Azoulay-Cayla A, Fournier E, Viala K. Motor chronic inflammatory demyelinating polyneuropathy (CIDP) in 17 patients: Clinical characteristics, electrophysiological study, and response to treatment. J Peripher Nerv Syst 2020; 25:162-170. [PMID: 32364302 DOI: 10.1111/jns.12380] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022]
Abstract
Motor chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare and poorly described subtype of CIDP. We aimed to study their clinical and electrophysiological characteristics and response to treatment. From a prospective database of CIDP patients, we included patients with definite or probable CIDP with motor signs and without sensory signs/symptoms at diagnosis. Patients were considered to have pure motor CIDP (PM-CIDP) if sensory conductions were normal or to have motor predominant CIDP (MPred-CIDP) if ≥2 sensory nerve action potential amplitudes were abnormal. Among the 700 patients with CIDP, 17 (2%) were included (PM-CIDP n = 7, MPred-CIDP n = 10); 71% were male, median age at onset was 48 years (range: 13-76 years), 47% had an associated inflammatory or infectious disease or neoplasia. At the more severe disease stage, 94% of patients had upper and lower limb weakness, with distal and proximal weakness in 4 limbs for 56% of them. Three-quarters (75%) responded to intravenous immunoglobulins (IVIg) and four of five patients to corticosteroids including three of three patients with MPred-CIDP. The most frequent conduction abnormalities were conduction blocks (CB, 82%) and F-wave abnormalities (88%). During follow up, 4 of 10 MPred-CIDP patients developed mild sensory symptoms; none with PM-CIDP did so. Patients with PM-CIDP had poorer outcome (median ONLS: 4; range: 22-5) compared to MPred-CIDP (2, range: 0-4; P = .03) at last follow up. This study found a progressive clinical course in the majority of patients with motor CIDP as well as frequent associated diseases, CB, and F-wave abnormalities. Corticosteroids might be considered as a therapeutic option in resistant IVIg patients with MPred-CIDP.
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Affiliation(s)
- Antoine Pegat
- Service de neurologie C pathologies neuromusculaires, service d'explorations fonctionnelles neurologiques, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France.,Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - William Boisseau
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Rabab Debs
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Dimitri Psimaras
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France.,Service de Neurologie 2-Mazarin, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France.,Université Pierre et Marie Curie Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière (CRICM), UMRS 975, Inserm U 975, CNRS, UMR 7225, Paris, France
| | - Arièle Azoulay-Cayla
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Fournier
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Karine Viala
- Département de Neurophysiologie Clinique, Hôpital Pitié Salpêtrière, Assistance publique-Hôpitaux de Paris, Paris, France
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95
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Doneddu PE, Hadden RDM. Daily grip strength response to intravenous immunoglobulin in chronic immune neuropathies. Muscle Nerve 2020; 62:103-110. [PMID: 32319099 DOI: 10.1002/mus.26898] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Monitoring grip strength at home may detect improvement between intravenous immunoglobulin (IVIg) treatments in patients with chronic inflammatory neuropathies (CINs). METHODS Fifteen patients recorded grip strength each day, from one IVIg treatment until the next. We analyzed grip strength changes comparing thresholds of 8 kPa and 14 kPa. "Random" fluctuations of grip strength were distinguished from treatment response by smoothing the data. RESULTS "Random" fluctuations of at least 8 kPa occurred in 27% of patients. Smoothed daily grip strength increased by at least 8 kPa above baseline in 11 (73%) patients. Grip strength increased by at least 8 kPa for 3 consecutive days in 9 (60%) patients, and 5-day block mean increased by at least 8 kPa in 10 (67%) patients. DISCUSSION Home monitoring of grip strength confirmed treatment response in most patients with CINs on IVIg. To detect improvement in an individual patient, we suggest a threshold of at least 8 kPa on 3 consecutive days or on 5-day block mean.
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Affiliation(s)
- Pietro E Doneddu
- Department of Neurology, King's College Hospital, King's College London, London, UK
| | - Robert D M Hadden
- Department of Neurology, King's College Hospital, King's College London, London, UK
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96
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van Rosmalen MHJ, Goedee HS, van der Gijp A, Witkamp TD, Froeling M, Hendrikse J, van der Pol WL. Low interrater reliability of brachial plexus MRI in chronic inflammatory neuropathies. Muscle Nerve 2020; 61:779-783. [PMID: 32012299 PMCID: PMC7317832 DOI: 10.1002/mus.26821] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/15/2020] [Accepted: 01/28/2020] [Indexed: 12/13/2022]
Abstract
Introduction Magnetic resonance imaging of the brachial plexus shows nerve thickening in approximately half of the patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). The reliability of qualitative evaluation of brachial plexus MRI has not been studied previously. Methods We performed an interrater study in a retrospective cohort of 19 patients with CIDP, 17 patients with MMN, and 14 controls. The objective was to assess interrater variability between radiologists by using a predefined scoring system that allowed the distinction of no, possible, or definite nerve thickening. Results Raters agreed in 26 of 50 (52%) brachial plexus images; κ‐coefficient was 0.30 (SE 0.08, 95% confidence interval 0.14–0.46, P < .0005). Discussion Our results provide evidence that interrater reliability of qualitative evaluation of brachial plexus MRI is low. Objective criteria for abnormality are required to optimize the diagnostic value of MRI for inflammatory neuropathies. See editorial on pages 679–680 in this issue.
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Affiliation(s)
- Marieke H J van Rosmalen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, The Netherlands
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, The Netherlands
| | - Anouk van der Gijp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theo D Witkamp
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Froeling
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, The Netherlands
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den Bergh PYK, Doorn PA, Jacobs BC, Querol L, Bunschoten C, Cornblath DR. Boundaries of chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2020; 25:4-8. [DOI: 10.1111/jns.12364] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Peter Y. K. den Bergh
- Neuromuscular Reference CentreUniversity Hospital St Luc, University of Louvain, Avenue Hippocrate 10 Brussels Belgium
| | - Pieter A. Doorn
- Department of Neurology, Erasmus MCUniversity Medical Center Rotterdam Wytemaweg 80 CN, Rotterdam The Netherlands
| | - Bart C. Jacobs
- Department of Neurology and Immunology, Erasmus MCUniversity Medical Center Rotterdam Wytemaweg 80 CN, Rotterdam The Netherlands
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant PauUniversitat Autònoma de Barcelona, Mas Casanovas 90 Barcelona Spain
| | - Carina Bunschoten
- Department of Neurology and Immunology, Erasmus MCUniversity Medical Center Rotterdam Wytemaweg 80 CN, Rotterdam The Netherlands
| | - David R. Cornblath
- Department of NeurologyJohns Hopkins University School of Medicine Meyer 6‐181a North, Wolfe Street, Baltimore US
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98
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Yeh WZ, Dyck PJ, van den Berg LH, Kiernan MC, Taylor BV. Multifocal motor neuropathy: controversies and priorities. J Neurol Neurosurg Psychiatry 2020; 91:140-148. [PMID: 31511307 DOI: 10.1136/jnnp-2019-321532] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/14/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
Despite 30 years of research there are still significant unknowns and controversies associated with multifocal motor neuropathy (MMN) including disease pathophysiology, diagnostic criteria and treatment. Foremost relates to the underlying pathophysiology, specifically whether MMN represents an axonal or demyelinating neuropathy and whether the underlying pathophysiology is focused at the node of Ranvier. In turn, this discussion promotes consideration of therapeutic approaches, an issue that becomes more directed in this evolving era of precision medicine. It is generally accepted that MMN represents a chronic progressive immune-mediated motor neuropathy clinically characterised by progressive asymmetric weakness and electrophysiologically by partial motor conduction block. Anti-GM1 IgM antibodies are identified in at least 40% of patients. There have been recent developments in the use of neuromuscular ultrasound and MRI to aid in diagnosing MMN and in further elucidation of its pathophysiological mechanisms. The present Review will critically analyse the knowledge accumulated about MMN over the past 30 years, culminating in a state-of-the-art approach to therapy.
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Affiliation(s)
- Wei Zhen Yeh
- Department of Neurology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - P James Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Leonard H van den Berg
- UMC Utrecht Brain Center, Department of Neurology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Matthew C Kiernan
- Bushell Chair of Neurology, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Bruce V Taylor
- Department of Neurology, Royal Hobart Hospital, Hobart, Tasmania, Australia .,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Herraets IJT, Goedee HS, Telleman JA, van Eijk RPA, van Asseldonk JT, Visser LH, van den Berg LH, van der Pol WL. Nerve ultrasound improves detection of treatment-responsive chronic inflammatory neuropathies. Neurology 2020; 94:e1470-e1479. [PMID: 31959710 DOI: 10.1212/wnl.0000000000008978] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/07/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To examine the diagnostic accuracy of nerve ultrasound in a prospective cohort of consecutive patients with a clinical suspicion of chronic inflammatory neuropathies, including chronic inflammatory demyelinating polyneuropathy, Lewis-Sumner syndrome, and multifocal motor neuropathy, and to determine the added value in the detection of treatment-responsive patients. METHODS Between February 2015 and July 2018, we included 100 consecutive incident patients with a clinical suspicion of chronic inflammatory neuropathy. All patients underwent nerve ultrasound, extensive standardized nerve conduction studies (NCS), and other relevant diagnostic investigations. We evaluated treatment response using predefined criteria. A diagnosis of chronic inflammatory neuropathy was established when NCS were abnormal (fulfilling criteria of demyelination of the European Federation of Neurological Societies/Peripheral Nerve Society) or when the degree of nerve enlargement detected by sonography was compatible with chronic inflammatory neuropathy and there was response to treatment. RESULTS A diagnosis of chronic inflammatory neuropathy was established in 38 patients. Sensitivity and specificity of nerve ultrasound and NCS were 97.4% and 69.4% and 78.9% and 93.5%, respectively. The added value of nerve ultrasound in detection of treatment-responsive chronic inflammatory neuropathy was 21.1% compared to NCS alone. CONCLUSIONS Nerve ultrasound and NCS are complementary techniques with superior sensitivity in the former and specificity in the latter. Addition of nerve ultrasound significantly improves the detection of chronic inflammatory neuropathies. Therefore, it deserves a prominent place in the diagnostic workup of chronic inflammatory neuropathies. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that nerve ultrasound is an accurate diagnostic tool to detect chronic inflammatory neuropathies.
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Affiliation(s)
- Ingrid J T Herraets
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Johan A Telleman
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - J Thies van Asseldonk
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leo H Visser
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - W Ludo van der Pol
- From the Department of Neurology and Neurosurgery (I.J.T.H., H.S.G., J.A.T., R.P.A.v.E., L.H.v.d.B., W.L.v.d.P.), UMC Utrecht Brain Center Rudolf Magnus; Department of Neurology and Clinical Neurophysiology (I.J.T.H., J.A.T., J.T.v.A., L.H.V.), Elisabeth-Tweesteden Hospital Tilburg; and Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands.
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Maeda H, Ishii R, Kusunoki S, Chiyonobu T. Childhood-onset multifocal motor neuropathy with IgM antibodies to GM2 and GalNac-GD1a. Brain Dev 2020; 42:88-92. [PMID: 31522790 DOI: 10.1016/j.braindev.2019.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multifocal motor neuropathy (MMN) is an acquired immune-mediated form of neuropathy characterized by upper and asymmetric limb weakness without sensory loss. The mean age of onset is 40 years (range, 20-70 years), and childhood-onset MMN is extremely rare. In the present report, we discuss a case of childhood-onset MMN in a patient who tested positive for anti-GM2 and anti-GalNac-GD1a immunoglobulin M (IgM) antibodies. CASE REPORT A 12-year-old girl presented with progressive weakness of the upper extremities without sensory loss. Electrophysiological assessments revealed definite conduction blocks in the left median and bilateral radial nerves. She was diagnosed with MMN in accordance with the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria. Serological studies revealed that she tested positive for IgM antibodies to GM2 and GalNac-GD1a. Partial improvements in both muscle weakness and electrophysiological assessments were achieved after 8 months of high-dose intravenous immunoglobulin (IVIg) treatment. CONCLUSION Although childhood-onset MMN is rare, most patients respond to IVIg treatment. This is the first case of childhood-onset MMN in a patient who tested positive for anti-GM2 and anti-GalNac-GD1a IgM antibodies. Although half of the adult patients with MMN test positive for anti-GM1 IgM antibodies, they were not detected in our patient. Comprehensive testing for serum anti-glycolipid antibodies in addition to GM1 may aid in the diagnosis of childhood-onset MMN.
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Affiliation(s)
- Hiroshi Maeda
- Department of Pediatrics, North Medical Center, Kyoto Prefectural University of Medicine, Japan
| | - Ryotaro Ishii
- Department of Emergency, North Medical Center, Kyoto Prefectural University of Medicine, Japan
| | - Susumu Kusunoki
- Department of Neurology, Kinki University School of Medicine, Japan
| | - Tomohiro Chiyonobu
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Japan.
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