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Rochkind S, Sirota S, Kushnir A. Nerve Reconstruction Using ActiGraft Blood Clot in Rabbit Acute Peripheral Injury Model: Preliminary Study. Bioengineering (Basel) 2024; 11:298. [PMID: 38671720 PMCID: PMC11047591 DOI: 10.3390/bioengineering11040298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/16/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
This preliminary study aimed to investigate an ActiGraft blood clot implant (RedDress Ltd., Pardes-Hanna, Israel) attempting to treat and induce the regeneration of a completely injured peripheral nerve with a massive loss defect. The tibial portion of the sciatic nerve in 11 rabbits was transected, and a 25 mm nerve gap was reconnected using a collagen tube. A comparison was performed between the treatment group (eight rabbits; reconnection using a tube filled with ActiGraft blood clot) and the control group (three rabbits; gap reconnection using an empty tube). The post-operative follow-up period lasted 18 weeks and included electrophysiological and histochemical assessments. The pathological severity score was high in the tube cross sections of the control group (1.33) compared to the ActiGraft blood clot treatment group (0.63). Morphometric analysis showed a higher percentage of the positive myelin basic protein (MBP) stained area in the ActiGraft blood clot group (19.57%) versus the control group (3.67%). These differences were not statistically significant due to the small group sizes and the large intra-group variability. The results of this preliminary study suggest that the application of an ActiGraft blood clot (into the collagen tube) can enable nerve recovery. However, a future study using a larger animal group is required to achieve objective statistical results.
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Affiliation(s)
- Shimon Rochkind
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Sharon Sirota
- RedDress Ltd., Pardes Hana 3701142, Israel; (S.S.); (A.K.)
| | - Alon Kushnir
- RedDress Ltd., Pardes Hana 3701142, Israel; (S.S.); (A.K.)
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2
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Fellin CR, Steiner RC, Buchen JT, Anders JJ, Jariwala SH. Photobiomodulation and Vascularization in Conduit-Based Peripheral Nerve Repair: A Narrative Review. Photobiomodul Photomed Laser Surg 2024; 42:1-10. [PMID: 38109199 DOI: 10.1089/photob.2023.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Background: Peripheral nerve injuries pose a significant clinical issue for patients, especially in the most severe cases wherein complete transection (neurotmesis) results in total loss of sensory/motor function. Nerve guidance conduits (NGCs) are a common treatment option that protects and guides regenerating axons during recovery. However, treatment outcomes remain limited and often fail to achieve full reinnervation, especially in critically sized defects (>3 cm) where a lack of vascularization leads to neural necrosis. Conclusions: A multitreatment approach is, therefore, necessary to improve the efficacy of NGCs. Stimulating angiogenesis within NGCs can help alleviate oxygen deficiency through rapid inosculation with the host vasculature, whereas photobiomodulation therapy (PBMT) has demonstrated beneficial therapeutic effects on regenerating nerve cells and neovascularization. In this review, we discuss the current trends of NGCs, vascularization, and PBMT as treatments for peripheral nerve neurotmesis and highlight the need for a combinatorial approach to improve functional and clinical outcomes.
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Affiliation(s)
- Christopher R Fellin
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Richard C Steiner
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Jack T Buchen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Juanita J Anders
- Department of Anatomy, Physiology and Genetics, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Shailly H Jariwala
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- The Center for Rehabilitation Sciences Research, Department of Physical Medicine and Rehabilitation, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
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3
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Klehmet J, Tackenberg B, Haas J, Kieseier BC. Fatigue, depression, and product tolerability during long-term treatment with intravenous immunoglobulin (Gamunex® 10%) in patients with chronic inflammatory demyelinating polyneuropathy. BMC Neurol 2023; 23:207. [PMID: 37237267 DOI: 10.1186/s12883-023-03223-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 04/22/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION/AIMS Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is characterized by progressive weakness and sensory loss, often affecting patient's ability to walk and perform activities of daily living independently. Furthermore, patients often report fatigue and depression which can affect their quality of life. These symptoms were assessed in CIDP patients receiving long-term intravenous immunoglobulin (IVIG) treatment. METHODS GAMEDIS was a multi-center, prospective, non-interventional study in adult CIDP patients treated with IVIG (10%) and followed for two years. Inflammatory Neuropathy Cause and Treatment (INCAT) disability score, Hughes Disability Scale (HDS), Fatigue Severity Scale (FSS), Beck Depression Inventory II (BDI), Short Form-36 health survey (SF-36) and Work Productivity and Activity Impairment Score Attributable to General Health (WPAI-GH) were assessed at baseline and quarterly. Dosing and treatment intervals, changes in outcome parameters, and adverse events (AEs) were analyzed. RESULTS 148 evaluable patients were followed for a mean of 83.3 weeks. The mean maintenance IVIG dose was 0.9 g/kg/cycle (mean cycle interval 38 days). Disability and fatigue remained stable throughout the study. Mean INCAT score: 2.4 ± 1.8 at baseline and 2.5 ± 1.9 at study end. HDS: 74.3% healthy/minor symptoms at baseline and 71.6% at study end. Mean FSS: 4.2 ± 1.6 at baseline and 4.1 ± 1.7 at study end. All patients reported minimal/no depression at baseline and throughout. SF-36 and WPAI-GH scores remained stable. Fifteen patients (9.5%) experienced potentially treatment-related AEs. There were no AEs in 99.3% of infusions. DISCUSSION Long-term treatment of CIDP patients with IVIG 10% in real-world conditions maintained clinical stability on fatigue and depression over 96 weeks. This treatment was well-tolerated and safe.
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Affiliation(s)
- Juliane Klehmet
- Charité - Universitätsmedizin Berlin, Neurocure Clinical Research Center Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, 13347, Berlin-Mitte, Germany
| | - Björn Tackenberg
- Klinik Und Poliklinik Für Neurologie, Baldingerstrasse 1, 35043, Marburg, Germany
| | - Judith Haas
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, 13347, Berlin-Mitte, Germany
| | - Bernd C Kieseier
- Klinik Fur Neurologie, Heinrich-Heine Universität, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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4
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Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
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Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
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5
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Younger DS. On the path to evidence-based therapy in neuromuscular disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:315-358. [PMID: 37562877 DOI: 10.1016/b978-0-323-98818-6.00007-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neuromuscular disorders encompass a diverse group of acquired and genetic diseases characterized by loss of motor functionality. Although cure is the goal, many therapeutic strategies have been envisioned and are being studied in randomized clinical trials and entered clinical practice. As in all scientific endeavors, the successful clinical translation depends on the quality and translatability of preclinical findings and on the predictive value and feasibility of the clinical models. This chapter focuses on five exemplary diseases: childhood spinal muscular atrophy (SMA), Charcot-Marie-Tooth (CMT) disorders, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), acquired autoimmune myasthenia gravis (MG), and Duchenne muscular dystrophy (DMD), to illustrate the progress made on the path to evidenced-based therapy.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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6
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Doneddu PE, De Lorenzo A, Manganelli F, Cocito D, Fazio R, Briani C, Mazzeo A, Filosto M, Cosentino G, Benedetti L, Schenone A, Marfia GA, Antonini G, Matà S, Luigetti M, Liberatore G, Spina E, Peci E, Strano C, Cacciavillani M, Gentile L, Cotti Piccinelli S, Cortese A, Bianchi E, Nobile-Orazio E. Comparison of the diagnostic accuracy of the 2021 EAN/PNS and 2010 EFNS/PNS diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol Neurosurg Psychiatry 2022; 93:1239-1246. [PMID: 36190959 DOI: 10.1136/jnnp-2022-329357] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/13/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare the sensitivity and specificity of the 2021 European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with those of the 2010 European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS). METHODS Sensitivity and specificity of the two sets of criteria were evaluated in 330 patients with CIDP and 166 axonal peripheral neuropathy controls. Comparison of the utility of nerve conduction studies with different number of nerves examined and of the sensitivity and specificity of the two criteria in typical CIDP and its variants were assessed. RESULTS EFNS/PNS criteria had a sensitivity of 92% for possible CIDP and 85% for probable/definite CIDP, while the EAN/PNS criteria had a sensitivity of 83% for possible CIDP and 74% for CIDP. Using supportive criteria, the sensitivity of the EAN/PNS criteria for possible CIDP increased to 85% and that of CIDP to 77%, remaining lower than that of the EFNS/PNS criteria. Specificity of the EFNS/PNS criteria was 68% for possible CIDP and 84% for probable/definite CIDP, while the EAN/PNS criteria had a specificity of 88% for possible CIDP and 98% for CIDP. More extended studies increased the sensitivity of both sets of criteria by 4%-7% but reduced their specificity by 2%-3%. The EFNS/PNS criteria were more sensitive for the diagnosis of typical CIDP while the EAN/PNS criteria were more specific for the diagnosis of distal and sensory CIDP. CONCLUSIONS In our population, the EAN/PNS criteria were more specific but less sensitive than the EFNS/PNS criteria. With the EAN/PNS criteria, more extended nerve conduction studies are recommended to obtain an acceptable sensitivity while maintaining a high specificity.
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Affiliation(s)
- Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, Humanitas Clinical and Research Center-IRCCS, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alberto De Lorenzo
- Neuromuscular and Neuroimmunology Unit, Humanitas Clinical and Research Center-IRCCS, Milano, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Napoli, Campania, Italy
| | - Dario Cocito
- Divisione di Riabilitazione Neuromotoria, Istituti Clinici Scientifici Maugeri-Presidio Sanitario Major, Torino, Italy, Torino, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Lombardia, Italy
| | - Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, Unit of Neurology, University of Messina, Messina, Sicilia, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, NeMO-Brescia Clinical Center for Neuromuscular Diseases, University of Brescia, Brescia, Italy
| | - Giuseppe Cosentino
- IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | | | - Angelo Schenone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Girolama Alessandra Marfia
- Dysimmune Neuropathies Unit, Department of Systems Medicine, University of Rome Tor Vergata, Roma, Italy
| | - Giovanni Antonini
- Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, University of Rome La Sapienza, Rome, Italy
| | - Sabrina Matà
- Dipartimento Neuromuscoloscheletrico e degli organi di Senso, Neurology Unit, Careggi University Hospital, Firenze, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giuseppe Liberatore
- Neuromuscular and Neuroimmunology Unit, Humanitas Clinical and Research Center-IRCCS, Milano, Italy
| | - Emanuele Spina
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Napoli, Campania, Italy
| | - Erdita Peci
- Department of Neuroscience, University of Turin, Torino, Italy
| | - Camilla Strano
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milano, Lombardia, Italy
| | | | - Luca Gentile
- Department of Clinical and Experimental Medicine, Unit of Neurology, University of Messina, Messina, Sicilia, Italy
| | - Stefano Cotti Piccinelli
- Department of Clinical and Experimental Sciences, NeMO-Brescia Clinical Center for Neuromuscular Diseases, University of Brescia, Brescia, Italy
| | - Andrea Cortese
- IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Elisa Bianchi
- Laboratorio di Malattie Neurologiche, Istituto di ricerche farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, Humanitas Clinical and Research Center-IRCCS, Milano, Italy .,Department of Medical Biotechnology, Translational Medicine Milan University, Italy
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7
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Chen Y, Tang X. Chronic Inflammatory Demyelinating Polyradiculoneuropathy in Association With Concomitant Diseases: Identification and Management. Front Immunol 2022; 13:890142. [PMID: 35860284 PMCID: PMC9289227 DOI: 10.3389/fimmu.2022.890142] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare, heterogeneous, but treatable autoimmune-mediated peripheral neuropathy characterized by demyelination. CIDP can occur independently or simultaneously with a variety of diseases such as diabetes, monoclonal gammopathy of undetermined significance (MGUS), connective tissue disease, and HIV. It is important to identify CIDP and specific peripheral neuropathies caused by these diseases; this review aims to summarize the CIDP literatures related to diabetes, MGUS, SLE, and HIV, and to be helpful for the management of such patients.
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8
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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9
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Lino AMM, Castelli JB, Szor RS, Fernandes F, Aiello VD. Diagnostic challenges in systemic amyloidosis: a case report with clinical and laboratorial pitfalls. AUTOPSY AND CASE REPORTS 2021; 11:e2021326. [PMID: 34631606 PMCID: PMC8489187 DOI: 10.4322/acr.2021.326] [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: 03/29/2021] [Accepted: 07/22/2021] [Indexed: 12/02/2022] Open
Abstract
Currently, there is growing evidence in the literature warning of misdiagnosis involving amyloidosis and chronic inflammatory demyelinating polyneuropathy (CIDP). Although inducing clinical manifestations outside the peripheral nervous system, light chain and transthyretin amyloidosis may initially present with peripheral neuropathy, which can be indistinguishable from CIDP, leading to a delay in the correct diagnosis. Besides, the precise identification of the amyloid subtype is often challenging. This case report exemplifies clinical and laboratory pitfalls in diagnosing amyloidosis and subtyping amyloid, exposing the patient to potentially harmful procedures.
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Affiliation(s)
- Angelina Maria Martins Lino
- Universidade de São Paulo (USP), Hospital das Clínicas, Department of Neurology, Clinical Peripheral Nerve Group, São Paulo, SP, Brasil
| | - Jussara Bianchi Castelli
- Universidade de São Paulo (USP), Instituto do Coração, Laboratory of Pathology, São Paulo, SP, Brasil.,Grupo Fleury, Department of Pathology, São Paulo, SP, Brasil
| | - Roberta Shcolnik Szor
- Universidade de São Paulo (USP), Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Fabio Fernandes
- Universidade de São Paulo (USP), Instituto do Coração, Cardiomiopathy Group, São Paulo, SP, Brasil
| | - Vera Demarchi Aiello
- Universidade de São Paulo (USP), Instituto do Coração, Laboratory of Pathology, São Paulo, SP, Brasil
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10
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Pillittere J, Mian S, Richardson TE, Perl A. Hydroxychloroquine-Induced Toxic Myopathy Causing Diaphragmatic Weakness and Lung Collapse Requiring Prolonged Mechanical Ventilation. J Investig Med High Impact Case Rep 2021; 8:2324709620950113. [PMID: 32787461 PMCID: PMC7427040 DOI: 10.1177/2324709620950113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 42-year-old woman with juvenile idiopathic arthritis was treated with anakinra, corticosteroids, and hydroxychloroquine when she developed chronic hypoxic respiratory myopathy. She was admitted to the intensive care unit for acute hypercapnic respiratory failure and required prolonged intubation, subsequent tracheostomy, and long-term ventilatory support due to multiple failed spontaneous breathing trials after discontinuation of anakinra and steroids. Muscle biopsy revealed type II fiber atrophy with the accumulation of autophagosomes and vacuoles presenting as curvilinear bodies, elevated MHC class I antigen expression, and infiltration by CD68+ macrophages and CD8+ T cells. Type II fiber atrophy was attributed to corticosteroid use and curvilinear bodies due to blockade of autophagy by hydroxychloroquine. After hydroxychloroquine was discontinued, the patient recovered to her prehospitalization baseline.
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Affiliation(s)
- Julie Pillittere
- State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Sundus Mian
- State University of New York, Upstate Medical University, Syracuse, NY, USA
| | | | - Andras Perl
- State University of New York, Upstate Medical University, Syracuse, NY, USA
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11
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Castillo JJ, Callander NS, Baljevic M, Sborov DW, Kumar S. The evaluation and management of monoclonal gammopathy of renal significance and monoclonal gammopathy of neurological significance. Am J Hematol 2021; 96:846-853. [PMID: 33709474 PMCID: PMC8252623 DOI: 10.1002/ajh.26155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 12/24/2022]
Abstract
Despite the benign nature of monoclonal gammopathy of undetermined significance (MGUS), mounting data are associating MGUS with the development of organ dysfunction, specifically monoclonal gammopathy of renal significance (MGRS) and monoclonal gammopathy of neurological significance (MGNS), which could be associated with substantial morbidity. Emerging evidence suggests that patients with MGRS and MGNS could benefit from treatments used for myeloma, Waldenström macroglobulinemia, or chronic lymphocytic leukemia, depending on the underlying pathology. However, the treatment of MGRS and MGNS is not standardized, and potentially effective therapies might not be reimbursed because these conditions do not formally meet the criteria for malignant processes. The present review aims at establishing standards for the evaluation and management of MGRS and MGNS, which can facilitate the diagnosis of and provide therapeutic options for treating practitioners and patients affected by these conditions. The careful design and execution of clinical trials for patients with MGRS and MGNS are positively encouraged.
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Affiliation(s)
- Jorge J. Castillo
- Dana‐Farber Cancer Institute Harvard Medical School Boston Massachusetts
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12
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Vizcarra JA, Harrison TB, Garcia-Santibanez R. Update on Nodopathies of the Peripheral Nerve. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Leavell Y, Shin SC. Paraproteinemias and Peripheral Nerve Disease. Clin Geriatr Med 2021; 37:301-312. [PMID: 33858612 DOI: 10.1016/j.cger.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article provides an overview of the clinical features, diagnosis, and treatment of the major paraprotein-related peripheral neuropathies, including monoclonal gammopathy of undetermined significance, Waldenström macroglobulinemia, POEMS syndrome, multiple myeloma, transthyretin amyloidosis, and light chain amyloidosis. For each paraprotein neuropathy, the epidemiology, demographics, systemic findings, and electrophysiologic features are presented. Pharmacologic treatment of transthyretin amyloid polyneuropathy also is reviewed.
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Affiliation(s)
- Yaowaree Leavell
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susan C Shin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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14
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Babatin MA, AlJohani A. Demyelinating polyneuropathy associated with chronic inactive hepatitis B infection. BMJ Case Rep 2021; 14:14/3/e237070. [PMID: 33766960 PMCID: PMC7996366 DOI: 10.1136/bcr-2020-237070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is a case report of a 42-year-old female patient with chronic inactive hepatitis B virus (HBV) infection who presented with relapsing chronic inflammatory demyelinating polyneuropathy (CIDP). Her initial attack was of acute onset (ie, acute CIDP) resembling Guillain-Barré syndrome that responded well to intravenous immunoglobulin (IVIG) therapy. The second episode was chronic and refractory to IVIG. She was managed with plasma exchange, long-term corticosteroids, immunosuppressants and HBV antiviral therapy. She showed both clinical and electromyographic improvement, with no recurrence after 2 years of follow-up.
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15
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Shouman K, Dubey D, Engelstad JK, Dyck PJB. Focal sensory chronic inflammatory demyelinating polyneuropathy (CIDP). Muscle Nerve 2021; 63:E46-E49. [PMID: 33594681 DOI: 10.1002/mus.27206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Kamal Shouman
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Rosario-Concepción RA, Pagán-Rosado RD. Exertional Painless Weakness: Chronic Inflammatory Demyelinating Polyradiculoneuropathy in a Recreational Runner. Curr Sports Med Rep 2021; 20:76-79. [PMID: 33560029 DOI: 10.1249/jsr.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Nugraha ES, Huang I, Supriyadi R, Girawan D, Bestari MB. Successful Nucleoside Analog and Corticosteroid Therapy for Chronic Inflammatory Demyelinating Polyneuropathy in a Patient With Hepatitis B Virus Liver Cirrhosis. ACG Case Rep J 2021; 8:e00519. [PMID: 33457438 PMCID: PMC7808564 DOI: 10.14309/crj.0000000000000519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/04/2020] [Indexed: 11/17/2022] Open
Abstract
Here, we describe the case of a 44-year-old man with chronic hepatitis B virus (HBV) infection, who was admitted with progressive muscle weakness and paresthesia in all extremities. He showed slight icterus. Positive HBV e-antigen test, significant HBV-deoxyribonucleic acid load, hypoalbuminemia, hyperbilirubinemia, mild ascites, and demyelinating peripheral axonal lesions in both sensory and motor nerves led to the diagnosis of Child-Pugh class B HBV cirrhosis with chronic inflammatory demyelinating polyneuropathy. Oral lamivudine, intravenous steroids, calcium, and vitamin D therapy led to a significant recovery of muscle strength within 6 weeks and a gradual return to normal after 24 weeks.
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Affiliation(s)
- Eka Surya Nugraha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Ian Huang
- Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Rudi Supriyadi
- Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Dolvy Girawan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Muhammad Begawan Bestari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
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18
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Malik A, Berry R, Fung BM, Tabibian JH. Association between chronic inflammatory demyelinating polyneuropathy and gastrointestinal malignancies. Clin J Gastroenterol 2020; 14:1-13. [PMID: 33146871 DOI: 10.1007/s12328-020-01281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon and under-recognized immune-mediated disorder of the peripheral nervous system. It is associated with both infectious and non-infectious etiologies and presents in several variant forms. In rare instances, CIDP has been reported in association with gastrointestinal (esophageal, hepatic, colorectal, and pancreatic) malignancies. The diagnosis of malignancy is typically preceded by weeks to months by that of CIDP, though the inverse may also be seen. As with other etiologies of CIDP, cases associated with gastrointestinal malignancies are often treated with corticosteroids, intravenous immunoglobulins, and/or plasma exchange, with improvement or resolution of neurological symptoms in the majority of cases. In this review, we provide a practical overview of CIDP, with an emphasis on recognizing the clinical association between CIDP and gastrointestinal malignancies.
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Affiliation(s)
- Adnan Malik
- Division of Hepatology, Loyola University Medical Center, Maywood, IL, USA
| | - Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Brian M Fung
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA, 2B-182, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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19
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Ogata H, Zhang X, Inamizu S, Yamashita KI, Yamasaki R, Matsushita T, Isobe N, Hiwatashi A, Tobimatsu S, Kira JI. Optic, trigeminal, and facial neuropathy related to anti-neurofascin 155 antibody. Ann Clin Transl Neurol 2020; 7:2297-2309. [PMID: 33080117 PMCID: PMC7664262 DOI: 10.1002/acn3.51220] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/19/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To characterize the frequency and patterns of optic, trigeminal, and facial nerve involvement by neuroimaging and electrophysiology in IgG4 anti-neurofascin 155 antibody-positive (NF155+ ) chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS Thirteen IgG4 NF155+ CIDP patients with mean onset age of 34 years (11 men) were subjected to neurological examination, blink reflex, and visual-evoked potential (VEP) testing, and axial and/or coronal T2-weighted head magnetic resonance imaging (MRI). RESULTS Among 13 patients, facial sensory impairment, facial weakness, and apparent visual impairment were observed in three (23.1%), two (15.4%), and two (15.4%) patients, respectively. All 12 patients tested had blink reflex abnormalities: absent and/or delayed R1 in 11 (91.7%), and absent and/or delayed R2 in 10 (83.3%). R1 latencies had strong positive correlations with serum anti-NF155 antibody levels (r = 0.9, P ≤ 0.0001 on both sides) and distal and F wave latencies of the median and ulnar nerves. Absent and/or prolonged VEPs were observed in 10/13 (76.9%) patients and 17/26 (65.4%) eyes. On MRI, hypertrophy, and high signal intensity of trigeminal nerves were detected in 9/13 (69.2%) and 10/13 (76.9%) patients, respectively, whereas optic nerves were normal in all patients. The intra-orbital trigeminal nerve width on coronal sections showed a significant positive correlation with disease duration. INTERPRETATION Subclinical demyelination frequently occurs in the optic, trigeminal, and facial nerves in IgG4 NF155+ CIDP, suggesting that both central and peripheral myelin structures of the cranial nerves are involved in this condition, whereas nerve hypertrophy only develops in myelinated peripheral nerve fibers.
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Affiliation(s)
- Hidenori Ogata
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Xu Zhang
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Translational Neuroscience Center, Graduate School of Medicine, International University of Health and Welfare, Okawa, Japan
| | - Saeko Inamizu
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken-Ichiro Yamashita
- Department of Clinical Neurophysiology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriko Isobe
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akio Hiwatashi
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shozo Tobimatsu
- Translational Neuroscience Center, Graduate School of Medicine, International University of Health and Welfare, Okawa, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Translational Neuroscience Center, Graduate School of Medicine, International University of Health and Welfare, Okawa, Japan.,School of Pharmacy at Fukuoka, International University of Health and Welfare, Okawa, Japan.,Department of Neurology, Brain and Nerve Center, Fukuoka Central Hospital, International University of Health and Welfare, Fukuoka, Japan
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20
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Anagnostouli M, Vakrakou AG, Zambelis T, Boufidou F, Nikolaou C, Karandreas N, Kilidireas C. Myasthenia gravis, atypical polyneuropathy and multiple autoimmune phenomena in the same patient, with HLA-immunogenetic profile expectable for Greek chronic inflammatory demyelinating polyneuropathy: a case report. Int J Neurosci 2020; 132:593-600. [PMID: 32988257 DOI: 10.1080/00207454.2020.1829616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The comorbidity of myasthenia gravis (MG), with other autoimmune disorders like systemic lupus erythematosus (SLE), is relatively frequent but the co-occurrence with chronic inflammatory demyelinating polyneuropathy (CIDP) along with various autoimmune manifestations in the absence of thymoma is of extreme rarity. Our aim is to report a case of a woman who presented the concomitant appearance of MG, axonal sensory-motor polyneuropathy and hepatitis that may indicate an underlying pathogenetic link among the different autoimmune disorders. MATERIALS AND METHODS/RESULTS We present a case of a 54-year-old woman, with a generalized MG and a chronic sensory-motor polyneuropathy, hypothyroidism, anaemia, hepatitis, livedo reticularis and facial flush, of assumed autoimmune background, like SLE, although with persistent negative ANA antibodies, from the beginning and through the whole following years. The Human Leukocyte Antigen (HLA)-DRB1 genotyping showed a profile of alleles (DRB1*11:01/11:04) compatible with CIDP of mainly female gender in Greece and frequencies close to those of Sjogren's syndrome and scleroderma's in the Greek population. The diagnostic problems, the atypical clinical, electrophysiological and immunological features are discussed, along with the rarity of the case, with this exceptional combination of autoimmune manifestations, which could be truly associated under the clinical umbrella of a systemic disease, like SLE. However, our patient did not ever fulfil the SLE criteria. CONCLUSIONS To raise awareness among clinicians about the exceptional combination of autoimmune manifestations driven by a specific HLA background.
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Affiliation(s)
- Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Immunogenetics Laboratory, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Thomas Zambelis
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Fotini Boufidou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Chrysoula Nikolaou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Nikolaos Karandreas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Neuroimmunology Laboratory, 1st Department of Neurology of Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
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21
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Dörner M, Schreiber F, Stephanik H, Tempelmann C, Winter N, Stahl JH, Wittlinger J, Willikens S, Kramer M, Heinze HJ, Vielhaber S, Schelle T, Grimm A, Schreiber S. Peripheral Nerve Imaging Aids in the Diagnosis of Immune-Mediated Neuropathies-A Case Series. Diagnostics (Basel) 2020; 10:diagnostics10080535. [PMID: 32751486 PMCID: PMC7459443 DOI: 10.3390/diagnostics10080535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Diagnosis of immune-mediated neuropathies and their differentiation from amyotrophic lateral sclerosis (ALS) can be challenging, especially at early disease stages. Accurate diagnosis is, however, important due to the different prognosis and available treatment options. We present one patient with a left-sided dorsal flexor paresis and initial suspicion of ALS and another with multifocal sensory deficits. In both, peripheral nerve imaging was the key for diagnosis. Methods: We performed high-resolution nerve ultrasound (HRUS) and 7T or 3T magnetic resonance neurography (MRN). Results: In both patients, HRUS revealed mild to severe, segmental or inhomogeneous, nerve enlargement at multiple sites, as well as an area increase of isolated fascicles. MRN depicted T2 hyperintense nerves with additional contrast-enhancement. Discussion: Peripheral nerve imaging was compatible with the respective diagnosis of an immune-mediated neuropathy, i.e., multifocal motor neuropathy (MMN) in patient 1 and multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) in patient 2. Peripheral nerve imaging, especially HRUS, should play an important role in the diagnostic work-up for immune-mediated neuropathies and their differentiation from ALS.
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Affiliation(s)
- Marc Dörner
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
- Correspondence: ; Tel.: +49-0707-1298-2141
| | - Frank Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
| | - Heike Stephanik
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Claus Tempelmann
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Natalie Winter
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Jan-Hendrik Stahl
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Julia Wittlinger
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Sophia Willikens
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Magdalena Kramer
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
- Leibniz Institue for Neurobiology (LIN), 39120 Magdeburg, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, 06847 Dessau, Germany;
| | - Alexander Grimm
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
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22
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Pathological Findings in Chronic Inflammatory Demyelinating Polyradiculoneuropathy: A Single-Center Experience. Brain Sci 2020; 10:brainsci10060383. [PMID: 32560468 PMCID: PMC7349397 DOI: 10.3390/brainsci10060383] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Objective: Segmental demyelination is the pathological hallmark of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but other elementary lesions are frequently observed, configuring a series of different pathological pictures. In this article, we review the pathological findings of a large series of sural nerve biopsies from our cohort of CIDP patients. Patients and Methods: Patients with CIDP who underwent nerve biopsy were retrospectively selected from those referred to the Institute of Neurology of the “Università Cattolica del Sacro Cuore” in Rome, Italy, from 1982 to February 2020. Sural nerve biopsy was performed according to standard protocols. Results: Sural nerve biopsy was performed in 43/130 CIDP patients. Demyelinating abnormalities and axonal loss were found in 67.4% and 83.7% of biopsies, respectively. Conversely, onion bulbs and inflammatory infiltrates were rare (18.6% and 4.7%, respectively). In three cases, we observed normal pathological findings. Conclusions: A pathognomonic pathological finding of CIDP cannot be established, but we confirm the utility of nerve biopsy in this setting to confirm the diagnosis (also in atypical phenotypes) and to elucidate pathogenic mechanisms.
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23
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Ong TL, Goh KJ, Shahrizaila N, Wong KT, Tan CY. A Severe Form of M - protein Negative Distal Acquired Demyelinating Symmetric Neuropathy. Neurol India 2020; 67:1532-1535. [PMID: 31857554 DOI: 10.4103/0028-3886.273621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Distal acquired demyelinating symmetric neuropathy (DADS) is a variant of chronic inflammatory demyelinating polyneuropathy (CIDP) characterized by symmetrical, distal, sensory or sensorimotor involvement. DADS with M-protein (DADS-M) is less responsive to immunotherapy compared to those without M-protein (DADS-I). We report a case of DADS-I with severe clinical presentation viz. early hand involvement with marked wasting, inexcitable peripheral nerves on neurophysiology and poor response to immunotherapy. Despite the unusual presentation, ancillary tests including cerebrospinal fluid analysis, nerve biopsy and nerve ultrasound were supportive of an inflammatory demyelinating polyneuropathy. This case demonstrated the heterogeneity of the disorder and expands the clinical spectrum of DADS neuropathy.
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Affiliation(s)
- Tien Lee Ong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya; Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kum-Thong Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cheng-Yin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Abstract
There is a growing realization that many patients are incorrectly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP), with at least half of patients that carry a diagnosis of CIDP in the USA possibly having a different explanation for their neuropathy or having no neuropathy at all. Many misdiagnosed patients go on to receive costly and potentially harmful treatments for a disease that they do not have, while at the same time missing an opportunity to treat their true ailment. The cost of misdiagnosis on patients and society is not trivial. Many factors contribute to misdiagnosis. Particular points of vulnerability include the evaluation of "atypical" CIDP, interpretation of equivocal nerve conduction studies, over-reliance on elevations in cerebrospinal fluid protein concentration in indeterminate ranges, and placing excessive diagnostic weight on subjective changes following the initiation of immunotherapy. In addition to heighted awareness of the challenges, adherence to CIDP diagnostic guidelines, utilization of objective metrics to document clinical change, and referrals to CIDP centers of excellence are strategies that may improve diagnostic accuracy.
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Affiliation(s)
- Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, USA.
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25
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Toz H, Gozke E. Investigation of insulin resistance and vitamin E deficiency in chronic inflammatory demyelinatıng polyneuropathy: A 5-year retrospective study. NEUROL SCI NEUROPHYS 2020. [DOI: 10.4103/nsn.nsn_19_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Kinno R, Osakabe Y, Takahashi S, Kurokawa S, Owan Y, Ono K, Baba Y. Nonsystemic vasculitic neuropathy in a patient with IgG-monoclonal gammopathy of undetermined significance: A case report. Medicine (Baltimore) 2020; 99:e19036. [PMID: 32000451 PMCID: PMC7004602 DOI: 10.1097/md.0000000000019036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Monoclonal gammopathy of undetermined significance (MGUS) is a plasma cell proliferative disorder that consistently precedes multiple myeloma. Peripheral neuropathy in patients with IgG-MGUS tends to vary in clinical phenotype. We report a rare case of a patient with IgG-MGUS who had nonsystemic vasculitic neuropathy (NSVN). PATIENT CONCERNS A 56-year-old Japanese woman presented with progressive sensory ataxia with episodic paresthesia. Her clinical and laboratory values were compatible with IgG-MGUS. A nerve conduction study suggested possible chronic inflammatory demyelinating polyneuropathy. However, intravenous immunoglobulin therapy was not effective. A sural nerve biopsy specimen revealed mildly reduced myelinated fiber density and myelin ovoid formation, with epineural arterioles infiltrated by inflammatory cells. DIAGNOSES We accordingly diagnosed her condition as NSVN. INTERVENTIONS She was accordingly started on oral prednisolone (40 mg/d) at 3 months after the onset of her neurological symptoms. OUTCOMES At 1 year after the oral prednisolone treatment was begun, the patient's neurological symptoms showed no worsening. LESSONS These findings indicate NSVN as a possible cause of peripheral neuropathy in patients with IgG-MGUS. Cumulatively, our findings highlight the need for a nerve biopsy for peripheral neuropathy in patients with IgG-MGUS as a possible cause of NSVN. The early diagnosis of NSVN is expected to be beneficial for such patients.
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Affiliation(s)
- Ryuta Kinno
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
| | - Yuyuko Osakabe
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
| | - Seiya Takahashi
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
| | - Shinji Kurokawa
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
| | - Yoshiyuki Owan
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
| | - Kenjiro Ono
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Hatanodai Shinagawa-ku, Tokyo
| | - Yasuhiko Baba
- Department of Neurology, Showa University Fujigaoka Hospital, Fujigaoka Aoba-ku, Yokohama-shi, Kanagawa
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27
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Therapeutic Plasma Exchange in Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Presse Med 2019; 48:338-346. [PMID: 31679897 DOI: 10.1016/j.lpm.2019.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/05/2019] [Indexed: 12/28/2022] Open
Abstract
Therapeutic plasma exchange (TPE) has been used as a treatment modality in many autoimmune disorders, including neurological conditions, such as Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The American Society for Apheresis (ASFA) publishes its guidelines on the use of therapeutic apheresis every 3 years based on published evidence to assist physicians with both the medical and technical aspects of apheresis consults. The ASFA Guidelines included the use of TPE in both GBS and CIDP as an acceptable first-line therapy, either alone and/or in conjunction with other therapeutic modalities. In this article, we briefly reviewed GBS and CIDP, discussed the role of apheresis in these conditions as well as various technical aspects of the TPE procedure, such as apheresis calculation, number of volume exchange, replacement fluid, and management of potential complications.
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28
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Rodríguez Y, Vatti N, Ramírez-Santana C, Chang C, Mancera-Páez O, Gershwin ME, Anaya JM. Chronic inflammatory demyelinating polyneuropathy as an autoimmune disease. J Autoimmun 2019; 102:8-37. [DOI: 10.1016/j.jaut.2019.04.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
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Abstract
Sensory polyneuropathies, which are caused by dysfunction of peripheral sensory nerve fibers, are a heterogeneous group of disorders that range from the common diabetic neuropathy to the rare sensory neuronopathies. The presenting symptoms, acuity, time course, severity, and subsequent morbidity vary and depend on the type of fiber that is affected and the underlying cause. Damage to small thinly myelinated and unmyelinated nerve fibers results in neuropathic pain, whereas damage to large myelinated sensory afferents results in proprioceptive deficits and ataxia. The causes of these disorders are diverse and include metabolic, toxic, infectious, inflammatory, autoimmune, and genetic conditions. Idiopathic sensory polyneuropathies are common although they should be considered a diagnosis of exclusion. The diagnostic evaluation involves electrophysiologic testing including nerve conduction studies, histopathologic analysis of nerve tissue, serum studies, and sometimes autonomic testing and cerebrospinal fluid analysis. The treatment of these diseases depends on the underlying cause and may include immunotherapy, mitigation of risk factors, symptomatic treatment, and gene therapy, such as the recently developed RNA interference and antisense oligonucleotide therapies for transthyretin familial amyloid polyneuropathy. Many of these disorders have no directed treatment, in which case management remains symptomatic and supportive. More research is needed into the underlying pathophysiology of nerve damage in these polyneuropathies to guide advances in treatment.
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Affiliation(s)
- Kelly Graham Gwathmey
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kathleen T Pearson
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
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Hess SR, Waligora AC, Jiranek WA, Golladay GJ. Inflammatory demyelinating polyneuropathy after total hip arthroplasty. Arthroplast Today 2019; 5:17-20. [PMID: 31020015 PMCID: PMC6470325 DOI: 10.1016/j.artd.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 12/29/2022] Open
Abstract
Inflammatory demyelinating polyneuropathy is a rare but devastating condition. Guillain-Barré syndrome is the most common cause with acute inflammatory demyelinating polyneuropathy being the most common subtype that follows a monophasic course and does not recur. Chronic inflammatory demyelinating polyneuropathy occurs when symptoms persist for greater than 8 weeks. With many proposed etiologies, few reports have described acute inflammatory demyelinating polyneuropathy after total joint arthroplasty. To our knowledge, this is the first case report of chronic inflammatory demyelinating polyneuropathy developing after total hip arthroplasty that was further complicated by dislocation.
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Affiliation(s)
- Shane R Hess
- Department of Orthopedics, The CORE Institute, Phoenix, AZ, USA
| | | | | | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Ricci L, Luigetti M, Florio L, Capone F, Di Lazzaro V. Causes of chronic neuropathies: a single-center experience. Neurol Sci 2019; 40:1611-1617. [PMID: 31001716 DOI: 10.1007/s10072-019-03899-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 04/12/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Chronic neuropathies are a common cause of neurological disability worldwide. However, few reports have evaluated, in real life, the prevalence of the several conditions which can cause it. PATIENTS AND METHODS The authors reviewed informatic database for outpatient office to confirm identification of chronic neuropathy in a 3-year interval period. RESULTS Among the 100 selected patients with chronic neuropathies, almost one fifth (19%) remained idiopathic. The most common etiologies were diabetes (17%), dysimmune neuropathies (38%), and vitamin B12 deficiency (9%). In the "dysimmune neuropathies" group, we distinguished various etiologies, including dysimmune neuropathies associated or not with systemic autoimmune diseases (7 and 3%, respectively), chronic inflammatory polyneuropathy (CIDP) (8%), multifocal motor neuropathy (MMN) (3%), paraproteinemic (8%), celiac disease-related (6%), and paraneoplastic (3%) neuropathies. CONCLUSIONS In this report from a single neurological center, treatable causes of chronic neuropathies, such as dysimmune neuropathies, including CIDP, and celiac disease-associated neuropathy, were common. These findings suggest the utility of routine screening with blood testing for dysimmune neuropathy and celiac disease for all patients presenting with idiopathic chronic polyneuropathy in whom primary diagnostic testings had failed to identify an etiology for the disease. SIGNIFICANCE Our results indicate that patients with peripheral neuropathy could receive a benefit from being evaluated routinely in a specialized neurological center, as many of the conditions that were discovered represented potentially treatable causes of neuropathy.
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Affiliation(s)
- Lorenzo Ricci
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy.
| | - Marco Luigetti
- IRCCS, UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy.,Università Cattolica del Sacro Cuore, Sede di Roma, Rome, Italy
| | - Lucia Florio
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
| | - Fioravante Capone
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
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Shible AA, Ramadurai D, Gergen D, Reynolds PM. Dry Beriberi Due to Thiamine Deficiency Associated with Peripheral Neuropathy and Wernicke's Encephalopathy Mimicking Guillain-Barré syndrome: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:330-334. [PMID: 30862772 PMCID: PMC6429982 DOI: 10.12659/ajcr.914051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Beriberi due to thiamine (vitamin B1) deficiency has two clinical presentations. Patients with dry beriberi present with neuropathy, and patients with wet beriberi present with heart failure, with or without neuropathy. Dry beriberi can mimic the most common form of Guillain-Barre syndrome (GBS), an acute inflammatory demyelinating polyradiculoneuropathy (AIDP). Severe thiamine deficiency results in Wernicke's encephalopathy. This report of a case of dry beriberi and Wernicke's encephalopathy due to thiamine deficiency includes a review of the literature. CASE REPORT A 56-year old woman with a history of gallstone pancreatitis and protein-calorie malnutrition was treated six months previously with total parenteral nutrition (TPN). She initially presented at another hospital with paresthesia of the lower limbs, arms, and neck, and symptoms of encephalopathy. Initial diagnosis of GBS was made, based on magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) findings. Despite five days of intravenous immunoglobulin (IVIG) treatment, her encephalopathy worsened, requiring transfer to our hospital, where she required intubation and treatment with vasopressors. A repeat MRI of her brain showed changes consistent with Wernicke's encephalopathy. Following treatment with high-dose intravenous thiamine, her mental status improved within 48 hours, and by the third hospital day, she no longer required intubation. CONCLUSIONS Symptoms and signs of dry beriberi due to thiamine deficiency can mimic those of acute or chronic GBS. However, thiamine repletion leads to rapid clinical improvement and can prevent irreversible neurologic sequelae, including Korsakoff syndrome. Clinicians should consider thiamine deficiency in malnourished patients presenting with symptoms and signs of GBS.
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Affiliation(s)
- Ahmed A Shible
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Deepa Ramadurai
- University of Colorado Internal Medicine Residency Training Program, University of Colorado, Aurora, CO, USA
| | - Daniel Gergen
- University of Colorado Internal Medicine Residency Training Program, University of Colorado, Aurora, CO, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Broers MC, Bunschoten C, Nieboer D, Lingsma HF, Jacobs BC. Incidence and Prevalence of Chronic Inflammatory Demyelinating Polyradiculoneuropathy: A Systematic Review and Meta-Analysis. Neuroepidemiology 2019; 52:161-172. [PMID: 30669140 DOI: 10.1159/000494291] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/02/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Prevalence and incidence rates of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are required to determine the impact of CIDP on society. We aimed to estimate the prevalence and incidence of CIDP worldwide and to determine the effect of diagnostic criteria on prevalence and incidence. METHOD A systematic review was conducted for all published incidence and prevalence studies on CIDP until May 18, 2017. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. We performed a random effect meta-analysis to estimate pooled prevalence and incidence rates. RESULTS Of the 907 studies, 11 were included in the systematic review, 5 in the meta-analysis of incidence (818 cases; 220,513,514 person-years) and 9 in the meta-analysis of prevalence (3,160 cases; 160,765,325 population). These studies had a moderate quality. The pooled crude incidence rate was 0.33 per 100,000 person-years (95% CI 0.21-0.53; I2 = 95.7%) and the pooled prevalence rate was 2.81 per 100,000 (95% CI 1.58-4.39; I2 = 99.1%). Substantial heterogeneity in incidence and prevalence across studies seems to be partly explained by using different diagnostic criteria. CONCLUSION These findings provide a starting point to estimate the social burden of CIDP and demonstrate the need to reach consensus on diagnostic criteria for CIDP.
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Affiliation(s)
- Merel C Broers
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,
| | - Carina Bunschoten
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Diagnosis Particularities of Amyotrophic Lateral Sclerosis in an Elderly Patient. CURRENT HEALTH SCIENCES JOURNAL 2019; 44:92-96. [PMID: 30622763 PMCID: PMC6295188 DOI: 10.12865/chsj.44.01.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/22/2018] [Indexed: 11/24/2022]
Abstract
ABSTRACT: Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease (MND) which prognosis is poor. Early diagnosis permits to set up immediately adapted treatment. Available diagnostic criteria are based on the detection of both central and peripheral motor neuron injury in bulbar, cervical, thoracic and lumbar regions. Electrodiagnostic tests are key tools to identify peripheral motor neuron involvement. In the absence of a diagnostic biomarker of ALS, a careful clinical and neurophysiological work-up is essential to rule the differential diagnosis. The study presents the case of a 74 years-old woman who was diagnosed with ALS using clinical examination and electromyography.
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Bowley MP, Chad DA. Clinical neurophysiology of demyelinating polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:241-268. [DOI: 10.1016/b978-0-444-64142-7.00052-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Reda HM, Harvey HB, Venna N, Branda JA. Case 34-2018: A 58-Year-Old Woman with Paresthesia and Weakness of the Left Foot and Abdominal Wall. N Engl J Med 2018; 379:1862-1868. [PMID: 30403952 DOI: 10.1056/nejmcpc1810387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Haatem M Reda
- From the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - H Benjamin Harvey
- From the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - Nagagopal Venna
- From the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - John A Branda
- From the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (H.M.R., N.V.), Radiology (H.B.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
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Abstract
Since the discovery of an acute monophasic paralysis, later coined Guillain-Barré syndrome, almost 100 years ago, and the discovery of chronic, steroid-responsive polyneuropathy 50 years ago, the spectrum of immune-mediated polyneuropathies has broadened, with various subtypes continuing to be identified, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy (MMN). In general, these disorders are speculated to be caused by autoimmunity to proteins located at the node of Ranvier or components of myelin of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. Owing to the numerous subtypes of the immune-mediated neuropathies, making the right diagnosis in daily clinical practice is complicated. Moreover, treating these disorders, particularly their chronic variants, such as CIDP and MMN, poses a challenge. In general, management of these disorders includes immunotherapies, such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the emergence of more disease-specific immunotherapies should broaden the therapeutic options for these disabling diseases.
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Levine TD, Katz JS, Barohn R, Vaughan LJ, Dimachkie MM, Saperstein DS, Mozaffar T, Wolfe GI, Mayo MS, Badger GJ, Katzin L, Ritt E, Greer M, DiStefano J, Schmidt PM. Review process for IVIg treatment: Lessons learned from INSIGHTS neuropathy study. Neurol Clin Pract 2018; 8:429-436. [PMID: 30564497 PMCID: PMC6276327 DOI: 10.1212/cpj.0000000000000520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background This project is an effort to understand how orders for IV immunoglobulin (IVIg) are documented and prescribed by physicians, and subsequently, how they are reviewed by insurance companies for the treatment of immune neuropathies. Methods A panel of neuromuscular specialists reviewed case records from 248 IVIg-naive patients whose in-home IVIg infusion treatment was submitted to insurance for authorization. After reviewing a case record, 1 panelist was asked to make a diagnosis and to answer several questions about the treatment. A second panelist reviewed the original record and follow-up records that were obtained for reauthorization of additional treatments and was asked to determine whether the patient had responded to the treatment. Results Our specialists believed that only 32.2% of 248 patients had an immune neuropathy and were appropriate candidates for IVIg therapy, whereas 46.4% had neuropathies that were not immune mediated. Only 15.3% of cases met electrodiagnostic criteria for a demyelinating neuropathy. Our specialists believed that 36.7% of 128 cases with follow-up records had responded to therapy. In cases in which the initial reviewer had predicted that there would be a response to IVIg, the second reviewer found that 54% had responded. This is compared with a 27% response rate when the first reviewer predicted that there would be no response (p = 0.019). Conclusions Our expert review finds that the diagnosis of immune neuropathies made by providers, and subsequently approved for IVIg therapy by payers, is incorrect in a large percentage of cases. If payers include an expert in their review process, it would improve patient selection, appropriate use, and continuation of treatment with this expensive therapeutic agent.
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Affiliation(s)
- Todd D Levine
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Jonathan S Katz
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Richard Barohn
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Leslie J Vaughan
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Mazen M Dimachkie
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - David S Saperstein
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Tahseen Mozaffar
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Gil I Wolfe
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Matthew S Mayo
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Gary J Badger
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Lara Katzin
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Elissa Ritt
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Michelle Greer
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Joseph DiStefano
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
| | - Patrick M Schmidt
- Phoenix Neurological Associates, AZ (TDL, DSS); California Pacific Medical Center (JSK), San Francisco; The University of Kansas School of Medicine (RB, MMD, MSM); NuFACTOR, Inc. (LJV, GJB, ER, MG, JD, PMS), Temecula, CA; University of California Irvine (TM); State University of New York at Buffalo (GIW); and Grand Rounds LLC (LK), San Francisco, CA
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Abstract
PURPOSE OF REVIEW This article provides a conceptual framework for the evaluation of patients with suspected polyneuropathy to enhance the clinician's ability to localize and confirm peripheral nervous system pathology and, when possible, identify an etiologic diagnosis through use of rational clinical and judicious testing strategies. RECENT FINDINGS Although these strategies are largely time-honored, recent insights pertaining to the pathophysiology of certain immune-mediated neuropathies and to evolving genetic testing strategies may modify the way that select causes of neuropathy are conceptualized, evaluated, and managed. SUMMARY The strategies suggested in this article are intended to facilitate accurate bedside diagnosis in patients with suspected polyneuropathy and allow efficient and judicious use of supplementary testing and application of rational treatment when indicated.
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Abstract
PURPOSE OF REVIEW This article reviews the spectrum of neurologic complications associated with lymphoma, leukemia, and paraproteinemic disorders. While leptomeningeal metastasis is the most common complication of lymphoma and leukemia and peripheral neuropathy is the most common complication of paraproteinemic disorders, clinicians need to be familiar with the diverse neurologic complications of these disorders. RECENT FINDINGS Lymphomatous nervous system involvement can be difficult to diagnose, especially when it is the presenting symptom. CSF cytology and flow cytometry, as well as the imaging pattern, assist in diagnosis. Neurologic complications are less common in Hodgkin lymphoma; however, some unique paraneoplastic syndromes are associated with Hodgkin lymphoma, including primary central nervous system angiitis, limbic encephalitis, and cerebellar degeneration. Recent reports suggest that anti-metabotropic glutamate receptor 5 (mGluR5) antibodies are associated with limbic encephalitis and that anti-Tr antibodies are associated with cerebellar degeneration in Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is often misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). A lambda protein, thrombocytosis, and elevated vascular endothelial growth factor (VEGF) can all be helpful clues in diagnosis. Early recognition is important, as the neuropathy responds to radiation therapy or chemotherapy. SUMMARY Neurologic involvement can occur throughout the disease course in lymphoma and leukemia, including at presentation, with systemic progression, and at relapse. In paraproteinemias, the peripheral neuropathy phenotype, monoclonal protein type, and associated autonomic and systemic features aid in identification of an underlying plasma cell disorder.
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Dyck PJB, Tracy JA. History, Diagnosis, and Management of Chronic Inflammatory Demyelinating Polyradiculoneuropathy. Mayo Clin Proc 2018; 93:777-793. [PMID: 29866282 DOI: 10.1016/j.mayocp.2018.03.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/21/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is probably the best recognized progressive immune-mediated peripheral neuropathy. It is characterized by a symmetrical, motor-predominant peripheral neuropathy that produces both distal and proximal weakness. Large-fiber abnormalities (weakness and ataxia) predominate, whereas small-fiber abnormalities (autonomic and pain) are less common. The pathophysiology of CIDP is inflammatory demyelination that manifests as slowed conduction velocities, temporal dispersion, and conduction block on nerve conduction studies and as segmental demyelination, onion-bulb formation, and endoneurial inflammatory infiltrates on nerve biopsies. Although spinal fluid protein levels are generally elevated, this finding is not specific for the diagnosis of ClDP. Other neuropathies can resemble CIDP, and it is important to identify these to ensure correct treatment of these various conditions. Consequently, metastatic bone surveys (for osteosclerotic myeloma), serum electrophoresis with immunofixation (for monoclonal gammopathies), and human immunodeficiency virus testing should be considered for testing in patients with suspected CIDP. Chronic inflammatory demyelinating polyradiculoneuropathy can present as various subtypes, the most common being the classical symmetrical polyradiculoneuropathy and the next most common being a localized asymmetrical form, multifocal CIDP. There are 3 well-established, first-line treatments of CIDP-corticosteroids, plasma exchange, and intravenous immunoglobulin-with most experts using intravenous immunoglobulin as first-line therapy. Newer immune-modulating drugs can be used in refractory cases. Treatment response in CIDP should be judged by objective measures (improvement in the neurological or electrophysiological examination), and treatment needs to be individualized to each patient.
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Lizarraga AA, Cochrane TI, Berkowitz AL. Improvement of distal acquired demyelinating symmetric (DADS) neuropathy after exposure to factor Xa inhibitor. J Neurol Sci 2018; 388:146-149. [DOI: 10.1016/j.jns.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/25/2018] [Accepted: 03/07/2018] [Indexed: 11/16/2022]
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Chandra SR, Karru VR, Mukheem Mudabbir MA, Ramakrishnan S, Mahadevan A. Immune-mediated Neuropathies Our Experience over 3 Years. J Neurosci Rural Pract 2018; 9:30-35. [PMID: 29456342 PMCID: PMC5812156 DOI: 10.4103/jnrp.jnrp_376_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Immune-mediated peripheral neuropathy is the term applied to a spectrum of peripheral nerve disorders where immune dysregulation plays a role. Therefore, they are treatable. We analyzed the cases seen in the past 3 years by us and evaluated the clinical, laboratory, and outcome parameters in these patients. Patients and Methods Consecutive patients seen by the authors and diagnosed as immune-mediated neuropathy were analyzed for etiology, pathology, and outcome assessed. Results A total of sixty patients, 31 acute and 29 chronic neuropathies, were identified. Their subtypes treatment and outcome assessed. Males were significantly more in both acute and chronic cases. Miller Fisher 4, AMAN 1, paraplegic type 1, motor dominant type 19, Sensory-motor 1, MADSAM 3, Bifacial 2. Nonsystemic vasculitis was seen in 16 out of 29 chronic neuropathy and HIV, POEMS, and diabetes mellitus one each. Discussion There is a spectrum of immune-mediated neuropathy which varies in clinical course, response to treatment, etc., Small percentage of uncommon cases are seen. In this group, mortality was nil and morbidity was minimal. Conclusion Immune-mediated neuropathies are treatable and hence should be diagnosed early for good quality outcome.
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Affiliation(s)
| | - Venkata Raviteja Karru
- Department of Neurocentre, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - M A Mukheem Mudabbir
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Subashree Ramakrishnan
- Department of Neurocentre, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Anitha Mahadevan
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Distal Acquired Demyelinating Symmetric Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lichtenstein T, Sprenger A, Weiss K, Slebocki K, Cervantes B, Karampinos D, Maintz D, Fink GR, Henning TD, Lehmann HC. MRI biomarkers of proximal nerve injury in CIDP. Ann Clin Transl Neurol 2017; 5:19-28. [PMID: 29376089 PMCID: PMC5771316 DOI: 10.1002/acn3.502] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/17/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022] Open
Abstract
Objective To evaluate the utility of nerve diffusion tensor imaging (DTI), nerve cross‐sectional area, and muscle magnetic resonance imaging (MRI) multiecho Dixon for assessing proximal nerve injury in chronic inflammatory demyelinating polyneuropathy (CIDP). Methods In this prospective observational cohort study, 11 patients with CIDP and 11 healthy controls underwent a multiparametric MRI protocol with DTI of the sciatic nerve and assessment of muscle proton‐density fat fraction of the biceps femoris and the quadriceps femoris muscles by multiecho Dixon MRI. Patients were longitudinally evaluated by MRI, clinical examination, and nerve conduction studies at baseline and after 6 months. Results In sciatic nerves of CIDP patients, mean cross‐sectional area was significantly higher and fractional anisotropy value was significantly lower, compared to controls. In contrast, muscle proton‐density fat fraction was significantly higher in thigh muscles of patients with CIDP, compared to controls. MRI parameters showed high reproducibility at baseline and 6 months. Interpretation Advanced MRI parameters demonstrate subclinical proximal nerve damage and intramuscular fat accumulation in CIDP. Data suggest DTI and multiecho Dixon MRI might be useful in estimating axonal damage and neurogenic muscle changes in CIDP.
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Affiliation(s)
- Thorsten Lichtenstein
- Institute of Diagnostic and Interventional Radiology University Hospital of Cologne Cologne Germany
| | - Alina Sprenger
- Department of Neurology University Hospital of Cologne Cologne Germany
| | - Kilian Weiss
- Institute of Diagnostic and Interventional Radiology University Hospital of Cologne Cologne Germany.,Philips Healthcare Germany Hamburg Germany
| | - Karin Slebocki
- Institute of Diagnostic and Interventional Radiology University Hospital of Cologne Cologne Germany
| | - Barbara Cervantes
- Cognitive Neuroscience Institute of Diagnostic and Interventional Radiology Technical University Munich Munich Germany
| | - Dimitrios Karampinos
- Cognitive Neuroscience Institute of Diagnostic and Interventional Radiology Technical University Munich Munich Germany
| | - David Maintz
- Institute of Diagnostic and Interventional Radiology University Hospital of Cologne Cologne Germany
| | - Gereon R Fink
- Department of Neurology University Hospital of Cologne Cologne Germany.,Institute of Neuroscience and Medicine (INM-3) Research Centre Juelich Jülich Germany
| | - Tobias D Henning
- Institute of Diagnostic and Interventional Radiology University Hospital of Cologne Cologne Germany.,Department of Neuroradiology Krankenhaus der Barmherzigen Brüder Trier Germany
| | - Helmar C Lehmann
- Department of Neurology University Hospital of Cologne Cologne Germany
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Abstract
POEMS syndrome is a rare, chronic and disabling condition. The causes of this condition remain unknown; however, chronic overproduction of proinflammatory cytokines appears to be a major contributor. Early diagnosis is essential to start treatment before the clinical state of the patient becomes compromised. A complete evaluation of the disease at its onset is critical to the treatment decision. In localized disease, curative doses of radiation (50 Gy) is the recommended therapy. On the other hand, patients with disseminated disease should be given systemic therapy. Treatment-related morbidity can be minimized by an efficient induction therapy that modifies the cytokine status, improving clinical condition and control disease severity before mobilization and transplantation. Patients not suitable for hematopoietic stem cell transplantation (HSCT) are usually treated with alkylator-based therapy. Novel agents may also offer benefits to patients with a poor performance status or renal dysfunction, and induce transplantation eligibility. Given the biological characteristics of POEMS, immunomodulatory effects and the absence of neurotoxicity, lenalidomide appears to be an effective therapy for the treatment of POEMS, both as short induction therapy before PBSCT and in non-transplant eligible patients, as it showed high response rate and durable responses. At present, however, guidelines for the diagnosis and treatment of POEMS are not available and appear advocated.
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Affiliation(s)
- Andrea Nozza
- Department of Medical Oncology and Hematology, Humanitas Cancer Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
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Mahdi‐Rogers M, Brassington R, Gunn AA, van Doorn PA, Hughes RAC. Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 5:CD003280. [PMID: 28481421 PMCID: PMC6481566 DOI: 10.1002/14651858.cd003280.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016. OBJECTIVES To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP. SEARCH METHODS On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. 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, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome. MAIN RESULTS Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23). AUTHORS' CONCLUSIONS Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.
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Affiliation(s)
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
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Chaudhry HM, Mauermann ML, Rajkumar SV. Monoclonal Gammopathy-Associated Peripheral Neuropathy: Diagnosis and Management. Mayo Clin Proc 2017; 92:838-850. [PMID: 28473042 PMCID: PMC5573223 DOI: 10.1016/j.mayocp.2017.02.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/31/2017] [Accepted: 02/03/2017] [Indexed: 11/25/2022]
Abstract
Monoclonal gammopathies comprise a spectrum of clonal plasma cell disorders that include monoclonal gammopathy of undetermined significance, multiple myeloma, and Waldenström macroglobulinemia. In this review, we outline the epidemiology, etiology, classification, diagnosis, and treatment of monoclonal gammopathy-associated peripheral neuropathy. Monoclonal gammopathy of undetermined significance is relatively common in the general population, with a prevalence of 3% to 4% among individuals older than age 50 years. Therefore, the presence of M protein in a patient with neuropathy does not automatically indicate a causal relationship. Monoclonal gammopathy-associated peripheral neuropathy is often a difficult diagnosis with limited treatment options. Studies addressing the optimal approach to diagnosis and management of this entity are limited. In addition to a review of the literature, we present a diagnostic approach to patients with monoclonal gammopathy-associated peripheral neuropathy and discuss available data and options for treatment.
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Gooneratne IK, Naidu L, Wimalaratna S. Lewis Sumner Syndrome with focal muscle hypertrophy and central demyelination. eNeurologicalSci 2017. [DOI: 10.1016/j.ensci.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Illes Z, Blaabjerg M. Cerebrospinal fluid findings in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:125-138. [PMID: 29110767 DOI: 10.1016/b978-0-12-804279-3.00009-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The classic immunologic alteration of the cerebrospinal fluid (CSF) in Guillain-Barré syndrome (GBS), albuminocytologic dissociation, has been known since the original paper by Guillain, Barré, and Strohl. Albuminocytologic dissociation has been also described in other forms of the GBS spectrum, such as axonal motor or motor-sensory forms (AMAN, AMSAN), the anti-GQ1b spectrum of Miller Fisher syndrome, and Bickerstaff brainstem encephalitis. Cytokines, chemokines, antibodies, complement components, and molecules with a putative neuroprotective role or indicating axonal damage have also been examined using different methods. Besides these candidate approaches, proteomics has been recently applied to discover potential biomarkers. The overall results support the immunopathogenesis of GBS, but albuminocytologic dissociation remained the only consistent CSF biomarker supporting the diagnosis of GBS. Chronic inflammatory neuropathies also comprise a heterogeneous group of diseases. Increased protein in the CSF is a supportive factor of chronic inflammatory demyelinating polyneuropathy, especially in the absence of definite electrophysiologic criteria. A number of other markers have also been investigated in the CSF of patients with chronic inflammatory neuropathies, similar to GBS. However, none has been used in supporting diagnosis, differentiating among syndromes, or predicting the clinical course and treatment responses.
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Affiliation(s)
- Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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