1
|
Traub R, Qarni T, Cohen AD, Karam C. Paraproteinemic neuropathies. Muscle Nerve 2024; 70:173-179. [PMID: 38816958 DOI: 10.1002/mus.28164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/14/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024]
Abstract
The diagnostic evaluation of a peripheral neuropathy includes testing for the presence of monoclonal gammopathy, which can be found in about 10% of patients with peripheral neuropathy. Our role, as physicians, is to determine whether the neuropathy is directly related to the gammopathy or whether the co-occurrence of these two disorders is purely coincidental. The evaluating physician needs to be familiar with the different types of neuropathies associated with monoclonal gammopathies, their clinical and electrodiagnostic characteristics, and their appropriate diagnostic evaluation and management. Testing for monoclonal protein disorders includes serum protein electrophoresis (SPEP) and immunofixation of blood, and in some cases of urine, as well as measurement of free light chains and quantitative immunoglobulins. Specific antibody testing is directed by paraprotein type and neuropathy phenotype. Patients with abnormal free light chains in association with sensory and autonomic neuropathy should be evaluated for AL amyloidosis. When a lambda monoclonal protein is identified together with a clinical phenotype of chronic inflammatory demyelinating neuropathy (CIDP), a diagnosis of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, skin changes (POEMS) syndrome should be considered. Patients with IgM paraprotein associated neuropathy should be assessed for distal acquired demyelinating sensorimotor (DADS) neuropathy, with or without anti myelin associated glycoprotein (MAG) antibody or CANOMAD syndrome. In many cases, a monoclonal gammopathy of uncertain significance (MGUS) is incidental and unrelated to the neuropathy. Collaboration with oncology is critical in evaluating patients with monoclonal proteins to assess for underlying plasma cell neoplasms or B cell lymphomas.
Collapse
Affiliation(s)
- Rebecca Traub
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Taha Qarni
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam D Cohen
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
Hearn SL, Stino AM, Howard IM, Malhotra G, Robinson L. Serial electrodiagnostic testing: Utility and indications in adult neurological disorders. Muscle Nerve 2024; 69:670-681. [PMID: 38549195 DOI: 10.1002/mus.28083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 05/08/2024]
Abstract
Although existing guidelines address electrodiagnostic (EDX) testing in identifying neuromuscular conditions, guidance regarding the uses and limitations of serial (or repeat) EDX testing is limited. By assessing neurophysiological change longitudinally across time, serial electrodiagnosis can clarify a diagnosis and potentially provide valuable prognostic information. This monograph presents four broad indications for serial electrodiagnosis in adult peripheral neurological disorders. First, where clinical change has raised suspicion for a new or ongoing lesion, EDX reassessment for spatial spread of abnormality, involvement of previously normal muscle or nerve, and/or evolving pathophysiology can clarify a diagnosis. Second, where diagnosis of a progressive neuromuscular condition is uncertain, electrophysiological data from a second time point can confirm or refute suspicion. Third, to establish prognosis after a static nerve injury, a repeat study can assess the presence and extent of reinnervation. Finally, faced with a limited initial study (as when complicated by patient or environmental factors), a repeat EDX study can supplement missing or limited data to provide needed clarity. Repeat EDX studies carry certain limitations, however, such as with prognostication in the setting of remote or chronic lesions, sensory predominant fascicular injury, or mild axonal injury. Nevertheless, serial electrodiagnosis remains a valuable and underused tool in the diagnostic and prognostic evaluation of neuromuscular conditions.
Collapse
Affiliation(s)
- Sandra L Hearn
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amro Maher Stino
- Division of Neuromuscular Medicine, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ileana M Howard
- Department of Rehabilitation Medicine, University of Washington, Washington, USA
| | - Gautam Malhotra
- Altair Health, Morristown, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lawrence Robinson
- Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Gonçalves TAP, Donadel CD, Frezatti RSS, Garibaldi PMM, Calado RT, Marques Junior W, Tomaselli PJ. Monoclonal gammopathy-associated peripheral neuropathies: Uncovering pearls and challenges. J Peripher Nerv Syst 2024; 29:161-172. [PMID: 38873841 DOI: 10.1111/jns.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024]
Abstract
Monoclonal gammopathy-related peripheral neuropathies encompass a spectrum of clinical presentations in which the monoclonal protein directly damages the tissues, including the peripheral nervous system. Given the prevalence of both peripheral neuropathy and monoclonal gammopathy in the general population, these conditions may overlap in clinical practice, posing a challenge for clinicians in determining causality. Therefore, a comprehensive understanding of primary clinical syndromes and their neurophysiological patterns is of great importance for accurate differential diagnoses and effective treatment strategies. In this article, we examine the main forms of monoclonal gammopathies that affect the peripheral nerve. We explore the clinical and electrophysiological aspects and their correlation with each syndrome's corresponding monoclonal protein type. This knowledge is essential for healthcare professionals to diagnose better and manage patients presenting with monoclonal gammopathy-related peripheral nervous system involvement.
Collapse
Affiliation(s)
- Trajano Aguiar Pires Gonçalves
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Camila Derminio Donadel
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Pedro Manoel Marques Garibaldi
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Rodrigo T Calado
- Department of Medical Imaging, Hematology, and Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Wilson Marques Junior
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Pedro José Tomaselli
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
4
|
Latov N, Brannagan TH, Sander HW, Gondim FDAA. Anti-MAG neuropathy: historical aspects, clinical-pathological correlations, and considerations for future therapeutical trials. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-7. [PMID: 38325389 PMCID: PMC10849826 DOI: 10.1055/s-0043-1777728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Patients with anti-MAG neuropathy present with distal demyelinating polyneuropathy, IgM monoclonal gammopathy, and elevated titers of anti-MAG antibodies. OBJECTIVE This paper reviews what is known about the clinical presentation, course, pathophysiology, and treatment of anti-MAG neuropathy, with considerations for the design of therapeutic trials. METHODS A literature review of the medical and scientific literature related to anti-MAG neuropathy, and the design of therapeutic clinical trials in peripheral neuropathy. RESULTS Anti-MAG neuropathy can remain indolent for many years but then enter a progressive phase. Highly elevated antibody titers are diagnostic, but intermediate titers can also occur in chronic inflammatory demyelinating polyneuropathy (CIDP). The peripheral nerves can become inexcitable, thereby masking the demyelinating abnormalities. There is good evidence that the anti-MAG antibodies cause neuropathy. Reduction of the autoantibody concentration by agents that target B-cells was reported to result in clinical improvement in case series and uncontrolled trials, but not in controlled clinical trials, probably due to inadequate trial design. CONCLUSION We propose that therapeutic trials for anti-MAG neuropathy include patients with the typical presentation, some degree of weakness, highly elevated anti-MAG antibody titers, and at least one nerve exhibiting demyelinating range abnormalities. Treatment with one or a combination of anti-B-cell agents would aim at reducing the autoantibody concentration by at least 60%. A trial duration of 2 years may be required to show efficacy. The neuropathy impairment score of the lower extremities (NIS-LL) plus the Lower Limb Function (LLF) score would be a suitable primary outcome measure.
Collapse
Affiliation(s)
- Norman Latov
- Weil Medical College of Cornell University, Peripheral Neuropathy Center, New York, New York, United States.
| | - Thomas H. Brannagan
- Columbia University, Vagelos College of Physicians and Surgeons, Peripheral Neuropathy Center, Department of Neurology, New York, New York, United States.
| | - Howard W. Sander
- New York University, Department of Neurology, New York, New York, United States.
| | | |
Collapse
|
5
|
Barkhaus PE, Nandedkar SD, de Carvalho M, Swash M, Stålberg EV. Revisiting the compound muscle action potential (CMAP). Clin Neurophysiol Pract 2024; 9:176-200. [PMID: 38807704 PMCID: PMC11131082 DOI: 10.1016/j.cnp.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/30/2024] Open
Abstract
The compound muscle action potential (CMAP) is among the first recorded waveforms in clinical neurography and one of the most common in clinical use. It is derived from the summated muscle fiber action potentials recorded from a surface electrode overlying the studied muscle following stimulation of the relevant motor nerve fibres innervating the muscle. Surface recorded motor unit potentials (SMUPs) are the fundamental units comprising the CMAP. Because it is considered a basic, if not banal signal, what it represents is often underappreciated. In this review we discuss current concepts in the anatomy and physiology of the CMAP. These have evolved with advances in instrumentation and digitization of signals, affecting its quantitation and measurement. It is important to understand the basic technical and biological factors influencing the CMAP. If these influences are not recognized, then a suboptimal recording may result. The object is to obtain a high quality CMAP recording that is reproducible, whether the study is done for clinical or research purposes. The initial sections cover the relevant CMAP anatomy and physiology, followed by how these principles are applied to CMAP changes in neuromuscular disorders. The concluding section is a brief overview of CMAP research where advances in recording systems and computer-based analysis programs have opened new research applications. One such example is motor unit number estimation (MUNE) that is now being used as a surrogate marker in monitoring chronic neurogenic processes such as motor neuron diseases.
Collapse
Affiliation(s)
- Paul E. Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Sanjeev D. Nandedkar
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
- Natus Medical Inc., Hopewell Junction, NY, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Institute of Physiology, Centro de Estudos Egas Moniz, Faculty of Medicine, University of Lisbon, Portugal
- Department of Neurosciences and Mental Health, CHULN-Hospital de Santa Maria, Lisbon, Portugal
| | - Michael Swash
- Barts and the London School of Medicine, Queen Mary University of London, London UK
| | - Erik V. Stålberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
6
|
Aotsuka Y, Misawa S, Suichi T, Shibuya K, Nakamura K, Kano H, Otani R, Morooka M, Ogushi M, Nagashima K, Sato Y, Kuriyama N, Kuwabara S. Prevalence and clinical profiles of anti-myelin-associated glycoprotein neuropathy in Japan: A nationwide survey study of 133 patients. Eur J Neurol 2024; 31:e16249. [PMID: 38375741 PMCID: PMC11235640 DOI: 10.1111/ene.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 01/28/2024] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to determine the prevalence of anti-myelin-associated glycoprotein (MAG) neuropathy and the current status of such patients in Japan. METHODS We conducted a nationwide survey in 2021 using established epidemiological methods. Questionnaires were sent to all neurology and pediatric neurology departments throughout Japan to identify patients with anti-MAG neuropathy. An initial questionnaire was used to determine the number of patients, with a second one used to collect detailed clinical information. RESULTS The estimated number of patients with anti-MAG neuropathy was 353, with a prevalence of 0.28 per 100,000 and an incidence of 0.05 per 100,000. The detailed clinical profiles of 133 patients were available. The median (range) age of onset was 67 (30-87) years, with a prominent peak in the age range 66-70 years, and the male-to-female ratio was 3.6. Most patients had distal sensory-predominant polyneuropathy, and neuropathic pain (50%), or sensory ataxia (42%), while 18% had Waldenström's macroglobulinemia or multiple myeloma. Intravenous immunoglobulin was the most frequently used treatment (65%), but the response rate was <50%, whereas rituximab was given in 32% of patients, and 64% of these showed improvement. At the last visit, 27% of patients could not walk independently. CONCLUSIONS This study on anti-MAG neuropathy provides updated insights into the epidemiology of this disease, clinical profiles, and treatment approaches in Japan. Rituximab therapy, used for only one-third of the patients, demonstrated efficacy. During the final visit, a quarter of the patients were unable to walk independently. Further studies are warranted to determine the optimal management of this rare and intractable disorder.
Collapse
Affiliation(s)
- Yuya Aotsuka
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Sonoko Misawa
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Tomoki Suichi
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Kazumoto Shibuya
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Keigo Nakamura
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Hiroki Kano
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Ryo Otani
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Marie Morooka
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Moeko Ogushi
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| | - Kengo Nagashima
- Biostatistics Unit, Clinical and Translational Research CenterKeio University HospitalTokyoJapan
- Department of Preventive Medicine and Public HealthKeio University of MedicineTokyoJapan
| | - Yasunori Sato
- Biostatistics Unit, Clinical and Translational Research CenterKeio University HospitalTokyoJapan
- Department of Preventive Medicine and Public HealthKeio University of MedicineTokyoJapan
| | - Nagato Kuriyama
- Department of Social Health MedicineShizuoka Graduate University of Public HealthShizuokaJapan
- Departments of Epidemiology for Community Health and MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of MedicineChiba UniversityChibaJapan
| |
Collapse
|
7
|
Stino AM, Elsheikh B, Allen JA. Anti-myelin-associated glycoprotein neuropathy: Where do we stand? Muscle Nerve 2023; 68:823-832. [PMID: 37602932 DOI: 10.1002/mus.27954] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/22/2023]
Abstract
Myelin-associated glycoprotein (MAG) is a transmembrane glycoprotein concentrated in periaxonal Schwann cell and oligodendroglial membranes of myelin sheaths that serves as an antigen for immunoglobulin M (IgM) monoclonal antibodies. Individuals who harbor anti-MAG antibodies classically develop a progressive autoimmune peripheral neuropathy characterized clinically by ataxia, distal sensory loss, and gait instability, and electrophysiologically by distally accentuated conduction velocity slowing. Although off-label immunotherapy is common, there are currently no proven effective disease-modifying therapeutics, and most patients experience slow accumulation of disability over years and decades. The typically slowly progressive nature of this neuropathy presents unique challenges when trying to find effective anti-MAG therapeutic agents. Drug development has also been hampered by the lack of validated outcome measures that can detect clinically meaningful changes in a reasonable amount of time as well as by the lack of disease activity biomarkers. In this invited review, we provide an update on the state of clinicometric outcome measures and disease activity biomarkers in anti-MAG neuropathy. We highlight the insensitivity of widely used existing clinicometric outcome measures such as the Inflammatory Neuropathy Cause and Treatment (INCAT) disability score as well as the INCAT sensory subscore in anti-MAG neuropathy, referencing the two previous negative randomized controlled clinical trials evaluating rituximab. We then discuss newly emerging candidate therapeutic agents, including tyrosine kinase inhibitors and enhanced B-cell-depleting agents, among others. We conclude with a practical approach to the evaluation and management of anti-MAG neuropathy patients.
Collapse
Affiliation(s)
- Amro Maher Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bakri Elsheikh
- Department of Neurology, Division of Neuromuscular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey A Allen
- Department of Neurology, Division of Neuromuscular Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
8
|
Beydoun SR, Darki L. Paraproteinemic Neuropathies. Continuum (Minneap Minn) 2023; 29:1492-1513. [PMID: 37851040 DOI: 10.1212/con.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Coexistence of polyneuropathy and gammopathy is a common but potentially challenging situation in clinical practice. This article reviews the clinical, electrophysiologic, and hematologic phenotypes of the paraproteinemic neuropathies and the diagnostic and treatment strategies for each. LATEST DEVELOPMENTS Advances in our understanding of the underlying pathophysiology of various paraproteinemic neuropathies and their corresponding phenotypes have identified potential new therapeutic targets. Therapeutic strategies to diminish anti-myelin-associated glycoprotein (MAG) IgM antibodies have shown partial and inconsistent efficacy; however, antigen-specific immune therapy is being investigated as a novel treatment to remove the presumably pathogenic anti-MAG antibody. Advances in genetic and cell signaling studies have resulted in the approval of Bruton tyrosine kinase inhibitors for Waldenström macroglobulinemia. Monoclonal antibodies are being investigated for the treatment of light chain amyloidosis. ESSENTIAL POINTS Early recognition and treatment of underlying plasma cell disorders improves clinical outcomes in patients with paraproteinemic neuropathy. Despite significant progress, our knowledge regarding underlying mechanisms for paraproteinemic neuropathy is still limited. Clinicians' awareness of clinical phenotypes, electrophysiologic hallmarks, and hematologic findings of the different paraproteinemic neuropathies is crucial to promptly identify and treat patients and to avert misdiagnosis. Multidisciplinary collaboration among specialists, including neurologists and hematologists, is paramount for the optimal treatment of these patients with overlapping conditions.
Collapse
|
9
|
Doneddu PE, Ruiz M, Bianchi E, Liberatore G, Manganelli F, Cocito D, Cosentino G, Benedetti L, Marfia GA, Filosto M, Briani C, Giannotta C, Nobile-Orazio E. A diagnostic score for anti-myelin-associated-glycoprotein neuropathy or chronic inflammatory demyelinating polyradiculoneuropathy in patients with anti-myelin-associated-glycoprotein antibody. Eur J Neurol 2023; 30:501-510. [PMID: 35191144 PMCID: PMC10078711 DOI: 10.1111/ene.15296] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE A diagnostic score was developed to discriminate anti-myelin-associated-glycoprotein (MAG) neuropathy from chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and applied it to patients with atypical anti-MAG neuropathy. METHODS The clinical and electrophysiological features of patients with a diagnosis of typical anti-MAG neuropathy were compared to those of patients with a diagnosis of CIDP. The association of each feature with the diagnosis was assessed in the two groups. Features showing a significant association with the diagnosis were included in a multivariable logistic regression model and adjusted odds ratios were estimated for each feature. A score ranging from 1 to 3 was applied to each feature based on the magnitude of the estimated odds ratios. The score was then applied to patients with a clinical diagnosis of CIDP who also had high anti-MAG antibody titers (CIDP-MAG). RESULTS Thirty-one anti-MAG neuropathy patients, 45 typical CIDP patients and 16 CIDP-MAG patients were included. Scores in anti-MAG antibody patients ranged from 1 to 5 and in CIDP patients from -7 to -1. Using the score, 4/16 CIDP-MAG patients were diagnosed to have anti-MAG neuropathy and 12/16 patients to have CIDP. Response to intravenous immunoglobulin in the CIDP-MAG patients classified as CIDP was similar to that of definite CIDP patients and higher than that of anti-MAG neuropathy patients. CONCLUSIONS Our score allowed an accurate discrimination to be made, amongst patients with anti-MAG antibodies, of those affected by CIDP and the patients with anti-MAG neuropathy. This score may help proper treatment to be chosen for patients with anti-MAG antibodies with a CIDP-like presentation.
Collapse
Affiliation(s)
- Pietro E Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marta Ruiz
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elisa Bianchi
- Laboratorio di Malattie Neurologiche, IRCCS-Istituto Mario Negri, Milan, Italy
| | - Giuseppe Liberatore
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Naples, Italy
| | - Dario Cocito
- Presidio Sanitario Major, Istituti Clinici Scientifici Maugeri, Turin, Italy
| | - Giuseppe Cosentino
- IRCCS Foundation C. Mondino National Neurological Institute, Pavia, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa and IRCCS AOU San Martino-IST, Genoa, Italy
| | - Girola A Marfia
- Dysimmune Neuropathies Unit, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, NeMO-Brescia Clinical Center for Neuromuscular Diseases, University of Brescia, Brescia, Italy
| | - Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Claudia Giannotta
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
| |
Collapse
|
10
|
Abstract
This article focuses on principles of nerve conduction studies and needle electromyography applied to the electrodiagnosis of polyneuropathy. The components of the electrodiagnostic evaluation of polyneuropathy and the electrophysiological characteristics of axonal and demyelinating neuropathies and nodo-paranodopathies are reviewed.
Collapse
Affiliation(s)
- Rocio Vazquez Do Campo
- Department of Neurology, University of Alabama at Birmingham, 260 Sparks Center, 1720 7th Avenue S, Birmingham, AL 35294, USA.
| |
Collapse
|
11
|
Multidimensional evaluation is necessary to assess hand function in patients with Charcot-Marie-Tooth disease type 1A. Ann Phys Rehabil Med 2020; 64:101362. [PMID: 32109594 DOI: 10.1016/j.rehab.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/29/2020] [Accepted: 02/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Charcot-Marie-Tooth (CMT) disease type 1A (CMT1A) is the most common hereditary neuropathy. Several studies have assessed the relation between axonal loss and grip strength; however, the functional impact on dexterity and health-related quality of life (HRQoL) is unknown. We hypothesized that the severity of axonal loss will be correlated with loss of function and HRQoL. OBJECTIVE The purpose of this study was to evaluate the relation between severity of electroneuromyography impairment and its impact on function and HRQoL in adults with CMT1A. METHODS Grip and lateral pinch strength were evaluated with specific dynamometers: the Jamar and the Pinch Gauge. Dexterity was explored with the Sollerman, Jebsen, and Nine-hole Peg tests. The CMT impact on well-being was assessed by the validated Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory, and Fatigue Severity Scale, and disease severity by the CMT neuropathy score and Inflammatory Neuropathy Cause and Treatment sensory sum score. Finally, axonal loss and demyelination process was assessed by electroneuromyography. RESULTS We included 33 participants with CMT1A (23 females, mean [SD] age 47.0 [4.7] years). We found lack of correlation between severe electroneuromyography impairment (frequency of abnormal results >80%), significant distal amyotrophy (70%) and quality of life (mean [SD] scores for physical and mental SF-36 36.4 [10.0] and 48.4 [11.5]), autonomy for activities of daily living, and hand function that remains relatively preserved. We found a correlation between lateral pinch and dexterity according to the Sollerman test (r=0.52, p<0.05) but a lack of correlation among the other parameters. CONCLUSIONS Electrophysiological follow-up seems to be of little relevance to follow HRQoL in individuals with CMT1A and manual function related to functional objectives for everyday physical medicine and rehabilitation practice. The manual function is complex and requires an overall, quantitative, qualitative and multidisciplinary assessment. Each tool (Pinch Gauge, Jamar, Sollerman, Jebsen, Nine-hole Peg) measures a specific element of manual function and is necessary when performing a grip function analysis.
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Svahn J, Petiot P, Antoine JC, Vial C, Delmont E, Viala K, Steck AJ, Magot A, Cauquil C, Zarea A, Echaniz-Laguna A, Iancu Ferfoglia R, Gueguen A, Magy L, Léger JM, Kuntzer T, Ferraud K, Lacour A, Camdessanché JP. Anti-MAG antibodies in 202 patients: clinicopathological and therapeutic features. J Neurol Neurosurg Psychiatry 2018; 89:499-505. [PMID: 29070644 DOI: 10.1136/jnnp-2017-316715] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the clinicopathological and therapeutic features of patients with low (≥1000 to <10 000 Bühlmann Titre Units) (BTU), medium (10 000-70 000) or high (≥70 000) anti-myelin-associated glycoprotein (anti-MAG) antibody titres. METHODS We retrospectively and prospectively analysed standardised report forms and medical records of 202 patients from 14 neuromuscular centres. RESULTS Mean age at onset and mean time between symptom onset to last follow-up were respectively 62.6 years (25-91.4) and 8.4 years (0.3-33.3). Anti-MAG antibody titres at diagnosis were low, medium or high in 11%, 51% and 38% of patients. Patients presented with monoclonal gammopathy of undetermined significance in 68% of cases. About 17% of patients presented with 'atypical' clinical phenotype independently of anti-MAG titres, including acute or chronic sensorimotor polyradiculoneuropathies (12.4%), and asymmetric or multifocal neuropathy (3%). At the most severe disease stage, 22.4% of patients were significantly disabled. Seventy-eight per cent of patients received immunotherapies. Transient clinical worsening was observed in 12% of patients treated with rituximab (11/92). Stabilisation after rituximab treatment during the 7-12-month follow-up period was observed in 29% of patients. Clinical response to rituximab during the 6-month and/or 7-12-month follow-up period was observed in 31.5% of patients and correlated with anti-MAG titre ≥10 000 BTU. CONCLUSION Our study highlights the extended clinical spectrum of patients with anti-MAG neuropathy, which appears unrelated to antibody titre. Besides, it may also suggest beneficial use of rituximab in the early phase of anti-MAG neuropathy.
Collapse
Affiliation(s)
- Juliette Svahn
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Philippe Petiot
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | | | - Christophe Vial
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Emilien Delmont
- Department of Neurology, University Hospital Timone, Marseille, France
| | - Karine Viala
- Department of Neurophysiology and Neuropathology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Andreas J Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Armelle Magot
- Neuromuscular Reference Center, University Hospital Nantes, Nantes, France
| | - Cecile Cauquil
- Department of Neurology, University Hospital Bicêtre, Le Kremlin Bicêtre, France
| | - Aline Zarea
- Neuromuscular Competence Center, University Hospital Rouen, Rouen, France
| | | | - Ruxandra Iancu Ferfoglia
- Electroneuromyography and Neuromuscular Disorders Unit, University Hospital Geneva, Geneva, Switzerland
| | - Antoine Gueguen
- Department of Neurology, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Laurent Magy
- Department of Neurology, University Hospital Limoges, Limoges, France
| | - Jean-Marc Léger
- Department of Neurology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Thierry Kuntzer
- Department of Clinical Neurosciences, Nerve-Muscle Unit, Neurology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Karine Ferraud
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
| | - Arnaud Lacour
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
| | | | | |
Collapse
|
14
|
Dalakas MC. Advances in the diagnosis, immunopathogenesis and therapies of IgM-anti-MAG antibody-mediated neuropathies. Ther Adv Neurol Disord 2018; 11:1756285617746640. [PMID: 29403542 PMCID: PMC5791554 DOI: 10.1177/1756285617746640] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/16/2017] [Indexed: 11/17/2022] Open
Abstract
Polyneuropathy with immunoglobulin M (IgM) monoclonal gammopathy is the most common paraproteinemic neuropathy, comprising a clinicopathologically and immunologically distinct entity. The clinical spectrum spans from distal paresthesias and mild gait imbalance to more severe sensory ataxia, with falls and a varying degree of distal sensorimotor deficits. In approximately 75% of patients, the monoclonal IgM immunoreacts with myelin-associated glycoprotein (MAG) and sulfoglucuronyl glycosphingolipid (SGPG), or other peripheral nerve glycolipids that serve as antigens. These antibodies are considered pathogenic because IgM and complement are deposited on the myelin sheath, splitting the myelin lamellae, while adoptive transfer of patients’ IgM into susceptible host animals causes sensory ataxia and reproduces the human pathology. In spite of the apparently convincing pathogenicity of these antibodies, the response to immunotherapies remains suboptimal. Clorambuscil, cladibrine, cyclophospamide and intravenous immunoglobulin may help some patients but the benefits are minimal and transient. Open-label studies in >200 patients indicate that rituximab is helpful in 30–50% of these patients, even with long-term benefits, probably by suppressing IgM anti-MAG antibodies or inducing immunoregulatory T cells. Two controlled studies with rituximab did not however meet the primary endpoint, mostly because of the poor sensitivity of the scales used; they did however show statistical improvement in secondary endpoints and improved clinical functions in several patients. This review provides an overview of the clinical phenotypes and immunoreactivity of IgM to glycolipids or glycoproteins of peripheral nerve myelin, summarizes the progress on treatment with rituximab as a promising therapy, discusses the pitfalls of scales used, identifies possible biomarkers of response to therapy and highlights the promising new anti-B cell or target-specific immunotherapies.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
15
|
Sakamoto Y, Shimizu T, Tobisawa S, Isozaki E. Chronic demyelinating neuropathy with anti-myelin-associated glycoprotein antibody without any detectable M-protein. Neurol Sci 2017; 38:2165-2169. [DOI: 10.1007/s10072-017-3133-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022]
|
16
|
Dalakas MC. Rituximab in anti-MAG neuropathy: More evidence for efficacy and more predictive factors. J Neurol Sci 2017; 377:224-226. [DOI: 10.1016/j.jns.2017.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/14/2022]
|
17
|
Österlund-Tauriala E, Partanen JV. Three cases of acute distal demyelinating neuropathy with recovery. Clin Case Rep 2017; 5:822-828. [PMID: 28588819 PMCID: PMC5457988 DOI: 10.1002/ccr3.943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 08/23/2016] [Accepted: 03/02/2017] [Indexed: 11/10/2022] Open
Abstract
Guillain–Barré syndrome (GBS) may present as distal acute inflammatory demyelinating polyradiculoneuropathy (AIDP), with severe distal demyelination of the peripheral nerves in the absence of radiculitis. Clinical course is benign, and prognosis seems favorable, but nerve conduction studies (NCS) findings at nadir may resemble some chronic forms of polyneuropathy, so close follow‐up during recovery is needed.
Collapse
Affiliation(s)
- Emilia Österlund-Tauriala
- Clinical Neurosciences, Neurology Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Juhani V Partanen
- Clinical Neurosciences, Clinical Neurophysiology Helsinki University Hospital University of Helsinki Helsinki Finland
| |
Collapse
|
18
|
Lozeron P, Ribrag V, Adams D, Brisset M, Vignon M, Baron M, Malphettes M, Theaudin M, Arnulf B, Kubis N. Is distal motor and/or sensory demyelination a distinctive feature of anti-MAG neuropathy? J Neurol 2016; 263:1761-70. [DOI: 10.1007/s00415-016-8187-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/27/2022]
|
19
|
Abstract
Background:Neuropathy is common in Waldenström's macroglobulinemia (WM, an IgM-associated lymphoplasmacytic lymphoma) and in IgM-monoclonal gammopathy of undetermined significance (IgM-MGUS). Paraneoplastic or paraimmune mechanisms are thought to be involved in the pathogenesis of these neuropathies. Attempts at distinguishing WM and IgM-MGUS neuropathies are lacking especially among bone marrow (BM) confirmed patients.Methods:Retrospective analyses were performed on BM confirmed WM (N=30) and IgM-MGUS (N=73) neuropathy patients with neurologic assessments and hematologic features.Results:The presence of anemia and quantity of IgM monoclonal protein were significantly greater in WM. Based on multiple neurologic assessments differences were not found for: 1) length of time from neurologic symptom onset to evaluation; 2) chief complaint of painless loss of feeling in the feet, Romberg's sign and tremor; and 3) clinical motor, sensory and reflex abnormalities. Autonomic testing was normal in both diseases. Using nerve conduction (NCS) criteria for demyelination, 62% of IgM-MGUS and 27% of WM met this criteria (p=0.013). IgM MGUS patients had greater terminal conduction slowing by ulnar residual latency calculation (<0.01). The degree of axonal loss as measured by summated compound muscle action potentials and available nerve biopsy was not significantly different between diseases.Conclusion:Although WM and IgM-MGUS must be distinguished for hematologic prognosis and treatment, clinical neuropathy presentations of WM and IgM-MGUS are similar and likely related to comparable axonal loss in both conditions. Despite these similarities, evidence of demyelination was found by electrophysiologic studies much more commonly in IgM-MGUS. This difference may reflect varied immune mechanism(s) in the two disorders.
Collapse
|
20
|
Klein CJ, Duan X, Shy ME. Inherited neuropathies: clinical overview and update. Muscle Nerve 2013; 48:604-22. [PMID: 23801417 DOI: 10.1002/mus.23775] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2013] [Indexed: 11/06/2022]
Abstract
Inherited neuropathy is a group of common neurologic disorders with heterogeneous clinical presentations and genetic causes. Detailed neuromuscular evaluations, including nerve conduction studies, laboratory testing, and histopathologic examination, can assist in identification of the inherited component beyond family history. Genetic testing increasingly enables definitive diagnosis of specific inherited neuropathies. Diagnosis, however, is often complex, and neurologic disability may have both genetic and acquired components in individual patients. The decision of which genetic test to order or whether to order genetic tests is often complicated, and the strategies to maximize the value of testing are evolving. Apart from rare inherited metabolic neuropathies, treatment approaches remain largely supportive. We provide a clinical update of the various types of inherited neuropathies, their differential diagnoses, and distinguishing clinical features (where available). A framework is provided for clinical evaluations, including the inheritance assessment, electrophysiologic examinations, and specific genetic tests.
Collapse
Affiliation(s)
- Christopher J Klein
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA; Department of Medical Genetics, Mayo Clinic, Rochester, Minnesota, USA
| | | | | |
Collapse
|
21
|
Antoine JC, Camdessanché JP. Paraneoplastic disorders of the peripheral nervous system. Presse Med 2013; 42:e235-44. [DOI: 10.1016/j.lpm.2013.01.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/16/2012] [Accepted: 01/07/2013] [Indexed: 11/28/2022] Open
|
22
|
Kodaira M, Yamamoto K. Rituximab Improves Subclinical Temporal Dispersion of Distal Compound Muscle Action Potential in Anti-MAG/SGPG Neuropathy Associated with Waldenström Macroglobulinemia: A Case Report. Case Rep Neurol 2013; 5:34-9. [PMID: 23525653 PMCID: PMC3604870 DOI: 10.1159/000348395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Patients with anti-myelin-associated glycoprotein (MAG)/sulfated glucuronyl paragloboside (SGPG) neuropathy associated with Waldenström macroglobulinemia show demyelinating neuropathy, but the temporal dispersion of distal compound muscle action potential (CMAP) in motor nerve conduction studies (NCS), which represents heterogeneous demyelination at the motor nerve terminal, is rare. We report on a 70-year-old man with anti-MAG/SGPG neuropathy associated with Waldenström macroglobulinemia; he had a 2-year history of mild dysesthesia of the foot sole without any motor symptoms. He showed marked temporal dispersion of distal CMAP in the tibial nerve with other demyelinating findings in the NCS. The temporal dispersion of distal CMAP in the tibial nerve improved significantly, and motor function was again normal 1 year after rituximab monotherapy. The temporal dispersion of distal CMAP in anti-MAG/SGPG neuropathy is rare, but it could occur from an early stage when the patients show mild or no motor symptoms. Rituximab therapy before secondary axonal degeneration has great potential to reverse the effects of the demyelination including the temporal dispersion of distal CMAP, and to prevent the deterioration of neuropathy in anti-MAG/SGPG neuropathy.
Collapse
Affiliation(s)
- Minori Kodaira
- Department of Neurology, Nagano Municipal Hospital, Nagano, Japan
| | | |
Collapse
|
23
|
Clinical and laboratory features of neuropathies with serum IgM binding to TS-HDS. Muscle Nerve 2012; 45:866-72. [DOI: 10.1002/mus.23256] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
24
|
|
25
|
Lange DJ, Nijjar R, Voustianiouk A, Seidel G, Panchal J, Wang AK. Do A-waves help predict intravenous immunoglobulin response in multifocal motor neuropathy without block? Muscle Nerve 2011; 43:537-42. [PMID: 21305570 DOI: 10.1002/mus.21914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2010] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Are there electrophysiological findings that predict response to intravenous immunoglobulin (IVIg) in patients with lower motor neuron (LMN) syndromes without multifocal conduction block (MCB)? METHODS We enrolled 9 patients with LMN syndromes without MCB to receive 18 weeks of IVIg therapy. Response was measured at weeks 2 and 18 using the Appel Amyotrophic Lateral Sclerosis (AALS) score (includes grip and pincer strength measures), ALS Functional Rating Scale (ALSFRS), and electrophysiological measures, including motor unit estimates (MUNEs). RESULTS No change occurred in AALS or ALSFRS scores posttreatment. Grip/pincer strength increased in 7 patients (P = 0.028) after initial treatment (responders); 2 showed no improvement (non-responders). No electrophysiological measure changed after treatment in either group but MUNEs trended higher (P = 0.055). "Abnormal A-waves" (complex, repetitive biphasic, or present in multiple nerves) occurred in pretreatment studies more often in responders (P = 0.028). DISCUSSION "Abnormal A-waves" may signal IVIg-responsive LMN syndromes even if conduction block is absent.
Collapse
Affiliation(s)
- Dale J Lange
- Department of Neurology, Division of Neuromuscular Disease, Mount Sinai School of Medicine, New York, New York, USA.
| | | | | | | | | | | |
Collapse
|
26
|
Investigations and treatment of chronic inflammatory demyelinating polyradiculoneuropathy and other inflammatory demyelinating polyneuropathies. Curr Opin Neurol 2010; 23:242-8. [DOI: 10.1097/wco.0b013e3283394203] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
27
|
|
28
|
Les polyneuropathies avec IgM monoclonale anti-MAG : étude descriptive clinique, biologique, électrophysiologique et anatomopathologique d’une cohorte de 13 patients. Rev Neurol (Paris) 2009; 165:1071-9. [DOI: 10.1016/j.neurol.2009.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 03/17/2009] [Accepted: 04/24/2009] [Indexed: 11/17/2022]
|
29
|
Dalakas MC, Rakocevic G, Salajegheh M, Dambrosia JM, Hahn AF, Raju R, McElroy B. Placebo-controlled trial of rituximab in IgM anti-myelin-associated glycoprotein antibody demyelinating neuropathy. Ann Neurol 2009; 65:286-93. [PMID: 19334068 DOI: 10.1002/ana.21577] [Citation(s) in RCA: 217] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Report a double-blind, placebo-controlled study of rituximab in patients with anti-MAG demyelinating polyneuropathy (A-MAG-DP). METHODS Twenty-six patients were randomized to four weekly infusions of 375 mg/m(2) rituximab or placebo. Sample size was calculated to detect changes of > or = 1 Inflammatory Neuropathy Course and Treatment (INCAT) leg disability scores at month 8. IgM levels, anti-MAG titers, B cells, antigen-presenting cells, and immunoregulatory T cells were monitored every 2 months. RESULTS Thirteen A-MAG-DP patients were randomized to rituximab and 13 to placebo. Randomization was balanced for age, electrophysiology, disease duration, disability scores, and baseline B cells. After 8 months, by intention to treat, 4 of 13 rituximab-treated patients improved by > or = 1 INCAT score compared with 0 of 13 patients taking placebo (p = 0.096). Excluding one rituximab-randomized patient who had normal INCAT score at entry, and thus could not improve, the results were significant (p = 0.036). The time to 10m walk was significantly reduced in the rituximab group (p = 0.042) (intention to treat). Clinically, walking improved in 7 of 13 rituximab-treated patients. At month 8, IgM was reduced by 34% and anti-MAG titers by 50%. CD25+CD4+Foxp3+ regulatory cells significantly increased by month 8. The most improved patients were those with high anti-MAG titers and most severe sensory deficits at baseline. INTERPRETATION Rituximab is the first drug that improves some patients with A-MAG-DP in a controlled study. The benefit may be exerted by reducing the putative pathogenic antibodies or by inducing immunoregulatory T cells. The results warrant confirmation with a larger trial.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Neuromuscular Diseases Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Immunoglobulin M Deposition in Cutaneous Nerves of Anti-Myelin-Associated Glycoprotein Polyneuropathy Patients Correlates With Axonal Degeneration. J Neuropathol Exp Neurol 2009; 68:148-58. [DOI: 10.1097/nen.0b013e3181958187] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
31
|
Prise en charge multidisciplinaire de la maladie de Waldenström ou macroglobulinémie. ONCOLOGIE 2008. [DOI: 10.1007/s10269-008-0893-4] [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]
|
32
|
Garces-Sanchez M, Dyck PJ, Kyle RA, Zeldenrust S, Wu Y, Ladha SS, Klein CJ. Antibodies to myelin-associated glycoprotein (anti-Mag) in IgM amyloidosis may influence expression of neuropathy in rare patients. Muscle Nerve 2008; 37:490-5. [DOI: 10.1002/mus.20955] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
33
|
Bibliography. Current world literature. Neuro-muscular diseases: nerve. Curr Opin Neurol 2007; 20:600-4. [PMID: 17885452 DOI: 10.1097/wco.0b013e3282efeb3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|