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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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103
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Keh R, Kahlil A, Nihoyannopoulos L, Compton L, Kapoor M, Gosal D, Manji H, Rossor A, Reilly M, Lunn M, Lavin T, Carr A. Routine blood monitoring in maintenance immunoglobulin treatment of inflammatory neuropathy: Is it clinically relevant? J Neurol Sci 2020; 408:116527. [DOI: 10.1016/j.jns.2019.116527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/21/2019] [Accepted: 10/08/2019] [Indexed: 01/01/2023]
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104
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Ripellino P, Pons M, Izzo MGA, Gobbi C. Bilateral phrenic neuropathy responsive to intravenous immunoglobulin treatment. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x19891606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aetiology of phrenic neuropathy is often unknown, but immune mechanisms may play a role. In a typical case of bilateral phrenic neuropathy with paradoxical breathing (video), an inflammatory pathogenesis was suggested by prolonged distal latency of phrenic nerve compound muscle action potentials in nerve conduction studies and a clear-cut albumin-cytologic dissociation. This encouraged us to treat the patient with a standard dose of intravenous immunoglobulin. After obtaining a strong improvement at spirometry, we repeated the second cycle of intravenous immunoglobulin and observed normalization of symptoms within few weeks and no relapse after 3 years. This case suggests that lumbar puncture should be performed in the acute phase of phrenic neuropathies to detect potential responders to immunomodulatory treatment.
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Affiliation(s)
- Paolo Ripellino
- Department of Neurology, Neurocenter of Southern Switzerland, Lugano (CH), Switzerland
| | - Marco Pons
- Department of Internal Medicine, Ospedale Regionale di Lugano, Lugano (CH), Switzerland
| | | | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland, Lugano (CH), Switzerland
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105
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Vallat JM, Mathis S, Vegezzi E, Richard L, Duchesne M, Gallouedec G, Corcia P, Magy L, Uncini A, Devaux J. Antibody- and macrophage-mediated segmental demyelination in chronic inflammatory demyelinating polyneuropathy: clinical, electrophysiological, immunological and pathological correlates. Eur J Neurol 2019; 27:692-701. [PMID: 31769579 DOI: 10.1111/ene.14133] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a heterogeneous autoimmune disorder critically lacking diagnostic biomarkers. Autoantibodies to nodal and paranodal components have recently been described in a small subset of patients. Here, the diagnostic value of immune reactivity toward the myelin compartment was investigated. METHODS Ninety-four French CIDP patients were retrospectively studied. The reactivity toward the peripheral nerve was investigated. Sural nerve biopsies were examined by electron microscopy and immunofluorescence. RESULTS Twenty-one patients (22%) and three patients (3%) presented with a strong immunoglobulin G or immunoglobulin M reactivity respectively against the myelin compartment. The clinical, electrophysiological and morphological features were examined in nine of these patients for whom sural nerve biopsies were available. Seven patients were electrodiagnosed with definite CIDP, one with possible CIDP and one was unclassifiable but sural nerve biopsy argued for CIDP diagnosis. Electron microscopy of sural nerve biopsies demonstrated the presence of macrophage-mediated demyelination restricted to the internode in all nine patients. Immunolabelling for voltage-gated sodium channels, myelin and axonal markers confirmed the presence of segmental demyelination and of remyelination. The nodal and paranodal regions, however, were unaffected in these patients. Nerve conduction studies corroborated the multifocal and segmental profile, and seven patients showed increased duration of proximal (1.5-5.1 times) and/or distal (1.2-3.4 times) compound muscle action potential in at least two nerves. CONCLUSION Antibody- and macrophage-mediated demyelination appears responsible for conduction alterations in CIDP patients and nerve immunostaining assays may serve as a supportive diagnostic biomarker.
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Affiliation(s)
- J-M Vallat
- Department of Neurology, University Hospital, Limoges, France
| | - S Mathis
- Department of Neurology, University Hospital, Bordeaux, France
| | - E Vegezzi
- INSERM U1051, Institut des Neurosciences de Montpellier (INM), Université de Montpellier, Montpellier, France.,Neuroscience Consortium, University of Pavia, Monza Policlinico and Pavia Mondino, Pavia, Italy
| | - L Richard
- Department of Neurology, University Hospital, Limoges, France
| | - M Duchesne
- Department of Neurology, University Hospital, Limoges, France
| | - G Gallouedec
- Department of Neurology, University Hospital, Limoges, France
| | - P Corcia
- ALS Reference Center, University Hospital, Tours, France
| | - L Magy
- Department of Neurology, University Hospital, Limoges, France
| | - A Uncini
- Department of Neurosciences, Imaging and Clinical Sciences University G. d'Annunzio, Chieti-Pescara, Italy
| | - J Devaux
- INSERM U1051, Institut des Neurosciences de Montpellier (INM), Université de Montpellier, Montpellier, France
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106
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Content Ed Net. Improving Intravenous Immunoglobulin Dosing in Autoimmune Neuropathies. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10314832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This symposium took place on Monday 24th June 2019, as part of the 2019 Peripheral Nerve Society (PNS) Annual Meeting in Genoa, Italy. Immune-mediated neuropathies such as Guillain–Barré Syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and multifocal motor neuropathy (MMN) are diverse inflammatory peripheral nerve disorders. International consensus guidelines recommend intravenous Ig (IVIG) as Level A for the treatment of GBS, CIDP, and MMN. Suggested induction doses of IVIG are 2 g/kg divided over 2–5 days, but maintenance doses are purposely less clearly defined and left up to the judgement of the clinician, depending upon the specific needs of the individual patient. Community-based neurologists treating patients with these rare inflammatory neuropathies may be unaware of optimal dosing regimens and patient response to treatment may therefore be inadequate. In this symposium, world-renowned experts in GBS, CIDP, and MMN shared their expertise and review of the literature to provide reasonable dosing regimens for neurologists who may rarely encounter these conditions.
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107
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Oudeman J, Eftimov F, Strijkers GJ, Schneiders JJ, Roosendaal SD, Engbersen MP, Froeling M, Goedee HS, van Doorn PA, Caan MWA, van Schaik IN, Maas M, Nederveen AJ, de Visser M, Verhamme C. Diagnostic accuracy of MRI and ultrasound in chronic immune-mediated neuropathies. Neurology 2019; 94:e62-e74. [PMID: 31827006 DOI: 10.1212/wnl.0000000000008697] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/27/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess and compare the diagnostic performance of qualitative and (semi-)quantitative MRI and ultrasound for distinguishing chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) from segmental spinal muscular atrophy (sSMA). METHODS Patients with CIDP (n = 13), MMN (n = 10), or sSMA (n = 12) and healthy volunteers (n = 30) were included. MRI of the brachial plexus, using short tau inversion recovery (STIR), nerve-specific T2-weighted (magnetic resonance neurography [MRN]), and diffusion tensor imaging (DTI) sequences, was evaluated. Furthermore, with ultrasound, cross-sectional areas of the nerves were evaluated. Three radiologists blinded for diagnosis qualitatively scored hypertrophy and increased signal intensity (STIR and MRN), and intraobserver and interobserver agreement was assessed. For the (semi-)quantitative modalities, group differences and receiver operator characteristics were calculated. RESULTS Hypertrophy and increased signal intensity were found in all groups including healthy controls. Intraobserver and interobserver agreements varied considerably (intraclass correlation coefficients 0.00-0.811 and 0.101-0.491, respectively). DTI showed significant differences (p < 0.05) among CIDP, MMN, sSMA, and controls for fractional anisotropy, axial diffusivity, and radial diffusivity in the brachial plexus. Ultrasound showed significant differences in cross-sectional area (p < 0.05) among CIDP, MMN, and sSMA in upper arm and brachial plexus. For distinguishing immune-mediated neuropathies (CIDP and MMN) from sSMA, ultrasound yielded the highest area under the curve (0.870). CONCLUSION Qualitative assessment of hypertrophy and signal hyperintensity on STIR or MRN is of limited value. DTI measures may discriminate among CIDP, MMN, and sSMA. Currently, ultrasound may be the most appropriate diagnostic imaging aid in the clinical setting.
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Affiliation(s)
- Jos Oudeman
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands.
| | - Filip Eftimov
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Gustav J Strijkers
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Joppe J Schneiders
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Stefan D Roosendaal
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Maurits P Engbersen
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Martijn Froeling
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - H Stephan Goedee
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Pieter A van Doorn
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Matthan W A Caan
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Ivo N van Schaik
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Mario Maas
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Aart J Nederveen
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Marianne de Visser
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
| | - Camiel Verhamme
- From the Departments of Radiology and Nuclear Medicine (J.O., S.D.R., M.P.E., M.W.A.C., M.M., A.J.N.), Neurology (F.E., I.N.v.S., M.d.V., C.V.), and Biomedical Engineering and Physics (G.J.S., M.W.A.C.), Amsterdam UMC, University of Amsterdam; Departments of Radiology (J.J.S.) and Neurology (P.A.v.D.), Erasmus Medical Center, Rotterdam; and Departments of Radiology (M.F.) and Neurology (H.S.G.), University Medical Center Utrecht, the Netherlands
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Corazza G, Le Corroller T, Grapperon AM, Salort-Campana E, Verschueren A, Attarian S, Delmont E. Comparison of MRI and motor evoked potential with triple stimulation technique for the detection of brachial plexus abnormalities in multifocal motor neuropathy. Muscle Nerve 2019; 61:325-329. [PMID: 31792993 DOI: 10.1002/mus.26773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Conduction blocks (CB) are the diagnostic hallmark of multifocal motor neuropathy (MMN). Conventional nerve conduction studies cannot detect CB above Erb's point. Our purpose was to compare the performance of the motor evoked potential with triple stimulation technique (MEP-TST) and MRI in the detection of abnormalities of the brachial plexus. METHODS Examinations were performed on 26 patients with MMN (11 definite, 6 probable, 9 possible), of whom 7 had no CB. RESULTS MEP-TST detected proximal CB in 19/26 patients. Plexus MRI showed T2 hyperintensity in 18/26 patients, with nerve enlargement in 14/18. A combination of both techniques increased the detection rate of brachial plexus abnormalities to 96% of patients (25/26). CONCLUSIONS MEP-TST and MRI have high sensitivities for detecting brachial plexus abnormalities. A combination of the two techniques increases the detection rate of supportive criteria for the diagnosis of MMN.
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Affiliation(s)
- Giovanni Corazza
- Referral Centre for Neuromuscular Diseases and ALS, Hôpital La Timone, Marseille, France
| | - Thomas Le Corroller
- Department of Radiology, Institute for Locomotion, Hôpital Sainte-Marguerite, Marseille, France
| | - Aude-Marie Grapperon
- Referral Centre for Neuromuscular Diseases and ALS, Hôpital La Timone, Marseille, France
| | | | - Annie Verschueren
- Referral Centre for Neuromuscular Diseases and ALS, Hôpital La Timone, Marseille, France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS, Hôpital La Timone, Marseille, France
| | - Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS, Hôpital La Timone, Marseille, France.,Aix-Marseille University, Timone Neuroscience Institute, UMR CNRS 7289, Marseille, France
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Martín-Aguilar L, Pascual-Goñi E, Querol L. Autoantibodies in immune-mediated inflammatory neuropathies. Med Clin (Barc) 2019; 153:360-367. [PMID: 31443948 DOI: 10.1016/j.medcli.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Inflammatory neuropathies are a rare and heterogeneous group of diseases of the nervous system characterized by the dysfunction and damage of different structures of the peripheral nerves. This group includes Guillain-Barré syndrome, chronic demyelinating inflammatory polyradiculoneuropathy, multifocal motor neuropathy or neuropathies associated with monoclonal gammopathy. The aetiology of these diseases is unknown, but B cells and autoantibodies play a key role in their pathogenesis. Autoantibodies against peripheral nerve molecules such as gangliosides, proteins of the Ranvier node or myelin-associated glycoprotein have been described, allowing the identification of subgroups of patients with specific clinical phenotypes. For all these reasons, these antibodies are useful in clinical practice. This review focuses on the diagnostic and therapeutic relevance of autoantibodies in inflammatory neuropathies.
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Affiliation(s)
- Lorena Martín-Aguilar
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Elba Pascual-Goñi
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Luis Querol
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
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Sommer C, Geber C, Young P, Forst R, Birklein F, Schoser B. Polyneuropathies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:83-90. [PMID: 29478436 DOI: 10.3238/arztebl.2018.083] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 06/29/2017] [Accepted: 11/15/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Polyneuropathies (peripheral neuropathies) are the most common type of disorder of the peripheral nervous system in adults, and specifically in the elderly, with an estimated prevalence of 5-8%, depending on age. The options for treatment depend on the cause, which should therefore be identified as precisely as possible by an appropriate diagnostic evaluation. METHODS This review is based on the current guidelines and on large-scale cohort studies and randomized, controlled trials published from 2000 to 2017, with an emphasis on non-hereditary types of polyneuropathy, that were retrieved by a selective search in PubMed. RESULTS Diabetes is the most common cause of polyneuropathy in Europe and North America. Alcohol-associated polyneuropathy has a prevalence of 22-66% among persons with chronic alcoholism. Because of the increasing prevalence of malignant disease and the use of new chemotherapeutic drugs, chemotherapy-induced neuropathies (CIN) have gained in clinical importance; their prevalence is often stated to be 30-40%, with high variation depending on the drug(s) and treatment regimen used. Polyneuropathy can also arise from genetic causes or as a consequence of vitamin deficiency or overdose, exposure to toxic substances and drugs, and a variety of immunological processes. About half of all cases of polyneu - ropathy are associated with pain. Neuropathic pain can be treated symptomatically with medication. Exercise, physiotherapy, and ergotherapy can also be beneficial, depending on the patient's symptoms and functional deficits. CONCLUSION A timely diagnosis of the cause of polyneuropathy is a prerequisite for the initiation of appropriate specific treatment. Patients with severe neuropathy of unidentified cause should be referred to a specialized center for a thorough diagnostic evaluation.
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Affiliation(s)
- Claudia Sommer
- Department of Neurology, University Hospital Würzburg; DRK Pain Center Mainz; Department of Sleep Medicine and Neuromuscular Disorders, Münster University; University Orthopedic Clinic Erlangen; Department of Neurology, University Hospital Mainz; Friedrich-Baur Institute, Department of Neurology, Ludwig-Maximilians-Universität Munich
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111
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Goedee HS, Herraets IJT, Visser LH, Franssen H, van Asseldonk JTH, van der Pol WL, van den Berg LH. Nerve ultrasound can identify treatment-responsive chronic neuropathies without electrodiagnostic features of demyelination. Muscle Nerve 2019; 60:415-419. [PMID: 31294858 PMCID: PMC6771613 DOI: 10.1002/mus.26629] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
Introduction We present a case series of six treatment‐naive patients with clinical phenotypes compatible with chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy without electrodiagnostic features of demyelination but with abnormal peripheral ultrasound findings who responded to treatment. Methods All six patients underwent a complete set of ancillary investigations, including extensive nerve conduction studies. We also performed standardized nerve ultrasound of median nerves and brachial plexus as part of a larger effort to evaluate diagnostic value of sonography. Results Nerve conduction studies did not show conduction block or other signs of demyelination in any of the six patients. Sonographic nerve enlargement was present in all patients and was most prominent in proximal segments of the median nerve and brachial plexus. Treatment with intravenous immunoglobulin resulted in objective clinical improvement. Discussion Our study provides evidence that nerve ultrasound represents a useful complementary diagnostic tool for the identification of treatment‐responsive inflammatory neuropathies.
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Affiliation(s)
- H Stephan Goedee
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid J T Herraets
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Hessel Franssen
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Thies H van Asseldonk
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - W Ludo van der Pol
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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112
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Herraets IJT, Bakers JNE, van Eijk RPA, Goedee HS, van der Pol WL, van den Berg LH. Human immune globulin 10% with recombinant human hyaluronidase in multifocal motor neuropathy. J Neurol 2019; 266:2734-2742. [PMID: 31325017 PMCID: PMC6803588 DOI: 10.1007/s00415-019-09475-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/12/2019] [Accepted: 07/13/2019] [Indexed: 11/26/2022]
Abstract
Objective The primary aim was to determine the safety of treatment with human immune globulin 10% with recombinant human hyaluronidase (fSCIg) compared to intravenous immunoglobulin (IVIg) in a prospective open-label study in patients with multifocal motor neuropathy (MMN). Methods Our study consisted of two phases: the IVIg phase (visits 1–3; 12 weeks), in which patients remained on IVIg treatment, and the fSCIg phase (visits 4–7; 36 weeks), in which patients received fSCIg treatment. After visit 3, IVIg was switched to an equivalent dose and frequency of fSCIg. Outcome measures were safety, muscle strength, disability and treatment satisfaction. Results Eighteen patients were enrolled in this study. Switching to fSCIg reduced the number of systemic adverse events (IVIg 11.6 vs. fSCIg 5.0 adverse events/per person-year, p < 0.02), and increased the number of local reactions at the injection site (IVIg 0 vs. fSCIg 3.3 local reactions/per person-year, p < 0.01). Overall, no significant differences in muscle strength and disability between fSCIg and IVIg were found. Treatment with fSCIg was perceived as optimal treatment option by 8 of the 17 patients (47.1%) and they continued with fSCIg after study closure because of improved independence and flexibility to administer treatment. Conclusion Treatment with fSCIg can be considered a safe alternative for patients with MMN on IVIg treatment. fSCIg could be a favorable option in patients who prefer self-treatment and more independency, and in patients who experience systemic adverse events on IVIg or have difficult intravenous access. Electronic supplementary material The online version of this article (10.1007/s00415-019-09475-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid J T Herraets
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jaap N E Bakers
- Department of Rehabilitation, Brain Center Rudolf Magnus, UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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113
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Li Y, Niu J, Liu T, Guan Y, Wu S, Ding Q, Cui L, Liu M. Motor conduction block and conduction velocity in Lewis-Sumner syndrome and multifocal motor neuropathy. J Clin Neurosci 2019; 67:10-13. [PMID: 31272830 DOI: 10.1016/j.jocn.2019.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/31/2019] [Accepted: 06/21/2019] [Indexed: 11/29/2022]
Abstract
Motor conduction blocks (CBs) and decreased motor nerve conduction velocity (MCV) are both demyelination electrophysiological characteristics. Though CBs are both common in Lewis-Sumner syndrome (LSS) and multifocal motor neuropathy (MMN), they are two distinct disease groups, so their MCV and CBs electrophysiological characteristics may be different. In this paper, we aimed to discuss the relationship between CBs and MCV in Lewis-Sumner syndrome (LSS) and multifocal motor neuropathy (MMN). Sixteen patients with LSS and 11 with MMN were retrospectively collected. Motor nerve conduction studies were performed on bilateral median and ulnar nerves. 16/23 segments with CBs in MMN, and 50/53 segments with CBs in LSS had decreased conduction velocities respectively. There was significant difference in MCV between these two groups (MMN 53.1 ± 12.5 m/s; LSS 34.3 ± 17.1 m/s, mean ± SD, P < 0.05) as well as significant difference in MCV for segment with or without CBs between MMN and LSS patients (P < 0.05). Patients with LSS were prone to be found MCV decrease in segments of motor CB than patients with MMN (P = 0.017). Forty one segments in LSS patients and 6 segments in MMN had MCV ≤ 38 m/s (P < 0.05). There exist two relationships between CB and MCV no matter in LSS or MMN. The characteristics of MCV and CB can be used to distinguish these two disease groups.
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Affiliation(s)
- Yi Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Tanxin Liu
- Department of Medical English, Peking University Health Science Center, Beijing 100191, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shuang Wu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Qingyun Ding
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China; Neuroscience Center, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.
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114
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Kim SW, Kim EH, Lee J, Choi YC, Kim SM, Shin HY. Risk of osteoporosis in patients with chronic inflammatory neuropathy- a population-based cohort study. Sci Rep 2019; 9:9131. [PMID: 31235735 PMCID: PMC6591220 DOI: 10.1038/s41598-019-45591-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
The risk of osteoporosis in patients with chronic inflammatory neuropathy (CIN) has not been evaluated in detail. We conducted a population-based case-control study nested in a retrospective cohort to analyze osteoporosis risk among patients with CIN using a nationwide database. Patients with CIN based on the Korean Classification of Disease diagnostic code were included and were matched to controls. A Cox proportional hazards regression model was used to evaluate the effect of CIN on osteoporosis. After propensity score matching, 585 CIN patients and 585 controls were selected. Patients with CIN had an increased osteoporosis risk (hazard ratio [HR] = 2.293, 95% confidence interval [CI] 1.460-3.601) compared with controls. The osteoporosis risk was higher among male patients with CIN than among male controls (HR = 5.404, 95% CI 2.252-12.969), while there were no significant differences among women. Among the CIN patients, the average daily dose of corticosteroids was higher in those who developed osteoporosis (19.6 mg [10.8-49.3]) than those who did not (16.2 mg [7.2-29.1], p = 0.001). The osteoporosis risk among CIN patients is higher than among controls. High risk of osteoporosis in male patients may indicate that osteoporosis in CIN patients results from the disease itself or related treatments.
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Affiliation(s)
- Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Hwa Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.
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Al‐Zuhairy A, Jakobsen J, Andersen H, Sindrup SH, Markvardsen LK. Randomized trial of facilitated subcutaneous immunoglobulin in multifocal motor neuropathy. Eur J Neurol 2019; 26:1289-e82. [DOI: 10.1111/ene.13978] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/23/2019] [Indexed: 12/14/2022]
Affiliation(s)
- A. Al‐Zuhairy
- Department of Neurology Copenhagen University Hospital (Rigshospitalet) Copenhagen Denmark
| | - J. Jakobsen
- Department of Neurology Copenhagen University Hospital (Rigshospitalet) Copenhagen Denmark
| | - H. Andersen
- Department of Neurology Aarhus University Hospital Aarhus Denmark
| | - S. H. Sindrup
- Department of Neurology Odense University Hospital Odense Denmark
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Ultrasound in Multifocal Motor Neuropathy: Clinical and Electrophysiological Correlations. J Clin Neuromuscul Dis 2019; 20:165-172. [PMID: 31135619 DOI: 10.1097/cnd.0000000000000250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Multifocal motor neuropathy (MMN) is a treatable autoimmune polyneuropathy, which may prove challenging diagnostically in the setting of absent conduction blocks or advanced axonal loss. Relatively few studies have examined the role of ultrasound (US) in MMN. METHODS Retrospective, cross-sectional study of patients with MMN who underwent peripheral nerve US. Charts were reviewed to extract clinical, sonographic, and electrophysiological data. RESULTS Eleven patients with MMN underwent US between 2013 and 2015; of these 11 patients, 7 had ≥3 abnormal nerve segments, and 6 had ≥5 sites of increased cross-sectional area (CSA). There was moderate correlation between the degree of amplitude drop observed in the median and ulnar motor nerves, and CSA. Significant correlation between CSA and limb strength was only observed for the median nerve. CONCLUSIONS Peripheral nerve US shows promise as a diagnostic tool in MMN and may be helpful to distinguish MMN from motor neuron disease.
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Kronlage M, Knop KC, Schwarz D, Godel T, Heiland S, Bendszus M, Bäumer P. Amyotrophic Lateral Sclerosis versus Multifocal Motor Neuropathy: Utility of MR Neurography. Radiology 2019; 292:149-156. [PMID: 31063079 DOI: 10.1148/radiol.2019182538] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Differential diagnosis between amyotrophic lateral sclerosis (ALS) and multifocal motor neuropathy (MMN) relies on clinical examination and electrophysiological criteria. Peripheral nerve imaging might assist this differential diagnosis. Purpose To assess diagnostic accuracy of MR neurography in the differential diagnosis of ALS and MMN. Materials and Methods This prospective study was conducted between December 2015 and April 2017. Study participants with ALS or MMN underwent MR neurography of the lumbosacral plexus, midthigh, proximal calf, and midupper arm of the clinically more affected side using high-resolution T2-weighted sequences. Matched healthy study participants who underwent MR neurography served as a control group. Two blinded readers independently rated fascicular lesions and muscle denervation signs on a five-point scale and made an image-only diagnosis, which was compared with the clinical diagnosis to assess diagnostic accuracy (reported for ALS vs non-ALS and MMN vs non-MMN). The Kruskal-Wallis test was used to compare readers' scoring results. Results Twenty-two participants with ALS (12 men and 10 women; mean age ± standard deviation, 62.3 years ± 9.0), eight participants with MMN (seven men and one woman; mean age, 57.6 years ± 18.6), and 15 healthy participants (seven men and eight women; mean age, 59.1 years ± 10.9) were enrolled in this study. Nerves of participants with ALS either appeared normal or showed T2-weighted hyperintensities without fascicular enlargement (reader 1, 22 of 22 participants; reader 2, 21 of 22 participants). In contrast, nerves in MMN were characterized by fascicular swellings (reader 1, six of eight participants; reader 2, seven of eight participants). Muscle denervation signs were more prominent in ALS than in MMN. Inter-rater reliability for blinded diagnosis was κ of 0.82. By consensus, the sensitivity to diagnose ALS (vs MMN and healthy control participants) was 19 of 22 (86% [95% confidence interval {CI}: 67%, 95%]). The corresponding specificity was 23 of 23 (100% [95% CI: 86%, 100%]). The sensitivity to diagnose MMN (vs ALS and healthy control participants) was seven of eight (88% [95% CI: 53%, 99%]). The corresponding specificity was 37 of 37 (100% [95% CI: 91%, 100%]). Conclusion MR neurography is an accurate method for assisting in the differential diagnosis of amyotrophic lateral sclerosis and multifocal motor neuropathy. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Andreisek in this issue.
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Affiliation(s)
- Moritz Kronlage
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Karl Christian Knop
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Daniel Schwarz
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Tim Godel
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Sabine Heiland
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Martin Bendszus
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
| | - Philipp Bäumer
- From the Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany (M.K., D.S., T.G., S.H., M.B., P.B.); Neurologie Neuer Wall, Hamburg, Germany (K.C.K.); Department of Radiology, German Cancer Research Center, Heidelberg, Germany (P.B.); and dia.log, Altoetting Center for Radiology, Altoetting, Germany (P.B.)
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119
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Goedee HS, van der Pol WL, Hendrikse J, van den Berg LH. Nerve ultrasound and magnetic resonance imaging in the diagnosis of neuropathy. Curr Opin Neurol 2019; 31:526-533. [PMID: 30153189 DOI: 10.1097/wco.0000000000000607] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the most relevant developments in the fields of nerve ultrasound and MRI in the diagnosis of treatable inflammatory neuropathies over the last 18 months. RECENT FINDINGS MRI and nerve ultrasound can accurately identify potentially treatable neuropathies and thereby help to improve diagnosis. Advanced MRI techniques also show potential to dissect pathophysiology. The apparent mismatch between nerve function and morphology is not surprising and reflects different dimensions of the disease process in neuropathies. SUMMARY MRI and nerve ultrasound have become useful tools in the diagnosis of inflammatory neuropathies. VIDEO ABSTRACT.
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Affiliation(s)
- H Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery
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120
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Garg N, Park SB, Howells J, Vucic S, Yiannikas C, Mathey EK, Nguyen T, Noto Y, Barnett MH, Krishnan AV, Spies J, Bostock H, Pollard JD, Kiernan MC. Conduction block in immune-mediated neuropathy: paranodopathy versus axonopathy. Eur J Neurol 2019; 26:1121-1129. [PMID: 30882969 DOI: 10.1111/ene.13953] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Conduction block is a pathognomonic feature of immune-mediated neuropathies. The aim of this study was to advance understanding of pathophysiology and conduction block in chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). METHODS A multimodal approach was used, incorporating clinical phenotyping, neurophysiology, immunohistochemistry and structural assessments. RESULTS Of 49 CIDP and 14 MMN patients, 25% and 79% had median nerve forearm block, respectively. Clinical scores were similar in CIDP patients with and without block. CIDP patients with median nerve block demonstrated markedly elevated thresholds and greater threshold changes in threshold electrotonus, whilst those without did not differ from healthy controls in electrotonus parameters. In contrast, MMN patients exhibited marked increases in superexcitability. Nerve size was similar in both CIDP groups at the site of axonal excitability. However, CIDP patients with block demonstrated more frequent paranodal serum binding to teased rat nerve fibres. In keeping with these findings, mathematical modelling of nerve excitability recordings in CIDP patients with block support the role of paranodal dysfunction and enhanced leakage of current between the node and internode. In contrast, changes in MMN probably resulted from a reduction in ion channel density along axons. CONCLUSIONS The underlying pathologies in CIDP and MMN are distinct. Conduction block in CIDP is associated with paranodal dysfunction which may be antibody-mediated in a subset of patients. In contrast, MMN is characterized by channel dysfunction downstream from the site of block.
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Affiliation(s)
- N Garg
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - S B Park
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - J Howells
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - S Vucic
- Departments of Neurology and Neurophysiology, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | - C Yiannikas
- Department of Neurology, Concord and Royal North Shore Hospitals, University of Sydney, Sydney, NSW, Australia
| | - E K Mathey
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - T Nguyen
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Y Noto
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - M H Barnett
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - A V Krishnan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - J Spies
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - H Bostock
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.,Institute of Neurology, University College London, London, UK
| | - J D Pollard
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - M C Kiernan
- Brain and Mind Centre, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Klehmet J, Märschenz S, Ruprecht K, Wunderlich B, Büttner T, Hiemann R, Roggenbuck D, Meisel A. Analysis of anti-ganglioside antibodies by a line immunoassay in patients with chronic-inflammatory demyelinating polyneuropathies (CIDP). Clin Chem Lab Med 2019; 56:919-926. [PMID: 29329103 DOI: 10.1515/cclm-2017-0792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/01/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Unlike for acute immune-mediated neuropathies (IN), anti-ganglioside autoantibody (aGAAb) testing has been recommended for only a minority of chronic IN yet. Thus, we used a multiplex semi-quantitative line immunoassay (LIA) to search for aGAAb in chronic-inflammatory demyelinating polyneuropathy (CIDP) and its clinical variants. METHODS Anti-GAAb to 11 gangliosides and sulfatide (SF) were investigated by LIA in 61 patients with IN (27 typical CIDP, 12 distal-acquired demyelinating polyneuropathy, 6 multifocal-acquired demyelinating sensory/motor polyneuropathy, 10 sensory CIDP, 1 focal CIDP and 5 multifocal-motoric neuropathy), 40 with other neuromuscular disorders (OND) (15 non-immune polyneuropathies, 25 myasthenia gravis), 29 with multiple sclerosis (MS) and 54 healthy controls (HC). RESULTS In contrast to IgG, positive anti-GAAB IgM against at least one ganglioside/SF was found in 17/61 (27.9%) IN compared to 2/40 (5%) in OND, 2/29 MS (6.9%) and 4/54 (7.4%) in HC (p=0.001). There was a statistically higher prevalence of anti-sulfatide (aSF) IgM in IN compared to OND (p=0.008). Further, aGM1 IgM was more prevalent in IN compared to OND and HC (p=0.009) as well as GD1b in IN compared to HC (p<0.04). The prevalence of aGM1 IgM in CIDP was lower compared to in multifocal motor neuropathy (MMN) (12% vs. 60%, p=0.027). Patients showing aSF, aGM1 and aGM2 IgM were younger compared to aGAAb negatives (p<0.05). Patients with aSF IgM positivity presented more frequently typical CIDP and MMN phenotypes (p<0.05, respectively). CONCLUSIONS The aGAAb LIA revealed an elevated frequency of at least one aGAAb IgM in CIDP/MMN patients. Anti-SF, aGM1 and aGM2 IgM were associated with younger age and anti-SF with IN phenotypes.
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Affiliation(s)
- Juliane Klehmet
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany, Phone: +0049 30 450 639807.,Charité - Universitätsmedizin Berlin, Department of Neurology, Berlin, Germany
| | - Stefanie Märschenz
- Charité - Universitätsmedizin Berlin, NeuroCure Clinical Research Center, Berlin, Germany
| | - Klemens Ruprecht
- Charité - Universitätsmedizin Berlin, Department of Neurology, Berlin, Germany
| | - Benjamin Wunderlich
- Charité - Universitätsmedizin Berlin, Department of Neurology, Berlin, Germany
| | | | - Rico Hiemann
- Institute of Biotechnology, Faculty Environment and Natural Scienes, Brandenburg University of Technology, Senftenberg, Germany
| | - Dirk Roggenbuck
- GA Generic Assays GmbH, Dahlewitz/Berlin, Germany.,Institute of Biotechnology, Faculty Environment and Natural Scienes, Brandenburg University of Technology, Senftenberg, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, NeuroCure Clinical Research Center, Berlin, Germany
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Bozovic I, Peric S, Basta I, Kacar A, Nikolic A, Belanovic B, Lavrnic D, Rakocevic-Stojanovic V, Stevic Z. Quality of life in patients with multifocal motor neuropathy from Serbia. J Neurol Sci 2019; 399:151-154. [DOI: 10.1016/j.jns.2019.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/26/2019] [Accepted: 02/19/2019] [Indexed: 11/25/2022]
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Shimizu F, Oishi M, Sawai S, Beppu M, Misawa S, Matsui N, Miyashiro A, Maeda T, Takeshita Y, Nishihara H, Sano Y, Sato R, Kaji R, Kuwabara S, Kanda T. Increased IP-10 production by blood-nerve barrier in multifocal acquired demyelinating sensory and motor neuropathy and multifocal motor neuropathy. J Neurol Neurosurg Psychiatry 2019; 90:444-450. [PMID: 30523038 DOI: 10.1136/jnnp-2018-319270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/06/2018] [Accepted: 11/14/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Dysfunction of the blood-nerve barrier (BNB) plays important roles in chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). The aim of the present study was to identify the candidate cytokines/chemokines that cause the breakdown of the BNB using sera from patients with CIDP and MMN. METHODS We determined the levels of 27 cytokines and chemokines in human peripheral nerve microvascular endothelial cells (PnMECs) after exposure to sera obtained from patients with CIDP variants (typical CIDP and multifocal acquired demyelinating sensory and motor neuropathy [MADSAM]), MMN and amyotrophic lateral sclerosis (ALS), and healthy controls (HC), using a multiplexed fluorescent bead-based immunoassay system. RESULTS The induced protein (IP)10 level in the cells in both the MADSAM and MMN groups was markedly increased in comparison with the typical CIDP, ALS and HC groups. The other cytokines, including granulocyte colony-stimulating factor,vascular endothelial growth factor (VEGF) and interleukin-7, were also significantly upregulated in the MADSAM group. The increase of IP-10 produced by PnMECs was correlated with the presence of conduction block in both the MADSAM and MMN groups. CONCLUSION The autocrine secretion of IP-10 induced by patient sera in PnMECs was markedly upregulated in both the MADSAM and MMN groups. The overproduction of IP-10 by PnMECs leads to the focal breakdown of the BNB and may help to mediate the transfer of pathogenic T cells across the BNB, thereby resulting in the appearance of conduction block in electrophysiological studies of patients with MADSAM and MMN.
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Affiliation(s)
- Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Mariko Oishi
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Setsu Sawai
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Minako Beppu
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoko Matsui
- Department of Clinical Neuroscience, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Ai Miyashiro
- Department of Clinical Neuroscience, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Toshihiko Maeda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yukio Takeshita
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hideaki Nishihara
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yasuteru Sano
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Ryota Sato
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Ryuji Kaji
- Department of Clinical Neuroscience, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
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Nishijima H, Onodera K, Sato N, Ueno T, Hikichi H, Haga R, Arai A, Suzuki C, Nunomura JI, Baba M, Tomiyama M. Subacute Sensory Ataxic Neuronopathy With Thymoma Presenting Marked Improvement After Steroid Therapy. Front Neurol 2019; 10:268. [PMID: 30949123 PMCID: PMC6435522 DOI: 10.3389/fneur.2019.00268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/27/2019] [Indexed: 12/03/2022] Open
Abstract
Subacute sensory ataxic neuronopathy is a well-known form of paraneoplastic syndrome. Most sensory neuronopathies are associated with small cell lung cancer and anti-Hu antibodies, and usually show only slight improvement with immunotherapy. To date, there have been few reports of neuropathy associated with thymoma and no treatment strategy has been established for thymoma-related neuropathy. Here, we provide the first report of a case of sensory ataxic neuronopathy with thymoma that showed marked improvement after steroid therapy, even though preceding intravenous immunoglobulin treatments and tumor resection were less effective. A 57-year-old Japanese man was referred to our hospital with a 6-week history of distal paresthesia in his four limbs and an unsteady gait. He presented with left-dominant ataxia in his four limbs due to reduced sensation in his extremities. He also complained of constipation, difficulty urinating, and erectile dysfunction. Upon investigation, including electrodiagnostic studies, the patient was diagnosed as having sensory ataxic neuronopathy with invasive thymoma. A first round of intravenous immunoglobulin therapy, a following thymectomy, and a second round of intravenous immunoglobulin therapy after the surgery were not effective in treating his neurological symptoms. Subsequently, oral steroid therapy was started, which brought about a remarkable improvement; 6 weeks after the beginning of the steroid therapy, his neurological symptoms were resolved, except for slight distal paresthesia in his feet. Although rarely reported, thymoma can underlie sensory neuronopathy, and the response of thymoma-associated sensory neuronopathy to immunotherapy might be better than that of anti-Hu antibody-related neuropathies. Even if the first immunotherapy is not effective in treating neuropathy with thymoma, further immunomodulatory treatment should be tried after treating the tumor.
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Affiliation(s)
- Haruo Nishijima
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Ken Onodera
- Department of Thoracic Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobuyuki Sato
- Department of Thoracic Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Hiroki Hikichi
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Rie Haga
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Chieko Suzuki
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Jin-Ichi Nunomura
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masayuki Baba
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
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Vacchiano V, Di Stasi V, Donadio V, Sturiale C, Liguori R. Clinical Reasoning: A 58-year-old man with distal hand weakness. Neurology 2019; 92:e1395-e1400. [DOI: 10.1212/wnl.0000000000007140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Intravenous immunoglobulins in patients with clinically suspected chronic immune-mediated neuropathy. J Neurol Sci 2019; 397:141-145. [DOI: 10.1016/j.jns.2018.12.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/28/2018] [Accepted: 12/31/2018] [Indexed: 02/07/2023]
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127
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Telleman JA, Herraets IJT, Goedee HS, Verhamme C, Nikolakopoulos S, van Asseldonk JTH, van der Pol WL, van den Berg LH, Visser LH. Nerve ultrasound: A reproducible diagnostic tool in peripheral neuropathy. Neurology 2019; 92:e443-e450. [PMID: 30593519 DOI: 10.1212/wnl.0000000000006856] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 10/01/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To determine interobserver variability of nerve ultrasound in peripheral neuropathy in a prospective, systematic, multicenter study. METHODS We enrolled 20 patients with an acquired chronic demyelinating or axonal polyneuropathy and 10 healthy controls in 3 different centers. All participants underwent an extensive nerve ultrasound protocol, including cross-sectional area measurements of median, ulnar, fibular, tibial, and sural nerves, and brachial plexus. Real-time image acquisition was performed blind by a local and a visiting investigator (reference). Five patients were investigated using different types of sonographic devices. Intraclass correlation coefficients were calculated, and a random-effects model was fitted to identify factors with significant effect on interobserver variability. RESULTS Systematic differences between measurements made by different investigators were small (mean difference 0.11 mm2 [95% confidence interval 0.00-0.23 mm2]). Intraclass correlation coefficients were generally higher in arm nerves (0.48-0.96) than leg nerves (0.46-0.61). The hospital site and sonographic device did not contribute significantly to interobserver variability in the random-effects model. CONCLUSIONS Interobserver variability of nerve ultrasound in peripheral neuropathy is generally limited, especially in arm nerves. Different devices and a multicenter setting have no effect on interobserver variability. Therefore, nerve ultrasound is a reproducible tool for diagnostics in routine clinical practice and (multicenter) research.
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Affiliation(s)
- Johan A Telleman
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Ingrid J T Herraets
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - H Stephan Goedee
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Camiel Verhamme
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Stavros Nikolakopoulos
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Jan-Thies H van Asseldonk
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - W Ludo van der Pol
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands
| | - Leo H Visser
- From the Department of Neurology and Clinical Neurophysiology (J.A.T., I.J.T.H., J.-T.H.v.A., L.H.V.), Elisabeth-Tweesteden Hospital, Tilburg; Department of Neurology and Neurosurgery (J.A.T., I.J.T.H., H.S.G., W.L.v.d.P., L.H.v.d.B.), Brain Center Rudolf Magnus, UMC Utrecht; Department of Neurology and Clinical Neurophysiology (C.V.), Academic Medical Center, Amsterdam; and Department of Biostatistics (S.N.), Julius Center for Health Sciences and Primary Care, UMC Utrecht, the Netherlands.
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Rajabally YA, Bergh P, Fowle A, Leger J, Nobile‐Orazio E, Uncini A, Doorn P. Compliance with international guidelines for chronic inflammatory neuropathies. Eur J Neurol 2019; 26:557-558. [DOI: 10.1111/ene.13873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Y. A. Rajabally
- School of Life and Health Sciences Aston Brain Centre Aston University Birmingham UK
| | - P. Bergh
- Centre Neuromusculaire Cliniques Universitaires St Luc Université Catholique de Louvain Brussels Belgium
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Bowley MP, Chad DA. Clinical neurophysiology of demyelinating polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:241-268. [DOI: 10.1016/b978-0-444-64142-7.00052-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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130
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Higgoda R, Perera D, Thirumavalavan K. Multifocal motor neuropathy presenting as a post-infectious complication of dengue: a CASE report. BMC Infect Dis 2018; 18:415. [PMID: 30134860 PMCID: PMC6103970 DOI: 10.1186/s12879-018-3334-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 08/15/2018] [Indexed: 11/16/2022] Open
Abstract
Background Dengue infection is an endemic illness in the tropics and it is associated with a wide variety of post infectious complications. With the increasing prevalence of dengue infection in endemic regions, post-infectious neurological complications following dengue infection are now been reported more frequently. We report a patient who developed multifocal motor neuropathy (MMN) with conduction blocks following dengue infection during the immediate post-infectious period. MMN is a rare neurological disorder with an autoimmune etiology and to best of our knowledge this is the first reported case of MMN occurring following dengue infection as a post dengue neurological complication. Case presentation A 20 year old Sri Lankan male who was treated for serologically confirmed dengue infection presented to us with 1 month history of bilateral hand weakness which has started 5 days after the dengue infection (5 days after the discharge). On examination he had asymmetrical motor weakness of the hands and to a lesser degree in feet. There was no sensory impairment. Nerve conduction studies confirmed MMN with conduction blocks. He was started on intravenous immunoglobulin therapy for which he showed a good response. Conclusion The authors report the first case of MMN complicating dengue fever in a previously healthy male from Sri Lanka. Thus it should be borne in mind that although rare, MMN can occur as a post-infectious complication of dengue fever.
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Šinkūnaitė L, Burbaud P, Soulages A, Vergnet S, Duval F, Solé G, Tang HMA, Le Masson G, Mathis S. Focal neurogenic muscle hypertrophy and fasciculations in multifocal motor neuropathy. Muscle Nerve 2018; 58:E36-E39. [DOI: 10.1002/mus.26185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - Fanny Duval
- Department of Neurology; Nerve-Muscle Unit
- Centre de référence des pathologies neuromusculaires
| | - Guilhem Solé
- Department of Neurology; Nerve-Muscle Unit
- Centre de référence des pathologies neuromusculaires
| | | | - Gwendal Le Masson
- Department of Neurology; Nerve-Muscle Unit
- Centre de référence des pathologies neuromusculaires
- Department of Neurology, Movement Disorders Unit; ALS Center, CHU Bordeaux (groupe hospitalier Pellegrin), place Amélie Raba-Léon; Bordeaux France
| | - Stéphane Mathis
- Department of Neurology; Nerve-Muscle Unit
- Centre de référence des pathologies neuromusculaires
- Department of Neurology, Movement Disorders Unit; ALS Center, CHU Bordeaux (groupe hospitalier Pellegrin), place Amélie Raba-Léon; Bordeaux France
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132
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Rosier C, Graveline N, Lacour A, Antoine JC, Camdessanché JP. Intravenous immunoglobulin for treatment of chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy in France: are daily practices in accordance with guidelines? Eur J Neurol 2018; 26:575-580. [PMID: 30326184 DOI: 10.1111/ene.13841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) are rare autoimmune diseases. Guidelines were published in 2010 for their diagnosis and treatment. In France, intravenous immunoglobulins (IVIGs) are mainly used for the first-line treatment. The burden of healthcare costs is often underlined but rarely studied. The aim of this survey was to compare to guidelines, the daily practice of French neurologists with IVIGs for CIDP and MMN treatment. METHODS This was a retrospective observational study consisting of an online questionnaire performed between March and May 2014. A total of 49 questionnaires were included, a quarter of which were from neurologists working in neuromuscular reference centers (NRCs). RESULTS A total of 182 patient case reports were studied. Patients were referred to an NRC for initial diagnosis in approximately 30% of cases in CIDP and 50% of cases in MMN. The initial management of IVIG (frequency, dose and duration) was not different between NRCs and non-NRCs. Guidelines were followed and neurologists were relatively at ease in diagnosing and treating patients. CONCLUSIONS This was the first national study to describe the implementation of the European Federation of Neurological Sciences/Peripheral Nerve Society guidelines in the daily management of IVIGs in patients with MMN and CIDP in France. Efforts are needed to improve long-term tailored treatment and home treatment to reduce economic costs.
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Affiliation(s)
- C Rosier
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne
| | - N Graveline
- Laboratoire Français du Fractionnement et des Biotechnologies Biomédicaments, Courtaboeuf
| | - A Lacour
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne.,Centre Référent Maladies Neuromusculaires Rares Provence Alpes Côte d'Azur Rhône-Alpes Réunion, Saint-Etienne, France
| | - J-C Antoine
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne.,Centre Référent Maladies Neuromusculaires Rares Provence Alpes Côte d'Azur Rhône-Alpes Réunion, Saint-Etienne, France
| | - J-P Camdessanché
- Department of Neurology, University Hospital of Saint-Etienne, Saint-Etienne.,Centre Référent Maladies Neuromusculaires Rares Provence Alpes Côte d'Azur Rhône-Alpes Réunion, Saint-Etienne, France
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Noto YI, Garg N, Li T, Timmins HC, Park SB, Shibuya K, Shahrizaila N, Huynh W, Matamala JM, Dharmadasa T, Yiannikas C, Vucic S, Kiernan MC. Comparison of cross-sectional areas and distal-proximal nerve ratios in amyotrophic lateral sclerosis. Muscle Nerve 2018; 58:777-783. [PMID: 30019401 DOI: 10.1002/mus.26301] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 07/04/2018] [Accepted: 07/08/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study explored potential diagnostic markers of nerve ultrasound in differentiating amyotrophic lateral sclerosis (ALS) from mimic disorders. METHODS Ultrasound of the median, ulnar, and tibial nerves was conducted in 53 patients with ALS, 32 patients with ALS-mimic disorders, and 30 controls. Nerve cross-sectional area (CSA) and distal-proximal ratios were calculated. RESULTS The median nerve CSA in the upper arm was decreased (7.9 ± 1.3 mm2 vs. 9.0 ± 1.4 mm2 , P < 0.05), and the median nerve wrist-upper arm ratio was increased in ALS patients compared with controls (1.3 ± 0.4 vs. 1.1 ± 0.2; P < 0.01). In differentiating ALS from mimic presentations, assessment of median nerve CSA in the upper arm and comparison of a median and ulnar nerve CSA distal-proximal ratio provide diagnostic potential. DISCUSSION Assessment of nerve CSA combined with calculation of nerve CSA distal-proximal ratio provides a useful marker to aid in the diagnosis of ALS. Muscle Nerve 58:777-783, 2018.
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Affiliation(s)
- Yu-Ichi Noto
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Nidhi Garg
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Tiffany Li
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Hannah C Timmins
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Susanna B Park
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Kazumoto Shibuya
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Nortina Shahrizaila
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - William Huynh
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - José M Matamala
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Thanuja Dharmadasa
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Con Yiannikas
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
| | - Steve Vucic
- Western Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, Sydney Medical School, University of Sydney, 94 Mallett Street, Camperdown, Sydney, New South Wales, 2040, Australia.,Royal Prince Alfred Hospital Sydney, Sydney, New South Wales, Australia
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Abstract
Since the discovery of an acute monophasic paralysis, later coined Guillain-Barré syndrome, almost 100 years ago, and the discovery of chronic, steroid-responsive polyneuropathy 50 years ago, the spectrum of immune-mediated polyneuropathies has broadened, with various subtypes continuing to be identified, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy (MMN). In general, these disorders are speculated to be caused by autoimmunity to proteins located at the node of Ranvier or components of myelin of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. Owing to the numerous subtypes of the immune-mediated neuropathies, making the right diagnosis in daily clinical practice is complicated. Moreover, treating these disorders, particularly their chronic variants, such as CIDP and MMN, poses a challenge. In general, management of these disorders includes immunotherapies, such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the emergence of more disease-specific immunotherapies should broaden the therapeutic options for these disabling diseases.
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136
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Löscher WN, Oberreiter EM, Erdler M, Quasthoff S, Culea V, Berek K, Embacher N, Grinzinger S, Hess I, Höger FS, Horlings CGC, Huemer M, Jecel J, Kleindienst W, Laich E, Müller P, Oel D, Örtl W, Lenzenweger E, Rath J, Stadler K, Stieglbauer K, Thaler-Wolf C, Wanschitz J, Zimprich F, Cetin H, Topakian R. Multifocal motor neuropathy in Austria: a nationwide survey of clinical features and response to treatment. J Neurol 2018; 265:2834-2840. [PMID: 30259176 PMCID: PMC6244652 DOI: 10.1007/s00415-018-9071-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Multifocal motor neuropathy (MMN) is a rare neuropathy and detailed descriptions of larger patient cohorts are scarce. The objective of this study was to evaluate epidemiological, clinical, and laboratory features of MMN patients and their response to treatment in Austria and to compare these data with those from the literature. METHODS Anonymized demographic and clinical data about MMN patients until 31.12.2017 were collected from registered Austrian neurologists. Exploratory statistics on clinical and laboratory features as well as treatment regimens and responses were performed. RESULTS 57 Patients with MMN were identified, resulting in a prevalence of 0.65/100.000. Mean age of onset was 44.1 ± 13.1 years, the diagnostic delay 5.5 ± 8.4 years. In 77% of patients, symptom onset was in the upper limbs, and in 92%, it occurred in distal muscles. Proximal onset was never observed in the lower limbs. At the final follow-up, the majority of patients had atrophy (88%) in affected regions. Definite motor conduction blocks (CB) were found in 54 patients. Anti-GM1-IgM antibodies were present in 43%. Treatment with intravenous immunoglobulins improved muscle strength and INCAT score initially, but at last follow-up, both scores deteriorated to values before treatment. DISCUSSION The findings of the present study corroborate the previous findings in MMN. Onset typically occurs in the upper limbs and mostly distal, CBs are found in the majority of cases, while anti-GM1-IgM antibodies are detected in only approximately 40%. Our study underlines that the initial good response to treatment fades over time.
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Affiliation(s)
- Wolfgang N Löscher
- Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
| | - Eva-Maria Oberreiter
- Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | | | - Stefan Quasthoff
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Valeriu Culea
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Klaus Berek
- Department of Neurology, BKH Kufstein, Kufstein, Austria
| | - Norbert Embacher
- Department of Neurology, St. Pölten University, Sankt Pölten, Austria
| | - Susanne Grinzinger
- Department of Neurology, Paracelsus University of Salzburg, Salzburg, Austria
| | | | | | - Corinne G C Horlings
- Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Michael Huemer
- Department of Neurology, Kardinal Schwarzenberg Hospital, Schwarzach im Pongau, Austria
| | - Julia Jecel
- 2. Department of Neurology, KH Hietzing, Vienna, Austria
| | | | - Eva Laich
- Department of Neurology, LKH Steyr, Steyr, Austria
| | - Petra Müller
- Department of Neurology, KH Wels-Grieskirchen, Wels, Austria
| | - Dierk Oel
- Department of Neurology, KH Wels-Grieskirchen, Wels, Austria
| | - Wolfgang Örtl
- Department of Neurology, Johannes Kepler-University Linz, Linz, Austria
| | - Eva Lenzenweger
- Department of Neurology 2, Johannes Kepler-University Linz, Linz, Austria
| | - Jakob Rath
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Klaus Stadler
- Department of Neurology, KH Wels-Grieskirchen, Wels, Austria
| | | | | | - Julia Wanschitz
- Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Raffi Topakian
- Department of Neurology, KH Wels-Grieskirchen, Wels, Austria
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Graf J, Jansen L, Ingwersen J, Ringelstein M, Harmel J, Rybak J, Kolbe R, Rhöse L, Gemerzki L, Lee JI, Klistorner A, Guthoff R, Hartung HP, Aktas O, Albrecht P. Multifocal visual evoked potentials in chronic inflammatory demyelinating polyneuropathy. Ann Clin Transl Neurol 2018; 5:952-961. [PMID: 30128319 PMCID: PMC6093840 DOI: 10.1002/acn3.593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/08/2018] [Accepted: 05/17/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Studies using conventional full‐field visual evoked potentials (ffVEP) have reported subtle abnormalities in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). We hypothesize that these abnormalities can be detected in the majority of CIDP patients using enhanced methods. Methods We performed a cross‐sectional noninterventional study comparing 18 CIDP patients and 18 matched healthy controls using multifocal VEP (mfVEP) as a technique with enhanced sensitivity to detect conduction abnormalities across the spectrum of optic nerve fibers. Patients with confounding diseases (ophthalmologic, diabetes mellitus) were excluded. Results The mean amplitude and latency, as well as the low‐contrast visual acuity, did not differ between CIDP patients and controls. Subanalyses revealed latency differences concerning the superior sector of the visual field. Severity markers of CIDP (ODSS, motor nerve conduction velocity) were associated with mfVEP latency delay. Interpretation We could not adduce evidence for clinically or diagnostically relevant visual pathway involvement in CIDP. The latency differences identified were very subtle and restricted to the superior visual field which cannot be readily explained biologically, anatomically, or pathologically. In summary, we conclude that our study revealed no relevant differences in mfVEP parameters between CIDP patients and controls.
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Affiliation(s)
- Jonas Graf
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Lea Jansen
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Jens Ingwersen
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Marius Ringelstein
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Jens Harmel
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Jana Rybak
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Robert Kolbe
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Laura Rhöse
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Lena Gemerzki
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - John-Ih Lee
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Alexander Klistorner
- Save Sight Institute Sydney Medical School University of Sydney Sydney New South Wales Australia
| | - Rainer Guthoff
- Department of Ophthalmology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Hans-Peter Hartung
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Orhan Aktas
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
| | - Philipp Albrecht
- Department of Neurology University Hospital Medical Faculty Heinrich-Heine-University Düsseldorf Germany
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Klupp E, Cervantes B, Sollmann N, Treibel F, Weidlich D, Baum T, Rummeny EJ, Zimmer C, Kirschke JS, Karampinos DC. Improved Brachial Plexus Visualization Using an Adiabatic iMSDE-Prepared STIR 3D TSE. Clin Neuroradiol 2018; 29:631-638. [DOI: 10.1007/s00062-018-0706-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
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140
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Nakashima D, Noto YI, Tsuji Y, Fujii C, Tanaka A, Ohara T, Nakagawa M, Mizuno T. A case of acute-onset multifocal motor neuropathy after Mycoplasma infection. Muscle Nerve 2018; 58:E18-E20. [PMID: 29742802 DOI: 10.1002/mus.26165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/18/2018] [Accepted: 05/05/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Daisuke Nakashima
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yu-Ichi Noto
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukiko Tsuji
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Chihiro Fujii
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akihiro Tanaka
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masanori Nakagawa
- North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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141
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Safety of Intravenous Immunoglobulin (Tegeline®), Administered at Home in Patients with Autoimmune Disease: Results of a French Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8147251. [PMID: 29736397 PMCID: PMC5875056 DOI: 10.1155/2018/8147251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/31/2018] [Indexed: 11/17/2022]
Abstract
The efficacy of intravenous immunoglobulins (IVIg) in patients with autoimmune diseases (AID) has been known for several decades. Majority of these patients received IVIg in hospital. A retrospective study was conducted in 22 centers in France to evaluate the feasibility of the administration of Tegeline, an IVIg from LFB Biomedicaments, and assess its safety at home, compared to in hospital, in patients with AID. The included patients were at least 18 years old, suffering from AID, and treated with at least 1 cycle of Tegeline at home after receiving 3 consecutive cycles of hospital-based treatment with Tegeline at a dose between 1 and 2 g/kg/cycle. Forty-six patients with AID, in most cases immune-mediated neuropathies, received a total of 138 cycles of Tegeline in hospital and then 323 at home. Forty-five drug-related adverse events occurred in 17 patients who received their cycles at home compared to 24 adverse events in hospital in 15 patients. Serious adverse events occurred in 3 patients during home treatment, but they were not life-threatening and did not lead to discontinuation of Tegeline. Forty-five patients continued their treatment with Tegeline at home or in hospital; 39 (84.8%) were still receiving home treatment at the end of the study. In conclusion, the study demonstrates the good safety profile of Tegeline administered at home at high doses in patients with AID who are eligible for home administration of Tegeline.
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142
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Kuwabara S, Misawa S, Mori M, Iwai Y, Ochi K, Suzuki H, Nodera H, Tamaoka A, Iijima M, Toda T, Yoshikawa H, Kanda T, Sakamoto K, Kusunoki S, Sobue G, Kaji R. Intravenous immunoglobulin for maintenance treatment of multifocal motor neuropathy: A multi-center, open-label, 52-week phase 3 trial. J Peripher Nerv Syst 2018; 23:115-119. [PMID: 29635876 PMCID: PMC6033107 DOI: 10.1111/jns.12268] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022]
Abstract
Intravenous immunoglobulin (IVIg) therapy is currently the only established treatment in patients with multifocal motor neuropathy (MMN), and many patients have an IVIg-dependent fluctuation. We aimed to investigate the efficacy and safety of every 3 week IVIg (1.0 g/kg) for 52 weeks. This study was an open-label phase 3 clinical trial, enrolling 13 MMN patients. After an induction IVIg therapy (0.4 g/kg/d for 5 consecutive days), maintenance dose (1.0 g/kg) was given every 3 weeks for 52 weeks. The major outcome measures were the Medical Research Council (MRC) sum score and hand-grip strength at week 52. This trial is registered with ClinicalTrials.gov, number NCT01827072. At week 52, 11 of the 13 patients completed the study, and all 11 had a sustained improvement. The mean (SD) MRC sum score was 85.6 (8.7) at the baseline, and 90.6 (12.8) at week 52. The mean grip strength was 39.2 (30.0) kPa at the baseline and 45.2 (32.8) kPa at week 52. Two patients dropped out because of adverse event (dysphagia) and decision of an investigator, respectively. Three patients developed coronary spasm, dysphagia, or inguinal herniation, reported as the serious adverse events, but considered not related with the study drug. The other adverse effects were mild and resolved by the end of the study period. Our results show that maintenance treatment with 1.0 g/kg IVIg every 3 week is safe and efficacious for MMN patients up to 52 weeks. Further studies are required to investigate optimal dose and duration of maintenance IVIg for MMN.
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Affiliation(s)
- Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Sonoko Misawa
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Masahiro Mori
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Yuta Iwai
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Kazuhide Ochi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Hidekazu Suzuki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Hiroyuki Nodera
- Department of Neurology, Tokushima University School of Medicine, Tokushima, Japan
| | - Akira Tamaoka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University School of Medicine, Aichi, Japan
| | - Tatsushi Toda
- Division of Neurology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroo Yoshikawa
- Division of Neurology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Kanda
- Department of Neurology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | | | - Susumu Kusunoki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University School of Medicine, Aichi, Japan.,Research Division of Dementia and Neurodegenerative Disease, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryuji Kaji
- Department of Neurology, Tokushima University School of Medicine, Tokushima, Japan
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143
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Vestibulo-cochlear function in inflammatory neuropathies. Clin Neurophysiol 2018; 129:863-873. [DOI: 10.1016/j.clinph.2017.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/03/2017] [Accepted: 11/19/2017] [Indexed: 11/20/2022]
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144
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Landais A, Fanhan R. A case of multifocal-motor-neuropathy-like disease with conduction blocks under infliximab with spontaneous progressive recovery. Presse Med 2018; 47:298-301. [DOI: 10.1016/j.lpm.2017.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 08/05/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022] Open
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145
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Abstract
Concurrent association of idiopathic thrombocytopenic purpura (ITP) and peripheral neuropathy is a rare condition. There are only few case reports published concerning peripheral neuropathy with ITP. One of the etiopathogenetic mechanisms proposed is intraneural hemorrhage, but the pathogenesis is not fully understood. Autoimmune nature with common antibodies to the platelets and the nerve´s myelin sheath should also be considered. Here we describe a 47-year-old woman, with a family history of autoimmune diseases. She was diagnosed 2 years ago with ITP and later developed a chronic combined inflammatory demyelinating polyneuropathy. Treatment with high-dose steroids was initiated with a poor response. The patient showed a clear improvement in platelet count and in the peripheral neuropathy symptoms when treatment with intravenous immunoglobulin was administered. Common etiologic mechanism of the two diseases should be considered, both, because of the simultaneous time of development and a similar response to intravenous immunoglobulin treatment.
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Affiliation(s)
- Valeria Katchan
- Departamento de Medicina Interna, Hospital La Paz, Madrid, Spain.,Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Paula David
- Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, 52621, Tel-Hashomer, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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146
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Sommer C, Geber C, Young P, Forst R, Birklein F, Schoser B. Polyneuropathies. DEUTSCHES ÄRZTEBLATT INTERNATIONAL 2018. [DOI: 10.3238/arztebl.2018.0083] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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147
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Le Masson G, Solé G, Desnuelle C, Delmont E, Gauthier‐Darnis M, Puget S, Durand‐Zaleski I. Home versus hospital immunoglobulin treatment for autoimmune neuropathies: A cost minimization analysis. Brain Behav 2018; 8:e00923. [PMID: 29484273 PMCID: PMC5822576 DOI: 10.1002/brb3.923] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/14/2017] [Accepted: 12/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Prior clinical trials have suggested that home-based Ig treatment in multifocal motor neuropathy (MMN) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and its variant Lewis-Sumner syndrome (LSS) is safe and effective and is less costly than hospital-administered intravenous immunoglobulin (IVIg). Methods A French prospective, dual-center, cost minimization analysis was carried out to evaluate IVIg administration (5% concentrated) at home versus in hospital with regard to costs, patients' autonomy, and patients' quality of life. The primary endpoint was the overall cost of treatment, and we adopted the perspective of the payer (French Social Health Insurance). Results Twenty-four patients aged 52.3 (12.2) years were analyzed: nine patients with MMN, eight with CIDP, and seven with LSS. IVIg (g/kg) dosage was 1.51 ± 0.43 in hospital and 1.52 ± 0.4 at home. Nine-month total costs per patient extrapolated to 1 year of treatment were €48,189 ± 26,105 versus €91,798 ± 51,125 in the home and hospital groups, respectively (p < .0001). The most frequently reported factors for choosing home treatment were the good tolerance and absence of side effects of IVIg administration, as well as a good understanding of the advantages and drawbacks of home treatment (75% of respondents). The mRankin scores before and after switch to home treatment were 1.61 ± 0.72 and 1.36 ± 0.76, respectively (p = .027). Discussion The switch from hospital-based to home-based IVIg treatment for patients with immune neuropathy represents potentially significant savings in the management of the disease.
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Affiliation(s)
- Gwendal Le Masson
- Neuromuscular Diseases DepartmentUniversity Hospital PellegrinBordeauxFrance
| | - Guilhem Solé
- Neuromuscular Diseases DepartmentUniversity Hospital PellegrinBordeauxFrance
| | - Claude Desnuelle
- Neuromuscular Diseases DepartmentUniversity Hospital L'ArchetNiceFrance
| | - Emilien Delmont
- Neuromuscular Diseases DepartmentUniversity Hospital La TimoneMarseilleFrance
| | | | - Sophie Puget
- International Scientific Affairs UnitLFB BiomedicamentsLes UlisFrance
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Martinez-Thompson JM, Snyder MR, Ettore M, McKeon A, Pittock SJ, Roforth MM, Mandrekar J, Mauermann ML, Taylor BV, Dyck PJB, Windebank AJ, Klein CJ. Composite ganglioside autoantibodies and immune treatment response in MMN and MADSAM. Muscle Nerve 2018; 57:1000-1005. [DOI: 10.1002/mus.26051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 12/14/2022]
Affiliation(s)
| | - Melissa R. Snyder
- Department of Laboratory Medicine and Pathology; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
| | - Michael Ettore
- Department of Laboratory Medicine and Pathology; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
| | - Andrew McKeon
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
- Division of Autoimmune Neurology; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
| | - Sean J. Pittock
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
- Division of Autoimmune Neurology; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
| | - Matthew M. Roforth
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
| | - Jay Mandrekar
- Division of Biostatistics; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
| | | | - Bruce V. Taylor
- Menzies Institute for Medical Research; University of Tasmania; Tasmania Australia
| | - P. James B. Dyck
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
| | - Anthony J. Windebank
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
| | - Christopher J. Klein
- Department of Neurology; 200 First Street Southwest Rochester Minnesota 55905 USA
- Department of Laboratory Medicine and Pathology; Mayo Clinic and Mayo Foundation; Rochester Minnesota USA
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149
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Telleman JA, Grimm A, Goedee S, Visser LH, Zaidman CM. Nerve ultrasound in polyneuropathies. Muscle Nerve 2018; 57:716-728. [PMID: 29205398 DOI: 10.1002/mus.26029] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 11/30/2017] [Accepted: 11/30/2017] [Indexed: 12/13/2022]
Abstract
Ultrasound can be used to visualize pathology in the peripheral nerves of patients with polyneuropathy. Nerve enlargement is the most frequent pathology, but other abnormalities, including abnormal nerve echogenicity and vascularity, are also encountered. This monograph presents an overview of the role of nerve ultrasound in the evaluation and management of both inherited and acquired polyneuropathies. A description of the sonographic techniques and common abnormalities is provided, followed by a presentation of typical findings in different neuropathies. Scoring systems for characterizing the presence and pattern of nerve abnormalities as they relate to different polyneuropathies are presented. Muscle Nerve 57: 716-728, 2018.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Alexander Grimm
- Department Neurology, University Hospital Tuebingen, Germany
| | - Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Craig M Zaidman
- Departments of Neurology and Pediatrics, Washington University St. Louis, Missouri, 660 South Euclid, Box 8111, St. Louis, Missouri, 63110-1093, USA
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150
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Khadilkar SV, Yadav RS, Patel BA. Multifocal Motor Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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