251
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Tsui H, Chan Y, Tang L, Winer S, Cheung RK, Paltser G, Selvanantham T, Elford AR, Ellis JR, Becker DJ, Ohashi PS, Dosch HM. Targeting of pancreatic glia in type 1 diabetes. Diabetes 2008; 57:918-28. [PMID: 18198358 DOI: 10.2337/db07-0226] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Type 1 diabetes reflects autoimmune destruction of beta-cells and peri-islet Schwann cells (pSCs), but the mechanisms of pSC death and the T-cell epitopes involved remain unclear. RESEARCH DESIGN AND METHODS Primary pSC cultures were generated and used as targets in cytotoxic T-lymphocyte (CTL) assays in NOD mice. Cognate interaction between pSC and CD8(+) T-cells was assessed by transgenic restoration of beta2-microglobulin (beta2m) to pSC in NOD.beta2m(-/-) congenics. I-A(g7) and K(d) epitopes in the pSC antigen glial fibrillary acidic protein (GFAP) were identified by peptide mapping or algorithms, respectively, and the latter tested by immunotherapy. RESULTS pSC cultures did not express major histocompatibility complex (MHC) class II and were lysed by ex vivo CTLs from diabetic NOD mice. In vivo, restoration of MHC class I in GFAP-beta2m transgenics significantly accelerated adoptively transferred diabetes. Target epitopes in the pSC autoantigen GFAP were mapped to residues 79-87 and 253-261 for K(d) and 96-110, 116-130, and 216-230 for I-A(g7). These peptides were recognized spontaneously in NOD spleens as early as 2.5 weeks of age, with proliferative responses peaking around weaning and detectable lifelong. Several were also recognized by T-cells from new-onset type 1 diabetic patients. NOD mouse immunotherapy at 8 weeks with the CD8(+) T-cell epitope, GFAP 79-87 but not 253-261, significantly inhibited type 1 diabetes and was associated with reduced gamma-interferon production to whole protein GFAP. CONCLUSIONS Collectively, these findings elucidate a role for pSC-specific CD8(+) T-cells in islet inflammation and type 1 diabetes pathogenesis, further supporting neuronal involvement in beta-cell demise.
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Affiliation(s)
- Hubert Tsui
- The Hospital for Sick Children, 555 University Ave., 10th Floor Elm Wing, Rm. 10126, Toronto, Ontario, M5G 1X8, Canada
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252
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Nguyen D, Dyck PJ, Daube JR. Intraneural perineurioma of the radial nerve visualized by 3.0 Tesla MRI. Muscle Nerve 2008; 36:715-20. [PMID: 17471567 DOI: 10.1002/mus.20795] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A progressive radial neuropathy of unknown etiology despite 1.5T magnetic resonance imaging (MRI) and surgical exploration was identified as an intraneural perineurioma by a localized Tinel's sign, an enlarged radial nerve at the spiral groove by 3.0T MRI, and a fascicular biopsy. The distinction between the initial diagnoses of inflammatory, demyelinating polyneuropathy and perineurioma was made by immunohistochemistry and electron microscopy. A slowly progressing, localized mononeuropathy should include perineurioma in the differential diagnosis.
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Affiliation(s)
- Doris Nguyen
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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253
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Autoimmune peripheral neuropathies. Clin Immunol 2008. [DOI: 10.1016/b978-0-323-04404-2.10066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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254
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Smyth S, Menkes DL. Coincident membranous glomerulonephritis and chronic inflammatory demyelinating polyradiculoneuropathy: Questioning the autoimmunity hypothesis. Muscle Nerve 2008; 37:130-5. [PMID: 17614320 DOI: 10.1002/mus.20841] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and membranous glomerulonephritis (MGN) are both autoimmune disorders that are rarely observed concurrently. We describe a patient who developed MGN nearly 20 years after the onset of CIDP, resulting in a secondary progression of his neuropathy. He responded dramatically to a novel regimen of plasma exchange and methotrexate. We propose a mechanism other than autoimmunity for the coincidence of these disorders and discuss the theoretical superiority of the treatment regimen that he received.
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Affiliation(s)
- Shane Smyth
- Department of Neurology, University of Tennessee Health Sciences Center at Memphis, 855 Monroe Avenue, Link 415, Memphis, Tennessee 38163, USA
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255
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Kale HA, Sklar E. Magnetic resonance imaging findings in chronic inflammatory demyelinating polyneuropathy with intracranial findings and enhancing, thickened cranial and spinal nerves. ACTA ACUST UNITED AC 2007; 51 Spec No.:B21-4. [PMID: 17875147 DOI: 10.1111/j.1440-1673.2007.01793.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy is a rare autoimmune disorder characterized by chronically progressive or relapsing symmetric sensorimotor involvement. We describe the imaging findings in our patient. Magnetic resonance imaging showed presence of an intracranial white matter lesion and enhancing, thickened cranial and spinal nerves. This disorder has been described very infrequently in the radiology literature.
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Affiliation(s)
- H A Kale
- Department of Radiology, Jackson Memorial Hospital, University of Miami, Miami, Florida 33136, USA.
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256
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Chiò A, Cocito D, Bottacchi E, Buffa C, Leone M, Plano F, Mutani R, Calvo A. Idiopathic chronic inflammatory demyelinating polyneuropathy: an epidemiological study in Italy. J Neurol Neurosurg Psychiatry 2007; 78:1349-53. [PMID: 17494979 PMCID: PMC2095630 DOI: 10.1136/jnnp.2007.114868] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Revised: 03/15/2007] [Accepted: 04/09/2007] [Indexed: 11/03/2022]
Abstract
AIM The clinical and epidemiological characteristics of chronic inflammatory demyelinating polyneuropathy (CIDP) in an Italian population were assessed. SUBJECTS AND METHODS All subjects with a diagnosis of demyelinating neuropathy after 1990 in Piemonte and Valle d'Aosta (4,334,225 inhabitants) were considered. The diagnosis of CIDP was based on the research criteria of the American Academy of Neurology. 165 of 294 patients met the diagnostic criteria. RESULTS The crude prevalence rate was 3.58/100,000 population (95% CI 3.02 to 4.20). At the prevalence day, 76 (49.0%) cases had definite, 67 (43.2%) probable and 12 (7.7%) possible CIDP; disability was mild in 105 (67.7%) cases, moderate in 32 (20.6%) and severe in 18 (11.6%). The course was remitting-relapsing in 40 cases (25.8%), chronic progressive in 96 (61.9%) and monophasic in 19 (12.3%). Considering the 95 patients whose disorder presented in the period 1995-2001, the mean annual crude incidence rate was 0.36/100,000 population (95% CI 0.29 to 0.44), with a male to female ratio of 2.3:1. 14 cases were affected by diabetes mellitus. In multivariate analysis, factors related to severe disability at the prevalence day were: age >60 years; failure of immunomodulating therapies at the time of diagnosis; worse disability at nadir; and chronic course. CONCLUSION Incidence and prevalence rates of CIDP in Italy were higher than those observed in most previous studies. At the prevalence day, more than 80% of cases had a mild or moderate disability, indicating either a good response to immunomodulating therapy or a tendency of CIDP to have a mild course in most cases.
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Affiliation(s)
- A Chiò
- Department of Neuroscience, University of Torino, Italy.
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257
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Shemin D, Briggs D, Greenan M. Complications of therapeutic plasma exchange: A prospective study of 1,727 procedures. J Clin Apher 2007; 22:270-6. [PMID: 17722046 DOI: 10.1002/jca.20143] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The type and number of complications was prospectively examined in 1,727 successive TPE treatments in 174 patients over 66 months at a single center. Most treatments were prescribed for thrombotic thrombocytopenic purpura (TTP; 42%), recurrent focal segmental glomerulosclerosis (FSGS; 22%), or myasthenia gravis (MG; 13%). About 57% of treatments used albumin-saline as the replacement solution and 43% used fresh-frozen plasma (FFP), almost all for TTP. There were 889 complications; 614 treatments (36% of the total) involved a complication. Most complications were minor; there were no deaths. Three treatments (0.2%) were discontinued due to a complication, and 2 (0.1%) required transfer to a higher acuity hospital bed. The most common complications were fever (7.7% of treatments), urticaria (7.4%), and hypocalcemic symptoms (7.3%). 42% of treatments with FFP involved a complication, compared to 30% of treatments using albumin-saline (P < 0.0001). The most common complications with FFP were urticaria (17%) and pruritus (13%); these occurred more commonly than in patients receiving albumin-saline. The most common complications with albumin-saline replacement were hypocalcemic symptoms (8.2%) and mild hypotension (8.1%). Mild and severe hypotension was significantly (P < 0.0001) more common with albumin-saline replacement. TPE is associated with a number of minor complications. Complications occur more commonly with FFP replacement compared to albumin-saline replacement. Pruritus and urticaria occur more commonly with FFP, and hypotension occurs more commonly with albumin-saline.
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Affiliation(s)
- Douglas Shemin
- Division of Renal Diseases, Rhode Island Hospital, Department of Medicine, Brown University School of Medicine, Providence, Rhode Island 02903, USA.
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258
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Gladstone DE, Golightly MG, Brannagan TH. High dose cyclophosphamide preferentially targets naïve T (CD45/CD4/RA+) cells in CIDP and MS patients. J Neuroimmunol 2007; 190:121-6. [PMID: 17854912 DOI: 10.1016/j.jneuroim.2007.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 07/06/2007] [Accepted: 07/06/2007] [Indexed: 11/25/2022]
Abstract
INTRODUCTION T cells occupy a central role in MS and CIDP pathogenesis. High dose cyclophosphamide's in-vivo cytotoxic-effect on circulating memory and naïve T cells is unknown. METHOD Three MS and five CIDP patients received cyclophosphamide (200 mg/kg) for refractory disease. Before and after chemotherapy administration, peripheral blood T-cell subsets were determined. Patients underwent serial neurologic evaluations quarterly. RESULTS Cyclophosphamide uniformly decreased clinical disease activity. Compared to memory T cells, naïve T cells were preferentially eradicated. DISCUSSION Cyclophosphamide effectiveness in autoimmune illness may result from Naïve T-cell destruction, as this compartment may be the source of autoreactive lymphocytes.
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Affiliation(s)
- Douglas E Gladstone
- Hematology Oncology Associates of Western Suffolk, 24 East Main Street, Bay Shore, NY 11706, USA.
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259
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Meyer zu Hörste G, Hu W, Hartung HP, Lehmann HC, Kieseier BC. The immunocompetence of Schwann cells. Muscle Nerve 2007; 37:3-13. [PMID: 17823955 DOI: 10.1002/mus.20893] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Schwann cells are the myelinating glial cells of the peripheral nervous system that support and ensheath axons with myelin to enable rapid saltatory signal propagation in the axon. Immunocompetence, however, has only recently been recognized as an important feature of Schwann cells. An autoimmune response against components of the peripheral nervous system triggers disabling inflammatory neuropathies in patients and corresponding animal models. The immune system participates in nerve damage and disease manifestation even in non-inflammatory hereditary neuropathies. A growing body of evidence suggests that Schwann cells may modulate local immune responses by recognizing and presenting antigens and may also influence and terminate nerve inflammation by secreting cytokines. This review summarizes current knowledge on the interaction of Schwann cells with the immune system, which is involved in diseases of the peripheral nervous system.
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Affiliation(s)
- Gerd Meyer zu Hörste
- Department of Neurology, Heinrich-Heine-University, Moorenstrasse 5, 40225 Düsseldorf, Germany
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260
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Uzenot D, Azulay JP, Pouget J. Initier le traitement de la PRNC. Rev Neurol (Paris) 2007. [DOI: 10.1016/s0035-3787(07)92163-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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261
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Ducray F, Costedoat-Chalumeau N, Bouhour F, Rousset H, Vial C. Polyradiculonévrite chronique et sarcoïdose : association fortuite. Rev Neurol (Paris) 2007. [DOI: 10.1016/s0035-3787(07)92165-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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262
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Mehndiratta MM, Singh AC. Plasmapheresis for chronic inflammatory demyelinating polyradiculoneuropathy. Curr Allergy Asthma Rep 2007; 7:274-9. [PMID: 17547849 DOI: 10.1007/s11882-007-0041-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated disorder characterized by progressive or relapsing symmetrical motor or sensory symptoms and signs in more than one limb, developing over at least 2 months. It may cause prolonged periods of disability and even death. Evidence from trials suggests that plasma exchange provides significant short-term benefit in about two thirds of patients with chronic inflammatory demyelinating polyradiculoneuropathy. This review evaluates the role of plasmapheresis in CIDP.
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Affiliation(s)
- Man Mohan Mehndiratta
- Professor of Neurology, #502, Academic Block, Department of Neurology, G.B. Pant Hospital, New Delhi 110002, India.
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263
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Rossi D, Franceschetti S, Cerri M, Conconi A, Lunghi M, Capello D, Cantello R, Gaidano G. Hairy cell leukaemia complicated by anti-MAG paraproteinemic demyelinating neuropathy: resolution of neurological syndrome after cladribrine treatment. Leuk Res 2007; 31:873-6. [PMID: 17007925 DOI: 10.1016/j.leukres.2006.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 08/25/2006] [Accepted: 08/26/2006] [Indexed: 11/21/2022]
Abstract
Hairy cell leukaemia (HCL) occasionally displays a monoclonal gammopathy, yet the association of HCL with paraproteinemic demyelinating neuropathy (PDN) has not been reported. We describe a HCL case complicated by PDN and high titers of monoclonal IgM against myelin associated glycoprotein (MAG). Heavy and light chains of the patient's anti-MAG monoclonal protein were consistent with those expressed by HCL cells. After treatment with cladribrine, remission of HCL strictly paralleled disappearance of the IgM monoclonal protein and of the serum anti-MAG activity, and led to PDN clinical and electrophysiological improvement. Purine analogs may represent a choice in IgM PDN associated with lymphoproliferative disorders.
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Affiliation(s)
- Davide Rossi
- Division of Haematology, Department of Clinical and Experimental Medicine & IRCAD, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.
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264
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Meyer zu Hörste G, Hartung HP, Kieseier BC. From bench to bedside--experimental rationale for immune-specific therapies in the inflamed peripheral nerve. ACTA ACUST UNITED AC 2007; 3:198-211. [PMID: 17410107 DOI: 10.1038/ncpneuro0452] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Accepted: 02/06/2007] [Indexed: 12/28/2022]
Abstract
Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy are autoimmune-mediated inflammatory diseases of the PNS. In recent years, substantial progress has been made towards understanding the immune mechanisms that underlie these conditions, in large part through the study of experimental models. Here, we review the available animal models that partially mimic human Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy, and discuss the wide range of therapeutic approaches that have been successfully established in these models of inflammatory neuropathies. Transfer of this preclinical knowledge to patients has been far less successful, and inflammatory neuropathies are still associated with significant morbidity and mortality. We will summarize successful therapeutic trials in human autoimmune neuropathies to provide a vantage point for the transfer of experimental treatment strategies to clinical practice in immune-mediated diseases of the peripheral nerve.
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265
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Toothaker TB, Brannagan TH. Chronic inflammatory demyelinating polyneuropathies: Current treatment strategies. Curr Neurol Neurosci Rep 2007; 7:63-70. [PMID: 17217856 DOI: 10.1007/s11910-007-0023-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy (CIDP), considered an immune-mediated disease, is likely under-recognized and under-treated due to its heterogeneous presentation and the limitations of clinical, serologic, and electrophysiologic diagnostic criteria. Despite these limitations, early diagnosis and treatment is important in preventing irreversible axonal loss and improving functional recovery. Primary treatment modalities include intravenous immunoglobulin and plasmapheresis, for which there is randomized, double-blind, placebo-controlled evidence. In addition, despite less definitive published evidence of efficacy, corticosteroids are considered standard therapies because of their long history of use. Studies have failed to demonstrate a difference in efficacy among these three treatments; consequently, the choice is usually based on availability and side-effect profile. A number of chemotherapeutic and immunosuppressive agents have also shown to be effective in treating CIDP but significant evidence is lacking; therefore, these agents are primarily used in conjunction with other modalities. Regardless of the treatment choice, long-term therapy is required to maintain a response and prevent relapse.
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Affiliation(s)
- Thomas B Toothaker
- Department of Neurology, Weill Medical College of Cornell University, Peripheral Neuropathy Center, New York, NY 10022, USA
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266
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Lehmann HC, Köhne A, Meyer zu Hörste G, Dehmel T, Kiehl O, Hartung HP, Kastenbauer S, Kieseier BC. Role of Nitric Oxide as Mediator of Nerve Injury in Inflammatory Neuropathies. J Neuropathol Exp Neurol 2007; 66:305-12. [PMID: 17413321 DOI: 10.1097/nen.0b013e3180408daa] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Different lines of evidence suggest that nitric oxide (NO) plays a key role in the pathogenesis of inflammatory neuropathies; however, it is still unclear which structures in the peripheral nerve are the primary targets of NO-mediated nerve injury. To address this issue, we determined the expression of NO metabolites in sural nerve biopsies and in cerebrospinal fluid from patients with inflammatory neuropathies and studied the pathologic effects of NO in an in vitro model of myelinated Schwann cell-neuron cocultures. In cerebrospinal fluid samples, nitrite levels remained unaltered; however, nitrotyrosine, a marker for peroxynitrite formation, could be identified in nerve biopsies from patients with inflammatory neuropathies. In an in vitro model of Schwann cell neuron cocultures, high concentrations of NO induced robust demyelination, which was the result of NO-mediated axonal injury, whereas Schwann cell viability remained unaffected. These findings suggest that in contrast to Schwann cells, sensory neurons are the primary target of NO-mediated cytotoxicity and the loss of myelin is the result of selective damage to axons rather than a direct harmful effect to Schwann cells. Our findings imply that NO contributes to the pathologic changes seen in the inflamed peripheral nervous system, which is characterized by the features of axonal injury and subsequent myelin degradation, previously described as Wallerian-like degeneration.
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Affiliation(s)
- Helmar C Lehmann
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany.
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267
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Münch C, Anagnostou P, Meyer R, Haas J. Rituximab in chronic inflammatory demyelinating polyneuropathy associated with diabetes mellitus. J Neurol Sci 2007; 256:100-2. [PMID: 17382963 DOI: 10.1016/j.jns.2007.02.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 02/16/2007] [Accepted: 02/19/2007] [Indexed: 11/29/2022]
Abstract
The authors report a 57-year-old patient with chronic inflammatory demyelinating polyneuropathy (CIDP) associated with diabetes mellitus (DM) who was treated successfully with rituximab. The B lymphocyte suppression using rituximab was followed 4 weeks later by neurological improvement and a stable disease course of over 10 months. We suggest that rituximab may be a treatment option in CIDP increasingly less responsive to intravenous immunoglobulin, particularly in patients with concurrent DM.
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Affiliation(s)
- Christoph Münch
- Department of Neurology, Jewish Hospital Berlin, Berlin, Germany.
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268
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Gorson KC, Natarajan N, Ropper AH, Weinstein R. Rituximab treatment in patients with IVIg-dependent immune polyneuropathy: a prospective pilot trial. Muscle Nerve 2007; 35:66-9. [PMID: 16967492 DOI: 10.1002/mus.20664] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We studied the effect of rituximab in allowing a reduction in dose of intravenous immune globulin (IVIg) in six patients with IVIg-dependent, relapsing immune polyneuropathy. Rituximab (375 mg/m(2) intravenously each week for 4 weeks) was administered in a prospective, open-label design to two patients with chronic inflammatory demyelinating polyneuropathy (CIDP), two with multifocal motor neuropathy (MMN), one with neuropathy and anti-myelin-associated glycoprotein (MAG) antibody neuropathy, and one with Sjögren syndrome (SS) ataxic neuropathy. The primary endpoint was a reduced cumulative IVIg dosage by at least 25% at 1 year after rituximab therapy compared to the previous year. Secondary endpoints included an improved summed strength score by at least 5 points on the Medical Research Council scale, an increased sensory score by at least 4 points, or an improved Rankin disability score by at least 1 grade. Total IVIg dosage decreased by greater than 25% in one patient with SS neuropathy and one with MMN; the dosage was unchanged in one with CIDP, slightly reduced in the patient with anti-MAG neuropathy, and increased in one with CIDP and another with MMN. There was no improvement in secondary endpoints. No adverse events occurred. In this small prospective study, rituximab did not reduce IVIg requirements in the majority of patients with IVIg-dependent, immune-mediated polyneuropathies.
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Affiliation(s)
- Kenneth C Gorson
- Department of Neurology, Caritas St. Elizabeth's Medical Center, Tufts University School of Medicine, 736 Cambridge Street, Boston, Massachusetts 02135, USA.
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269
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Kieseier BC, Wiendl H, Hartung HP. The inflamed peripheral nervous system: update on immune therapies. Curr Opin Neurol 2007; 19:433-6. [PMID: 16969151 DOI: 10.1097/01.wco.0000245364.51823.3b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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270
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Abstract
PURPOSE OF REVIEW The aim of this review is to describe the local immune circuitry in the peripheral nervous system and its dialogue with systemic immunity under pathological conditions. Specifically, interactions of the immune system with cellular and extracellular components within peripheral nerve and immune functions of tissue-resident endoneurial macrophages and Schwann cells will be discussed. RECENT FINDINGS New insights into the elements involved in the pathogenesis of immune-mediated disorders of the peripheral nervous system provide a better understanding of the complex interplay of these cellular and molecular components in the immunology of the peripheral nervous system. SUMMARY The application of innovative and cutting-edge technologies to the study of immunoinflammatory disorders of the peripheral nervous system provides a better understanding of underlying principles of the organization of the immune network present in the peripheral nerve and its dialogue with the systemic immune system. This may foster the development of specific and highly effective therapies for immune-mediated disorders of the peripheral nerve.
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Affiliation(s)
- Bernd C Kieseier
- Department of Neurology, Heinrich-Heine-University, Düsseldorf, Germany
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271
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Lehmann HC, Hartung HP, Hetzel GR, Kieseier BC. [Plasma exchange as a therapeutic option in neurological disorders]. DER NERVENARZT 2007; 78:166, 168-70, 172-6. [PMID: 17268791 DOI: 10.1007/s00115-006-2229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Plasma exchange is a therapeutic procedure commonly used in various neurological disorders. Here we review its current role as a treatment option in diseases of the central and peripheral nervous system.
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Affiliation(s)
- H C Lehmann
- Neurologische Klinik, Heinrich-Heine-Universität Düsseldorf
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272
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Szczepiorkowski ZM, Bandarenko N, Kim HC, Linenberger ML, Marques MB, Sarode R, Schwartz J, Shaz BH, Weinstein R, Wirk A, Winters JL. Guidelines on the use of therapeutic apheresis in clinical practice—Evidence-based approach from the apheresis applications committee of the American society for apheresis. J Clin Apher 2007; 22:106-75. [PMID: 17394188 DOI: 10.1002/jca.20129] [Citation(s) in RCA: 189] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. This elaborate process had been undertaken every 7 years resulting in three prior publications in 1986, 1993, and 2000 of "The ASFA Special Issues." This article is the integral part of the Fourth ASFA Special Issue. The Fourth ASFA Special Issue is significantly modified in comparison to the previous editions. A new concept of a fact sheet has been introduced. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. A detailed description of the fact sheet is provided. The article consists of 53 fact sheets devoted to each disease entity currently categorized by the ASFA. Categories I, II, and III are defined as previously in the Third Special Issue. However, a few new therapeutic apheresis modalities, not yet approved in the United States or are currently in clinical trials, have been assigned category P (pending) by the ASFA Clinical Categories Subcommittee. The diseases assigned to category IV are discussed in a separate article in this issue.
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Affiliation(s)
- Zbigniew M Szczepiorkowski
- Transfusion Medicine Service, Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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273
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Immune-Mediated Neuropathies. Neurobiol Dis 2007. [DOI: 10.1016/b978-012088592-3/50021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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274
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Köller H, Schroeter M, Feischen H, Hartung HP, Kieseier BC. Subcutaneous self-infusions of immunoglobulins as a potential therapeutic regimen in immune-mediated neuropathies. J Neurol 2006; 253:1505-6. [PMID: 16972122 DOI: 10.1007/s00415-006-0258-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 04/10/2006] [Indexed: 11/30/2022]
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275
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Dellon AL. From there to here: a personal viewpoint after three decades of neuropathy research. Clin Podiatr Med Surg 2006; 23:497-508. [PMID: 16958384 DOI: 10.1016/j.cpm.2006.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Currently there is unprecedented interest in research, writing, and clinical experience related to lower extremity peripheral nerve surgery. Its time is here, now. Application of the concepts for diagnosis and treatment of nerve compression, painful neuroma, and neuropathy has been a direct extension from the upper extremity to the lower extremity. By the end of 2005, there were more than a dozen studies demonstrating that the basic neuropathy causes metabolic changes that render the peripheral nerve susceptible to chronic nerve compressions. My hypothesis continues to assert that surgical decompression of known sites of compression can relieve symptoms of neuropathy that are caused by superimposed nerve compressions.
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276
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Abstract
Increasingly, surgeons are becoming aware of the successful treatment of symptomatic peripheral neuropathy by surgical decompression of peripheral nerves. Armed with the knowledge that patients can have underlying neuropathy with overlying anatomic compressions, surgeons have affected improvement in diabetes-induced neuropathy, neuropathy of unknown etiology, and chemotherapy-induced neuropathy. This article details the most well-known culprits in chemotherapy-induced neuropathy and discusses the putative mechanisms of action, medical management, and surgical data.
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Affiliation(s)
- Gedge D Rosson
- Division of Plastic Surgery, JHOC 8th Floor, McElderry 8152-A, 601 North Caroline Street, Baltimore, MD 21287, USA.
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277
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Celik Y, Turgut N, Turgut B, Pamuk GE, Demir M. Chronic idiopathic demyelinating polyneuropathy (CIDP) associated with Kaposi's sarcoma. J Neurooncol 2006; 79:323-4. [PMID: 16794750 DOI: 10.1007/s11060-006-9150-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Accepted: 03/13/2006] [Indexed: 11/24/2022]
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278
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Kuntzer T. [Treatment options for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)]. Rev Neurol (Paris) 2006; 162:539-43. [PMID: 16585918 DOI: 10.1016/s0035-3787(06)75048-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Limits of treatment in chronic inflammatory demyelinating poly(radiculo)neuropathies (CIDP) patients are better known thanks to recent Cochrane reviews. (1) Randomized controlled trials have only focused on short-term effects, but most patients need long-term therapy, (2) There are three proven effective treatments available (prednisone; intravenous immunoglobulin or IVIg and plasma exchange or PE) which are useful in more than 60 p. 100 of patients, (3) New open studies indicated possible efficacy for mycophenolate, rituximab, etanercept, ciclosporine and interferons, and (4) Whether CIDP variants need specific treatment is still unknown. Many CIDP patients need treatment for years. The fear of side effects during long-term steroid treatment, the high costs of IVIg, the necessity for specialized equipment and the invasive nature of PE, are important factors determining the choice for one of these treatments. In most up-to-date treatment options, patients are initially treated with IVIg at a dosage of 2 g/kg administered for 25 days, clinical improvement can be judged within 10 days. The percentage of patients responding seems to be approximately 70 percent, with a very high chance (approximately 85 percent) that repeated administration of IVIg will be necessary, explaining why most neurologists add an immunosuppressive drug at this stage, but there is no consensus concerning the best drug to be used. Combinations of drugs are most likely to be useful in the next future, using IVIg, prednisone, and a immunosuppressor agent, such as mycophenolate, rituximab, etanercept, or ciclosporine. General measures to rehabilitate patients and to manage symptoms like fatigue and other residual findings are important.
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Affiliation(s)
- T Kuntzer
- Unité Nerf-Muscle, Service de Neurologie, CHU Vaudois, Lausanne, Suisse.
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279
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Affiliation(s)
- J-M Léger
- Centre de Référence des Maladies Neuro-musculaires rares Paris-Est, Hôpital de la Salpêtrière, Paris
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280
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Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy is an autoimmune disease that target myelin sheats of peripheral nerves. Its diagnosis is often difficult to make, and a number of cases are probably not identified because of the clinical heterogeneity. Numerous sets of diagnostic criteria have sought to define CIDP but clinical criteria are generally not detailed. OBJECTIVES To review the main clinical characteristics suggestive of CIDP (that means not compatible with a length-dependent axonal process) and the critical clinical points of the neuropathy which make the differential diagnosis with the main other forms of chronic auto immune neuropathy sometimes difficult. RESULTS The main clinical characteristic are: a symmetric proximal and distal motor weakness predominantly affecting the lower limbs, a diffuse areflexia, a sensory deficit characterized by a preferential involvement of large fibers, an evolution which may be either chronic progressive or recurrent. These aspects raise many questions concerning overlap with other inflammatory neuropathies such as Guillain Barre syndrome, Lewis-Sumner neuropathy, chronic ataxic neuropathy. The distinction of a subgroup of CIDP associated with other diseases such as diabetes or HIV are also controversial. CONCLUSION The growing body of knowledge on the pathogenesis of CIDP and clinical or electrophysiological differentiation of subforms may help to develop more effective therapies for CIDP in the next few years.
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Affiliation(s)
- J P Azulay
- Service de Neurologie, Hôpital de la Timone, Marseille.
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281
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Gorshtein A, Levy Y. Intravenous immunoglobulin in therapy of peripheral neuropathy. Clin Rev Allergy Immunol 2006; 29:271-9. [PMID: 16391402 DOI: 10.1385/criai:29:3:271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Peripheral neuropathy (PN) can be a manifestation of various neurological, infectious, metabolic, autoimmune, rheumatic, and malignant diseases. During the past decade, intravenous immunoglobulin (IVIg) has been increasingly used in the therapy of PN. Compared with other immunomodulatory therapies, IVIg has an excellent safety profile. IVIg is used today as a first-line therapy in the treatment of Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Some small studies and reports of clinical cases presented in this article found benefit from IVIg in treating PN associated with diabetes, paraproteinemia, HIV, multisystem rheumatic diseases, and paraneoplastic PN. No clear recommendations can be made relating the use of IVIg in these conditions. Prospective, randomized trials are required to clarify this issue.
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282
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Vina ER, Fang AJ, Wallace DJ, Weisman MH. Chronic inflammatory demyelinating polyneuropathy in patients with systemic lupus erythematosus: prognosis and outcome. Semin Arthritis Rheum 2006; 35:175-84. [PMID: 16325658 DOI: 10.1016/j.semarthrit.2005.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify clinical characteristics, laboratory features, approaches to management, and predictors of outcome of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients with systemic lupus erythematosus (SLE). METHODS An analysis of 6 adults with the concurrent diagnosis of CIDP and SLE seen at a SLE Clinic from 1994 to 2004 with a review of 13 patients with SLE and CIDP reported in the medical literature from 1950 through 2004. RESULTS Among our 6 patients with SLE and CIDP, 3 (50%) achieved a substantial clinical response to intravenous immunoglobulin (IVIg) and the remainder had a minimal response. The improved patients were more likely to have received treatment earlier (within 1 year of CIDP onset) and to respond faster (<1 to 3 months) than minimally improved patients. They tended to have CIDP features of weakness of all extremities, hyporeflexia of the upper extremities, and slowed nerve conduction velocity of the motor median nerve. Compared with minimal responders, responders had more serious internal organ manifestations and multiple autoantibodies associated with SLE. Review of the literature identified 13 previously reported CIDP patients with SLE. Many had neurological involvement of all extremities, nerve biopsies showing demyelination, and serious SLE internal organ manifestations. Most were treated with steroids, but the 1 treated with IVIg had similar characteristics to our subset of patients who improved with IVIg. CONCLUSIONS CIDP is an uncommon, but not rare, manifestation of SLE. Certain characteristics including early CIDP diagnosis, involvement of all 4 extremities, hyporeflexia of the upper extremities, and slowed motor nerve conduction velocity of the median nerve in addition to SLE involvement of critical internal organs and the presence of multiple antibodies associated with SLE all appear to predict a good response to IVIg.
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Affiliation(s)
- Ernest R Vina
- Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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283
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Hughes RAC, Allen D, Makowska A, Gregson NA. Pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2006; 11:30-46. [PMID: 16519780 DOI: 10.1111/j.1085-9489.2006.00061.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The acute lesions of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consist of endoneurial foci of chemokine and chemokine receptor expression and T cell and macrophage activation. The myelin protein antigens, P2, P0, and PMP22, each induce experimental autoimmune neuritis in rodent models and might be autoantigens in CIDP. The strongest evidence incriminates P0, to which antibodies have been found in 20% of cases. Failure of regulatory T-cell mechanism is thought to underlie persistent or recurrent disease, differentiating CIDP from the acute inflammatory demyelinating polyradiculoneuropathy form of Guillain-Barré syndrome. Corticosteroids, intravenous immunoglobulin and plasma exchange each provide short term benefit but the possible long-term benefits of immunosuppressive drugs have yet to be confirmed in randomised, controlled trials.
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Affiliation(s)
- Richard A C Hughes
- Department of Clinical Neuroscience, King's College London, Guy's Hospital, London, UK.
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284
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De Sousa EA, Brannagan TH. Diagnosis and treatment of chronic inflammatory demyelinating polyneuropathy. Curr Treat Options Neurol 2006; 8:91-103. [PMID: 16464406 DOI: 10.1007/s11940-006-0001-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated acquired polyneuropathy that may lead to disability. CIDP is characterized by an autoimmune attack against peripheral nervous system myelin, by cellular and humoral mechanisms. Early diagnosis and treatment may yield better functional recovery, probably by minimizing secondary axonal loss from a primary demyelinating insult. Intravenous immunoglobulin and plasmapheresis are considered standard-of-care therapy in CIDP, based on randomized, double-blinded, placebo-controlled evidence. Corticosteroids, despite less robust evidence, are also considered standard therapy for CIDP. Other nonstandard therapies may work in refractory patients. These include azathioprine, cyclophosphamide, cyclosporine A, etanercept, interferon-alpha 2a, mycophenolate mofetil, and tacrolimus. Emerging therapies include interferon-beta 1a, rituximab, and high-dose cyclophosphamide without stem-cell rescue. Because most patients will require prolonged therapy, long-term side effects are important considerations.
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Affiliation(s)
- Eduardo Adonias De Sousa
- Department of Neurology, Weill Medical College of Cornell University, 635 Madison Avenue, Suite 400, New York, NY 10022, USA
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285
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Zhang G, Lopez PHH, Sheikh KA. Comparison of different brands of IVIg in an in vitro model of immune neuropathy. J Neuroimmunol 2006; 173:200-3. [PMID: 16413615 DOI: 10.1016/j.jneuroim.2005.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Accepted: 12/02/2005] [Indexed: 11/23/2022]
Abstract
Intravenous immunoglobulin (IVIg) is used for the treatment of a number of autoimmune neurological disorders. Whether different brands of IVIg or different lots of the same brand are comparably efficacious for the treatment of neurological disorders is not clear. To examine this issue we compared the efficacy of different brands and/or lots of IVIg in a cell culture model of immune neuropathy. We report that products examined were equally effective and there was no lot-to-lot variability in our experimental model. These findings support the notion that efficacy of different IVIg products is comparable in a standardized model.
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Affiliation(s)
- Gang Zhang
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N-Wolfe Street, 509 Pathology Bldg., Baltimore, MD 21287, USA
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286
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Abstract
This presentation discusses the immunobiology of the Guillain Barré syndromes (GBS), the world's leading cause of acute autoimmune neuromuscular paralysis. By gaining an understanding of the clinical and pathophysiological pathways operating in GBS, we can hope to develop novel immunotherapies that will improve clinical outcome. Here we focus on GBS mediated by anti-ganglioside antibodies and highlight the correlations between anti-ganglioside antibody patterns and clinical phenotypes, the development of models of GBS, and the application of novel therapies based on inhibition of complement activation.
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Affiliation(s)
- H J Willison
- Division of Clinical Neurosciences, Southern General Hospital, Glasgow, Scotland, UK.
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287
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Fudge E, Carol J, She JX, Dosch M, Atkinson M, Muir A. Chronic inflammatory demyelinating polyradiculoneuropathy in two children with type 1 diabetes mellitus. Pediatr Diabetes 2005; 6:244-8. [PMID: 16390395 DOI: 10.1111/j.1399-543x.2005.00130.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
An association between chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and type 1 diabetes has been described in adults, but not previously in children. Two adolescents with both CIDP and type 1 diabetes are reported here. In order to raise the awareness of CIDP among pediatricians, a description of the clinical and laboratory features, treatment, and prognosis of the condition is provided. A preliminary study was undertaken to determine whether responses to autoantigens in peri-islet Schwann cells and Schwann cells may account for the association between type 1 diabetes and CIDP. Lymphocyte proliferation in response to these autoantigens was abnormal in one of the two patients, but was also abnormal in one control subject.
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Affiliation(s)
- Elizabeth Fudge
- Department of Pediatrics, Medical College of Georgia, Augusta, GA, USA
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288
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Donofrio PD. Chronic inflammatory demyelinating polyradiculoneuropathy: new views and guidelines. J Peripher Nerv Syst 2005; 10:217-9. [PMID: 16221282 DOI: 10.1111/j.1085-9489.2005.10301.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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289
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Abstract
PURPOSE OF THIS REVIEW To conduct a critical review of recent studies on the clinical and therapeutic aspects of multifocal motor neuropathy, and to analyse their implications for patient management. RECENT FINDINGS Recent studies have contributed to defining the specific position of multifocal motor neuropathy within the spectrum of chronic immune-mediated polyneuropathies. One study compared features of this condition with multifocal acquired demyelinating sensory and motor neuropathy, while others have focused on pathological alterations at the site of conduction blocks. A further study described six new cases of multifocal acquired motor neuropathy, which should be considered as a variant of multifocal motor neuropathy. Several Cochrane reviews and review articles have shown evidence of the efficacy of intravenous immunoglobulins in the treatment of multifocal motor neuropathy. The issue of long-term intravenous immunoglobulins in multifocal motor neuropathy, however, has yielded controversial results. Two studies have shown progressive motor deterioration in most patients, correlated with electrophysiological signs indicative of axonal degeneration, while a third study found signs of sustained clinical and electrophysiological improvement after a mean follow up of 7.25 years. SUMMARY Multifocal motor neuropathy is a distinct clinical entity that differs from chronic inflammatory demyelinating polyradiculoneuropathy and multifocal acquired demyelinating sensory and motor neuropathy, although they share some electrophysiological characteristics. Although the aetiology remains unsolved, frequent association with high-titer antibodies against ganglioside GM1, together with an often positive response to intravenous immunoglobulins further support an autoimmune mechanism. New therapeutic strategies are required, however, that focus on the effects and the costs of treatment over long-term follow up.
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Affiliation(s)
- Jean-Marc Léger
- consutation de Pathologie Neuro-Musculaire, Babinski Building, Salpêtrière Hospital, Paris, France.
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290
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Hobson-Webb LD, Donofrio PD. Inflammatory neuropathies: an update on evaluation and treatment. Curr Rheumatol Rep 2005; 7:348-55. [PMID: 16174482 DOI: 10.1007/s11926-005-0019-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Inflammatory neuropathies are a diverse group of illnesses sharing the pathologic characteristic of inflammation surrounding nerve fibers. They may be autoimmune, granulomatous, infectious, paraneoplastic, or paraproteinemic in origin. All can result in significant morbidity and rarely, death. It is critical to correctly diagnose these illnesses, as many respond well to treatment. In this paper, the diagnosis and latest developments in the treatment of the most common inflammatory neuropathies (Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, neurosarcoidosis, anti-myelin-associated glycoprotein neuropathy, Sjögren's syndrome, paraneoplastic neuronopathy, and vasculitic neuropathies) will be discussed.
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Affiliation(s)
- Lisa D Hobson-Webb
- Department of Neurology, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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291
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Abstract
Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating poly-(radiculo)neuropathy (CIDP) are immune-mediated disorders with a variable duration of progression and a range in severity of weakness. Infections can trigger GBS and exacerbate CIDP. Anti-ganglioside antibodies are important, but there is debate on the role of genetic factors in the pathogenesis of these disorders. Randomized controlled trials (RCT) have shown that intravenous immunoglobulin (IVIg) and plasma exchange (PE) are effective in both GBS and CIDP. Most CIDP patients also improve after steroid therapy. Despite current treatment options, many patients have residual deficits or need to be treated for a long period of time. Therefore, new treatment trials are highly indicated. This review focuses on the current and possible new treatment options that could be guided by recent results from laboratory experiments.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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292
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Hughes RAC, Swan AV, van Doorn PA. Cytotoxic drugs and interferons for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2004:CD003280. [PMID: 15495046 DOI: 10.1002/14651858.cd003280.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy is a disease causing progressive or relapsing and remitting weakness and numbness. It is probably due to an autoimmune inflammatory process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. OBJECTIVES We aimed to review systematically the evidence from randomised trials concerning cytotoxic drugs and interferons for chronic inflammatory demyelinating polyradiculoneuropathy. SEARCH STRATEGY We searched the Cochrane Neuromuscular Disease Group trials register (searched May 2004), MEDLINE (searched January 1977 to May 2004), EMBASE (January 1980 to May 2004), CINAHL (searched January 1982 to December 2001) and LILACS (searched January 1982 to December 2001). We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials. SELECTION CRITERIA We sought randomised and quasi-randomised trials of all immunosuppressive agents such as azathioprine, cyclophosphamide, methotrexate, cyclosporin A, mycophenolate mofetil, and rituximab and all immunomodulatory agents such as alpha interferon and beta interferon in participants fulfilling standard diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy. DATA COLLECTION AND ANALYSIS Two of us independently selected the trials which met our criteria, judged their methodological quality and extracted the data onto specially designed forms. We wanted to measure the change in disability after one year as our primary outcome measure. MAIN RESULTS We found one parallel group open trial of azathioprine for nine months involving 27 participants and another of interferon beta involving 10 participants in a double blind crossover trial with each treatment period lasting 12 weeks. Neither trial provided our primary outcome measure and neither showed a significant beneficial effect on any of the outcome measures selected by the authors or ourselves in the protocol for this review. REVIEWERS' CONCLUSIONS The evidence is inadequate to decide whether azathioprine, interferon beta or any other immunosuppressive drug or interferon is beneficial in chronic inflammatory demyelinating polyradiculoneuropathy.
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Affiliation(s)
- R A C Hughes
- Department of Clinical Neurosciences, Guy's, King's and St Thomas' School of Medicine, Hodgkin Building, Guy's Hospital, London, UK, SE1 1UL.
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