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Uncini A, Cavallaro T, Fabrizi GM, Manganelli F, Vallat JM. Conduction slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies: Electrophysiology meets pathology. J Peripher Nerv Syst 2024; 29:135-160. [PMID: 38600691 DOI: 10.1111/jns.12625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/02/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
Nerve conduction studies are usually the first diagnostic step in peripheral nerve disorders and their results are the basis for planning further investigations. However, there are some commonplaces in the interpretation of electrodiagnostic findings in peripheral neuropathies that, although useful in the everyday practice, may be misleading: (1) conduction block and abnormal temporal dispersion are distinctive features of acquired demyelinating disorders; (2) hereditary neuropathies are characterized by uniform slowing of conduction velocity; (3) axonal neuropathies are simply diagnosed by reduced amplitude of motor and sensory nerve action potentials with normal or slightly slow conduction velocity. In this review, we reappraise the occurrence of uniform and non-uniform conduction velocity slowing, conduction block and temporal dispersion in demyelinating, dysmyelinating and axonal neuropathies attempting, with a translational approach, a correlation between electrophysiological and pathological features as derived from sensory nerve biopsy in patients and animal models. Additionally, we provide some hints to navigate in this complex field.
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Affiliation(s)
- Antonino Uncini
- Department of Neurosciences, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti-Pescara, Italy
| | - Tiziana Cavallaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Gian Maria Fabrizi
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Jean-Michel Vallat
- Department of Neurology, National Reference Center for "Rare Peripheral Neuropathies", CHU Dupuytren, Limoges, France
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Plantone D, Primiano G, Righi D, Romano A, Luigetti M, De Stefano N. Current Evidence Supporting the Role of Immune Response in ATTRv Amyloidosis. Cells 2023; 12:2383. [PMID: 37830598 PMCID: PMC10572348 DOI: 10.3390/cells12192383] [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: 08/16/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/14/2023] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis with polyneuropathy, also known as familial amyloid polyneuropathy (FAP), represents a progressive, heterogeneous, severe, and multisystemic disease caused by pathogenic variants in the TTR gene. This autosomal-dominant neurogenetic disorder has an adult onset with variable penetrance and an inconstant phenotype, even among subjects carrying the same mutation. Historically, ATTRv amyloidosis has been viewed as a non-inflammatory disease, mainly due to the absence of any mononuclear cell infiltration in ex vivo tissues; nevertheless, a role of inflammation in its pathogenesis has been recently highlighted. The immune response may be involved in the development and progression of the disease. Fibrillary TTR species bind to the receptor for advanced glycation end products (RAGE), probably activating the nuclear factor κB (NF-κB) pathway. Moreover, peripheral blood levels of several cytokines, including interferon (IFN)-gamma, IFN-alpha, IL-6, IL-7, and IL-33, are altered in the course of the disease. This review summarizes the current evidence supporting the role of the immune response in ATTRv amyloidosis, from the pathological mechanisms to the possible therapeutic implications.
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Affiliation(s)
- Domenico Plantone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Guido Primiano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Delia Righi
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
| | - Angela Romano
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Luigetti
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.P.); (A.R.); (M.L.)
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (D.R.); (N.D.S.)
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Lorenzoni PJ, Giugno VR, Ducci RDP, Werneck LC, Kay CSK, Scola RH. Genetic screening for transthyretin familial amyloid polyneuropathy to avoid misdiagnosis in patients with polyneuropathy associated with high protein in the cerebrospinal fluid. Acta Neurol Belg 2023:10.1007/s13760-023-02215-z. [PMID: 36840806 DOI: 10.1007/s13760-023-02215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/13/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Paulo José Lorenzoni
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil.
| | - Vinicius Riegel Giugno
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Renata Dal-Prá Ducci
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Lineu Cesar Werneck
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Claudia Suemi Kamoi Kay
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
| | - Rosana Herminia Scola
- Service of Neuromuscular Disorders, Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, 80060-900, Brazil
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Manganelli F, Fabrizi GM, Luigetti M, Mandich P, Mazzeo A, Pareyson D. Hereditary transthyretin amyloidosis overview. Neurol Sci 2022; 43:595-604. [PMID: 33188616 PMCID: PMC9780126 DOI: 10.1007/s10072-020-04889-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/05/2020] [Indexed: 01/12/2023]
Abstract
Hereditary amyloidogenic transthyretin (ATTRv) amyloidosis is a rare autosomal dominantly inherited disorder caused by mutations in the transthyretin (TTR) gene. The pathogenetic model of ATTRv amyloidosis indicates that amyloidogenic, usually missense, mutations destabilize the native TTR favouring the dissociation of the tetramer into partially unfolded species that self-assemble into amyloid fibrils. Amyloid deposits and monomer-oligomer toxicity are the basis of multisystemic ATTRv clinical involvement. Peripheral nervous system (autonomic and somatic) and heart are the most affected sites. In the last decades, a better knowledge of pathomechanisms underlying the disease led to develop novel and promising drugs that are rapidly changing the natural history of ATTRv amyloidosis. Thus, clinicians face the challenge of timely diagnosis for addressing patients to appropriate treatment. As well, the progressive nature of ATTRv raises the issue of presymptomatic testing and risk management of carriers. The main aim of this review was to focus on what we know about ATTRv so far, from pathogenesis to clinical manifestations, diagnosis and hence patient's monitoring and treatment, and from presymptomatic testing to management of carriers.
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Affiliation(s)
- Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy.
| | - Gian Maria Fabrizi
- Section of Neurology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli. UOC Neurologia, Rome, Italy
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paola Mandich
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genoa, Italy
| | - Anna Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Davide Pareyson
- Rare Neurodegenerative and Neurometabolic Diseases Unit, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Relevance of Nerve Biopsy in the Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy—A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12071691. [PMID: 35885595 PMCID: PMC9315483 DOI: 10.3390/diagnostics12071691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic Inflammatory Demyelinating Polyneuropathy is an immune-mediated pathology of the peripheral nerves and nerve roots that leads to weakness and sensory symptoms. Given its clinical heterogeneity, often times diagnosis is challenging. Even though nerve conduction studies and clinical features are the main criteria used for diagnosis, supplementary investigations, such as nerve biopsies, cerebral spinal fluid examination and magnetic resonance studies, may be used in order to confirm the diagnosis. Given the fact that the hallmark in CIDP physiopathology is the demyelination process, nerve biopsies are used to demonstrate and assess the magnitude of the phenomenon. The question and the main interest of this review is whether histopathological findings are relevant for the diagnosis and can be useful in disease assessment.
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Elderly patients with suspected Charcot-Marie-Tooth disease should be tested for the TTR gene for effective treatments. J Hum Genet 2022; 67:353-362. [PMID: 35027655 DOI: 10.1038/s10038-021-01005-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Some hereditary transthyretin (ATTRv) amyloidosis patients are misdiagnosed as Charcot-Marie-Tooth disease (CMT) at onset. We assess the findings to identify ATTRv amyloidosis among patients with suspected CMT to screen transthyretin gene variants for treatments. METHODS We assessed clinical, cerebrospinal fluid, and electrophysiological findings by comparing ATTRv amyloidosis patients with suspected CMT (n = 10) and CMT patients (n = 489). RESULTS The median (interquartile range) age at onset of neurological symptoms was 69 (64.2-70) years in the ATTRv amyloidosis vs 12 (5-37.2) years in CMT group (Mann-Whitney U, p < 0.01). The proportion of patients with initial sensory symptoms was 70% in the ATTRv amyloidosis group vs 7.1% in CMT group (Fisher's exact, p < 0.01). The proportion of patients with histories of suspected chronic inflammatory demyelinating polyneuropathy (CIDP) were 50% in the ATTRv amyloidosis group vs 8.7% in CMT group (Fisher's exact, p < .01). Other measures and outcomes were not different between the two groups. Five of the six patients with ATTRv amyloidosis received treatment and survived. INTERPRETATION For effective treatments, the transthyretin gene should be screened in patients with suspected CMT with old age at onset of neurological symptoms, initial sensory symptoms, and histories of suspected CIDP.
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Qian M, Qin L, Shen K, Guan H, Ren H, Zhao Y, Guan Y, Zhou D, Peng B, Li J, Chen L. Light-Chain Amyloidosis With Peripheral Neuropathy as an Initial Presentation. Front Neurol 2021; 12:707134. [PMID: 34650504 PMCID: PMC8505956 DOI: 10.3389/fneur.2021.707134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to better understand the clinical, electrophysiological, pathological features and prognosis of peripheral nerve involvements in primary immunoglobulin light-chain (AL) amyloidosis. Methods: We retrospectively reviewed the clinical data of eight AL amyloidosis patients with peripheral neuropathy as the initial presentation including clinical features, histopathological findings and treatment. Results: There were seven males and one female aged from 52 to 66 years. Initial symptoms included symmetrical lower extremity numbness, lower extremity pain and carpal tunnel syndrome. Seven patients suffered from severe pain and required pain management. Six patients had predominant autonomic dysfunction. Six patients had cardiac involvement, and one patient had renal involvement. Monoclonal proteins were found in all patients, with IgA λ in one, IgG λ in two, λ alone in three, κ alone in one and IgM κ in one. Sural nerve biopsies were performed in 7 cases, all of which showed amyloid deposition in the endoneurium (in the perivascular region in some cases), in addition to moderate to severe myelinated fiber loss with axonal degeneration. Six patients were treated with combined chemotherapy. In three patients who began chemotherapy earlier (6-10 months after onset), two achieved a hematological complete response, and one achieved a partial response. three patients who had delayed chemotherapy (36 months after onset) died between 5 and 12 months after diagnosis. Conclusion: Early recognition of AL amyloidosis with peripheral neuropathy as the initial symptom is very important. Nerve biopsy can help to make the diagnosis. Early diagnosis and chemotherapy are critical to achieve better outcomes.
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Affiliation(s)
- Min Qian
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Lan Qin
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Kaini Shen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Haitao Ren
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Yanhuan Zhao
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
| | - Lin Chen
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing, China
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Deschamps N, Mathis S, Duchesne M, Ghorab K, Gallouedec G, Richard L, Boulesteix JM, Corcia P, Magy L, Vallat JM. CIDP and hemopathies, an underestimated association. J Neurol Sci 2021; 429:118055. [PMID: 34455207 DOI: 10.1016/j.jns.2021.118055] [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: 07/06/2021] [Revised: 08/02/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated and treatable disease that may be associated with various systemic conditions. Our objective is to describe the clinical, electrophysiological and pathological data of a series of patients with both CIDP and hemopathy. In this retrospective study, we analyzed 21 patients with CIDP and various hemopathies (malignant or not), consecutively observed for almost five years. In this particular context (with a risk of neurological complications of the hemopathy), a nerve biopsy was taken from each patient (after written consent). All the patients fulfilled the EAN/PNS electrodiagnostic criteria (2021) of CIDP: 16 with 'CIDP' and 2 with 'possible CIDP' (no data for 3 patients). For each patient, pathological analysis of nerve biopsy was compatible with the diagnosis of CIDP, and there was no evidence for hematological complication of the peripheral nervous system. In cases of peripheral neuropathy and malignant hemopathy, the possibility that the peripheral neuropathy is CIDP should not be overlooked because CIDP is clearly accessible to appropriate therapies, with high potential for a positive clinical response. If the diagnosis of CIDP is usually suspected clinically and electrophysiologically, it should be confirmed by pathological study (nerve biopsy) in certain cases. The management of such patients benefits from the collaboration of neurologists, hematologists and oncologists.
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Affiliation(s)
- Nathalie Deschamps
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, AOC National Reference Center for Neuromuscular Disorders, ALS Center, University Hospital of Bordeaux (CHU Bordeaux - Pellegrin Hospital), place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Mathilde Duchesne
- Department of Pathology, University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Karima Ghorab
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Gaël Gallouedec
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Laurence Richard
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Jean-Marc Boulesteix
- Department of Neurology, Cahors Hospital (CH Cahors), 335 rue Wilson, 46005 Cahors, France
| | - Philippe Corcia
- Department of Neurology, ALS Center, University Hospital of Tours (CHU Tours - Bretonneau Hospital), 2 boulevard Tonnellé, 37044 Tours, France
| | - Laurent Magy
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France
| | - Jean-Michel Vallat
- Department of Neurology, National Reference Center for 'Rare Peripheral Neuropathies', University Hospital of Limoges (CHU Limoges - Dupuytren Hospital), 2 avenue Martin Luther King, 87042 Limoges, France.
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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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Koike H, Katsuno M. Paraproteinemia and neuropathy. Neurol Sci 2021; 42:4489-4501. [PMID: 34529193 DOI: 10.1007/s10072-021-05583-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/28/2021] [Indexed: 12/16/2022]
Abstract
Paraproteinemia is associated with different peripheral neuropathies. The major causes of neuropathy correlated with paraproteinemia are the deposition of immunoglobulin in the myelin, represented by anti-myelin-associated glycoprotein (MAG) neuropathy; deposition of immunoglobulin or its fragment in the interstitium, represented by immunoglobulin light chain amyloidosis (AL amyloidosis); and paraneoplastic mechanisms that cannot be solely attributed to the deposition of immunoglobulin or its fragment, represented by polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin change (POEMS) syndrome. Patients with anti-MAG neuropathy and POEMS syndrome present with slowing of nerve conduction parameters. This characteristic fulfills the electrodiagnostic criteria for chronic inflammatory demyelinating polyneuropathy (CIDP) defined by the European Academy of Neurology and Peripheral Nerve Society (EAN/PNS). Although direct damage caused by the deposition of amyloid can induce axonal damage in AL amyloidosis, some patients with this condition have features fulfilling the EAN/PNS electrodiagnostic criteria for CIDP. Conventional immunotherapies for CIDP, such as steroids, intravenous immunoglobulin, and plasma exchange, offer no or only minimal-to-modest benefit. Although rituximab can reduce the level of circulating autoantibodies, it may only be effective in some patients with anti-MAG neuropathy. Drugs including melphalan, thalidomide, lenalidomide, and bortezomib for POEMS syndrome and those including melphalan, thalidomide, lenalidomide, pomalidomide, bortezomib, ixazomib, and daratumumab for AL amyloidosis are considered. Since there will be more therapeutic options in the future, thereby enabling appropriate treatments for individual neuropathies, there is an increasing need for early diagnosis.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Cavallaro T, Tagliapietra M, Fabrizi GM, Bai Y, Shy ME, Vallat JM. Hereditary neuropathies: A pathological perspective. J Peripher Nerv Syst 2021; 26 Suppl 2:S42-S60. [PMID: 34499384 DOI: 10.1111/jns.12467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/30/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022]
Abstract
Hereditary neuropathies may result from mutations in genes expressed by Schwann cells or neurons that affect selectively the peripheral nervous system (PNS) or may represent a minor or major component of complex inherited diseases that involve also the central nervous system and/or other organs and tissues. The chapter is constantly expanding and reworking, thanks to advances of molecular genetics; next-generation sequencing is identifying a plethora of new genes and is revolutionizing the diagnostic approach. In the past, diagnostic sural nerve biopsies paved the way to the discovery and elucidation of major genes and molecular pathways associated to most frequent hereditary motor-sensory neuropathies. Nowadays, a sural nerve biopsy may prove useful in selected cases for the differential diagnosis of an acquired neuropathy when clinical examination, nerve conduction studies, and molecular tests are not sufficiently informative. Skin biopsy has emerged as a minimally invasive window on the PNS, which may provide biomarkers of progression and clues to the physiopathology and molecular pathology of inherited neuropathies. The aim of our review is to illustrate the pathological features of more frequent and paradigmatic hereditary neuropathies and to highlight their correlations with the roles of the involved genes and functional consequences of related molecular defects.
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Affiliation(s)
- Tiziana Cavallaro
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, VR, Italy
| | - Matteo Tagliapietra
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, VR, Italy
| | - Gian Maria Fabrizi
- Department of Neurosciences, Biomedicine, and Movement Sciences, University of Verona, Verona, VR, Italy
| | - Yunhong Bai
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Michael E Shy
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Jean-Michel Vallat
- Department of Neurology, National Reference Center for "Rare Peripheral Neuropathies", CHU Dupuytren, Limoges, France
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Felice KJ, Whitaker CH, Khorasanizadeh S. Diagnostic yield of advanced genetic testing in patients with hereditary neuropathies: A retrospective single-site study. Muscle Nerve 2021; 64:454-461. [PMID: 34232518 DOI: 10.1002/mus.27368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION/AIMS Advanced genetic testing including next-generation sequencing (AGT/NGS) has facilitated DNA testing in the clinical setting and greatly expanded new gene discovery for the Charcot-Marie-Tooth neuropathies and other hereditary neuropathies (CMT/HN). Herein, we report AGT/NGS results, clinical findings, and diagnostic yield in a cohort of CMT/HN patients evaluated at our neuropathy care center. METHODS We reviewed the medical records of all patients with suspected CMT/HN who underwent AGT/NGS at the Hospital for Special Care from January 2017 through January 2020. Patients with variants reported as pathogenic or likely pathogenic were included for further clinical review. RESULTS We ordered AGT/NGS on 108 patients with suspected CMT/HN. Of these, pathogenic or likely pathogenic variants were identified in 17 patients (diagnostic yield, 15.7%), including 6 (35%) with PMP22 duplications; 3 (18%) with MPZ variants; 2 (12%) with MFN2 variants; and 1 each with NEFL, IGHMBP2, GJB1, BSCL2, DNM2, and TTR variants. Diagnostic yield increased to 31.0% for patients with a positive family history. DISCUSSION AGT/NGS panels can provide specific genetic diagnoses for a subset of patients with CMT/HN disorders, which improves disease and genetic counseling and prepares patients for disease-focused therapies. Despite these advancements, many patients with known or suspected CMT/HN disorders remain without a specific genetic diagnosis. Continued advancements in genetic testing, such as multiomic technology and better understanding of genotype-phenotype correlation, will further improve detection rates for patients with suspected CMT/HN disorders.
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Affiliation(s)
- Kevin J Felice
- Department of Neuromuscular Medicine, Hospital for Special Care, New Britain, Connecticut, USA
| | - Charles H Whitaker
- Department of Neuromuscular Medicine, Hospital for Special Care, New Britain, Connecticut, USA
| | - Sadaf Khorasanizadeh
- Department of Neuromuscular Medicine, Hospital for Special Care, New Britain, Connecticut, USA
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13
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Tozza S, Severi D, Spina E, Iovino A, Aruta F, Ruggiero L, Dubbioso R, Iodice R, Nolano M, Manganelli F. The neuropathy in hereditary transthyretin amyloidosis: A narrative review. J Peripher Nerv Syst 2021; 26:155-159. [PMID: 33960565 PMCID: PMC8360044 DOI: 10.1111/jns.12451] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 01/10/2023]
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a condition with adult onset, caused by mutation of the transthyretin (TTR) gene and characterized by extracellular deposition of amyloid fibrils in tissue, especially in the peripheral nervous system (PNS) and heart. PNS involvement leads to a rapidly progressive and disabling sensory‐motor axonal neuropathy. Although awareness among neurologists increased in recent years thanks to new treatment options, ATTRv is frequently misdiagnosed, and thus a correct diagnosis can be delayed by several years. This review aims to draw the history and features of polyneuropathy in ATTRv based on pathological and electrophysiological correlates. We assessed original articles and case reports based on their relevance to ATTRv neuropathy and we included those appropriate for the scheme of this narrative review. Amyloid fibrils initially deposit in ganglia, causing an axonal neuropathy without amyloid deposits in distal segments (eg, sural nerve biopsy). Over time, amyloid fibrils spread along the nerves, leading to some demyelinating features in the context of severe axonal loss. This review highlights how the features of neuropathy change based on type of ATTRv (early vs late onset) and stage of disease.
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Affiliation(s)
- Stefano Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Daniele Severi
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Emanuele Spina
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Aniello Iovino
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Francesco Aruta
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Lucia Ruggiero
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Raffaele Dubbioso
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Rosa Iodice
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Maria Nolano
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Science, University of Naples "Federico II", Naples, Italy
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Broers MC, Bunschoten C, Drenthen J, Beck TAO, Brusse E, Lingsma HF, Allen JA, Lewis RA, van Doorn PA, Jacobs BC. Misdiagnosis and diagnostic pitfalls of chronic inflammatory demyelinating polyradiculoneuropathy. Eur J Neurol 2021; 28:2065-2073. [PMID: 33657260 PMCID: PMC8252611 DOI: 10.1111/ene.14796] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/13/2021] [Accepted: 02/19/2021] [Indexed: 01/16/2023]
Abstract
Background and purpose The aim of this study was to determine the frequency of over‐ and underdiagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to identify related diagnostic pitfalls. Methods We conducted a retrospective study in Dutch patients referred to the Erasmus University Medical Centre Rotterdam between 2011 and 2017 with either a diagnosis of CIDP or another diagnosis that was revised to CIDP. We used the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) 2010 diagnostic criteria for CIDP to classify patients into three groups: overdiagnosis, underdiagnosis, or confirmed diagnosis of CIDP. Clinical and laboratory features and treatment history were compared between groups. Results A referral diagnosis of CIDP was revised in 32% of patients (31/96; overdiagnosis). Of 81 patients diagnosed with CIDP, 16 (20%) were referred with another diagnosis (underdiagnosis). In the overdiagnosed patients, 20% of muscle weakness was asymmetric, 48% lacked proximal muscle weakness, 29% only had distal muscle weakness, 65% did not fulfil the electrodiagnostic criteria for CIDP, 74% had an elevated cerebrospinal fluid (CSF) protein level, and 97% had another type of neuropathy. In the underdiagnosed patients, all had proximal muscle weakness, 50% had a clinically atypical CIDP, all fulfilled the electrodiagnostic criteria for CIDP, and 25% had an increased CSF protein level. Conclusion Over‐ and underdiagnosis of CIDP is common. Diagnostic pitfalls include lack of attention to proximal muscle weakness as a diagnostic hallmark of CIDP, insufficient recognition of clinical atypical phenotypes, overreliance on CSF protein levels, misinterpretation of nerve conduction studies and poor adherence to electrodiagnostic criteria, and failure to exclude other causes of polyneuropathy.
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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
| | - Judith Drenthen
- Department of Clinical Neurophysiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tiago A O Beck
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther Brusse
- Department of Neurology, 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
| | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pieter A van Doorn
- Department of Neurology, 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 Rotterdam, Rotterdam, The Netherlands
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15
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Canadian Guidelines for Hereditary Transthyretin Amyloidosis Polyneuropathy Management. Can J Neurol Sci 2021; 49:7-18. [PMID: 33631091 DOI: 10.1017/cjn.2021.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hereditary transthyretin-mediated (hATTR) amyloidosis is a progressive disease caused by mutations in the TTR gene leading to multisystem organ dysfunction. Pathogenic TTR aggregation, misfolding, and fibrillization lead to deposition of amyloid in multiple body organs and frequently involve the peripheral nerve system and the heart. Common neurologic manifestations include: sensorimotor polyneuropathy (PN), autonomic neuropathy, small-fiber PN, and carpal tunnel syndrome. Many patients have significant progression due to diagnostic delays as hATTR PN is not considered within the differential diagnosis. Recently, two effective novel disease-modifying therapies, inotersen and patisiran, were approved by Health Canada for the treatment of hATTR PN. Early diagnosis is crucial for the timely introduction of these disease-modifying treatments that reduce impairments, improve quality of life, and extend survival. In this guideline, we aim to improve awareness and outcomes of hATTR PN by making recommendations directed to the diagnosis, monitoring, and treatment in Canada.
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Koike H, Mouri N, Fukami Y, Iijima M, Matsuo K, Yagi N, Saito A, Nakamura H, Takahashi K, Nakae Y, Okada Y, Tanaka F, Sobue G, Katsuno M. Two distinct mechanisms of neuropathy in immunoglobulin light chain (AL) amyloidosis. J Neurol Sci 2021; 421:117305. [PMID: 33540321 DOI: 10.1016/j.jns.2020.117305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/28/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Although polyneuropathy in patients with immunoglobulin light chain (AL) amyloidosis has been considered to be attributable to axonal degeneration resulting from amyloid deposition, patients with nerve conduction parameters indicating demyelination that mimics chronic inflammatory demyelinating polyneuropathy (CIDP) have also been reported anecdotally. METHODS We evaluated the electrophysiological and pathological features of 8 consecutive patients with AL amyloidosis who were referred for sural nerve biopsy. RESULTS Although findings of axonal neuropathy predominantly in the lower limbs were the cardinal feature, all patients showed one or more abnormalities of nerve conduction velocities or distal motor latencies. In particular, 2 of these patients fulfilled the definite electrophysiological for CIDP defined by the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS). On electron microscopic examination of sural nerve biopsy specimens, Schwann cells apposed to amyloid fibrils became atrophic in all patients, suggesting that amyloid deposits directly affect neighboring tissues. Additionally, detachment of the neurilemma from the outermost compacted myelin lamella was seen where amyloid fibrils were absent in 4 patients. Electrophysiological findings suggestive of demyelination were more conspicuous in these patients compared with the other patients. The detachment of the neurilemma from the outermost compacted myelin lamella was particularly conspicuous in patients who fulfilled the definite EFNS/PNS electrophysiological criteria for CIDP. CONCLUSION Abnormalities of myelinated fibers unrelated to amyloid deposition may frequently occur in AL amyloidosis. Disjunction between myelin and the neurilemma may induce nerve conduction abnormalities suggestive of demyelination.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Naohiro Mouri
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Koji Matsuo
- Department of Neurology, Kariya Toyota General Hospital, Aichi, Japan
| | - Nobuyasu Yagi
- Department of Neurology, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Asami Saito
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Haruko Nakamura
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keita Takahashi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshiharu Nakae
- Department of Neurology, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
| | - Yohei Okada
- Department of Neurology, Aichi Medical University School of Medicine, Aichi, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Gen Sobue
- Research Division of Dementia and Neurodegenerative Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Immunoglobulin variable domain high-throughput sequencing reveals specific novel mutational patterns in POEMS syndrome. Blood 2020; 135:1750-1758. [PMID: 32243509 DOI: 10.1182/blood.2019004197] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/13/2020] [Indexed: 12/22/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare multisystem disease resulting from an underlying plasma cell (PC) dyscrasia. The pathophysiology of the disease remains unclear, but the role of the monoclonal immunoglobulin (Ig) light chain (LC) is strongly suspected because of the highly restrictive usage of 2 λ variable (V) domains (IGLV1-40 and IGLV1-44) and the general improvement of clinical manifestations after PC clone-targeted treatment. However, the diagnostic value of Ig LC sequencing, especially in the case of incomplete forms of the disease, remains to be determined. Using a sensitive high-throughput Ig repertoire sequencing on RNA (rapid amplification of cDNA ends-based repertoire sequencing [RACE-RepSeq]), we detected a λ LC monoclonal expansion in the bone marrow (BM) of 83% of patients with POEMS syndrome, including some in whom BM tests routinely performed to diagnose plasma cell dyscrasia failed to detect λ+ monoclonal PCs. Twenty-four (83%) of the 29 LC clonal sequences found were derived from the IGLV1-40 and IGLV1-44 germline genes, as well as 2 from the closely related IGLV1-36 gene, and all were associated with an IGLJ3*02 junction (J) gene, confirming the high restriction of VJ region usage in POEMS syndrome. RACE-RepSeq VJ full-length sequencing additionally revealed original mutational patterns, the strong specificity of which might crucially help establish or eliminate the diagnosis of POEMS syndrome in uncertain cases. Thus, RACE-RepSeq appears as a sensitive, rapid, and specific tool to detect low-abundance PC clones in BM and assign them to POEMS syndrome, with all the consequences for therapeutic options.
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18
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Abstract
PURPOSE OF REVIEW This article provides a summary of the autonomic neuropathies, including neuropathies associated with diabetes mellitus, neuropathies due to amyloid deposition, immune-mediated autonomic neuropathies (including those associated with a paraneoplastic syndrome), inherited autonomic neuropathies, and toxic autonomic neuropathies. The presenting features, diagnostic investigations, and natural history of these neuropathies are discussed. RECENT FINDINGS Recent findings in autonomic peripheral neuropathy include data on the epidemiology and atypical presentations of diabetic autonomic neuropathy, treatment-induced neuropathy of diabetes mellitus, the presentation of immune-mediated neuropathies, and advances in hereditary neuropathy associated with amyloidosis and other hereditary neuropathies. SUMMARY Knowledge and recognition of the clinical features of the autonomic neuropathies, combined with appropriate laboratory and electrophysiologic testing, will facilitate accurate diagnosis and management.
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Vallat JM, Duchesne M, Corcia P, Richard L, Ghorab K, Magy L, Mathis S. The Wide Spectrum of Pathophysiologic Mechanisms of Paraproteinemic Neuropathy. Neurology 2020; 96:214-225. [PMID: 33277411 DOI: 10.1212/wnl.0000000000011324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/08/2020] [Indexed: 11/15/2022] Open
Abstract
Monoclonal gammopathy is encountered quite frequently in the general population. This type of hematologic abnormality may be mild, referred to as monoclonal gammopathy of undetermined significance or related to different types of hematologic malignancies. The association of a peripheral neuropathy with monoclonal gammopathy is also fairly common, and hemopathy may be discovered in an investigation of peripheral neuropathy. In such a situation, it is essential to determine the exact nature of the hematologic process in order not to miss a malignant disease and thus initiate the appropriate treatment (in conjunction with hematologists and oncologists). In this respect, nerve biopsy (discussed on a case-by-case basis) is of great value in the management of such patients. We therefore propose to present the objectives and main interests of nerve biopsy in this situation.
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Affiliation(s)
- Jean-Michel Vallat
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France.
| | - Mathilde Duchesne
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Philippe Corcia
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Laurence Richard
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Karima Ghorab
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Laurent Magy
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Stéphane Mathis
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
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20
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Thaisetthawatkul P, Dyck PJB. Peripheral Nervous System Involvement. Hematol Oncol Clin North Am 2020; 34:1091-1098. [DOI: 10.1016/j.hoc.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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21
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Vallat JM, Duchesne M, Magy L. Biopsia del nervo periferico. Neurologia 2020. [DOI: 10.1016/s1634-7072(20)44225-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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22
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Dohrn MF, Auer-Grumbach M, Baron R, Birklein F, Escolano-Lozano F, Geber C, Grether N, Hagenacker T, Hund E, Sachau J, Schilling M, Schmidt J, Schulte-Mattler W, Sommer C, Weiler M, Wunderlich G, Hahn K. Chance or challenge, spoilt for choice? New recommendations on diagnostic and therapeutic considerations in hereditary transthyretin amyloidosis with polyneuropathy: the German/Austrian position and review of the literature. J Neurol 2020; 268:3610-3625. [PMID: 32500375 PMCID: PMC8463516 DOI: 10.1007/s00415-020-09962-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023]
Abstract
Hereditary transthyretin amyloidosis is caused by pathogenic variants (ATTRv) in the TTR gene. Alongside cardiac dysfunction, the disease typically manifests with a severely progressive sensorimotor and autonomic polyneuropathy. Three different drugs, tafamidis, patisiran, and inotersen, are approved in several countries, including the European Union and the United States of America. By stabilizing the TTR protein or degrading its mRNA, all types of treatment aim at preventing amyloid deposition and stopping the otherwise fatal course. Therefore, it is of utmost importance to recognize both onset and progression of neuropathy as early as possible. To establish recommendations for diagnostic and therapeutic procedures in the follow-up of both pre-symptomatic mutation carriers and patients with manifest ATTRv amyloidosis with polyneuropathy, German and Austrian experts elaborated a harmonized position. This paper is further based on a systematic review of the literature. Potential challenges in the early recognition of disease onset and progression are the clinical heterogeneity and the subjectivity of sensory and autonomic symptoms. Progression cannot be defined by a single test or score alone but has to be evaluated considering various disease aspects and their dynamics over time. The first-line therapy should be chosen based on individual symptom constellations and contra-indications. If symptoms worsen, this should promptly implicate to consider optimizing treatment. Due to the rareness and variability of ATTRv amyloidosis, the clinical course is most importantly directive in doubtful cases. Therefore, a systematic follow-up at an experienced center is crucial to identify progression and reassure patients and carriers.
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Affiliation(s)
- Maike F Dohrn
- Neuromuscular Outpatient Clinic, Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Michaela Auer-Grumbach
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Frank Birklein
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Fabiola Escolano-Lozano
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Christian Geber
- Department of Neurology, Red Cross Pain Centre Mainz, Mainz, Germany
| | - Nicolai Grether
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Ernst Hund
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Schilling
- Department of Neurology with Institute of Translational Neurology, University Hospital of Muenster, Münster, Germany
| | - Jens Schmidt
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Wilhelm Schulte-Mattler
- Department of Psychiatry and Psychotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Claudia Sommer
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Markus Weiler
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gilbert Wunderlich
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Center for Rare Diseases, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Katrin Hahn
- Department of Neurology, Charité University Medicine, Berlin, Germany
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23
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Fortanier E, Delmont E, Verschueren A, Attarian S. Quantitative sudomotor test helps differentiate transthyretin familial amyloid polyneuropathy from chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2020; 131:1129-1133. [PMID: 32217467 DOI: 10.1016/j.clinph.2020.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/24/2019] [Accepted: 01/26/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Transthyretin familial amyloid polyneuropathy (TTR-FAP) is an aggressive hereditary neuropathy characterized by sensory and autonomic dysfunction. There are numerous reports of TTR-FAP misdiagnosed and treated as chronic inflammatory demyelinating polyneuropathy (CIDP), leading to delayed diagnosis, risk of iatrogenic adverse events and increased socio-economic costs. Quantitative sudomotor function measured by electrochemical skin conductance (ESC) appears to be a sensitive test in TTR-FAP. We aimed to evaluate the performance of ESC in differentiating TTR-FAP from CIDP. METHODS Thirty-eight patients with genetically confirmed hereditary TTR amyloidosis and 26 with definite CIDP according to the EFNS/PNS guidelines and negative TTR-FAP genetic testing were involved in this study. We compared the ESC for feet and hands measured by Sudoscan for each patient. RESULTS ESC (µS) was significantly lower in TTR-FAP for both hands (72 vs 45, p < 0.0001) and feet (77 vs 35, p < 0.0001). Feet ESC < 64 µS had a 89% sensitivity and a 96% specificity to differentiate between CIDP and TTR-FAP. CONCLUSION Sudoscan is a fast, non-invasive and easy to perform test, able to distinguish CIDP and TTR-FAP patients with good sensitivity and specificity. SIGNIFICANCE Sudoscan can be helpful in distinguishing between CIDP and TTR-FAP.
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Affiliation(s)
- E Fortanier
- Neuromuscular Disease and ALS Reference Center, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - E Delmont
- Neuromuscular Disease and ALS Reference Center, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - A Verschueren
- Neuromuscular Disease and ALS Reference Center, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - S Attarian
- Neuromuscular Disease and ALS Reference Center, Timone University Hospital, Aix-Marseille University, Marseille, France.
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24
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Gondim FDAA, Filha JGH, Jordanova A. Transthyretin familial amyloid polyneuropathy due to lle107Val mutation mimicking atypical chronic inflammatory demyelinating polyneuropathy: case report. Acta Neurol Belg 2020; 120:201-203. [PMID: 30560419 DOI: 10.1007/s13760-018-01069-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 12/12/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Francisco de Assis Aquino Gondim
- Clinical Neurophysiology Division, Department of Internal Medicine, Universidade Federal do Ceará, Rua Professor Costa Mendes, 1608, CEP 60.430-140, Fortaleza, CE, Brazil.
- Centro Universitário Unichristus, Fortaleza, Ceará, Brazil.
| | - Joana G Holanda Filha
- Ophthalmology Division, Department of Surgery, Universidade Federal do Ceará, Fortaleza, Brazil
| | - Albena Jordanova
- Molecular Neurogenomics Group, VIB-UAntwerp Center for Molecular Neurology, University of Antwerp, Antwerp, Belgium
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25
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Campagnolo M, Taioli F, Cacciavillani M, Ruiz M, Luigetti M, Salvalaggio A, Castellani F, Testi S, Ferrarini M, Cavallaro T, Gasparotti R, Fabrizi GM, Briani C. Sporadic hereditary neuropathies misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy: Pitfalls and red flags. J Peripher Nerv Syst 2020; 25:19-26. [DOI: 10.1111/jns.12362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022]
Affiliation(s)
| | - Federica Taioli
- Department of Neurology, Azienda Ospedaliera Universitaria IntegrataUniversity Hospital G.B. Rossi Verona Italy
| | | | - Marta Ruiz
- Department of NeurosciencesUniversity of Padova Padova Italy
| | - Marco Luigetti
- Neurology Unit, Fondazione Policlinico Universitario Gemelli IRCCS Rome Italy
| | | | | | - Silvia Testi
- Department of Neurology, Azienda Ospedaliera Universitaria IntegrataUniversity Hospital G.B. Rossi Verona Italy
| | - Moreno Ferrarini
- Department of Neurology, Azienda Ospedaliera Universitaria IntegrataUniversity Hospital G.B. Rossi Verona Italy
| | - Tiziana Cavallaro
- Department of Neurology, Azienda Ospedaliera Universitaria IntegrataUniversity Hospital G.B. Rossi Verona Italy
| | - Roberto Gasparotti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of Brescia Brescia Italy
| | - Gian Maria Fabrizi
- Department of Neurology, Azienda Ospedaliera Universitaria IntegrataUniversity Hospital G.B. Rossi Verona Italy
| | - Chiara Briani
- Department of NeurosciencesUniversity of Padova Padova Italy
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26
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Expert consensus recommendations to improve diagnosis of ATTR amyloidosis with polyneuropathy. J Neurol 2020; 268:2109-2122. [PMID: 31907599 PMCID: PMC8179912 DOI: 10.1007/s00415-019-09688-0] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
Amyloid transthyretin (ATTR) amyloidosis with polyneuropathy (PN) is a progressive, debilitating, systemic disease wherein transthyretin protein misfolds to form amyloid, which is deposited in the endoneurium. ATTR amyloidosis with PN is the most serious hereditary polyneuropathy of adult onset. It arises from a hereditary mutation in the TTR gene and may involve the heart as well as other organs. It is critical to identify and diagnose the disease earlier because treatments are available to help slow the progression of neuropathy. Early diagnosis is complicated, however, because presentation may vary and family history is not always known. Symptoms may be mistakenly attributed to other diseases such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), idiopathic axonal polyneuropathy, lumbar spinal stenosis, and, more rarely, diabetic neuropathy and AL amyloidosis. In endemic countries (e.g., Portugal, Japan, Sweden, Brazil), ATTR amyloidosis with PN should be suspected in any patient who has length-dependent small-fiber PN with autonomic dysfunction and a family history of ATTR amyloidosis, unexplained weight loss, heart rhythm disorders, vitreous opacities, or renal abnormalities. In nonendemic countries, the disease may present as idiopathic rapidly progressive sensory motor axonal neuropathy or atypical CIDP with any of the above symptoms or with bilateral carpal tunnel syndrome, gait disorders, or cardiac hypertrophy. Diagnosis should include DNA testing, biopsy, and amyloid typing. Patients should be followed up every 6–12 months, depending on the severity of the disease and response to therapy. This review outlines detailed recommendations to improve the diagnosis of ATTR amyloidosis with PN.
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Stengel H, Vural A, Brunder AM, Heinius A, Appeltshauser L, Fiebig B, Giese F, Dresel C, Papagianni A, Birklein F, Weis J, Huchtemann T, Schmidt C, Körtvelyessy P, Villmann C, Meinl E, Sommer C, Leypoldt F, Doppler K. Anti-pan-neurofascin IgG3 as a marker of fulminant autoimmune neuropathy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/5/e603. [PMID: 31454780 PMCID: PMC6705632 DOI: 10.1212/nxi.0000000000000603] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/25/2019] [Indexed: 12/31/2022]
Abstract
Objective To identify and characterize patients with autoantibodies against different neurofascin (NF) isoforms. Methods Screening of a large cohort of patient sera for anti-NF autoantibodies by ELISA and further characterization by cell-based assays, epitope mapping, and complement binding assays. Results Two different clinical phenotypes became apparent in this study: The well-known clinical picture of subacute-onset severe sensorimotor neuropathy with tremor that is known to be associated with IgG4 autoantibodies against the paranodal isoform NF-155 was found in 2 patients. The second phenotype with a dramatic course of disease with tetraplegia and almost locked-in syndrome was associated with IgG3 autoantibodies against nodal and paranodal isoforms of NF in 3 patients. The epitope against which these autoantibodies were directed in this second phenotype was the common Ig domain found in all 3 NF isoforms. In contrast, anti–NF-155 IgG4 were directed against the NF-155–specific Fn3Fn4 domain. The description of a second phenotype of anti–NF-associated neuropathy is in line with some case reports of similar patients that were published in the last year. Conclusions Our results indicate that anti–pan-NF-associated neuropathy differs from anti–NF-155-associated neuropathy, and epitope and subclass play a major role in the pathogenesis and severity of anti–NF-associated neuropathy and should be determined to correctly classify patients, also in respect to possible differences in therapeutic response.
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Affiliation(s)
- Helena Stengel
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Atay Vural
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Anna-Michelle Brunder
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Annika Heinius
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Luise Appeltshauser
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Bianca Fiebig
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Florian Giese
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Christian Dresel
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Aikaterini Papagianni
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Frank Birklein
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Joachim Weis
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Tessa Huchtemann
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Christian Schmidt
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Peter Körtvelyessy
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Carmen Villmann
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Edgar Meinl
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Claudia Sommer
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Frank Leypoldt
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey
| | - Kathrin Doppler
- From the Department of Neurology (H.S., A.M.B., L.A., B.F., A.P., C.S., K.D.), University Hospital Würzburg; Institute of Clinical Neuroimmunology (A.V., E.M.), Biomedical Center, University Hospitals, Ludwig-Maximilians-Universität München, Planegg-Martinsried; Universitätsklinikum Schleswig-Holstein Campus Kiel (A.H., F.L.), Neuroimmunology Section, Institute of Clinical Chemistry, Kiel/Lübeck; Department of Neurology (F.G.), University Hospital Halle; Department of Neurology (C.D., F.B.), University Hospital Mainz, Mainz; University Hospital Aachen (J.W.), Institute of Neuropathology, Aachen; Department of Neurology (T.H., P.K.), University Hospital Magdeburg; Institute for Pharmacology and Toxicology (C.S.), Otto-von-Guericke University; German Center for Neurodegenerative Diseases (P.K.), Magdeburg; Institute for Clinical Neurobiology (C.V.), University Hospital Würzburg; Department of Neurology (F.L.), Universitätsklinikum Schleswig-Holstein, Kiel, Germany; and Research Center for Translational Medicine (A.V), Koç University, Istanbul, Turkey.
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Abstract
OBJECTIVE To elucidate the electrophysiological demyelinating features in patients with hereditary ATTR amyloidosis that may lead to a misdiagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS In 102 patients with hereditary ATTR amyloidosis (85 Val30Met and 17 non-Val30Met; 37 and 65 from endemic and non-endemic areas, respectively), results of motor nerve conduction studies (MNCSs) with a 2-Hz low-cut filter in the unilateral ulnar and tibial nerves were retrospectively investigated to assess whether each MNCS parameter demonstrated demyelinating features that fulfil the European Federation of Neurological Societies/Peripheral Nerve Society electrodiagnostic (EFNS/PNS EDX) criteria for CIDP. RESULTS Thirteen patients with low compound muscle action potential (CMAP) amplitude in the tibial nerve (0.7 ± 0.7 mV) and prolonged distal CMAP duration in the ulnar nerve satisfied the definite EFNS/PNS EDX criteria for CIDP. Abnormal temporal dispersion and prolongation of distal latency in the tibial nerve were observed in 5 of 13 patients. However, only one of the 13 patients presented with the reduction of motor conduction velocity in each nerve. No patient exhibited conduction block in any nerve. CONCLUSION Patients with hereditary ATTR amyloidosis occasionally show electrophysiological demyelinating features without conduction block following severe axonal degeneration.
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Affiliation(s)
- Nobuhiko Ohashi
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan
| | - Minori Kodaira
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan
| | - Hiroshi Morita
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan.,b Center for Health, Safety and Environmental Management , Shinshu University , Matsumoto , Japan
| | - Yoshiki Sekijima
- a Department of Medicine (Neurology and Rheumatology) , Shinshu University School of Medicine , Matsumoto , Japan.,c Institute for Biomedical Sciences , Shinshu University , Matsumoto , Japan
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Zanazzi G, Arshad M, Maurer MS, Brannagan TH, Tanji K. Demyelinating Neuropathy in a Patient Treated With Revusiran for Transthyretin (Thr60Ala) Amyloidosis. J Clin Neuromuscul Dis 2019; 20:120-128. [PMID: 30801482 PMCID: PMC6392216 DOI: 10.1097/cnd.0000000000000242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Transthyretin amyloidosis patients develop length-dependent peripheral neuropathy, autonomic dysfunction, and restrictive cardiomyopathy associated with deposition of amyloid fibrils in these tissues. Despite advances in management over the past decade, this disorder causes profound debilitation and ultimately proves fatal. In this report, we describe a man with late-onset cardiac amyloidosis due to a transthyretin Thr60Ala mutation who was treated with an investigational RNAi therapeutic, revusiran, which targets hepatic transthyretin production. Sixteen months into treatment, he developed bilateral lower-extremity weakness and numbness, worsening balance, difficulty manipulating objects with his hands, and finger numbness. Nerve conduction studies were consistent with multifocal demyelinating neuropathy. Intravenous immunoglobulin therapy improved sensation in his hands and feet, and improved hand dexterity. A sural nerve biopsy demonstrated demyelination with substantial axonal loss in the absence of histologically detectable endoneurial amyloid deposition. This case expands the clinicopathologic spectrum of transthyretin amyloidosis and may represent complex disease and treatment effects.
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Affiliation(s)
- George Zanazzi
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | - Muhammad Arshad
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Mathew S. Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Thomas H. Brannagan
- Department of Neurology, Columbia Neuropathy Research Center, The Neurological Institute of New York, Columbia University Medical Center, New York, NY; and
| | - Kurenai Tanji
- Division of Neuropathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
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McCorquodale D, Smith AG. Clinical electrophysiology of axonal polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:217-240. [PMID: 31307603 DOI: 10.1016/b978-0-444-64142-7.00051-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Axonal neuropathies encompass a wide range of acquired and inherited disorders with electrophysiologic characteristics that arise from the unique neurophysiology of the axon. Accurate interpretation of nerve conduction studies and electromyography requires an in-depth understanding of the pathophysiology of the axon. Here we review the unique neurophysiologic properties of the axon and how they relate to clinical electrodiagnostic features. We review the length-dependent Wallerian or "dying-back" processes as well as the emerging body of literature from acquired axonal neuropathies that highlights the importance of axonal disease at the nodes of Ranvier. Neurophysiologic features of individual inherited and acquired axonal diseases, including primary nerve disease as well as systemic immune mediated, metabolic, and toxic diseases involving the peripheral nerve, are reviewed. This comprehensive review of electrodiagnostic findings coupled with the current understanding of pathophysiology will aid the clinician in the evaluation of axonal polyneuropathies.
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Affiliation(s)
- Donald McCorquodale
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - A Gordon Smith
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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Wang L, Yuan XZ, Zhao XM, Wang FY, Wang Y. Incomplete intestinal obstruction as an initial and persistent presentation in chronic inflammatory demyelinating polyneuropathy: A case report. Medicine (Baltimore) 2018; 97:e13538. [PMID: 30544461 PMCID: PMC6310579 DOI: 10.1097/md.0000000000013538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Autonomic symptoms are not uncommon in chronic inflammatory demyelinating polyneuropathy (CIDP), but they are mostly mild and transient and are overshadowed by somatic manifestations. Here, we report a very unusual case of CIDP with severe autonomic symptom, intestinal obstruction, as initial and persistent symptom which responded well to high-dose glucocorticoid and intravenous immunoglobulin treatment. PATIENT CONCERNS We described a patient with CIDP with precedent and long-lasting incomplete intestinal obstruction. Clinical manifestations were precedent and chronic abdominal pain, distension and constipation, and later numbness and weakness of lower and upper limbs. Radiograph showed incomplete intestinal obstruction, cerebrospinal fluid (CSF) showed albuminocytological dissociation and electromyography indicated neurogenic lesion. DIAGNOSES CIDP with incomplete intestinal obstruction was diagnosed based on the history, related symptoms, typical abdominal radiograph, CSF albuminocytological dissociation, and electromyographic findings. INTERVENTIONS The patient was treated with intravenous methylprednisolone and immunoglobulin. OUTCOMES After treatment, the intestinal obstruction disappeared and the somato-symptoms improved greatly and gradually. LESSONS This case highlights the need for diagnostic vigilance in cases of incomplete intestinal obstruction of unknown cause. We recommend CSF and electromyography examination in view of rare but possibility of CIDP.
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Affiliation(s)
- Long Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei
| | | | | | - Fu-Yu Wang
- Department of Pharmacy, General Hospital of Wanbei Coal and Electrical Group, Suzhou, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei
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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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Intracranial and systemic manifestations of familial leptomeningeal amyloidosis, as seen on CT and MRI. Radiol Case Rep 2018; 13:1179-1184. [PMID: 30233755 PMCID: PMC6140409 DOI: 10.1016/j.radcr.2018.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022] Open
Abstract
Leptomeningeal amyloidosis is a subset of familial transthyretin amyloidosis, a family of diseases occurring in conjunction with multiple known mutations of the transthyretin gene. Though this is primarily a disease of the central nervous system, amyloid deposition is multisystemic. We describe a case of a 61-year-old man with known central nervous system amyloidosis presenting to the emergency room with stroke-like symptoms, including left hemineglect, right gaze paresis, and left hemiplegia, atop baseline dementia. A noncontrast CT head demonstrated ventriculomegaly and no acute hemorrhage. Urinalysis indicated an underlying urinary tract infection, ultimately believed to have prompted a breakthrough seizure. Electroencephalogram revealed diffuse encephalopathy. Contrast-enhanced MRI demonstrated hallmarks of intracranial amyloid with no new infarct. Previously taken noncontrast CT neck and thorax demonstrated evidence of systemic disease.
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Mathis S, Magy L, Le Masson G, Richard L, Soulages A, Solé G, Duval F, Ghorab K, Vallat JM, Duchesne M. Value of nerve biopsy in the management of peripheral neuropathies. Expert Rev Neurother 2018; 18:589-602. [DOI: 10.1080/14737175.2018.1489240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Stéphane Mathis
- Department of Neurology (Nerve-Muscle Unit), CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
- National Reference Center ‘maladies neuromusculaires du grand sud-ouest’, CHU Bordeaux (Pellegrin Hospital), University of Bordeaux, Bordeaux, France
| | - Laurent Magy
- Department of Neurology, University hospital, Limoges, France
- National Reference Center for ‘rare peripheral neuropathies’, University Hospital, Limoges, France
| | - Gwendal Le Masson
- Department of Neurology (Nerve-Muscle Unit), CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
- National Reference Center ‘maladies neuromusculaires du grand sud-ouest’, CHU Bordeaux (Pellegrin Hospital), University of Bordeaux, Bordeaux, France
| | - Laurence Richard
- Department of Neurology, University hospital, Limoges, France
- National Reference Center for ‘rare peripheral neuropathies’, University Hospital, Limoges, France
| | - Antoine Soulages
- Department of Neurology (Nerve-Muscle Unit), CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
| | - Guilhem Solé
- Department of Neurology (Nerve-Muscle Unit), CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
- National Reference Center ‘maladies neuromusculaires du grand sud-ouest’, CHU Bordeaux (Pellegrin Hospital), University of Bordeaux, Bordeaux, France
| | - Fanny Duval
- Department of Neurology (Nerve-Muscle Unit), CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
- National Reference Center ‘maladies neuromusculaires du grand sud-ouest’, CHU Bordeaux (Pellegrin Hospital), University of Bordeaux, Bordeaux, France
| | - Karima Ghorab
- Department of Neurology, University hospital, Limoges, France
- National Reference Center for ‘rare peripheral neuropathies’, University Hospital, Limoges, France
| | - Jean-Michel Vallat
- Department of Neurology, University hospital, Limoges, France
- National Reference Center for ‘rare peripheral neuropathies’, University Hospital, Limoges, France
| | - Mathilde Duchesne
- National Reference Center for ‘rare peripheral neuropathies’, University Hospital, Limoges, France
- Department of Pathology, University Hospital, Limoges, France
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Lozeron P, Mariani LL, Dodet P, Beaudonnet G, Théaudin M, Adam C, Arnulf B, Adams D. Transthyretin amyloid polyneuropathies mimicking a demyelinating polyneuropathy. Neurology 2018; 91:e143-e152. [PMID: 29907605 DOI: 10.1212/wnl.0000000000005777] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/09/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To clearly define transthyretin familial amyloid polyneuropathies (TTR-FAPs) fulfilling definite clinical and electrophysiologic European Federation of Neurological Societies/Peripheral Nerve Society criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS From a cohort of 194 patients with FAP, 13 of 84 patients (15%) of French ancestry had late-onset demyelinating TTR-FAP. We compared clinical presentation and electrophysiology to a cohort with CIDP and POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome. We assessed nerve histology and the correlation between motor/sensory amplitudes/velocities. Predictors of demyelinating TTR-FAP were identified from clinical and electrophysiologic data. RESULTS Pain, dysautonomia, small fiber sensory loss above the wrists, upper limb weakness, and absence of ataxia were predictors of demyelinating TTR-FAP (p < 0.01). The most frequent demyelinating features were prolonged distal motor latency of the median nerve and reduced sensory conduction velocity of the median and ulnar nerves. Motor axonal loss was severe and frequent in the median, ulnar, and tibial nerves (p < 0.05) in demyelinating FAP. Ulnar nerve motor amplitude <5.4 mV and sural nerve amplitude <3.95 μV were distinguishing characteristics of demyelinating TTR-FAP. Nerve biopsy showed severe axonal loss and occasional segmental demyelination-remyelination. CONCLUSION Misleading features of TTR-FAP fulfilling criteria for CIDP are not uncommon in sporadic late-onset TTR-FAP, which highlights the limits of European Federation of Neurological Societies/Peripheral Nerve Society criteria. Specific clinical aspects and marked electrophysiologic axonal loss are red flag symptoms that should alert to this diagnosis and prompt TTR gene sequencing.
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Affiliation(s)
- Pierre Lozeron
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France.
| | - Louise-Laure Mariani
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - Pauline Dodet
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - Guillemette Beaudonnet
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - Marie Théaudin
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - Clovis Adam
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - Bertrand Arnulf
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
| | - David Adams
- From Service de Physiologie Clinique-Explorations Fonctionnelles (P.L.), AP-HP, Hôpital Lariboisière, Paris; INSERM UMR965 (P.L.), Paris; Université Paris Diderot Sorbonne Paris Cité (P.L., B.A.), Paris; French National Reference Center for FAP (NNERF) (L.-L.M., P.D., G.B., M.T., C.A., D.A.), Le Kremlin-Bicêtre; Service de Neurologie (L.-L.M., P.D., M.T., D.A.) and Service d'anatomopathologie (C.A.), APHP, Hôpital Bicêtre, Le Kremlin-Bicêtre; Unité de Neurophysiologie Clinique et d'épileptologie (G.B.), Hôpital Bicêtre, Le Kremlin-Bicêtre; Immuno-Hematology Department (B.A.), Saint-Louis Hospital, Paris; Université Paris 11 (D.A.); and INSERM UMR1195 (D.A.), Le Kremlin-Bicêtre, France
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Escolano-Lozano F, Barreiros AP, Birklein F, Geber C. Transthyretin familial amyloid polyneuropathy (TTR-FAP): Parameters for early diagnosis. Brain Behav 2018; 8:e00889. [PMID: 29568686 PMCID: PMC5853640 DOI: 10.1002/brb3.889] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/16/2017] [Accepted: 11/04/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Familial transthyretin amyloidosis is a life-threatening disease presenting with sensorimotor and autonomic polyneuropathy. Delayed diagnosis has a detrimental effect on treatment and prognosis. To facilitate diagnosis, we analyzed data patterns of patients with transthyretin familial amyloid polyneuropathy (TTR-FAP) and compared them to polyneuropathies of different etiology for clinical and electrophysiological discriminators. METHODS Twenty-four patients with TTR-FAP and 48 patients with diabetic polyneuropathy (dPNP) were investigated (neurological impairment score NIS; neurological disability score NDS) in a cross-sectional design. Both groups were matched for gender and presence of pain. Quantitative sensory testing (QST), sympathetic skin response (SSR), heart rate variability (HRV), and nerve conduction studies (NCV) were performed. Both groups were compared using univariate analysis. In a stepwise discriminant analysis, discriminators between both neuropathies were identified. These discriminators were validated comparing TTR-FAP patients with a cohort of patients with chemotherapy-induced polyneuropathy (CIN) and chronic inflammatory demyelinating neuropathy (CIDP). RESULTS TTR-FAP patients scored higher in NDS and NIS and had impaired cold detection (CDT, p = .024), cold-warm discrimination (TSL, p = .019) and mechanical hyperalgesia (MPT, p = .029) at the hands, SSR (upper limb, p = .022) HRV and ulnar and sural NCS (all p < .05) were more affected in TTR-FAP. Ulnar nerve sensory NCV, CDT, and the MPT but not the other parameters discriminated TTR-FAP from dPNP (82% of cases), from CIN (86.7%) and from CIDP (68%; only ulnar sNCV). CONCLUSION Low ulnar SNCV, impaired cold perception, and mechanical hyperalgesia at the hands seem to characterize TTR-FAP and might help to differentiate from other polyneuropathies.
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Affiliation(s)
- Fabiola Escolano-Lozano
- Department of Neurology University Medical Center of the Johannes Gutenberg University Mainz Mainz Germany
| | | | - Frank Birklein
- Department of Neurology University Medical Center of the Johannes Gutenberg University Mainz Mainz Germany
| | - Christian Geber
- Department of Neurology University Medical Center of the Johannes Gutenberg University Mainz Mainz Germany.,Red Cross Pain Center Mainz Germany
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38
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Li J, Li Y, Chen H, Xing S, Feng H, Liu D, Wang D, Zeng J, Fan Y. Autonomic Neuropathy and Albuminocytologic Dissociation in Cerebrospinal Fluid As the Presenting Features of Primary Amyloidosis: A Case Report. Front Neurol 2017; 8:368. [PMID: 28798722 PMCID: PMC5526844 DOI: 10.3389/fneur.2017.00368] [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: 04/15/2017] [Accepted: 07/12/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Primary amyloidosis is a disease with a poor prognosis and multi-organ involvement. Here, we report the clinical and pathological features of a patient with primary amyloidosis featuring autonomic neuropathy as the initial symptom and albuminocytologic dissociation in the cerebrospinal fluid (CSF). METHODS The patient was a 60-year-old Chinese male with numbness, orthostatic hypotension, and gastrointestinal symptoms. For diagnosis, we performed an electromyogram (EMG), lumbar puncture, Bence Jones protein urine test, serum electrophoresis blood test, sural nerve and rectal membrane biopsies, transthyretin (TTR) gene sequencing, and bone marrow puncture. RESULTS Congo red staining of sural nerve and rectal membrane biopsies showed amyloid deposition and apple-green birefringence was visualized under polarized light microscopy. TTR gene sequencing showed no causative mutation. Following lumbar puncture, normal CSF cell counts and elevated CSF protein concentration (1,680 mg/L) were detected. Bone marrow puncture showed that out of the total number of whole blood cells, 0.56% were abnormal plasma cells and that 87.4% of the total number of plasma cells were abnormal. EMG results showed mixed peripheral nerve damage predominately in the sensory nerve fibers. CONCLUSION Obvious symptoms of neuropathy, particularly autonomic neuropathy, albuminocytologic dissociation, and organ function damage suggested a diagnosis of amyloidosis. In such patients, neurologists should use caution to differentiate between chronic inflammatory demyelinating polyneuropathy, primary amyloidosis, and familial amyloid neuropathy.
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Affiliation(s)
- Jingjing Li
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Li
- Department of Neurology, Guangzhou Red Cross Hospital, Medical College, Jinan University, Guangzhou, China
| | - Hongbing Chen
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shihui Xing
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huiyu Feng
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dawei Liu
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dilong Wang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinsheng Zeng
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Cortese A, Vegezzi E, Lozza A, Alfonsi E, Montini A, Moglia A, Merlini G, Obici L. Diagnostic challenges in hereditary transthyretin amyloidosis with polyneuropathy: avoiding misdiagnosis of a treatable hereditary neuropathy. J Neurol Neurosurg Psychiatry 2017; 88:457-458. [PMID: 28188196 PMCID: PMC5529976 DOI: 10.1136/jnnp-2016-315262] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/31/2016] [Accepted: 01/05/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Andrea Cortese
- IRCCS, C Mondino National Neurological Institute, Pavia, Italy.,Molecular Neuroscience, University College London Institute of Neurology, London, UK
| | - Elisa Vegezzi
- Neuroscience Consortium, University of Pavia, Monza Policlinico and Pavia Mondino, Pavia, Italy.,Department of Neurology, Casimiro Mondino National Neurological Institute, Pavia, Italy
| | | | - Enrico Alfonsi
- IRCCS, C Mondino National Neurological Institute, Pavia, Italy
| | | | - Arrigo Moglia
- IRCCS, C Mondino National Neurological Institute, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Laura Obici
- Amyloidosis Research and Treatment Center, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
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Rosenbaum E, Marks D, Raza S. Diagnosis and management of neuropathies associated with plasma cell dyscrasias. Hematol Oncol 2017; 36:3-14. [PMID: 28397326 DOI: 10.1002/hon.2417] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
Abstract
Neuropathies associated with plasma cell dyscrasias are a major cause of morbidity for patients managed by medical oncologists. Because of similarities in clinical presentation and on nerve conduction studies, identifying the underlying disease leading to a paraproteinemic neuropathy can often be difficult. In addition, the degree of neurologic deficit does not strictly correlate with the extent of abnormalities on common clinical laboratory testing. Fortunately, with increasing understanding into the biologic mechanisms of underlying hematologic diseases, additional biomarkers have recently been developed, thus improving our diagnostic capacity. Neuropathies associated with plasma cells dyscrasias are seen with Monoclonal gammopathy of undetermined significance (MGUS) particularly IgM subtype, followed by IgG and IgA MGUS, multiple myeloma, Waldenström's macroglobulinemia, amyloid, Castleman's disease, and POEMS syndrome. The mechanisms of neuronal injury associated with plasma cell dyscrasia vary based on underlying diagnosis and include malignant infiltration, immune-mediated antibody deposition, or local compression of nerve roots. The polyneuropathies are frequently demyelinating, although axonal and mixed neuropathies can also be seen. As demonstrated by the cases included in this review, patients frequently present with symmetric sensory disturbance, followed by progressive motor weakness. Unfortunately, because of the complexity of diagnostic testing, patients are frequently examined late, often after receiving several ineffective therapies. The aim of this case-based review is to provide clinicians with insight on how to properly recognize these atypical neuropathies and send the appropriate diagnostic work, increasing the likelihood of accurately classify the patient's underlying hematologic disorder.
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Affiliation(s)
- Evan Rosenbaum
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
| | - Douglas Marks
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
| | - Shahzad Raza
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
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Misumi Y, Ueda M, Yamashita T, Masuda T, Kinoshita Y, Tasaki M, Nagase T, Ando Y. Novel screening for transthyretin amyloidosis by using fat ultrasonography. Ann Neurol 2017; 81:604-608. [PMID: 28271559 DOI: 10.1002/ana.24914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/03/2017] [Accepted: 03/03/2017] [Indexed: 02/03/2023]
Abstract
We aimed to assess the possibility of using a noninvasive screening method for hereditary transthyretin amyloidosis by means of abdominal fat ultrasonography. Quantitative analysis of ultrasound B-mode images demonstrated a significant increase in mean echogenicity and a loss of the normal structure of the layers of fat tissue in patients with hereditary transthyretin amyloidosis (n = 19). The ultrasound features of the fat tissue and the degree of amyloid deposition seen histopathologically showed a significant correlation. These results suggest that abdominal fat ultrasonography may be a valuable method for screening for hereditary transthyretin amyloidosis. Ann Neurol 2017;81:604-608.
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Affiliation(s)
- Yohei Misumi
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Taro Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Teruaki Masuda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Yumiko Kinoshita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
| | - Masayoshi Tasaki
- Department of Morphological and Physiological Sciences, Graduate School of Health Sciences, Kumamoto University, Kumamoto
| | - Terumasa Nagase
- Department of Metabolism and Endocrinology, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto
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Rajabally YA, Adams D, Latour P, Attarian S. Hereditary and inflammatory neuropathies: a review of reported associations, mimics and misdiagnoses. J Neurol Neurosurg Psychiatry 2016; 87:1051-60. [PMID: 27010614 DOI: 10.1136/jnnp-2015-310835] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/28/2016] [Indexed: 02/03/2023]
Abstract
Distinguishing between hereditary and inflammatory neuropathy is usually straightforward on clinical grounds with the help of a family history. There are nevertheless cases where the distinction is less clear. The advent of molecular genetics has in the past several years aided confirmatory diagnosis for an increasing proportion of patients with genetic neuropathy. Various reports have described associations of Charcot-Marie-Tooth disease with a suspected or confirmed inflammatory neuropathy occasionally responding to immunotherapy. Possible predisposition to an inflammatory component was suggested in a subset of patients. Such reports have, however, been relatively few in number, suggesting the rarity of such associations and of such a predisposition if it exists. There have been a number of publications detailing clinical presentations suggestive of inflammatory neuropathy in patients with a known or later proven genetic aetiology, and subsequently felt to be part of the phenotype rather than representing an association. A number of genetically mediated multisystemic diseases with neuropathy have otherwise been reported as mimicking chronic inflammatory demyelinating polyneuropathy (CIDP). The most common example is that of familial amyloid polyneuropathy, of particular concern for the clinician when misdiagnosed as CIDP, in view of the therapeutic implications. We review the literature on reported associations, mimics and misdiagnoses of hereditary and inflammatory neuropathy and attempt to determine a practical approach to the problem in clinical practice using clinical features, electrophysiology, histopathology and targeted early genetic testing. The issue of attempting immunomodulatory therapy is discussed in view of the published literature.
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Affiliation(s)
- Yusuf A Rajabally
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK Regional Neuromuscular Clinic, Queen Elizabeth Hospital, University Hospitals of Birmingham, Birmingham, UK
| | - David Adams
- Department of Neurology, National Reference Centre for FAP and other rare peripheral neuropathies (NNERf) APHP, CHU Bicêtre, HUPS, INSERM U1195, Université Paris Sud, Le Kremlin-Bicêtre, France FILNEMUS, Filière nationale des Maladies neuromusculaires, Marseille, France
| | - Philippe Latour
- Laboratoire de Neurogénétique Moléculaire, Groupe Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Shahram Attarian
- FILNEMUS, Filière nationale des Maladies neuromusculaires, Marseille, France Reference Centre for Neuromuscular Diseases and ALS, Centre Hospitalier Universitaire La Timone, Marseille, France Inserm UMR_S 910 Medical Genetics and Functional Genomics, Aix-Marseille University, Marseille, France
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Abstract
PURPOSE OF REVIEW To highlight the advances in the knowledge of the clinical features, diagnostic techniques, clinimetrics, and therapeutics of transthyretin familial amyloid polyneuropathy. RECENT FINDINGS Expanding knowledge of the molecular underpinnings and therapeutics of transthyretin familial amyloid polyneuropathy have provided impetus to molecular-specific phenotype characterization, natural history studies, and target-based therapeutic interventions. These interventions have underscored the need for early, accurate diagnostic instruments and sensitive diagnostic and therapeutic biomarkers. SUMMARY Current and emerging target-based therapeutic interventions and novel diagnostic techniques may contribute to improved quality of life and survival in this disease.
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Meng LC, Lyu H, Zhang W, Liu J, Wang ZX, Yuan Y. Hereditary Transthyretin Amyloidosis in Eight Chinese Families. Chin Med J (Engl) 2016; 128:2902-5. [PMID: 26521788 PMCID: PMC4756886 DOI: 10.4103/0366-6999.168048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Mutations of transthyretin (TTR) cause the most common type of autosomal-dominant hereditary systemic amyloidosis, which occurs worldwide. To date, more and more mutations in the TTR gene have been reported. Some variations in the clinical presentation are often observed in patients with the same mutation or the patients in the same family. The purpose of this study was to find out the clinicopathologic and genetic features of Chinese patients with hereditary TTR amyloidosis. Methods: Clinical and necessary examination materials were collected from nine patients of eight families with hereditary TTR amyloidosis at Peking University First Hospital from January 2007 to November 2014. Sural nerve biopsies were taken for eight patients and skin biopsies were taken in the calf/upper arm for two patients, for light and electron microscopy examination. The TTR genes from the nine patients were analyzed. Results: The onset age varied from 23 to 68 years. The main manifestations were paresthesia, proximal and/or distal weakness, autonomic dysfunction, cardiomyopathy, vitreous opacity, hearing loss, and glossohypertrophia. Nerve biopsy demonstrated severe loss of myelinated fibers in seven cases and amyloid deposits in three. One patient had skin amyloid deposits which were revealed from electron microscopic examination. Genetic analysis showed six kinds of mutations of TTR gene, including Val30Met, Phe33Leu, Ala36Pro, Val30Ala, Phe33Val, and Glu42Gly in exon 2. Conclusions: Since the pathological examinations of sural nerve were negative for amyloid deposition in most patients, the screening for TTR mutations should be performed in all the adult patients, who are clinically suspected with hereditary TTR amyloidosis.
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Affiliation(s)
| | | | | | | | | | - Yun Yuan
- Department of Neurology, Peking University First Hospital, Beijing 100034, China
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Mariani LL, Lozeron P, Théaudin M, Mincheva Z, Signate A, Ducot B, Algalarrondo V, Denier C, Adam C, Nicolas G, Samuel D, Slama MS, Lacroix C, Misrahi M, Adams D. Genotype-phenotype correlation and course of transthyretin familial amyloid polyneuropathies in France. Ann Neurol 2015; 78:901-16. [PMID: 26369527 PMCID: PMC4738459 DOI: 10.1002/ana.24519] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 09/06/2015] [Accepted: 09/08/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare the natural history of familial transthyretin amyloid polyneuropathies (FAP) due to the Val30Met, Ser77Tyr, and Ile107Val mutations in France with the classical Portuguese Val30Met FAP. METHODS We compared 84 French patients with a control group of 110 Portuguese patients carrying the Val30Met mutation also living in France, all referred to and followed at the French National FAP Reference Center from 1988 to 2010. Clinical examination, functional and walking disability scores, nerve conduction studies, and muscle biopsies are reported. We also conducted a comprehensive literature review to further determine the range of phenotypic expression. RESULTS By comparison with Portuguese Val30Met FAP, French Ile107Val, Ser77Tyr, and LateVal30Met FAP showed more rapid and severe disease progression; onset of gait disorders was 3 times more rapid (p < 0.0001) and the rate of modified Norris test decline was up to 40 times faster in Ile107Val patients (p < 0.0001). Median survival was much shorter in Ile107Val and in Val30Met mutation with late onset (>50 years; LateMet30) FAP (p = 0.0005). Other distinctive features relative to the Portuguese patients included atypical clinical presentations, demyelination on nerve conduction studies (p = 0.0005), and difficult identification of amyloid deposits in nerve and muscle biopsies. INTERPRETATION Ile107Val and LateMet30 mutations are associated with the most debilitating and severe FAP ever described, with rapid onset of tetraparesis and shorter median survival. It could be explained by frequent large-fiber involvement and associated demyelination and more severe axonal loss. These findings have major implications for genetic counseling and patient management as new therapeutic options are being assessed in clinical trials (TTR gene silencing).
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Affiliation(s)
| | - Pierre Lozeron
- Department of Neurology, Bicêtre Hospital, Le Kremlin-Bicêtre;,French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,Department of Neurophysiology, APHP, Lariboisière Hospital, University Paris-Diderot Sorbonne Paris Cité, INSERM UMR-965, Paris, France
| | - Marie Théaudin
- Department of Neurology, Bicêtre Hospital, Le Kremlin-Bicêtre;,French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,National Institute of Health and Medical Research Unit U1191, Le Kremlin-Bicêtre
| | - Zoia Mincheva
- Department of Neurology, Bicêtre Hospital, Le Kremlin-Bicêtre;,French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre
| | - Aissatou Signate
- Department of Neurology, Pierre Zobda-Quitman Hospital, Fort de France
| | - Beatrice Ducot
- Reproduction and Child Development Team, Center for Research in Epidemiology and Population Health, Le Kremlin-Bicêtre.,University of Paris-South, Villejuif.,National Institute for Demographic Studies, Paris
| | - Vincent Algalarrondo
- French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,University Paris-Sud, Paris.,Department of Cardiology, Antoine Béclère Hospital, Clamart
| | - Christian Denier
- Department of Neurology, Bicêtre Hospital, Le Kremlin-Bicêtre;,National Institute of Health and Medical Research Unit U1191, Le Kremlin-Bicêtre.,University Paris-Sud, Paris
| | - Clovis Adam
- French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,Department of Neuropathology, Bicêtre Hospital, Le Kremlin-Bicêtre
| | - Guillaume Nicolas
- Department of Neurology, Raymond Poincaré Hospital, Garches.,University of Versailles Saint-Quentin-en-Yvelines, Versailles
| | - Didier Samuel
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif.,National Institute of Health and Medical Research Mixed Unit of Research S785, Villejuif
| | - Michel S Slama
- French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,University Paris-Sud, Paris.,Department of Cardiology, Antoine Béclère Hospital, Clamart
| | - Catherine Lacroix
- French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,Department of Neuropathology, Bicêtre Hospital, Le Kremlin-Bicêtre
| | - Micheline Misrahi
- French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,University Paris-Sud, Paris.,Department of Molecular Biology, Bicêtre Hospital, Le Kremlin-Bicêtre
| | - David Adams
- Department of Neurology, Bicêtre Hospital, Le Kremlin-Bicêtre;,French National Reference Center for Familial Amyloid Polyneuropathies (NNERf), Le Kremlin-Bicêtre.,National Institute of Health and Medical Research Unit U1191, Le Kremlin-Bicêtre.,University Paris-Sud, Paris.,FILNEMUS, Filière nationale de Santé Maladies Rares Neuromusculaires, Marseille, France
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47
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Lavigne Moreira C, Marques VD, Lourenço CM, Cabrini DI, Nuñez JC, Herrera RF, Marques W. Transthyretin Asp38Tyr: a new mutation associated to a late onset neuropathy. J Peripher Nerv Syst 2015; 20:60-2. [PMID: 25857202 DOI: 10.1111/jns.12112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 03/09/2015] [Accepted: 03/11/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Carolina Lavigne Moreira
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Vanessa D Marques
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Charles M Lourenço
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Daisy I Cabrini
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Jose C Nuñez
- Department of Neurophysiology, Neurocenter, Santa Cruz, Bolivia
| | - Ronaldo F Herrera
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Wilson Marques
- Division of Neurogenetics, Department of Neurosciences and Behavior Sciences, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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48
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Adams D, Cauquil C, Theaudin M, Rousseau A, Algalarrondo V, Slama MS. Current and future treatment of amyloid neuropathies. Expert Rev Neurother 2014; 14:1437-51. [DOI: 10.1586/14737175.2014.983905] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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Themistocleous AC, Kennett R, Husain M, Palace J, Mead S, Bennett DLH. Late onset hereditary sensory and autonomic neuropathy with cognitive impairment associated with Y163X prion mutation. J Neurol 2014; 261:2230-3. [PMID: 25287017 PMCID: PMC4221653 DOI: 10.1007/s00415-014-7521-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/25/2014] [Accepted: 09/27/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Andreas C. Themistocleous
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 6, West Wing, Oxford, OX3 9DU UK
| | - Robin Kennett
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 6, West Wing, Oxford, OX3 9DU UK
| | - Masud Husain
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 6, West Wing, Oxford, OX3 9DU UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 6, West Wing, Oxford, OX3 9DU UK
| | - Simon Mead
- Medical Research Council (MRC) Prion Unit, The National Prion Clinic, University College London (UCL) Institute of Neurology, Queen Square House, Queen Square, London, WC1N 3BG UK
| | - David L. H. Bennett
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Level 6, West Wing, Oxford, OX3 9DU UK
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Adams D, Théaudin M, Cauquil C, Algalarrondo V, Slama M. FAP neuropathy and emerging treatments. Curr Neurol Neurosci Rep 2014; 14:435. [PMID: 24482069 DOI: 10.1007/s11910-013-0435-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transthyretin familial amyloid polyneuropathy (TTR-FAP) classically presents as a length dependent small fiber polyneuropathy in endemic countries like Portugal. In nonendemic countries, it may mimic a variety of chronic polyneuropathies, with several phenotypes: ataxic, upper limb onset neuropathy, or motor. In these cases, there is usually a late onset and no positive family history. TTR gene sequencing appears the most pertinent first-line test for diagnosis. Cardiac involvement of various severities is common in FAP. Liver transplantation remains the standard antiamyloid therapy with better results in Val30Met TTR-FAP of early onset. Antiamyloid medication has been developed. (1) TTR stabilizers: Tafamidis was the first drug approved in Europe in stage 1 (walking unaided) TTR-FAP to slow progression of the disease; diflunisal has been assessed in a phase 3 clinical trial; (2) TTR gene silencing is a new strategy to inhibit production of both mutant and nonmutant TTR with antisense oligonucleotides or SiRNA (2 ongoing phase 3 clinical trials).
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Affiliation(s)
- David Adams
- APHP, HUPS, Univ Paris Sud, le Kremlin Bicêtre Cedex, France,
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