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Uncini A, Cavallaro T, Fabrizi GM, Manganelli F, Vallat JM. Conduction slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies: Electrophysiology meets pathology. J Peripher Nerv Syst 2024; 29:135-160. [PMID: 38600691 DOI: 10.1111/jns.12625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/02/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
Nerve conduction studies are usually the first diagnostic step in peripheral nerve disorders and their results are the basis for planning further investigations. However, there are some commonplaces in the interpretation of electrodiagnostic findings in peripheral neuropathies that, although useful in the everyday practice, may be misleading: (1) conduction block and abnormal temporal dispersion are distinctive features of acquired demyelinating disorders; (2) hereditary neuropathies are characterized by uniform slowing of conduction velocity; (3) axonal neuropathies are simply diagnosed by reduced amplitude of motor and sensory nerve action potentials with normal or slightly slow conduction velocity. In this review, we reappraise the occurrence of uniform and non-uniform conduction velocity slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies attempting, with a translational approach, a correlation between electrophysiological and pathological features as derived from sensory nerve biopsy in patients and animal models. Additionally, we provide some hints to navigate in this complex field.
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Affiliation(s)
- Antonino Uncini
- Department of Neurosciences, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Tiziana Cavallaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Gian Maria Fabrizi
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Jean-Michel Vallat
- Department of Neurology, National Reference Center for "Rare Peripheral Neuropathies", CHU Dupuytren, Limoges, France
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Barkhaus PE, Nandedkar SD, de Carvalho M, Swash M, Stålberg EV. Revisiting the compound muscle action potential (CMAP). Clin Neurophysiol Pract 2024; 9:176-200. [PMID: 38807704 PMCID: PMC11131082 DOI: 10.1016/j.cnp.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/30/2024] Open
Abstract
The compound muscle action potential (CMAP) is among the first recorded waveforms in clinical neurography and one of the most common in clinical use. It is derived from the summated muscle fiber action potentials recorded from a surface electrode overlying the studied muscle following stimulation of the relevant motor nerve fibres innervating the muscle. Surface recorded motor unit potentials (SMUPs) are the fundamental units comprising the CMAP. Because it is considered a basic, if not banal signal, what it represents is often underappreciated. In this review we discuss current concepts in the anatomy and physiology of the CMAP. These have evolved with advances in instrumentation and digitization of signals, affecting its quantitation and measurement. It is important to understand the basic technical and biological factors influencing the CMAP. If these influences are not recognized, then a suboptimal recording may result. The object is to obtain a high quality CMAP recording that is reproducible, whether the study is done for clinical or research purposes. The initial sections cover the relevant CMAP anatomy and physiology, followed by how these principles are applied to CMAP changes in neuromuscular disorders. The concluding section is a brief overview of CMAP research where advances in recording systems and computer-based analysis programs have opened new research applications. One such example is motor unit number estimation (MUNE) that is now being used as a surrogate marker in monitoring chronic neurogenic processes such as motor neuron diseases.
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Affiliation(s)
- Paul E. Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Sanjeev D. Nandedkar
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
- Natus Medical Inc., Hopewell Junction, NY, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Institute of Physiology, Centro de Estudos Egas Moniz, Faculty of Medicine, University of Lisbon, Portugal
- Department of Neurosciences and Mental Health, CHULN-Hospital de Santa Maria, Lisbon, Portugal
| | - Michael Swash
- Barts and the London School of Medicine, Queen Mary University of London, London UK
| | - Erik V. Stålberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Mouri N, Koike H, Fukami Y, Takahashi M, Yagi S, Furukawa S, Suzuki M, Kishimoto Y, Murate K, Nukui T, Yoshida T, Kudo Y, Tada M, Higashiyama Y, Watanabe H, Nakatsuji Y, Tanaka F, Katsuno M. Granuloma, vasculitis, and demyelination in sarcoid neuropathy. Eur J Neurol 2024; 31:e16091. [PMID: 37847215 PMCID: PMC11235865 DOI: 10.1111/ene.16091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Despite the suggestion that direct compression by granuloma and ischemia resulting from vasculitis can cause nerve fiber damage, the mechanisms underlying sarcoid neuropathy have not yet been fully clarified. METHODS We examined the clinicopathological features of sarcoid neuropathy by focusing on electrophysiological and histopathological findings of sural nerve biopsy specimens. We included 18 patients with sarcoid neuropathy who had non-caseating epithelioid cell granuloma in their sural nerve biopsy specimens. RESULTS Although electrophysiological findings suggestive of axonal neuropathy were observed, particularly in the lower limbs, all but three patients showed ≥1 abnormalities in nerve conduction velocity or distal motor latency. Additionally, a conduction block was observed in 11 of the 16 patients for whom waveforms were assessed; five of them fulfilled motor nerve conduction criteria strongly supportive of demyelination as defined in the European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) guideline for chronic inflammatory demyelinating polyneuropathy (CIDP). In most patients, sural nerve biopsy specimens revealed a mild to moderate degree of myelinated fiber loss. Fibrinoid necrosis was observed in one patient, and electron microscopy analysis revealed demyelinated axons close to granulomas in six patients. CONCLUSIONS Patients with sarcoid neuropathy may meet the EAN/PNS electrophysiological criteria for CIDP due to the frequent presence of conduction blocks. Based on our results, in addition to the ischemic damage resulting from granulomatous inflammation, demyelination may play an important role in the mechanism underlying sarcoid neuropathy.
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Affiliation(s)
- Naohiro Mouri
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
- Department of NeurologyGifu Prefectural Tajimi HospitalTajimiJapan
| | - Haruki Koike
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
- Division of Neurology, Department of Internal MedicineSaga University Faculty of MedicineSagaJapan
| | - Yuki Fukami
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Mie Takahashi
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Satoru Yagi
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Soma Furukawa
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Masashi Suzuki
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Yoshiyuki Kishimoto
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Kenichiro Murate
- Department of NeurologyFujita Health University School of MedicineToyoakeJapan
| | - Takamasa Nukui
- Department of Neurology, Faculty of MedicineUniversity of ToyamaToyamaJapan
| | - Tamaki Yoshida
- Department of NeurologyHiratsuka Kyosai HospitalHiratsukaJapan
| | - Yosuke Kudo
- Department of NeurologyHiratsuka Kyosai HospitalHiratsukaJapan
| | - Mikiko Tada
- Department of Neurology and Stroke MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Yuichi Higashiyama
- Department of Neurology and Stroke MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Hirohisa Watanabe
- Department of NeurologyFujita Health University School of MedicineToyoakeJapan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of MedicineUniversity of ToyamaToyamaJapan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke MedicineYokohama City University Graduate School of MedicineYokohamaJapan
| | - Masahisa Katsuno
- Department of NeurologyNagoya University Graduate School of MedicineNagoyaJapan
- Department of Clinical Research EducationNagoya University Graduate School of MedicineNagoyaJapan
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Mansueto G, Lanza G, Falleti J, Orabona P, Alaouieh D, Hong E, Girolami S, Montella M, Fisicaro F, Galdieri A, Singh P, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes from Pathology to Bedside: Part 2-Peripheral Nervous System. Curr Neurol Neurosci Rep 2023; 23:83-107. [PMID: 36820992 PMCID: PMC9947450 DOI: 10.1007/s11910-023-01249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Peripheral nervous system vasculitides (PNSV) are a heterogeneous group of disorders with a clinical subset that may differ in prognosis and therapy. We provide a comprehensive update on the clinical assessment, diagnosis, complications, treatment, and follow-up of PNSV. RECENT FINDINGS Progress in neuroimaging, molecular testing, and peripheral nerve biopsy has improved clinical assessment and decision-making of PNSV, also providing novel insights on how to prevent misdiagnosis and increase diagnostic certainty. Advances in imaging techniques, allowing to clearly display the vessel walls, have also enhanced the possibility to differentiate inflammatory from non-inflammatory vascular lesions, while recent histopathology data have identified the main morphological criteria for more accurate diagnosis and differential diagnoses. Overall, the identification of peculiar morphological findings tends to improve diagnostic accuracy by defining a clearer boundary between systemic and non-systemic neuropathies. Therefore, the definition of epineurium vessel wall damage, type of vascular lesion, characterization of lymphocyte populations, antibodies, and inflammatory factors, as well as the identification of direct nerve damage or degeneration, are the common goals for pathologists and clinicians, who will both benefit for data integration and findings translation. Nevertheless, to date, treatment is still largely empiric and, in some cases, unsatisfactory, thus often precluding precise prognostic prediction. In this context, new diagnostic techniques and multidisciplinary management will be essential in the proper diagnosis and prompt management of PNSV, as highlighted in the present review. Thirty to fifty percent of all patients with vasculitis have signs of polyneuropathy. Neuropathies associated with systemic vasculitis are best managed according to the guidelines of the underlying disease because appropriate workup and initiation of treatment can reduce morbidity. Steroids, or in severe or progressive cases, cyclophosphamide pulse therapy is the standard therapy in non-systemic vasculitic neuropathies. Some patients need long-term immunosuppression. The use of novel technologies for high-throughput genotyping will permit to determine the genetic influence of related phenotypes in patients with PNSV.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Piazza L. Miraglia 2, 80138, Naples, Italy.,Clinical Department of Laboratory Services and Public Health-Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy.,Pathology-Unit of Federico II University, Via S. Pansini 3, 80131, Naples, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.,Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Jessica Falleti
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | - Pasquale Orabona
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | | | - Emily Hong
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sara Girolami
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy
| | - Marco Montella
- Mental and Physical Health and Preventive Medicine Department, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Anna Galdieri
- AOU "Luigi Vanvitelli", Via Santa Maria Di Costantinopoli 104, 80138, Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, 147002, Punjab, India
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy.
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Loser V, Blanchard G, Guenova E, Théaudin M, Vicino A. Clinical Reasoning: A 39-Year-Old Man With Asymmetric Distal Weakness and Loss of Sensitivity. Neurology 2023; 100:88-93. [PMID: 36257711 DOI: 10.1212/wnl.0000000000201410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/30/2022] [Indexed: 02/05/2023] Open
Abstract
A 39-year-old man presented with an asymmetric distal weakness and loss of sensitivity sequentially affecting both lower extremities and the left upper limb. Nerve conduction studies showed a multifocal sensory and motor axonal neuropathy, and a pseudo-conduction block of the right fibular nerve, the whole being consistent with a mononeuropathy multiplex. An uncommon etiology was found after an extensive workup. Axonal loss was severe, with only partial response to treatment with corticosteroids and IV immunoglobulins.
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Affiliation(s)
- Valentin Loser
- From the Nerve-Muscle Unit (V.L., M.T., A.V.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; and Dermatology Service (G.B., E.G.), Lausanne University Hospital and University of Lausanne, Switzerland.
| | - Gabriela Blanchard
- From the Nerve-Muscle Unit (V.L., M.T., A.V.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; and Dermatology Service (G.B., E.G.), Lausanne University Hospital and University of Lausanne, Switzerland
| | - Emmanuella Guenova
- From the Nerve-Muscle Unit (V.L., M.T., A.V.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; and Dermatology Service (G.B., E.G.), Lausanne University Hospital and University of Lausanne, Switzerland
| | - Marie Théaudin
- From the Nerve-Muscle Unit (V.L., M.T., A.V.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; and Dermatology Service (G.B., E.G.), Lausanne University Hospital and University of Lausanne, Switzerland
| | - Alex Vicino
- From the Nerve-Muscle Unit (V.L., M.T., A.V.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; and Dermatology Service (G.B., E.G.), Lausanne University Hospital and University of Lausanne, Switzerland
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Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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7
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Goedee HS, Rajabally YA. Evidence base for investigative and therapeutic modalities in chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy. Neurodegener Dis Manag 2022; 12:35-47. [PMID: 35007438 DOI: 10.2217/nmt-2021-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy, its variants and multifocal motor neuropathy belong to a spectrum of peripheral nerve disorders with complex dysimmune disease mechanisms. Awareness of the unique clinical phenotypes but also heterogeneity between patients is vital to arrive at early suspicion and ordering appropriate tests. This includes requirements for optimal electrodiagnostic protocol, aimed to capture sufficient electrophysiologic evidence for relevant abnormalities, a case-based approach on the eventual need to further expand the diagnostic armamentarium and correct reading of their results. Considerable phenotypical variation, diverse combinations of abnormalities found on diagnostic tests and heterogeneity in disease course and treatment response, all contribute to widespread differences in success rates on timely diagnosis and optimal treatment. We aim to provide a practical overview and guidance on relevant diagnostic and management strategies, including pitfalls and present a summary of the relevant novel developments in this field.
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Affiliation(s)
- Hendrik Stephan Goedee
- Brain Center UMC Utrecht, Department of Neurology & Neurosurgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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Honda M, Takeshita Y, Koga M, Sato R, Omoto M, Kanda T. [Neuropathy presenting conduction block in ANCA-negative eosinophilic granulomatosis with polyangiitis]. Rinsho Shinkeigaku 2021; 61:613-617. [PMID: 34433740 DOI: 10.5692/clinicalneurol.cn-001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 74-year-old woman with a history of asthma and allergic rhinitis rapidly developed multiple mononeuropathy. Although anti-neutrophil cytoplasmic antibodies were negative, the presence of eosinophilia and eosinophilic infiltrations in the sural nerve led to a diagnosis of eosinophilic granulomatosis with polyangiitis. A motor nerve conduction study on admission revealed conduction block, which promptly disappeared after initiating immunotherapy without findings suggestive for remyelination or axonal degeneration. This electrophysiological change distinct from that of Wallerian degeneration. A biopsy of the sural nerve showed many eosinophil infiltrations and degranulation of eosinophilic cationic protein within nerve fascicles, whereas findings of necrotizing vasculitis were absent. These findings suggest that a direct effect of eosinophilic cationic protein, rather than ischemic damage due to vasculitis, was the main mechanism of transient nerve conduction failure in this patient.
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Affiliation(s)
- Masaya Honda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Yukio Takeshita
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Ryota Sato
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Masatoshi Omoto
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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Nascimento FA, Nunez-Wallace K. Images in Clinical Neurophysiology: a new subsection. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:467-468. [PMID: 34320051 DOI: 10.1590/0004-282x-anp-2021-e006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 11/22/2022]
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10
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Uncini A, Santoro L. The electrophysiology of axonal neuropathies: More than just evidence of axonal loss. Clin Neurophysiol 2020; 131:2367-2374. [PMID: 32828039 DOI: 10.1016/j.clinph.2020.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/15/2022]
Abstract
It is common belief that axonal neuropathies are characterized by simple axonal degeneration and loss and that the electrophysiological correlates are just reduced compound muscle action potential and sensory nerve action potential amplitudes with normal or slightly slow conduction velocity. However, axonal autoimmune neuropathies with involvement of the nodal region and axonal neuropathies due to energy restriction such as occurring in nerve ischemia, thiamine deficiency, critical illness, and mitochondrial disorders present conduction failure that can be either reversible with prompt recovery or progress to axonal degeneration with poor outcome. Moreover autoimmune axonal neuropathies due to nodal voltage gated sodium channels dysfunction/disruption may show slowing of conduction velocity, even in the demyelinating range, possibly due to prolongation of the depolarization time required to reach the threshold for action potential regeneration at subsequent nodes. These observations widen the spectrum of the electrophysiological features in some axonal neuropathies, should be taken into account to avoid misdiagnoses and for correct prognostication, and should stimulate the quest of timely targeted treatments that can eventually halt the progression from conduction failure to axonal degeneration.
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Affiliation(s)
- Antonino Uncini
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100 Chieti-Pescara, Italy.
| | - Lucio Santoro
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
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Abstract
OBJECTIVE To elucidate the electrophysiological demyelinating features in patients with hereditary ATTR amyloidosis that may lead to a misdiagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS In 102 patients with hereditary ATTR amyloidosis (85 Val30Met and 17 non-Val30Met; 37 and 65 from endemic and non-endemic areas, respectively), results of motor nerve conduction studies (MNCSs) with a 2-Hz low-cut filter in the unilateral ulnar and tibial nerves were retrospectively investigated to assess whether each MNCS parameter demonstrated demyelinating features that fulfil the European Federation of Neurological Societies/Peripheral Nerve Society electrodiagnostic (EFNS/PNS EDX) criteria for CIDP. RESULTS Thirteen patients with low compound muscle action potential (CMAP) amplitude in the tibial nerve (0.7 ± 0.7 mV) and prolonged distal CMAP duration in the ulnar nerve satisfied the definite EFNS/PNS EDX criteria for CIDP. Abnormal temporal dispersion and prolongation of distal latency in the tibial nerve were observed in 5 of 13 patients. However, only one of the 13 patients presented with the reduction of motor conduction velocity in each nerve. No patient exhibited conduction block in any nerve. CONCLUSION Patients with hereditary ATTR amyloidosis occasionally show electrophysiological demyelinating features without conduction block following severe axonal degeneration.
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Affiliation(s)
- Nobuhiko Ohashi
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan
| | - Minori Kodaira
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan
| | - Hiroshi Morita
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan.,b Center for Health, Safety and Environmental Management , Shinshu University , Matsumoto , Japan
| | - Yoshiki Sekijima
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan.,c Institute for Biomedical Sciences , Shinshu University , Matsumoto , Japan
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Volume conduction, waveform analysis, and near- and far-field potentials. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/b978-0-444-64032-1.00002-3] [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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14
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Park HJ, Shin HY, Kim SH, Jeong HN, Choi YC, Suh BC, Park KD, Kim SM. Partial Conduction Block as an Early Nerve Conduction Finding in Neurolymphomatosis. J Clin Neurol 2018; 14:73-80. [PMID: 29629543 PMCID: PMC5765259 DOI: 10.3988/jcn.2018.14.1.73] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/20/2017] [Accepted: 09/25/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neurolymphomatosis is a rare manifestation of hematological malignancy and is characterized by direct infiltration of the peripheral nervous system. The objective of this study was to identify the clinical and electrophysiological features of neurolymphomatosis. METHODS We retrospectively analyzed the medical records of 13 patients with neurolymphomatosis. Seven (54%) of the patients were men, and the median age at symptom onset was 60.0 years. RESULTS The most common type of underlying malignancy was diffuse large B-cell lymphoma (69%). Twelve patients had painful asymmetric neuropathies. The median survival time after diagnosis was 7 months, and 12 patients died during the study period. Thirty-eight motor nerve conduction studies (NCSs) were performed in the affected nerves. Ten and 28 motor nerves were classified into the conduction-block and simple-axon-degeneration groups, respectively. The median time interval between symptom onset and the NCS was significantly shorter in the conduction-block group than in the simple-axon-degeneration group (p=0.032). However, no significant differences in the motor nerve conduction velocities, terminal latencies, and distal compound muscle action potential amplitudes were identified between the conduction-block and simple-axon-degeneration groups. The conduction-block group showed excessive temporal dispersion in only five of the ten NCSs (50%). Follow-up NCSs revealed that partial conduction blocks had changed into axonal degeneration patterns. CONCLUSIONS This is the first study to analyze the electrophysiological features of patients with neurolymphomatosis. Our findings showed that a partial conduction block is not rare and is an early nerve conduction abnormality in neurolymphomatosis.
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Affiliation(s)
- Hyung Jun Park
- Department of Neurology, Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea.,Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Neul Jeong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Bum Chun Suh
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kee Duk Park
- Department of Neurology, Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea.
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
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15
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Cruz S, Schaefer AM, Joshi A, Baker MR. Clinical Reasoning: A 71-year-old woman with subacute progressive distal weakness and paresthesia after vaccination. Neurology 2017; 88:e168-e173. [DOI: 10.1212/wnl.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bortezomib-associated demyelinating neuropathy--clinical and pathologic features. J Clin Neuromuscul Dis 2016; 16:202-9. [PMID: 25996966 DOI: 10.1097/cnd.0000000000000077] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Bortezomib is a proteasome inhibitor that is frequently used for multiple myeloma and lymphoma. A sensory predominant axonal neuropathy is associated with bortezomib treatment but a demyelinating neuropathy is also described primarily based on electrodiagnostic findings. We report a series of patients treated with bortezomib who developed peripheral neuropathy and were found to have demyelinating features on electrodiagnostic testing. METHODS Four patients who developed a bortezomib-induced peripheral neuropathy underwent electrophysiological testing, and 1 patient had a nerve biopsy. RESULTS The four patients with bortezomib-induced peripheral neuropathy had demyelinating features on their electrophysiological testing. The nerve biopsy performed in 1 patient demonstrated a demyelinating component in a background of axonal degeneration. CONCLUSIONS Although most toxic neuropathies are symmetrical axonal neuropathies, bortezomib is part of a small list of agents that may cause a demyelinating polyneuropathy and axonal degeneration. These findings have been confirmed by nerve biopsy.
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Uncini A, Kuwabara S. Nodopathies of the peripheral nerve: an emerging concept. J Neurol Neurosurg Psychiatry 2015; 86:1186-95. [PMID: 25699569 DOI: 10.1136/jnnp-2014-310097] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/31/2015] [Indexed: 12/17/2022]
Abstract
Peripheral nerve diseases are traditionally classified as demyelinating or axonal. It has been recently proposed that microstructural changes restricted to the nodal/paranodal region may be the key to understanding the pathophysiology of antiganglioside antibody mediated neuropathies. We reviewed neuropathies with different aetiologies (dysimmune, inflammatory, ischaemic, nutritional, toxic) in which evidence from nerve conductions, excitability studies, pathology and animal models, indicate the involvement of the nodal region in the pathogenesis. For these neuropathies, the classification in demyelinating and axonal is inadequate or even misleading, we therefore propose a new category of nodopathy that has the following features: (1) it is characterised by a pathophysiological continuum from transitory nerve conduction block to axonal degeneration; (2) the conduction block may be due to paranodal myelin detachment, node lengthening, dysfunction or disruption of Na(+) channels, altered homeostasis of water and ions, or abnormal polarisation of the axolemma; (3) the conduction block may be promptly reversible without development of excessive temporal dispersion; (4) axonal degeneration, depending on the specific disorder and its severity, eventually follows the conduction block. The term nodopathy focuses to the site of primary nerve injury, avoids confusion with segmental demyelinating neuropathies and circumvents the apparent paradox that something axonal may be reversible and have a good prognosis.
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Affiliation(s)
- Antonino Uncini
- Department of Neuroscience, Imaging and Clinical Sciences, University "G d'Annunzio", Chieti-Pescara, Chieti, Italy
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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18
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Neuropatie delle vasculiti. Neurologia 2015. [DOI: 10.1016/s1634-7072(15)73992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
Entrapment of the ulnar nerve at the elbow is the second most common focal peripheral neuropathy. Recent advances have facilitated the electrodiagnosis of this common nerve entrapment. The goals of electrodiagnosis are to localize ulnar nerve dysfunction, confirm that the disturbance is confined to the ulnar nerve, and assess the severity of ulnar nerve dysfunction. The goal of this review is to highlight the important advances in anatomy, neurophysiology and methodology that impact upon the electrodiagnosis of entrapment of the ulnar nerve at the elbow, illustrate the limits of electrodiagnosis, and discuss methodological issues that may be the subject of further study. Careful attention to elbow position, temperature, and conservative estimates of conduction block should be part of common practice. Awareness of anatomical variations in structural anatomy, anomalous innervation and fascicular arrangement of ulnar nerve fibers are required to interpret electrodiagnostic studies accurately. The most reliable finding is slowing of the ulnar across-elbow motor nerve conduction velocity to less than 50 m/sec while recording from the abductor digiti minimi muscle, and should be carefully interpreted in the presence of a polyneuropathy or other neurogenic process. Alternative techniques such as relative ulnar slowing in different ulnar nerve segments, use of alternative muscles, sensory and mixed nerve techniques provide complementary information, and like all nerve conduction studies are highly operator-dependent and should be used on a case by case basis. Recent studies have focused the electromyographer's attention on the use of shorter across-elbow segments (2-5 cm). This may offer a reasonable trade-off between sensitivity and measurement error and may result in improved electrodiagnosis.
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Affiliation(s)
- Ralph Z Kern
- Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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21
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Lawson VH, Arnold WD. Multifocal motor neuropathy: a review of pathogenesis, diagnosis, and treatment. Neuropsychiatr Dis Treat 2014; 10:567-76. [PMID: 24741315 PMCID: PMC3983019 DOI: 10.2147/ndt.s39592] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is an uncommon, purely motor neuropathy associated with asymmetric deficits with predilection for upper limb involvement. Even in the early descriptions of MMN, the associations of anti-GM1 antibodies and robust response to immunomodulatory treatment were recognized. These features highlight the likelihood of an underlying autoimmune etiology of MMN. The clinical presentation of MMN can closely mimic several neurological conditions including those with more malignant prognoses such as motor neuron disease. Therefore early and rapid recognition of MMN is critical. Serological evidence of anti GM-1 antibodies and electrodiagnostic findings of conduction block are helpful diagnostic clues for MMN. Importantly, these diagnostic features are not universally present, and patients lacking these characteristic findings can demonstrate similar robust response to immunodulatory treatment. In the current review, recent research in the areas of diagnosis, pathogenesis, and treatment of MMN and needs for the future are discussed. The characteristic findings of MMN and treatment implications are reviewed and contrasted with other mimicking disorders.
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Affiliation(s)
- Victoria H Lawson
- Division of Neuromuscular Disorders, Department of Neurology, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - W David Arnold
- Division of Neuromuscular Disorders, Department of Neurology, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA ; Department of Physical Medicine and Rehabilitation, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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22
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Manousakis G, Koch J, Sommerville RB, El-Dokla A, Harms MB, Al-Lozi MT, Schmidt RE, Pestronk A. Multifocal radiculoneuropathy during ipilimumab treatment of melanoma. Muscle Nerve 2013; 48:440-4. [PMID: 23447136 DOI: 10.1002/mus.23830] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2013] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Ipilimumab, a monoclonal anti-CTLA-4 antibody, is used to treat melanoma. Neuromuscular side effects, possibly autoimmune, may occur. METHODS In this investigation we undertook a retrospective review of patient records. RESULTS After 3 doses of ipilimumab, a 31-year-old man developed asymmetric, severe weakness involving all limbs, respiration, and cranial nerves, which was progressive over 2 weeks. EMG/NCS showed an axonal polyradiculoneuropathy with multifocal motor conduction blocks. CSF protein was 749 mg/dl. Nerve pathology showed inflammation around the endoneurial microvessels and subperineurial edema and inflammation. Spine MRI showed leptomeningeal and anterior and posterior root enhancement. Strength improved slowly over months after ipilimumab discontinuation and immunomodulating treatment. CONCLUSIONS Ipilimumab toxicity presented as a monophasic, multifocal, asymmetric polyradiculoneuropathy involving roots and peripheral and cranial nerves. Ipilimumab may produce a polyradiculoneuropathy with disruption of the blood-nerve barrier due to a microvasculopathy.
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Affiliation(s)
- Georgios Manousakis
- Department of Neurology Washington University School of Medicine, 600 South Euclid Avenue, St. Louis, Missouri, 63110, USA
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Abstract
Neuropathies caused by jellyfish stings are extremely rare and poorly studied. A 20-year-old female patient was stung on the volar aspect of the right forearm by an unidentified species of jellyfish. Local cutaneous reaction was followed within few days by severe median mononeuropathy, involving the motor and sensory branches to the hand and forearm but sparing the palmar branch. The patient had neuropathic pain relieved by pregabaline. Electrodiagnostic studies confirmed a demyelinating lesion. Ultrasound and magnetic resonance imaging of the median nerve revealed uniform swelling with mild uptake of contrast along the forearm. Within 2 months, strength improved significantly, pain subsided, and numbness partially resolved. Literature review and discussion of the possible mechanisms and implications of this rare effect of marine animal envenomation is presented. Jellyfish sting may cause focal mononeuropathies most probably because of the local effects of the toxins.
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Ahdab R, Créange A, Saint-Val C, Farhat WH, Lefaucheur JP. Rapidly progressive amyotrophic lateral sclerosis initially masquerading as a demyelinating neuropathy. Neurophysiol Clin 2013; 43:181-7. [PMID: 23856174 DOI: 10.1016/j.neucli.2013.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 04/30/2013] [Accepted: 05/01/2013] [Indexed: 11/17/2022] Open
Abstract
Rare cases of demyelinating neuropathy have been described in association with amyotrophic lateral sclerosis (ALS). We report two patients with typical ALS whose initial electroneuromyographic (ENMG) presentation could suggest the existence of a process of motor nerve fiber demyelination. However, subsequent ENMG examinations and the fatal course of the disease in a few months rather supported severe ongoing axonal degeneration at the origin of motor nerve conduction abnormalities. Repeated examinations could be required to distinguish between ENMG features of concomitant demyelinating neuropathy and rapidly progressive motor neuron loss in ALS.
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Affiliation(s)
- R Ahdab
- EA 4391, faculté de médecine de Créteil, université Paris Est Créteil, Créteil, France
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25
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26
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Bsteh G, Wanschitz JV, Gruber H, Seppi K, Löscher WN. Prognosis and prognostic factors in non-traumatic acute-onset compressive mononeuropathies - radial and peroneal mononeuropathies. Eur J Neurol 2013; 20:981-5. [DOI: 10.1111/ene.12150] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/14/2013] [Indexed: 01/22/2023]
Affiliation(s)
- G. Bsteh
- Department of Neurology; Innsbruck Medical University; Innsbruck; Austria
| | - J. V. Wanschitz
- Department of Neurology; Innsbruck Medical University; Innsbruck; Austria
| | - H. Gruber
- Department of Radiology; Innsbruck Medical University; Innsbruck; Austria
| | - K. Seppi
- Department of Neurology; Innsbruck Medical University; Innsbruck; Austria
| | - W. N. Löscher
- Department of Neurology; Innsbruck Medical University; Innsbruck; Austria
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27
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Mauermann ML, Blumenreich MS, Dispenzieri A, Staff NP. A case of peripheral nerve microvasculitis associated with multiple myeloma and bortezomib treatment. Muscle Nerve 2013; 46:970-7. [PMID: 23225391 DOI: 10.1002/mus.23493] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2012] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Bortezomib-induced peripheral neuropathy typically presents as a painful, length-dependent sensory predominant neuropathy. METHODS A case report, including nerve pathology, is presented of a man with multiple myeloma who developed a severe motor predominant polyradiculoneuropathy in the setting of bortezomib treatment. We also review the Mayo Clinic Hematology Dysproteinemia database for patients treated with bortezomib. RESULTS A 53-year-old man with Stage III multiple myeloma developed a severe motor predominant polyradiculoneuropathy following bortezomib treatment with electrophysiological features of multiple conduction blocks and pathological evidence of peripheral nerve microvasculitis. Our institutional experience is that 36.5% of dysproteinemia patients treated with bortezomib develop treatment-emergent peripheral neuropathy, and the most common pattern is a painful sensory predominant peripheral neuropathy. CONCLUSIONS A motor predominant polyradiculoneuropathy is a rare presentation of bortezomib-associated peripheral neuropathy in multiple myeloma patients which may progress despite treatment withdrawal and may be due to microvasculitis.
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Affiliation(s)
- Michelle L Mauermann
- Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905, USA.
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28
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Kim RB, Kang DH, Lee SY, Han JS, Lim SK, Song SH, Seo YI, Kim HA. Multifocal Motor Neuropathy with Conduction Blocks During TNF-alpha Antagonist Therapy in a Patient with Spondyloarthropathy. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.3.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Rul Bin Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Dong Hoon Kang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung Yeon Lee
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Ji Suk Han
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Soo Kyung Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Su Hee Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young-Il Seo
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyun Ah Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Wolf J, Schmitt V, Palm F, Grau AJ, Bergner R. Peripheral neuropathy as initial manifestation of primary systemic vasculitides. J Neurol 2012; 260:1061-70. [PMID: 23212754 DOI: 10.1007/s00415-012-6760-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/06/2012] [Accepted: 11/12/2012] [Indexed: 01/24/2023]
Abstract
Peripheral neuropathies are well-known complications of primary systemic vasculitides. In rare cases, peripheral neuropathies are among the first symptoms of these diseases. In this prospective study, 89 consecutive adult patients with newly diagnosed primary systemic vasculitis were screened, of whom 22 patients (25 %, 12 men, ten women, mean age, 59 years, range, 26-82 years) suffered from peripheral neuropathy due to systemic vasculitis at initial presentation. Peripheral neuropathy was most frequent in newly diagnosed patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome, 12 out of 20 patients, 60 %) and polyarteritis nodosa (three out of six patients, 50 %), and less common in patients with granulomatosis with polyangiitis (six out of 47 patients, 13 %) and microscopic polyangiitis (one out of 16 patients, 6 %). Multiplex mononeuropathy was more frequent (n = 13, 59 %) than symmetric polyneuropathy (n = 9, 41 %). The nerves commonly affected were the peroneal nerve, followed by the sural, posterior tibial, and median nerves. Treatment options were chosen according to current guidelines of the national neurological and rheumatologic societies, with initial corticosteroid monotherapy for patients with a mild disease form and a combination of corticosteroids and intravenously pulsed cyclophosphamide for patients with a more extended organ involvement. During follow-up (mean, 34 months, range, 12-112 months), new neurological complications were rare (9 %): One patient suffered from a cerebral infarct while another patient sustained epileptic seizures. Two patients (9 %) died from sepsis (after 60 months) or severe gastrointestinal bleeding (after 13 months). The degree of neurological disability measured by the functional disability score (described by Prineas) improved in 20 of 22 patients after 12 months of therapy.
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Affiliation(s)
- Joachim Wolf
- Department of Neurology, Klinikum der Stadt Ludwigshafen, Bremserstraße 79, 67063 Ludwigshafen, Germany.
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Abstract
Peripheral nervous system (PNS) vasculitis and Guillain-Barré syndrome (GBS) are two distinct entities. Although there may be similarities in clinical presentation, the two are rarely confused. PNS vasculitis typically presents as a mononeuritis multiplex, as an overlapping mononeuritis multiplex, or as a distal symmetric sensorimotor polyneuropathy. Electrophysiologic studies are consistent with a primary axonal pathophysiologic process. In contrast, GBS typically presents with variable, mild sensory symptoms followed by symmetric progressive weakness. Early electrophysiologic studies, when abnormal, usually demonstrate findings consistent with demyelination. We describe two cases of PNS vasculitis in which the initial clinical presentation and the presence of multifocal conduction block on electrophysiologic studies led to the incorrect diagnosis of GBS early in the hospital course. Although GBS must always be considered in patients with rapidly progressive weakness, physicians must remain vigilant for alternative diagnoses, as illustrated by our cases.
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Mononeuropathy multiplex in sickle cell disease: a complication in need of recognition. J Clin Neuromuscul Dis 2012; 3:63-9. [PMID: 19078656 DOI: 10.1097/00131402-200112000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral nervous system involvement is rare in sickle cell disease. A review of the literature has uncovered only a few reports of nerve deficit in association with sickle cell disease, and often a clear relationship between the neuropathy and the anemia is absent. Mononeuropathy resulting from peripheral nerve infarction, as a complication of sickle vaso-occlusive crisis, seemingly is uncommon and, to our knowledge, has been reported only once. We report two patients who developed acute mononeuropathy multiplex in the setting of sickle cell pain crisis. The clinical and electrodiagnostic findings were consistent with a multifocal nerve disorder resulting from an ischemic process caused by a sickle cell vaso-occlusive crisis. We describe the clinical course, electrophysiological findings, diagnosis, and management of these patients. We also analyze the anatomic and pathophysiological basis of this disorder and offer a possible clinical explanation for its infrequent and exceptional diagnosis.
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Uncini A, Kuwabara S. Electrodiagnostic criteria for Guillain-Barrè syndrome: a critical revision and the need for an update. Clin Neurophysiol 2012; 123:1487-95. [PMID: 22480600 DOI: 10.1016/j.clinph.2012.01.025] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 01/02/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022]
Abstract
Electrophysiology plays a determinant role in Guillain-Barré syndrome (GBS) diagnosis, classification of the subtypes and in establishing prognosis. In the last three decades, different electrodiagnostic criteria sets have been proposed for acute inflammatory demyelinating neuropathy (AIDP), acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). Criteria sets for AIDP varied for the parameters indicative of demyelination considered, for the cut-off limits and the number of required abnormalities (all a priori established) showing different sensitivities. Criteria sets for AMAN and AMSAN were proposed on the initial assumption that these subtypes were pathologically characterised by simple axonal degeneration. However, some AMAN patients show transient conduction block/slowing in intermediate and distal nerve segments, mimicking demyelination but without the development of abnormal temporal dispersion, named reversible conduction failure (RCF). The lack of distinction between RCF and demyelinating conduction block leads to fallaciously classify AMAN patients with RCF as AIDP or AMAN with axonal degeneration. Serial electrophysiological studies are mandatory for proper diagnosis of GBS subtypes, identification of pathophysiological mechanisms and prognosis. More reliable electrodiagnostic criteria should be devised to distinguish axonal and demyelinating subtypes of GBS, taking into consideration the RCF pattern and focussing on temporal dispersion.
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Affiliation(s)
- Antonino Uncini
- Department of Neuroscience and Imaging, University G. d'Annunzio, Chieti-Pescara, Italy.
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33
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Arnold WD, Kissel JT. Vasculitic Neuropathies. Neuromuscul Disord 2011. [DOI: 10.1002/9781119973331.ch26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Corrélations anatomocliniques des neuropathies périphériques cryoglobulinémiques secondaires à l’hépatite C. Série consécutive de 22 cas. Rev Neurol (Paris) 2010; 166:509-14. [DOI: 10.1016/j.neurol.2009.10.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Revised: 09/26/2009] [Accepted: 10/28/2009] [Indexed: 01/20/2023]
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Kim CT, Dy R, Sollenberger J, Katz E. A Case of Suspected Mononeuritis Multiplex in a Teenager From Polysubstance Abuse. PM R 2009; 1:881-3. [DOI: 10.1016/j.pmrj.2009.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 06/19/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
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Nakamura M, Yabe I, Yaguchi H, Kishimoto R, Mito Y, Fujiki N, Houzen H, Tsuji-Akimoto S, Niino M, Sasaki H. Clinical characterization and successful treatment of 6 patients with Churg-Strauss syndrome-associated neuropathy. Clin Neurol Neurosurg 2009; 111:683-7. [PMID: 19647930 DOI: 10.1016/j.clineuro.2009.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 07/02/2009] [Accepted: 07/04/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To confirm the reported findings and clarify unknown clinical features of Churg-Strauss syndrome (CSS)-associated neuropathy and design appropriate treatment. PATIENTS AND METHODS We assessed the clinical features of 6 patients with CSS-associated neuropathy. RESULTS Mononeuritis multiplex was present in 4 cases and polyneuropathy in the remaining cases. Both groups progressed to sensori-motor polyneuropathy in an acute or subacute course. All cases showed bronchial asthma and eosinophilia. Two cases with serum antineutrophil cytoplasmic antibodies to myeloperoxidase (MPO-ANCA) had an acute clinical course and severe symptoms. Nerve conduction studies (NCS) of these 2 cases revealed conduction blocks at the initial stage, although NCS finally indicated sensori-motor axonopathy at the involved extremities. For treatment, high-dose corticosteroid therapy for 4 cases, and cyclophosphamide combined with corticosteroids for 1 case, were effective. For the remaining case, intravenous immunoglobulin (IVIg) at the chronic phase resulted in a slow improvement of neuropathy in the symptomatic aspect. There was no relapse of neuropathy with low-dose corticosteroid treatment for 14-24 months after the initial treatment, except 1 case. There was also no relapse in the other case that was treated with moderate-dose steroids. CONCLUSION Our study showed that CSS-associated neuropathy is a treatable disorder and that the first choice therapy is high-dose corticosteroid. In cases where corticosteroids are ineffective or for severe cases, immunosuppressive therapy (cyclophosphamide) with steroids should be considered, and IVIg might be a treatment option.
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Affiliation(s)
- Masakazu Nakamura
- Department of Neurology, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Japan
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Ahdab R, Michel M, Neves DO, Andre C, Lefaucheur JP. Persistent multifocal pseudo-conduction blocks in vasculitic neuropathy without antiganglioside antibodies. Muscle Nerve 2009; 40:290-3. [DOI: 10.1002/mus.21337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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38
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Berciano J, García A, Villagrá NT, González F, Ramón C, Illa I, Berciano MT, Lafarga M. Severe Guillain-Barré syndrome: sorting out the pathological hallmark in an electrophysiological axonal case. J Peripher Nerv Syst 2009; 14:54-63. [DOI: 10.1111/j.1529-8027.2009.00206.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Riva N, Cerri F, Butera C, Amadio S, Quattrini A, Fazio R, Comola M, Comi G. Churg Strauss syndrome presenting as acute neuropathy resembling Guillain Barré syndrome: case report. J Neurol 2008; 255:1843-4. [PMID: 19156494 DOI: 10.1007/s00415-008-0035-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 05/05/2008] [Accepted: 06/26/2008] [Indexed: 12/27/2022]
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Hooper DR, Tarnopolsky MA, Baker SK. Lewis-Sumner syndrome associated with infliximab therapy in rheumatoid arthritis. Muscle Nerve 2008; 38:1318-25. [DOI: 10.1002/mus.21051] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Tumor necrosis factor (TNF)-alpha plays an important role in many aspects of immune system development, immune-response regulation, and T-cell-mediated tissue injury. The evidence that TNF-alpha, released by autoreactive T cells and macrophages, may contribute to the pathogenesis of immune-mediated demyelinating neuropathies is reviewed. TNF-alpha antagonists (infliximab, etanercept, adalimumab) are indicated for the treatment of advanced inflammatory rheumatic and bowel disease, but these drugs can induce a range of autoimmune diseases that also attack the central and peripheral nervous systems. Case histories and series report on the association between anti-TNF-alpha treatment and various disorders of peripheral nerve such as Guillain-Barré syndrome, Miller Fisher syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy with conduction block, mononeuropathy multiplex, and axonal sensorimotor polyneuropathies. The proposed pathogeneses of TNF-alpha-associated neuropathies include both a T-cell and humoral immune attack against peripheral nerve myelin, vasculitis-induced nerve ischemia, and inhibition of signaling support for axons. Most neuropathies improve over a period of months by withdrawal of the TNF-alpha antagonist, with or without additional immune-modulating treatment. Preliminary observations suggest that TNF-alpha antagonists may be useful as an antigen-nonspecific treatment approach to immune-mediated neuropathies in patients with a poor response to, or intolerance of, standard therapies, but further studies are required.
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Affiliation(s)
- Joerg-Patrick Stübgen
- Department of Neurology and Neuroscience, Cornell University Medical College, New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10065-4897, USA.
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Cattaneo L, Chierici E, Pavone L, Grasselli C, Manganelli P, Buzio C, Pavesi G. Peripheral neuropathy in Wegener's granulomatosis, Churg-Strauss syndrome and microscopic polyangiitis. J Neurol Neurosurg Psychiatry 2007; 78:1119-23. [PMID: 17299018 PMCID: PMC2117551 DOI: 10.1136/jnnp.2006.111013] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the clinical aspects of peripheral neuropathy associated with Wegener's granulomatosis (WG), Churg-Strauss syndrome (CSS) and microscopic polyangiitis (MP). METHODS Cohort study conducted in a single university hospital. Patients were included when a definite diagnosis of WG, CSS or MP was made according to the current classification criteria in our hospital, between 1999 and 2006. All patients underwent periodically clinical and electrophysiological screening for peripheral neuropathy, assessment of disability, and clinical and laboratory evaluation during a mean follow-up of 38 months. RESULTS Sixty-four consecutive patients diagnosed with WG (26 patients), CSS (26 patients) and MP (12 patients) were recruited. Peripheral neuropathy occurred in 27/64 patients: six with WG, 15 with CSS and six with MP. Neuropathy occurred earlier in the disease history in CSS and MP compared with WG. Among patients with WG, those who developed peripheral neuropathy during follow-up were older than those without neuropathy both at the time of onset and of diagnosis of vasculitis. Distal symmetric polyneuropathy was present in 11 patients, and single or multiple mononeuropathy in 16. Patients with WG had a less severe form of mononeuritis multiplex than CSS or MPA patients. Disability and pain were greater in patients with mononeuropathy, although one-third of them were painless. Relapses of neuropathy were extremely infrequent. CONCLUSIONS Peripheral neuropathy in WG occurs less frequently, later in the disease course and in a milder form than in CSS and MP. Single or multiple mononeuropathy associated with these subsets of vasculitis can often be painless.
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Affiliation(s)
- Luigi Cattaneo
- Sezione di Neurologia, Dipartimento di Neuroscienze, Università degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italy.
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Petiot P. Intérêt de l’électroneuromyogramme dans le diagnostic des neuropathies dysimmunes. Rev Neurol (Paris) 2007. [DOI: 10.1016/s0035-3787(07)92158-x] [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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Vrancken AFJE, Hughes RAC, Said G, Wokke JHJ, Notermans NC. Immunosuppressive treatment for non-systemic vasculitic neuropathy. Cochrane Database Syst Rev 2007:CD006050. [PMID: 17253577 DOI: 10.1002/14651858.cd006050.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Non-systemic vasculitic neuropathy is a rare disabling disease that usually has a subacute onset of progressive or relapsing-remitting sensory or sensorimotor deficits. Asymmetry, pain and weakness are key features. The diagnosis can only be made by exclusion of other causes, the absence of systemic vasculitis or other rheumatic diseases, and the demonstration of vasculitis in a nerve or a combined nerve and muscle biopsy. There is a need for efficacious therapy to prevent disease progression and to improve prognosis. OBJECTIVES To assess if immunosuppressive treatment in non-systemic vasculitic neuropathy reduces disability, and ameliorates neurological symptoms, and if such therapy can be given safely. SEARCH STRATEGY The Cochrane Neuromuscular Disease Group Trials Register (March 2006), The Cochrane Library (Issue 1, 2006), MEDLINE, EMBASE, LILACS, and ISI were searched from January 1980 until April 2006. In addition, the reference lists of relevant articles, reviews and textbooks were handsearched. SELECTION CRITERIA All randomised or quasi-randomised trials that examined the efficacy of immunosuppressive treatment for non-systemic vasculitic neuropathy at least one year after the onset of therapy were sought. Participants had to fulfill the following criteria: absence of systemic or neurological disease, exclusion of any recognised cause of the neuropathy by appropriate clinical or laboratory investigations, electrophysiological studies in agreement with axonal neuropathy, confirmation of vasculitis in a nerve or a combined nerve and muscle biopsy. The primary outcome measure was to be improvement in disability. Secondary outcome measures were to be change in the mean disability score, change in muscle strength measured with the Medical Research Council sum score, change in pain or other positive sensory symptoms, number of relapses, and adverse events. DATA COLLECTION AND ANALYSIS Two authors independently reviewed and extracted details of all potentially relevant trials. For included studies pooled relative risks and pooled weighted standardised mean differences were to be calculated to assess treatment efficacy. MAIN RESULTS Fifty-nine studies were identified and assessed for possible inclusion in the review, but all were excluded because of insufficient quality or lack of relevance. AUTHORS' CONCLUSIONS No adequate randomised or quasi-randomised controlled clinical trials have been performed on which to base treatment for non-systemic vasculitic neuropathy. Randomised trials of corticosteroids and other immunosuppressive agents are needed.
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Affiliation(s)
- A F J E Vrancken
- University Medical Center Utrecht, Department of Neurology, The Rudolf Magnus Institute for Neuroscience, Heidelberglaan 100, PO Box 85500, Utrecht, Netherlands, 3508 GA.
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Notturno F, Caporale CM, Di Muzio A, Uncini A. Persistent multifocal conduction block in vasculitic neuropathy with IgM anti-gangliosides. Muscle Nerve 2007; 36:547-52. [PMID: 17405140 DOI: 10.1002/mus.20778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 30-year-old man with essential cryoglobulinemia presented with an axonal neuropathy and was found to have vasculitis at nerve biopsy. After 44 months, in accord with clinical deterioration, motor conduction studies showed excessive temporal dispersion multifocally, with partial conduction block persisting for 3 years. Antibody testing showed the presence of IgM anti-GM1, anti-GD1a, and anti-GM2 antibodies. Transitory conduction block has been reported occasionally in patients with vasculitis. The persistent multifocal conduction abnormalities found in this patient were more likely due to a superimposed immunomediated demyelination rather than to chronic nerve ischemia secondary to vasculitis.
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Affiliation(s)
- Francesca Notturno
- Department of Human Motor Sciences, University G d'Annunzio and Neuromuscular Diseases Unit, Institute of Aging, Foundation University G d'Annunzio, Via dei Vestini, I-66013, Chieti-Pescara, Italy
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Abstract
BACKGROUND Systemic vasculitis has been classically categorized as a primary disorder, such as polyarteritis nodosa, Churg-Strauss syndrome, and Wegener granulomatous, or as a secondary process, representing a complication from a connective tissue disorder (eg, rheumatoid vasculitis), infection, medication, or malignancy. Peripheral neuropathy is a well-recognized consequence of systemic vasculitis due to peripheral nerve infarction with Wallerian degeneration. Rarely, neuropathy is the sole manifestation of vasculitis, referred to as nonsystemic vasculitic neuropathy (NSVN). These conditions are defined pathologically by tissue biopsy demonstrating disruption or destruction of the vessel wall with inflammatory cell infiltrates. REVIEW SUMMARY The diagnosis of vasculitic neuropathy is straightforward in patients with an established diagnosis of systemic vasculitis and classic features of mononeuritis multiplex. Most patients have clinical features of a subacute, progressive, generalized but asymmetric, painful, sensorimotor polyneuropathy. Laboratory tests often indicate features of systemic inflammation, such as an elevated sedimentation rate or positive anti-neutrophil cytoplasmic antibody, and electrodiagnostic evaluation shows multiple mononeuropathies or a confluent, asymmetric axonal neuropathy. Nerve biopsy is necessary to establish the diagnosis in most cases, particularly in patients with NSVN. This review summarizes the current treatment of vasculitic neuropathy. CONCLUSION Long-term immunosuppressive therapy is required in most cases. High-dose prednisone combined with intravenous pulse or oral daily cyclophosphamide is standard initial therapy. In those with NSVN, cyclophosphamide also should be used if prednisone monotherapy is ineffective or the patient relapses with tapering. Other agents, such as azathioprine, methotrexate, intravenous immunoglobulin, mycophenolate mofetil, plasma exchange, and rituximab can be offered to patients who are intolerant or have a contraindication to cyclophosphamide. However, evidence for the benefit of these agents is limited to case reports and small case series.
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Affiliation(s)
- Kenneth C Gorson
- Tufts University School of Medicine, Boston, Massachusetts, USA.
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Birnbaum J. Infliximab-associated neuropathy in RA patients—the importance of considering the diagnosis of mononeuritis multiplex. Clin Rheumatol 2006; 26:281-2. [PMID: 17063281 DOI: 10.1007/s10067-006-0436-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 08/31/2006] [Indexed: 11/30/2022]
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Vital C, Vital A, Canron MH, Jaffré A, Viallard JF, Ragnaud JM, Brechenmacher C, Lagueny A. Combined nerve and muscle biopsy in the diagnosis of vasculitic neuropathy. A 16-year retrospective study of 202 cases. J Peripher Nerv Syst 2006; 11:20-9. [PMID: 16519779 DOI: 10.1111/j.1085-9489.2006.00060.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We reviewed 202 biopsies performed on patients with suspected vasculitic neuropathy, of which 24 Churg-Strauss cases are studied separately. Specimens from the superficial peroneal nerve and peroneus brevis muscle were taken simultaneously by one incision. Without taking into account constitutional signs, systemic involvement was present in 131 patients, whereas the remaining 47 corresponded to non-systemic patients with lesions limited to peripheral nervous system and adjoining muscles. Diagnosis of panarteritis nodosa or microscopic polyangiitis, according to the size of involved vessels, was attested by an infiltration of vessel walls by inflammatory cells associated with fibrinoid necrosis or sclerosis. Microvasculitis was diagnosed when inflammatory infiltration concerned small vessels with few or no smooth-muscle fibers and without any necrosis. Microvasculitis was present in 11 of 46 non-systemic cases, and this predominance is statistically significant. Isolated perivascular cell infiltrates in the epineurium were considered not significant but allowed the diagnosis of 'probable vasculitis' if associated with at least one of the following features: regenerating small vessels, endoneurial purpura, asymmetric nerve fiber loss, and/or asymmetric acute axonal degeneration. Necrotizing vasculitis was visible in 60 cases: in nerve (16 cases), in muscle (19 cases), and both (25 cases). Microvasculitis was present in 25 cases: in nerve (19 cases), muscle (four cases), or both (two cases). Moreover, granulomatous vasculitis was found in the nerve of one non-systemic patient presenting also sarcoid granulomas in muscle. There were 24 'probable vasculitis' and 68 negative cases. Muscle biopsy improved the yield of definite vasculitis by 27%.
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Affiliation(s)
- Claude Vital
- Neuropathology Laboratory, Victor Segalen University, Bordeaux, France.
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Nardin R, Rutkove S. Neuropathy and Rheumatologic Disease. NEUROLOGICAL DISEASE AND THERAPY 2005. [DOI: 10.1201/b14157-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
BACKGROUND The clinical and pathologic spectrum of Guillain Barre Syndrome (GBS) has expanded to include both demyelinating and axon loss forms. GBS may also have atypical presentations. For these reasons, clinicians are more likely to overlook unrelated disorders that mimic GBS. REVIEW SUMMARY In this article, the classic presentation and variants of GBS are briefly reviewed. Disorders that mimic GBS are reviewed in detail, including those caused by neurotoxins, heavy metals, chemical toxins, drugs, vasculitis, hereditary disorders, infections, critical illness, and myelopathy. Illustrative case studies accompany a number of the descriptions. CONCLUSIONS Failure to recognize the mimics of GBS can lead to erroneous diagnosis, inappropriate treatment, and significant morbidity. Appropriate diagnosis requires a combination of careful history and examination, and accurate interpretation of diagnostic testing.
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Affiliation(s)
- Kerry H Levin
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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