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Noioso CM, Bevilacqua L, Acerra GM, Valle PD, Serio M, Pecoraro A, Rienzo A, De Marca U, De Biasi G, Vinciguerra C, Piscosquito G, Toriello A, Tozza S, Barone P, Iovino A. The spectrum of anti-GQ1B antibody syndrome: beyond Miller Fisher syndrome and Bickerstaff brainstem encephalitis. Neurol Sci 2024:10.1007/s10072-024-07686-3. [PMID: 38987510 DOI: 10.1007/s10072-024-07686-3] [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: 01/18/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Since the initial identification of Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE),significant milestones have been achieved in understanding these diseases.Discoveries of common serum antibodies (IgG anti-GQ1b), antecedent infections, neurophysiological data, andneuroimaging suggested a shared autoimmune pathogenetic mechanism rather than distinct pathogenesis, leadingto the hypothesis that both diseases are part of a unified syndrome, termed "Fisher-Bickerstaff syndrome". The subsequent identification of atypical anti-GQ1b-positive forms expanded the classification to a broader condition known as "Anti-GQ1b-Antibody syndrome". METHODS An exhaustive literature review was conducted, analyzing a substantial body of research spanning from the initialdescriptions of the syndrome's components to recent developments in diagnostic classification and researchperspectives. RESULTS Anti-GQ1b syndrome encompasses a continuous spectrum of conditions defined by a common serological profilewith varying degrees of peripheral (PNS) and central nervous system (CNS) involvement. MFS and BBE represent theopposite ends of this spectrum, with MFS primarily affecting the PNS and BBE predominantly involving the CNS.Recently identified atypical forms, such as acute ophthalmoparesis, acute ataxic neuropathy withoutophthalmoparesis, Guillain-Barré syndrome (GBS) with ophthalmoparesis, MFS-GBS and BBE-GBS overlap syndromes,have broadened this spectrum. CONCLUSION This work aims to provide an extensive, detailed, and updated overview of all aspects of the anti-GQ1b syndromewith the intention of serving as a stepping stone for further shaping thereof. Special attention was given to therecently identified atypical forms, underscoring their significance in redefining the boundaries of the syndrome.
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Affiliation(s)
- Ciro Maria Noioso
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy.
| | - Liliana Bevilacqua
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Gabriella Maria Acerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Paola Della Valle
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Marina Serio
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Agnese Pecoraro
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Annalisa Rienzo
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Umberto De Marca
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe De Biasi
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Antonella Toriello
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Stefano Tozza
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Paolo Barone
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
| | - Aniello Iovino
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", University of Salerno, Salerno, Italy
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Pascual-Goñi E, Collet R, Tejada-Illa C, Martín-Aguilar L, Caballero-Ávila M, Lleixà C, Novelli S, López-Pardo J, Sanfeliu AE, Mariscal A, Álvaro Gargallo Y, Martínez-Hernández E, Cocho D, Querol L. Excellent response to anti-CD38 therapy with daratumumab in a patient with severe refractory CANOMAD. J Neurol Neurosurg Psychiatry 2024; 95:609-611. [PMID: 38341197 DOI: 10.1136/jnnp-2023-332443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/01/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) and rituximab are considered the first-line and second-line treatments for Chronic Ataxic Neuropathy and Ophthalmoplegia with IgM-paraprotein, cold Agglutinins, and anti-Disialosyl antibodies (CANOMAD), with an overall clinical response around 50%. New anti-CD38 daratumumab, targeting long-lived plasma cells, has been reported as a promising therapy for treatment-refractory antibody-mediated disorders. We report the first case of a severe refractory CANOMAD, successfully treated with daratumumab. METHODS A patient in their 70s with severe relapsing CANOMAD, refractory to IVIG, steroids, rituximab and ibrutinib developed severe tetraparesis and respiratory failure. Plasma exchange (PE) improved motor and ventilatory function; however, after 6 weeks, patient remained PE dependent. Intravenous daratumumab was initiated at 16 mg/kg weekly for 3 weeks, every 2 weeks for the second and third month, and monthly afterwards. RESULTS After 3 weeks of starting daratumumab, PE was discontinued and, since then, the patient evolved to complete recovery. Antidisialosyl antibody titres decreased after PE and remained stable during daratumumab. Serum neurofilament light-chain levels were elevated in the exacerbation phase and normalised after daratumumab. The patient remains in clinical remission under monthly daratumumab, 12 months after initiation. CONCLUSIONS The first patient with aggressive treatment-refractory CANOMAD treated with daratumumab provides proof-of-principle evidence that daratumumab may be an effective treatment in IgM-related neuropathies.
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Affiliation(s)
- Elba Pascual-Goñi
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Roger Collet
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Clara Tejada-Illa
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lorena Martín-Aguilar
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marta Caballero-Ávila
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Silvana Novelli
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi López-Pardo
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Esquirol Sanfeliu
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anais Mariscal
- Immunology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yolanda Álvaro Gargallo
- Immunology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Dolores Cocho
- Department of Neurology, Hospital General de Granollers, Granollers, Spain
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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3
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Fujioka T, Kondo K, Kohara N. Subacute Progressive Severe Ataxic Sensory Neuropathy with Sjögren's Syndrome. Intern Med 2024; 63:1637-1643. [PMID: 37926550 PMCID: PMC11189695 DOI: 10.2169/internalmedicine.2226-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
We herein report a 79-year-old woman with subacute progressive ataxic sensory neuropathy. The patient's symptoms began with numbness in the lower extremities, which rapidly deteriorated, resulting in gait disturbance and abnormal sensations in the extremities, reaching a peak over a period of approximately two months. Nerve conduction studies revealed pure axonal-type sensory polyneuropathy. The expeditious progression of the disease initially prompted suspicion of Guillain-Barré syndrome or paraneoplastic syndrome. Nevertheless, after comprehensive evaluations, the conclusive diagnosis was confirmed as ataxic sensory neuropathy with Sjögren's syndrome. Intensive immunotherapy was administered; however, it was ineffective in halting disease progression. Consequently, this case underscores the significance of an early comprehensive diagnosis and prompt immunotherapy for ataxic sensory neuropathy associated with Sjögren's syndrome.
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Affiliation(s)
| | | | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
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4
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Li CMF, Chang YC, Yang L, Budhram A. Evaluating yield and utilization of ganglioside antibody testing in clinical practice. J Neurol Sci 2024; 457:122903. [PMID: 38295535 DOI: 10.1016/j.jns.2024.122903] [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: 11/28/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Ganglioside antibodies can help diagnose distinct acute and chronic inflammatory neuropathies including axonal variants of Guillain-Barre syndrome, Miller-Fisher syndrome (MFS), multifocal motor neuropathy, and chronic sensory ataxic neuropathies. Because ganglioside antibody testing may be routinely ordered in patients with suspected inflammatory neuropathy, we sought to evaluate its yield and utilization in clinical practice. METHODS We performed a retrospective chart review of all patients at London Health Sciences Centre who underwent ganglioside antibody testing between April 2019 and August 2023. The disease phenotype was determined for each patient, and the proportion of all tests that yielded a true-positive result was calculated. Ganglioside antibody positivity was classified as a true-positive result if the disease phenotype was robustly associated with the detected ganglioside antibody and there was no other more likely diagnosis. RESULTS We identified 92 patients who underwent ganglioside antibody testing. One patient (1%) was classified as having a true-positive result; this patient had GQ1b-IgG positivity with MFS. Among 92 patients tested, 20 patients (22%) had a disease phenotype that was considered to be robustly associated with ganglioside antibody positivity. CONCLUSIONS The yield of ganglioside antibody testing in clinical practice is low. We found that this testing is frequently ordered in patients with disease phenotypes that are not robustly associated with ganglioside antibody positivity, indicating that suboptimal test utilization is a primary contributor to its low yield. Restricting ganglioside antibody testing to patients with characteristic disease phenotypes would be valuable to improving yield and utilization of this testing.
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Affiliation(s)
- Cathy Meng Fei Li
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Yiu-Chia Chang
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Liju Yang
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Adrian Budhram
- Department of Clinical Neurological Sciences, Western University, London Health Sciences Centre, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada.
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Collet R, Caballero-Ávila M, Querol L. Clinical and pathophysiological implications of autoantibodies in autoimmune neuropathies. Rev Neurol (Paris) 2023; 179:831-843. [PMID: 36907709 DOI: 10.1016/j.neurol.2023.02.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 03/13/2023]
Abstract
Autoimmune neuropathies are a heterogeneous group of rare and disabling diseases in which the immune system targets peripheral nervous system antigens and that respond to immune therapies. This review focuses on Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, polyneuropathy associated with IgM monoclonal gammopathy, and autoimmune nodopathies. Autoantibodies targeting gangliosides, proteins in the node of Ranvier, and myelin-associated glycoprotein have been described in these disorders, defining subgroups of patients with similar clinical features and response to therapy. This topical review describes the role of these autoantibodies in the pathogenesis of autoimmune neuropathies and their clinical and therapeutic importance.
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Affiliation(s)
- R Collet
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - M Caballero-Ávila
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L Querol
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain.
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6
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Tomkins O, Leblond V, Lunn MP, Viala K, Weil DR, D'Sa S. Investigation and Management of Immunoglobulin M- and Waldenström-Associated Peripheral Neuropathies. Hematol Oncol Clin North Am 2023; 37:761-776. [PMID: 37385714 DOI: 10.1016/j.hoc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
The immunoglobulin M (IgM)-associated peripheral neuropathies (PN) are a heterogeneous group of disorders representing most paraproteinemic neuropathy cases. They are associated with IgM monoclonal gammopathy of undetermined significance (MGUS) or Waldenström macroglobulinemia. Establishing a causal link between a paraprotein and neuropathy can be challenging but is necessary to adopt an appropriate therapeutic approach. The most common type of IgM-PN is Antimyelin-Associated-Glycoprotein neuropathy, but half of the cases are of other causes. Progressive functional impairment is an indication for treatment, even when the underlying disorder is IgM MGUS, involving either rituximab monotherapy or combination chemotherapy to achieve clinical stabilization.
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Affiliation(s)
- Oliver Tomkins
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK. https://twitter.com/tomkinsoliver
| | - Veronique Leblond
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Michael P Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Karine Viala
- Department of Clinical Neurophysiology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Damien Roos Weil
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Shirley D'Sa
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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Balestro G, Picelli A, Ortolani L, Marcante A. Combined effect of medical therapy and rehabilitation in Chronic Ataxic Neuropathy with anti-Disialosyl IgM Antibodies (CANDA): a case report. Eur J Transl Myol 2023; 33:11557. [PMID: 37522810 PMCID: PMC10583142 DOI: 10.4081/ejtm.2023.11557] [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: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023] Open
Abstract
Chronic Ataxic Neuropathy with anti-Disialosyl IgM Antibodies (CANDA) is a rare form of immune-mediated sensory ataxic neuropathy. We describe the case of a 45-year-old man, who was diagnosed with CANDA in October 2018. Since then, he has been treated with monthly courses of intravenous immunoglobulin administration (IV Ig) and, in October 2022, he underwent plasmapheresis, reporting a sudden worsening of clinical and motor picture. After a new IV Ig cycle admission, the patient was hospitalized to perform intensive rehabilitation, involving two individual sessions per day (90 minutes each) for 5 days a week. During hospitalization it was registered a relevant improvement in the muscle strength of the lower limbs (LLs). Furthermore, progressive improvements were recorded both in patient's motor performance and in his level of autonomy in activities of daily living. These results had a positive impact on his quality of life and made it possible to reduce the frequency of IV Ig treatments. This is the first case in literature reporting the combined effect of rehabilitation treatment and medical therapy in CANDA neuropathy.
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Affiliation(s)
- Giulio Balestro
- Unit of Neurorehabilitation, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital of Verona, University of Verona, Verona.
| | - Alessandro Picelli
- Unit of Neurorehabilitation, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital of Verona, University of Verona, Verona.
| | - Luca Ortolani
- U.O.C. Recovery and Functional Rehabilitation - Lonigo, Ulss8 Berica.
| | - Andrea Marcante
- U.O.C. Recovery and Functional Rehabilitation - Lonigo, Ulss8 Berica.
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Aguirre AS, Vivanco RA, Ortiz JF, Rozen V, InsuastI WE, Fiallos J, Gallegos C, Villavicencio A, Salazar K, Duenas F, Singla R. Efficacy of Rituximab in CANOMAD: A Systematic Review. Cureus 2023; 15:e39237. [PMID: 37337500 PMCID: PMC10277167 DOI: 10.7759/cureus.39237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/21/2023] Open
Abstract
CANOMAD, characterized by chronic ataxic neuropathy, ophthalmoplegia, immunoglobulin M (IgM) paraprotein, cold agglutinins, and disialosyl antibodies, encompasses a clinical, radiological, and laboratory diagnosis. CANOMAD is a rare condition, with fewer than 100 cases reported in the literature. The understanding and diagnosis of the disease have improved in the last few years, but the treatment of CANOMAD is mainly unknown, and there is not a clear consensus about it. We conducted a systematic review regarding the efficacy of rituximab in CANOMAD's treatment to investigate the clinical and biological response of CANOMAD in patients treated with rituximab. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines for this systematic review. To analyze the bias of the study, we used the Joanna Briggs Institute's (JBI) Critical Appraisal Checklist to analyze the bias of the case reports, and we used the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for the observational studies. We only included case reports, case series, and observational studies written in English with patients formally diagnosed with CANOMAD and treated with rituximab. We excluded systematic reviews, literature reviews, and meta-analyses. We investigated the clinical and biological responses of the patients to rituximab. The clinical response was classified as complete recovery (CR), partial response (PR), stable disease (SD), and non-response (NR). We gathered 34 patients. The literature uses a modified Rankin score to define complete improvement (CR), partial response (PR), stable disease (SD), and progression. Clinically, there were three patients with CR, five with PR, 15 with SD, and 11 with progression. The biological response was assessed by measuring the decrease in antibody titers in 27 patients. Among those, six patients had CR, 12 had PR, eight had SD, and one had progression. Among 15 patients with neurological evaluation, 10 had ocular symptoms, and two presented with bulbar symptoms. Seven of the ten patients with ocular symptoms had SD, two had PR, and one had progression. Only 14 patients had a report of demyelinating features. Three had an axonal pattern, six had a demyelinating pattern, and five had a mixed pattern. Among patients with an axonal pattern, three had an SD. Among patients with a demyelinating pattern, three had a PR, two had an SD, and one had progression. Among patients with a mixed pattern, four had SD, and one had progression. We concluded that patients with CR have a shorter disease duration than patients with PR, SD, or progression. In addition, patients with CR had longer follow-ups than the other groups, suggesting that being treated early with rituximab improves the clinical outcome and has a sustained effect. There were no differences in the frequency of ocular and bulbar symptoms among patients with CANOMAD. The axonal pattern is more common in patients with SD, suggesting that axonal and mixed patterns could be markers of a bad prognosis.
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Affiliation(s)
- Alex S Aguirre
- School of Medicine, Universidad San Francisco de Quito, Quito, ECU
| | - Ricardo A Vivanco
- Faculty of Health Sciences, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | | | - Valery Rozen
- School of Medicine, Michigan State University College of Human Medicine, Grand Rapids, USA
| | - Walter E InsuastI
- Division of Research and Academic Affairs, Larkin Health System, South Miami, USA
| | - John Fiallos
- Faculty of Health Sciences, Universidad de Guayaquil, Guayaquil, ECU
| | - Camila Gallegos
- School of Medicine, Universidad San Francisco de Quito, Quito, ECU
| | | | - Kevin Salazar
- Division of Research and Academic Affairs, Larkin Health System, Miami, USA
| | - Francisco Duenas
- Faculty of Health Sciences, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Ramit Singla
- Department of Vascular Neurology, University of Tennessee Health Science Centre, Memphis, USA
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Lee SU, Baek SH, Kim HJ, Choi JY, Kim BJ, Kim JS. Acute comitant strabismus in anti-GQ1b antibody syndrome. J Neurol 2023; 270:486-492. [PMID: 36175671 DOI: 10.1007/s00415-022-11394-3] [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: 08/01/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
Ophthalmoplegia is the diagnostic hallmark of anti-GQ1b antibody syndrome. This study aimed to define the patterns of acute comitant strabismus in patients with anti-GQ1b antibody syndromes. We retrospectively analyzed the ocular motor findings in 84 patients with anti-GQ1b antibody-associated ophthalmoplegia during the acute phases. Of the 84 patients, 11 (13%) showed acute comitant strabismus. Compared to those without, patients with acute comitant strabismus frequently showed abnormal ocular motor findings that included gaze-evoked (n = 8), spontaneous (n = 4) and positional nystagmus (n = 4), saccadic hypermetria (n = 3), head-shaking nystagmus (n = 2), pulse-step mismatch (n = 1), and impaired visual cancellation of the vestibulo-ocular reflex (n = 1, p < 0.001). On the contrary, iridoplegia (p = 0.029) and ptosis (p = 0.001) were more commonly observed in patients with paralytic (incomitant) strabismus than in those with acute comitant strabismus. Comitant strabismus can manifest during the acute phase of anti-GQ1b antibody syndromes in association with other central ocular motor abnormalities. These findings implicate that the cerebellum and/or brainstem can be the primary target of the anti-GQ1b antibodies.
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Affiliation(s)
- Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, Seoul, South Korea
| | - Seol-Hee Baek
- Department of Neurology, Korea University Medical Center, Seoul, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, South Korea.,Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medical Center, Seoul, South Korea.,BK21 FOUR Program in Learning Health Systems, Korea University, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, South Korea. .,Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.
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10
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Min YG, Ju W, Ha YE, Ban JJ, Shin JY, Kim SM, Hong YH, Park SH, Sung JJ. Skin Biopsy as a Novel Diagnostic Aid in Immune-Mediated Neuropathies. J Neuropathol Exp Neurol 2022; 81:1018-1025. [PMID: 36137254 PMCID: PMC9677240 DOI: 10.1093/jnen/nlac085] [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] [Indexed: 01/06/2023] Open
Abstract
Immune-mediated neuropathies are a heterogenous group of inflammatory peripheral nerve disorders. They can be classified according to the domain where the autoimmune process begins: the internode, paranode, or node. However, conventional diagnostic tools, electrodiagnosis (EDX), and autoantibody testing do not fully address this issue. In this institutional cohort study, we investigated the value of dermal myelinated fiber analysis for target domain-based classification. Twenty-seven consecutive patients with immune-mediated neuropathies underwent skin biopsies. The sections were stained with antibodies representative of myelinated fiber domains and were scanned using a confocal microscope. Clinical and pathological features of each patient were reviewed comprehensively. Quantitative morphometric parameters were subjected to clustering analysis, which stratified patients into 3 groups. Cluster 1 ("internodopathy") was characterized by prominent internodal disruption, intact nodes and paranodes, demyelinating EDX pattern, and absence of nodal-paranodal antibodies. Cluster 2 ("paranodopathy") was characterized by paranodal disruption and corresponding antibodies. Morphological changes were restricted to the nodes in cluster 3; we designated this cluster as "nodopathy." This report highlights the utility of skin biopsy as a diagnostic aid to gain pathogenic insight and classify patients with immune-mediated neuropathies.
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Affiliation(s)
- Young Gi Min
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woohee Ju
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Ye-Eun Ha
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Jae-Jun Ban
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Neuroscience Research Institute, Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Je-Young Shin
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul National University Seoul Metropolitan Government Boramae Hospital, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Soul, Korea
| | - Jung-Joon Sung
- Send correspondence to: Jung-Joon Sung, MD, PhD, Department of Neurology, Seoul National University Hospital, Department of Translational Medicine, Seoul National University College of Medicine, 101 Daehangno, Jongnogu, Seoul 03080, Korea; E-mail:
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Peillet C, Adams D, Attarian S, Bouhour F, Cauquil C, Cassereau J, Chanson JB, Cintas P, Creange A, Delmont E, Fargeot G, Genestet S, Gueguen A, Kaminsky AL, Kuntzer T, Labeyrie C, Michaud M, Pereon Y, Puma A, Viala K, Chretien P, Adam C, Echaniz-Laguna A. Anti-disialosyl-IgM chronic autoimmune neuropathies: a nationwide multicenter retrospective study. Eur J Neurol 2022; 29:3547-3555. [PMID: 35969369 DOI: 10.1111/ene.15523] [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: 06/02/2022] [Revised: 07/30/2022] [Accepted: 08/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND & PURPOSE In this retrospective study involving 14 University Hospitals from France and Switzerland, we aimed at defining the clinicopathologic features of chronic neuropathies with anti-disialosyl ganglioside IgM antibodies (CNDA). RESULTS Fifty-five patients with a polyneuropathy evolving for more than 2 months and with at least one anti-disialosyl ganglioside IgM antibody, i.e., anti-GD1b, -GT1b, -GQ1b, -GT1a, -GD2 and -GD3 were identified. Seventy-eight percent of patients were male, mean age at disease onset was 55 years (30-76), and disease onset was progressive (82%) or acute (18%). Patients presented with limb sensory symptoms (94% of cases), sensory ataxia (85%), oculomotor weakness (36%), limb motor symptoms (31%), and bulbar muscles weakness (18%). Sixty-five percent of patients had a demyelinating polyradiculoneuropathy electrodiagnostic profile, and 24% a sensory neuronopathy profile. Anti-GD1b antibodies were found in 78% of cases, while other anti-disialosyl antibodies were each observed in less than 51% of patients. Other features included nerve biopsy demyelination (100% of cases), increased cerebrospinal fluid protein content (75%), IgM paraprotein (50%), and malignant hemopathy (8%). Eighty six percent of CNDA patients were intravenous immunoglobulins (IVIg)-responsive, and rituximab was successfully used as second-line treatment in 50% of cases. Fifteen percent of patients had mild symptoms and were not treated. CNDA course was progressive (55%) or relapsing (45%), and 93% of patients still walked after a mean disease duration of 11 years. CONCLUSION CNDA have a recognizable phenotype, are mostly IgIV-responsive, and present with a good outcome in a majority of cases.
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Affiliation(s)
- Claire Peillet
- Neurology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France.,French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin-Bicêtre, 94276, France
| | - David Adams
- Neurology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France.,French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin-Bicêtre, 94276, France.,INSERM U1195, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Shahram Attarian
- Neurology Department, CHU Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Françoise Bouhour
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, 69500, Bron, France
| | - Cécile Cauquil
- Neurology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France.,French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin-Bicêtre, 94276, France.,INSERM U1195, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Julien Cassereau
- Reference Centre for Neuromuscular Disorders, Department of Neurology, Angers University Hospital, 49933 Angers, France, Service de Neurologie, CHU Angers, Angers, France
| | - Jean-Baptiste Chanson
- Department of Neurology, Reference Center for Neuromuscular Disorders NEIDF, University Hospital of Strasbourg, France
| | | | - Alain Creange
- Service de Neurologie, CHU Henri Mondor, APHP, UPEC, Créteil, France
| | - Emilien Delmont
- Neurology Department, CHU Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Guillaume Fargeot
- Department of Clinical Neurophysiology, APHP, CHU Pitié-Salpêtrière, Paris, France
| | - Steeve Genestet
- Department of Clinical Neurophysiology, University Hospital Brest, France
| | - Antoine Gueguen
- Department of Neurology, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Anne Laure Kaminsky
- Department of Neurology, Reference Center for Neuromuscular Disorders NEIDF, University Hospital of Nancy, France
| | - Thierry Kuntzer
- Nerve-muscle unit, Department of clinical neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland, Switzerland
| | - Céline Labeyrie
- Neurology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France.,French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin-Bicêtre, 94276, France.,INSERM U1195, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Maud Michaud
- Department of Neurology, Reference Center for Neuromuscular Disorders NEIDF, University Hospital of Nancy, France
| | - Yann Pereon
- Reference Centre for Neuromuscular Disorders AOC Filnemus, Euro-NMD, Hôtel-Dieu, Nantes University Hospital, Nantes, France
| | - Angela Puma
- Peripheral Nervous System and Muscle Department, Côte d'Azur University, Nice University Hospital, Nice, France
| | - Karine Viala
- Department of Clinical Neurophysiology, APHP, CHU Pitié-Salpêtrière, Paris, France
| | - Pascale Chretien
- Clinical Immunology Laboratory, APHP, CHU Bicêtre, 94276, France.,Université de Paris, CNRS, INSERM, UTCBS, Unité des technologies Chimiques et Biologiques pour la Santé, Paris, France
| | - Clovis Adam
- Pathology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- Neurology Department, APHP, CHU de Bicêtre, Le Kremlin-Bicêtre, France.,French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin-Bicêtre, 94276, France.,INSERM U1195, Paris-Saclay University, Le Kremlin-Bicêtre, France
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12
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Bellucci M, Germano F, Grisanti S, Castellano C, Tazza F, Mobilia EM, Visigalli D, Novi G, Massa F, Rossi S, Durando P, Cabona C, Schenone A, Franciotta D, Benedetti L. Case Report: Post-COVID-19 Vaccine Recurrence of Guillain-Barré Syndrome Following an Antecedent Parainfectious COVID-19-Related GBS. Front Immunol 2022; 13:894872. [PMID: 35924236 PMCID: PMC9339669 DOI: 10.3389/fimmu.2022.894872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/24/2022] [Indexed: 01/14/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is an autoimmune neurological disorder often preceded by viral illnesses or, more rarely, vaccinations. We report on a unique combination of postcoronavirus disease 2019 (COVID-19) vaccine GBS that occurred months after a parainfectious COVID-19-related GBS. Shortly after manifesting COVID-19 symptoms, a 57-year-old man developed diplopia, right-side facial weakness, and gait instability that, together with electrophysiology and cerebrospinal fluid examinations, led to a diagnosis of post-COVID-19 GBS. The involvement of cranial nerves and IgM seropositivity for ganglioside GD1b were noteworthy. COVID-19 pneumonia, flaccid tetraparesis, and autonomic dysfunction prompted his admission to ICU. He recovered after therapy with intravenous immunoglobulins (IVIg). Six months later, GBS recurred shortly after the first dose of the Pfizer/BioNTech vaccine. Again, the GBS diagnosis was confirmed by cerebrospinal fluid and electrophysiology studies. IgM seropositivity extended to multiple gangliosides, namely for GM3/4, GD1a/b, and GT1b IgM. An IVIg course prompted complete recovery. This case adds to other previously reported observations suggesting a possible causal link between SARS-CoV-2 and GBS. Molecular mimicry and anti-idiotype antibodies might be the underlying mechanisms. Future COVID-19 vaccinations/revaccinations in patients with previous para-/post-COVID-19 GBS deserve a reappraisal, especially if they are seropositive for ganglioside antibodies.
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Affiliation(s)
- Margherita Bellucci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Francesco Germano
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Stefano Grisanti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Chiara Castellano
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Francesco Tazza
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | | | | | - Giovanni Novi
- IRCCS, Ospedale Policlinico San Martino, Genova, Italy
| | - Federico Massa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Silvia Rossi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Paolo Durando
- IRCCS, Ospedale Policlinico San Martino, Genova, Italy
| | | | - Angelo Schenone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
- IRCCS, Ospedale Policlinico San Martino, Genova, Italy
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13
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Vallat JM, Deschamps N, Taithe F, Richard L, Duchesne M, Magy L, Mathis S. Are Miller Fisher syndrome and CANDA due to a paranodopathy? J Neurol Sci 2022; 438:120279. [DOI: 10.1016/j.jns.2022.120279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 01/06/2023]
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14
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Ogata S, Ishii Y, Asano K, Kobayashi E, Kubota S, Takahashi K, Miyaji Y, Higashiyama Y, Joki H, Doi H, Koga M, Takeuchi H, Tanaka F. Sensory Ataxic Guillain-Barré Syndrome with Dysgeusia after mRNA COVID-19 Vaccination. Intern Med 2022; 61:1757-1760. [PMID: 35342134 PMCID: PMC9259306 DOI: 10.2169/internalmedicine.8967-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Guillain-Barré syndrome (GBS) has occasionally occurred in people who have received coronavirus disease 2019 (COVID-19) vaccines. Dysgeusia is rare symptom of GBS. We herein report a rare case of sensory ataxic GBS with dysgeusia just after the second dose of the Pfizer-BioNTech COVID-19 vaccine. Although autoantibodies against glycolipids were not detected, immunotherapy with intravenous immunoglobulin and methylprednisolone pulse therapy effectively ameliorated the symptoms. Our report suggests that the COVID-19 vaccine may induce various clinical subtypes of GBS, including a rare variant with sensory ataxia and dysgeusia.
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Affiliation(s)
- Shunsuke Ogata
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Yoshito Ishii
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Keiichiro Asano
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Erena Kobayashi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Shun Kubota
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Keita Takahashi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Yosuke Miyaji
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Yuichi Higashiyama
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Hideto Joki
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Hiroshi Doi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Japan
| | - Hideyuki Takeuchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Japan
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15
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Cho H. Diagnosis and management of monoclonal gammopathy of clinical significance. Blood Res 2022; 57:20-26. [PMID: 35483921 PMCID: PMC9057659 DOI: 10.5045/br.2022.2022035] [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: 02/05/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
The term "monoclonal gammopathy of clinical significance" (MGCS) refers to any plasma cell or B-cell clonal disorder that does not meet the current criteria for malignant disorders but produces a monoclonal protein that directly or indirectly results in organ damage. The most commonly affected organs are the kidneys, nerves, and skin. This review summarizes the current classification of MGCS and its diagnostic and treatment approaches.
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Affiliation(s)
- Hyungwoo Cho
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Uncini A, Mathis S, Vallat JM. New classification of autoimmune neuropathies based on target antigens and involved domains of myelinated fibres. J Neurol Neurosurg Psychiatry 2022; 93:57-67. [PMID: 34373238 DOI: 10.1136/jnnp-2021-326889] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
Autoimmune neuropathies are named by eponyms, by descriptive terminology or because of the presence of specific antibodies and are traditionally classified, on the basis of pathology and electrophysiology, as primary demyelinating or axonal. However, autoimmune disorders targeting specific molecules of the nodal region, although not showing pathological evidence of demyelination, can exhibit all the electrophysiological changes considered characteristic of a demyelinating neuropathy and acute neuropathies with antiganglioside antibodies, classified as axonal and due to nodal dysfunction, can present with reversible conduction failure and prompt recovery that appear contradictory with the common view of an axonal neuropathy. These observations bring into question the concepts of demyelinating and axonal nerve conduction changes and the groundwork of the classical dichotomous classification.We propose a classification of autoimmune neuropathies based on the involved domains of the myelinated fibre and, when known, on the antigen. This classification, in our opinion, helps to better systematise autoimmune neuropathies because points to the site and molecular target of the autoimmune attack, reconciles some contrasting pathological and electrophysiological findings, circumvents the apparent paradox that neuropathies labelled as axonal may be promptly reversible and finally avoids taxonomic confusion and possible misdiagnosis.
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Affiliation(s)
- Antonino Uncini
- Neuroscience and Imaging, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Stephane Mathis
- Department of Neurology, National Reference Center for Neuromuscular Disorders, ALS Center, CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
| | - Jean-Michel Vallat
- National Reference Center for Rare Peripheral Neuropathies and Department of Neurology, CHU Limoges (Dupuytren Hospital), Limoges, France
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17
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CANOMAD: a neurological monoclonal gammopathy of clinical significance that benefits from B-cell-targeted therapies. Blood 2021; 136:2428-2436. [PMID: 32959046 DOI: 10.1182/blood.2020007092] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/01/2020] [Indexed: 12/15/2022] Open
Abstract
CANOMAD (chronic ataxic neuropathy, ophthalmoplegia, immunoglobulin M [IgM] paraprotein, cold agglutinins, and disialosyl antibodies) is a rare syndrome characterized by chronic neuropathy with sensory ataxia, ocular, and/or bulbar motor weakness in the presence of a monoclonal IgM reacting against gangliosides containing disialosyl epitopes. Data regarding associated hematologic malignancies and effective therapies in CANOMAD are scarce. We conducted a French multicenter retrospective study that included 45 patients with serum IgM antibodies reacting against disialosyl epitopes in the context of evocating neurologic symptoms. The main clinical features were sensitive symptoms (ataxia, paresthesia, hypoesthesia; n = 45, 100%), motor weakness (n = 18, 40%), ophthalmoplegia (n = 20, 45%), and bulbar symptoms (n = 6, 13%). Forty-five percent of the cohort had moderate to severe disability (modified Rankin score, 3-5). Cold agglutinins were identified in 15 (34%) patients. Electrophysiologic studies showed a demyelinating or axonal pattern in, respectively, 60% and 27% of cases. All patients had serum monoclonal IgM gammopathy (median, 2.6 g/L; range, 0.1-40 g/L). Overt hematologic malignancies were diagnosed in 16 patients (36%), with the most frequent being Waldenström macroglobulinemia (n = 9, 20%). Forty-one patients (91%) required treatment of CANOMAD. Intravenous immunoglobulins (IVIg) and rituximab-based regimens were the most effective therapies with, respectively, 53% and 52% of partial or better clinical responses. Corticosteroids and immunosuppressive drugs were largely ineffective. Although more studies are warranted to better define the optimal therapeutic sequence, IVIg should be proposed as the standard of care for first-line treatment and rituximab-based regimens for second-line treatment. These compiled data argue for CANOMAD to be included in neurologic monoclonal gammopathy of clinical significance.
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18
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Matà S, Torricelli S, Barilaro A, Grippo A, Forleo P, Del Mastio M, Sorbi S. Polyneuropathy and monoclonal gammopathy of undetermined significance (MGUS); update of a clinical experience. J Neurol Sci 2021; 423:117335. [PMID: 33647732 DOI: 10.1016/j.jns.2021.117335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Polyneuropathies associated with monoclonal gammopathy of undetermined significance (MGUS) encompass a group of phenotypically and immunologically heterogeneous neuropathies. While the best characterized is that associated with anti-myelin glycoprotein (MAG) antibodies, there are phenotypical and immunological neuropathy variants that still lack a clear classification. We analyzed a significant number of patients, in order to better evaluate the distribution of neuropathy phenotypes and to look for some common characteristics. METHODS Clinical, neurophysiological, and laboratory data from 87 consecutive MGUS patients with peripheral neuropathy were analyzed and compared among patient groups with different MGUS classes and autoantibody reactivity. RESULTS Anti-MAG neuropathy cases account for the most homogeneous group with regard to clinical and neurophysiological findings. Patients with anti-gangliosides or sulfatide (GS) antibodies, despite a marked phenotype heterogeneity, still share several common features, including a younger age at diagnosis, a more severe disease, and a prompt and sustained response to both immunoglobulin and rituximab therapies, mostly requiring chronic administration of immune treatment. CONCLUSIONS Although heterogeneous, MGUS-associated, anti-GS antibody positive neuropathies have important similar features possibly resulting from a similar biological background.
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Affiliation(s)
- Sabrina Matà
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Sara Torricelli
- Department of Neuroscience, Psychology, Drug Research and Child Health and Centro di Ricerca, University of Florence, Florence, Italy.
| | - Alessandro Barilaro
- SOD Neurologia 2, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Antonello Grippo
- SOD Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Paolo Forleo
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Monica Del Mastio
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sandro Sorbi
- Department of Neuroscience, Psychology, Drug Research and Child Health and Centro di Ricerca, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.
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19
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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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Dispenzieri A. Monoclonal gammopathies of clinical significance. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:380-388. [PMID: 33275738 PMCID: PMC7727544 DOI: 10.1182/hematology.2020000122] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
"Monoclonal gammopathy of clinical significance" (MGCS) is the term used to describe nonmalignant monoclonal gammopathies causing important disease. MGCS is the differential diagnosis for any patient presenting with what appears to be a monoclonal gammopathy of undetermined significance but is also experiencing other unexplained symptoms. Broadly, these conditions can be separated into symptoms and signs referable to the nerves, the kidneys, and the skin. The first step in making these diagnoses is to consider them. With a particular condition in mind, the next step is to order those tests that can help confirm or dismiss a particular diagnosis. Nearly all of the renal and dermatologic conditions are diagnosed by renal and skin biopsies, respectively. The importance of a highly competent renal pathologist and dermatopathologist cannot be underestimated. Biopsy is less specific for the neuropathic conditions. Because several of the MGCSs are syndromes, recognizing other manifestations is also key. Treatment recommendations for many of these conditions are anecdotal because of their rarity, but for several of the conditions, IV immunoglobulin, rituximab, and plasma cell-directed therapy are the best options.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology and Division of Clinical Chemistry, Mayo Clinic, Rochester, MN
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Masuccio FG, Barra M, Claudio G, Claudio S. A rare case of acute motor axonal neuropathy and myelitis related to SARS-CoV-2 infection. J Neurol 2020; 268:2327-2330. [PMID: 32940797 PMCID: PMC7497229 DOI: 10.1007/s00415-020-10219-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Abstract
We describe a rare case of post-infective Acute Motor Axonal Neuropathy (AMAN) variant of Guillain-Barrè Syndrome (GBS) associated with myelitis and anti-GD1b positivity after SARS-CoV-2 infection. The patient referred to the hospital reporting a history of ten days lasting moderate fever, myalgia and anosmia, with the onset of progressive quadriparesis and ascending paraesthesias in the four limbs since five days from defervescence. A chest computed tomography demonstrated interstitial pneumonia with “ground glass opacities”, suggesting Coronavirus disease (COVID-19). The patient exhibited three negative reverse-transcription polymerase chain reaction (RT-PCR) nasopharyngeal swabs, while SARS-CoV-2 IgG was found in plasma. The electrophysiological examination demonstrated an AMAN and the spinal cord Magnetic Resonance Imaging (MRI) showed a T2-weighted hyperintense lesion in the posterior part of the spinal cord at the C7-D1 levels. Furthermore, anti-GD1b IgM was detected. GBS and myelitis could exceptionally develop simultaneously. Our findings reasonably support a causality link between COVID-19 and the neurological symptoms, suggesting a post-infective autoimmune reaction.
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Affiliation(s)
- Fabio Giuseppe Masuccio
- Department of Neurorehabilitation, C.R.R.F. "Mons. L. Novarese", Loc. Trompone, SNC, 13040, Moncrivello, VC, Italy.
| | - Massimo Barra
- Department of Neurology, ASL TO4 Chivasso, C.so G. Ferraris 3, Chivasso, Italy
| | - Geda Claudio
- Department of Neurology, ASL TO4 Ivrea, P.za Credenza 2, Ivrea, Italy
| | - Solaro Claudio
- Department of Neurorehabilitation, C.R.R.F. "Mons. L. Novarese", Loc. Trompone, SNC, 13040, Moncrivello, VC, Italy
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23
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Mathis S, Duval F, Soulages A, Solé G, Le Masson G. The ataxic neuropathies. J Neurol 2020; 268:3675-3689. [DOI: 10.1007/s00415-020-09994-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022]
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24
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Sustained response to subcutaneous immunoglobulins in chronic ataxic neuropathy with anti-disialosyl IgM antibodies (CANDA): report of two cases and review of the literature. J Neurol 2020; 267:2353-2361. [PMID: 32347337 DOI: 10.1007/s00415-020-09843-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic ataxic neuropathy with anti-disialosyl IgM antibodies (CANDA) is a rare disorder for which the pathological, neurophysiological, and therapeutic evidence remains anecdotal and controversial. METHODS This report on CANDA focuses on the neurophysiological patterns and treatment responses shared by two cases. One patient underwent nerve ultrasound follow-up. A comprehensive review of the literature highlighted the diverse experiences with different treatment options. RESULTS Response to different therapies was similar in both patients: intravenous immunoglobulins achieved a favorable response albeit with significant wearing-off fluctuations; treatment with subcutaneous immunoglobulins (SCIg) was an effective alternative leading to a clinical response for at least 2 years. Rituximab, which was trialed in both patients, was not continued long enough to determine its efficacy in modifying the disease course and/or modulating responsiveness to immunoglobulins. Steroids caused clinical worsening in both patients. CONCLUSIONS Immunoglobulin therapy appeared as the most effective in the treatment of these two patients. SCIg provided an effective treatment option for the long-term management of CANDA.
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25
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Yu EH, Geraldi-Samara D. Pharyngeal-Cervico-Brachial/Miller Fisher Overlap Syndrome With Infliximab Exposure. J Clin Neuromuscul Dis 2020; 21:157-158. [PMID: 32073461 DOI: 10.1097/cnd.0000000000000274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Edward H Yu
- Department of Neurology, Northwell Health, Zucker School of Medicine at Hofstra University, Garden City, New York
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26
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Tagliapietra M, Zanusso G, Ferrari S, Orlandi R, Bertolasi L, Cavallaro T, Monaco S. Myelin uncompaction and axo-glial detachment in chronic ataxic neuropathy with monospecific IgM antibody to ganglioside GD1b. J Peripher Nerv Syst 2019; 25:54-59. [PMID: 31837178 DOI: 10.1111/jns.12359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 11/28/2022]
Abstract
To describe clinical features, disease course, treatment response, and sural nerve biopsy findings in a patient with chronic sensory ataxic neuropathy, Binet stage A chronic lymphocytic leukemia, and monoclonal IgMλ paraprotein against ganglioside GD1b. During 9 months of hospitalization at two neurologic centers, the patient underwent serial neurologic examinations, neurophysiologic studies, imaging investigations, extensive laboratory work-up, bone marrow, and sural nerve biopsies. The patient had a severe progressive sensory neuropathy accompanied by motor involvement, dysautonomia, and marked bulbar weakness with preserved ocular movements. Conduction studies were characterized by prolonged F-wave minimal latencies, prolonged distal latencies, reduction of compound motor action potentials, and absence of sensory nerve action potentials. Sural nerve biopsy showed endoneurial edema, axonal degeneration, and regeneration, in the absence of cellular inflammation, macrophagic activation, and B-lymphocyte infiltration; no IgM or complement deposition was detected. Myelinated fibers showed redundant/abnormally thickened myelin, myelin vacuolation, and frank intramyelinic edema with condensed axoplasm. Ultrastructural features included axo-glial detachment, disruption of membrane integrity, and myelin uncompaction. This study shows that monospecific anti-GD1b IgM paraprotein is associated with non-inflammatory nerve damage. We suggest that the loss of myelin and axonal integrity reflects antibody-induced disruption of membrane lipid rafts.
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Affiliation(s)
- Matteo Tagliapietra
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy.,Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Gianluigi Zanusso
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy.,Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sergio Ferrari
- Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Orlandi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy.,Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | - Salvatore Monaco
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy.,Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Abstract
Sensory polyneuropathies, which are caused by dysfunction of peripheral sensory nerve fibers, are a heterogeneous group of disorders that range from the common diabetic neuropathy to the rare sensory neuronopathies. The presenting symptoms, acuity, time course, severity, and subsequent morbidity vary and depend on the type of fiber that is affected and the underlying cause. Damage to small thinly myelinated and unmyelinated nerve fibers results in neuropathic pain, whereas damage to large myelinated sensory afferents results in proprioceptive deficits and ataxia. The causes of these disorders are diverse and include metabolic, toxic, infectious, inflammatory, autoimmune, and genetic conditions. Idiopathic sensory polyneuropathies are common although they should be considered a diagnosis of exclusion. The diagnostic evaluation involves electrophysiologic testing including nerve conduction studies, histopathologic analysis of nerve tissue, serum studies, and sometimes autonomic testing and cerebrospinal fluid analysis. The treatment of these diseases depends on the underlying cause and may include immunotherapy, mitigation of risk factors, symptomatic treatment, and gene therapy, such as the recently developed RNA interference and antisense oligonucleotide therapies for transthyretin familial amyloid polyneuropathy. Many of these disorders have no directed treatment, in which case management remains symptomatic and supportive. More research is needed into the underlying pathophysiology of nerve damage in these polyneuropathies to guide advances in treatment.
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Affiliation(s)
- Kelly Graham Gwathmey
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kathleen T Pearson
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
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Zucchi E, Cavallieri F, Giovannini G, Antonelli F, Mascia MT, Bedin R, Mandrioli J. Post-infectious sensory neuropathy with anti-GT1a and GQ1b antibodies associated with cold urticaria. J Clin Neurosci 2018; 56:175-177. [PMID: 30318072 DOI: 10.1016/j.jocn.2018.06.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
A 64 years-old woman presented subacute onset distal paraesthesia concurrently with cold-induced urticaria, a rare form of physical urticaria. Both the disturbances developed a fortnight after an upper respiratory tract infection. EMG confirmed an exclusively sensory polyneuropathy, with prolongation of distal latencies and reduction of amplitudes. Anti-GQ1b and anti-GT1a antigangliosides antibodies were found in serum. The clinical workout included CSF analysis, cryoglobulin and paraprotein search, neurotropic infective agents, neoplastic markers and extensive autoimmune disease antibodies analysis, all of which resulted negative. Intravenous immunoglobulins were administered, leading to progressive resolution of the sensory disturbance, while a combination of steroid and anti-histaminics treatment was used for the urticaria. The positivity for anti-ganglioside search with an EMG pattern characterized by a mixture of demyelinating and axonal features may suggest a nodo-paranodopathy at early stages. This is the first case of an association between an acute sensory neuropathy and cold urticaria, two immune mediated conditions apparently due to very different hypersensitivity pathways. A proposed mechanism for the co-occurence of these two conditions is presented, whereas this case expands the clinical spectrum of autoimmune diseases associated with anti-GQ1b and anti-GT1a antibodies.
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Affiliation(s)
- Elisabetta Zucchi
- Department of Neurosciences, St. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy.
| | - Francesco Cavallieri
- Department of Neurosciences, St. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, Azienda Ospedaliero Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Antonelli
- Neurology Unit, Azienda Ospedaliero Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Teresa Mascia
- Immune-Rheumatology Unit, Department of Diagnostic and Clinical Medicine and Public Health, University of Modena and Reggio Emilia, Modena, Italy.
| | - Roberta Bedin
- Neurology Unit, Azienda Ospedaliero Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.
| | - Jessica Mandrioli
- Neurology Unit, Azienda Ospedaliero Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.
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30
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Fehmi J, Scherer SS, Willison HJ, Rinaldi S. Nodes, paranodes and neuropathies. J Neurol Neurosurg Psychiatry 2018; 89:61-71. [PMID: 28819062 DOI: 10.1136/jnnp-2016-315480] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 12/13/2022]
Abstract
This review summarises recent evidence supporting the involvement of the specialised nodal and perinodal domains (the paranode and juxtaparanode) of myelinated axons in the pathology of acquired, inflammatory, peripheral neuropathies.The identification of new target antigens in the inflammatory neuropathies heralds a revolution in diagnosis, and has already begun to inform increasingly targeted and individualised therapies. Rapid progress in our basic understanding of the highly specialised nodal regions of peripheral nerves serves to strengthen the links between their unique microstructural identities, functions and pathologies. In this context, the detection of autoantibodies directed against nodal and perinodal targets is likely to be of increasing clinical importance. Antiganglioside antibodies have long been used in clinical practice as diagnostic serum biomarkers, and associate with specific clinical variants but not to the common forms of either acute or chronic demyelinating autoimmune neuropathy. It is now apparent that antibodies directed against several region-specific cell adhesion molecules, including neurofascin, contactin and contactin-associated protein, can be linked to phenotypically distinct peripheral neuropathies. Importantly, the immunological characteristics of these antibodies facilitate the prediction of treatment responsiveness.
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Affiliation(s)
- Janev Fehmi
- Department of Neurology, Southmead Hospital, Bristol, UK
| | - Steven S Scherer
- Department of Neurology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hugh J Willison
- Department of Neuroimmunology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Simon Rinaldi
- Department of Clinical Neurosciences, West Wing, John Radcliffe Hospital, Oxford, UK
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31
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Debs R, Reach P, Cret C, Demeret S, Saheb S, Maisonobe T, Viala K. A new treatment regimen with high-dose and fractioned immunoglobulin in a special subgroup of severe and dependent CIDP patients. Int J Neurosci 2016; 127:864-872. [PMID: 27918219 DOI: 10.1080/00207454.2016.1269328] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) is treated with intravenous immunoglobulins (IVIg), corticosteroids or plasma exchange (PE). IVIg dosage is not universal and markers for treatment management are needed. METHODS We report the response to high-dose and fractioned IVIg in a subgroup of definite CIDP patients, resistant to corticosteroids and PE, responders to IVIg but with an efficacy window <15 d. RESULTS Four patients were included with similar predominantly clinical motor form and conduction abnormalities. Treatment management consisted of fractioning IVIg and increasing the monthly cumulated dose (mean: 3 g/kg/month). Serum IgG concentration was measured and correlated to the clinical state. Monitoring of serum IgG helped to guide IVIg administration dosage and frequency. A mean of 10 months was required to improve symptoms; therapy was then switched to subcutaneous (SC) route (maintenance dose: 3.5 g/kg/month). The mean Overall Neuropathy Limitations Scale was improved from 11 to 3.2 and the mean Medical Research Council scale from 26 to 90. CONCLUSION It is important to distinguish patients with short IVIg efficacy window from those with classical resistance since the former may benefit from fractioning and increasing the IVIg dose. The monitoring of serum IgG level and its correlation to the clinical response could be of help in monitoring each individual's dosage.
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Affiliation(s)
- Rabab Debs
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Pauline Reach
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Corina Cret
- b Neurology Department , Centre Hospitalier de Meaux , Meaux , France
| | - Sophie Demeret
- c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Samir Saheb
- d Centre Clinique d'Hémobiothérapie, service d'Hématologie , Groupe Hospitalier Pitié-Salpêtrière , AP-HP , Paris , France
| | - Thierry Maisonobe
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Karine Viala
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
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32
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Martini R, Willison H. Neuroinflammation in the peripheral nerve: Cause, modulator, or bystander in peripheral neuropathies? Glia 2016; 64:475-86. [PMID: 26250643 PMCID: PMC4832258 DOI: 10.1002/glia.22899] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 12/15/2022]
Abstract
The role of innate and adaptive inflammation as a primary driver or modifier of neuropathy in premorbidly normal nerves, and as a critical player in amplifying neuropathies of other known causes (e.g., genetic, metabolic) is incompletely understood and under-researched, despite unmet clinical need. Also, cellular and humoral components of the adaptive and innate immune system are substantial disease modifying agents in the context of neuropathies and, at least in some neuropathies, there is an identified tight interrelationship between both compartments of the immune system. Additionally, the quadruple relationship between Schwann cell, axon, macrophage, and endoneurial fibroblast, with their diverse membrane bound and soluble signalling systems, forms a distinct focus for investigation in nerve diseases with inflammation secondary to Schwann cell mutations and possibly others. Identification of key immunological effector pathways that amplify neuropathic features and associated clinical symptomatology including pain should lead to realistic and timely possibilities for translatable therapeutic interventions using existing immunomodulators, alongside the development of novel therapeutic targets.
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Affiliation(s)
- Rudolf Martini
- Department of NeurologyDevelopmental Neurobiology, University Hospital WürzburgWürzburgD‐97080Germany
| | - Hugh Willison
- Institute of Infection, Immunity and Inflammation College of Medical Veterinary and Life Sciences, Glasgow Biomedical Research Centre, University of GlasgowGlasgowG12 8TA
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Stich O, Glos D, Brendle M, Dersch R, Rauer S. Cerebrospinal fluid profile and seroprevalence of antiganglioside reactivity in patients with neuralgic amyotrophy. J Peripher Nerv Syst 2016; 21:27-32. [DOI: 10.1111/jns.12157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 01/06/2016] [Accepted: 01/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Oliver Stich
- Department of Neurology; Albert Ludwigs University; Freiburg Germany
| | - Daniela Glos
- Department of Neurology; Albert Ludwigs University; Freiburg Germany
| | - Marie Brendle
- Department of Neurology; Albert Ludwigs University; Freiburg Germany
| | - Rick Dersch
- Department of Neurology; Albert Ludwigs University; Freiburg Germany
| | - Sebastian Rauer
- Department of Neurology; Albert Ludwigs University; Freiburg Germany
- Ravo Diagnostika GmbH; Freiburg Germany
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34
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Liao B, Kamiya-Matsuoka C, Fang X, Smith RG, Shanina E. Alternating ptosis associated with asialo-GM1 and GD1b antibodies. Int J Neurosci 2015; 126:1139-41. [PMID: 26710925 DOI: 10.3109/00207454.2015.1136825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Miller Fisher syndrome (MFS), variant of acute inflammatory demyelinating polyradiculoneuropathy, is recognized as clinical triad (ophthalmoplegia-ataxia-areflexia). Ganglioside antibodies play an important role in the pathogenesis of acute polyradiculoneuropathy including MFS. To our knowledge, there has been no report of MFS presenting with atypical alternating ptosis or with concurrent elevation of serum GD1 and asialo-GM1 antibody titers, and negative titers of GQ1b antibody such as our patient. Our objective is to report MFS with unusual symptoms and to share our diagnostic approach. We report a rare case of MFS presenting with alternating eyelid ptosis, paresthesia, and ataxia after a respiratory infection. Initial neurological examination revealed left eyelid ptosis, hyporeflexia, positive Romberg sign, and ataxia. The ice pack test was negative. Three days later, contralateral ptosis was observed, associated with areflexia and worsened ataxia. However, there was significant improvement of the previous left eyelid ptosis. Serology revealed elevated asialo-GM1 and GD1b antibodies. Acetylcholine receptor antibodies were negative. Cerebral spinal fluid revealed elevated IgG index. Nerve conduction studies (NCS) performed four days after the onset of symptoms showed normal nerve conduction velocities and F-waves, and absent bilateral H-reflexes. Repetitive nerve stimulation (3 Hz) showed no decrement of compound muscle action potentials. Trial with a single dose of pyridostigmine showed no clinical improvement. The symptoms resolved without intervention. NCS 18 days after onset of symptoms showed mildly prolonged F-waves and absent H-reflexes. This case highlights an atypical presentation of MFS and raises the awareness of a rare autoantibody associated with it.
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Affiliation(s)
- Bing Liao
- a 1 Department of Neurology , The University of Texas Medical Branch , Galveston , TX , USA.,b 2 Department of Neurology , Mayo Clinic , Rochester , MN , USA
| | - Carlos Kamiya-Matsuoka
- c 3 Department of Neuro-Oncology , The University of Texas MD Anderson Cancer Center , Houston , TX , United States
| | - Xiang Fang
- a 1 Department of Neurology , The University of Texas Medical Branch , Galveston , TX , USA
| | - Robert G Smith
- a 1 Department of Neurology , The University of Texas Medical Branch , Galveston , TX , USA
| | - Elena Shanina
- a 1 Department of Neurology , The University of Texas Medical Branch , Galveston , TX , USA
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Facial Involuntary Movements and Respiratory Failure in CANOMAD, Responsive to IVIG Therapy. Case Rep Med 2015; 2015:170543. [PMID: 26697071 PMCID: PMC4677173 DOI: 10.1155/2015/170543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 11/13/2015] [Accepted: 11/15/2015] [Indexed: 11/17/2022] Open
Abstract
CANOMAD is a rare chronic neuropathy, characterized by chronic sensory ataxia and intermittent brain stem symptoms due to antidisialosyl antibodies. The disorder results in significant morbidity but is poorly understood and often misdiagnosed. We describe a unique case of CANOMAD, associated with involuntary movements of the face; patient reported exacerbations with citrus and chocolate and respiratory muscle weakness. Our patient was initially misdiagnosed with Miller Fisher Syndrome, highlighting the need for vigilance should neurological symptoms recur in patients initially diagnosed with a Guillain Barre variant. Moreover, the optimal treatment is unknown. This patient responded remarkably to intravenous immunoglobulin and has been maintained on this treatment, without further exacerbations.
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36
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Décard BF, Fladt J, Axer H, Fischer D, Grimm A. Nerve ultrasound in Miller Fisher variant of Guillain-Barré syndrome. Muscle Nerve 2015; 52:1106-10. [PMID: 26123539 DOI: 10.1002/mus.24753] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Focal enlargement of the peripheral and spinal nerves, visualized using high-resolution ultrasound (HRUS), has been reported in early Guillain-Barré syndrome, but not in the Miller Fisher variant. We report the use of HRUS in 2 patients who presented with acute ataxic neuropathy, areflexia, and ophthalmoparesis. METHODS Ultrasound and/or nerve conduction studies (NCS) of peripheral nerves, the vagus, and spinal nerves C5/6 were performed at onset and 2 weeks after immunoglobulin therapy. RESULTS Both patients fulfilled criteria for diagnosis of Miller Fisher syndrome (MFS). Laboratory findings revealed elevated ganglioside Q1b antibodies in both and an albuminolocytologic dissociation in 1 patient. In addition, 1 patient had NCS evidence for demyelinating neuropathy. However, ultrasound showed focal enlargement in the vagus, the spinal nerves, and/or in the peripheral nerves in both patients. After therapy, nerve enlargement decreased in parallel with clinical improvement. CONCLUSION Spinal and/or peripheral nerve enlargement supports the diagnosis of MFS in early phases of the disease.
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Affiliation(s)
- Bernhard F Décard
- Department of Neurology, Basel University Hospital, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Joachim Fladt
- Department of Neurology, Basel University Hospital, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dirk Fischer
- Department of Neurology, Basel University Hospital, Petersgraben 4, CH-4031, Basel, Switzerland.,Division of Neuropaediatrics, University Children's Hospital Basel, Basel, Switzerland.,University Clinic of Internal Medicine, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Alexander Grimm
- Department of Neurology, Basel University Hospital, Petersgraben 4, CH-4031, Basel, Switzerland.,Department of Neurology and Epileptology, University of Tuebingen, Tuebingen, Germany
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37
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Doppler K, Appeltshauser L, Wilhelmi K, Villmann C, Dib-Hajj SD, Waxman SG, Mäurer M, Weishaupt A, Sommer C. Destruction of paranodal architecture in inflammatory neuropathy with anti-contactin-1 autoantibodies. J Neurol Neurosurg Psychiatry 2015; 86:720-8. [PMID: 25694474 DOI: 10.1136/jnnp-2014-309916] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/31/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Autoantibodies against paranodal proteins have been described in patients with inflammatory neuropathies, but their association with pathology of nodes of Ranvier is unclear. We describe the clinical phenotype and histopathological changes of paranodal architecture of patients with autoantibodies against contactin-1, identified from a cohort with chronic inflammatory demyelinating polyradiculoneuropathy (n=53) and Guillain-Barré syndrome (n=21). METHODS We used ELISA to detect autoantibodies against contactin-1. Specificity of the autoantibodies was confirmed by immunoblot assay, binding to contactin-1-transfected human embryonic kidney cells, binding to paranodes of murine teased fibres and preabsorption experiments. Paranodal pathology was investigated by immunofluorescence labelling of dermal myelinated fibres. RESULTS High reactivity to contactin-1 by ELISA was found in four patients with chronic inflammatory demyelinating polyradiculoneuropathy and in none of the patients with Guillain-Barré syndrome, which was confirmed by cell binding assays in all four patients. The four patients presented with a typical clinical picture, namely acute onset of disease and severe motor symptoms, with three patients manifesting action tremor. Immunofluorescence-labelling of paranodal proteins of dermal myelinated fibres revealed disruption of paranodal architecture. Semithin sections showed axonal damage but no classical signs of demyelination. INTERPRETATION We conclude that anti-contactin-1-related neuropathy constitutes a presumably autoantibody-mediated form of inflammatory neuropathy with distinct clinical symptoms and disruption of paranodal architecture as a pathological correlate. Anti-contactin-1-associated neuropathy does not meet morphological criteria of demyelinating neuropathy and therefore, might rather be termed a 'paranodopathy' rather than a subtype of demyelinating inflammatory neuropathy.
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Affiliation(s)
- Kathrin Doppler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Kai Wilhelmi
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Carmen Villmann
- Institute for Clinical Neurobiology, University Hospital Würzburg, Würzburg, Germany
| | - Sulayman D Dib-Hajj
- Department of Neurology, Yale University School of Medicine, New Haven, USA Center of Neuroscience and Regeneration Research, Veterans Affairs Medical Center, West Haven, USA
| | - Stephen G Waxman
- Department of Neurology, Yale University School of Medicine, New Haven, USA Center of Neuroscience and Regeneration Research, Veterans Affairs Medical Center, West Haven, USA
| | - Mathias Mäurer
- Department of Neurology, Caritas-Krankenhaus Bad Mergentheim GmbH, Bad Mergentheim, Germany
| | - Andreas Weishaupt
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
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38
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Abstract
A wide range of autoantibodies have been described in immune-mediated nerve disorders that target glycans borne by glycolipids and glycoproteins enriched in the peripheral nerves. Their use as diagnostic biomarkers is very widespread, despite some limitations on sensitivity and specificity, and the lack of standardized assays and access to quality assurance schemes. Although many methods have been applied to measurement, ELISA, in the form of commercial kits or in-house assays, still remains the most widely available and convenient assay methodology.Some antibodies have a particularly robust and widely appreciated clinical significance. Thus, the anti-MAG IgM antibodies that are found in IgM paraprotein related neuropathies define a relatively uniform clinical and prognostic phenotype. IgG antibodies against gangliosides GM1 and GD1a are strongly associated with motor axonal variants of Guillain-Barré syndrome, and anti-GQ1b with Miller Fisher syndrome. In other chronic neuropathies, antibodies against disialylated gangliosides including GD1b and GD3 are detected in ataxic neuropathies, usually associated with an IgM paraprotein, and antibodies against GM1 and the complex GM1:GalC are frequently found in multifocal motor neuropathy. Unfortunately, autoantibodies strongly associated with the diagnosis of chronic inflammatory demyelinating polyneuropathies and with demyelinating forms of GBS are still lacking.Identification of autoantibodies that map onto a specific clinical phenotype not only allows for improved classification, but also provides better understanding of the pathophysiology of inflammatory neuropathies and the potential for therapeutic interventions.
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Affiliation(s)
- Delmont Emilien
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Referral centre for ALS and Neuromuscular diseases, hospital La Timone, Marseille, France
| | - Willison Hugh
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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39
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Shihashi G, Yagi T, Suzuki S, Seki M, Kohashi S, Ueda T, Kameyama K, Kusunoki S, Nakajima H, Okamoto S, Suzuki N. Immune-mediated Neuropathy with Anti-disialosyl IgM Antibodies in Diffuse Large B-cell Lymphoma: A Case Report and Literature Review. Intern Med 2015; 54:1647-51. [PMID: 26134199 DOI: 10.2169/internalmedicine.54.4451] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 36-year-old man with diffuse large B-cell lymphoma presented with polyneuropathy, and the diagnostic work-up revealed the presence of IgM antibodies against gangliosides with disialosyl residues (GD1b, GD3). He was treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone and received high-dose intravenous immunoglobulin for the treatment of neuropathy. After initiating the treatments, the patient's neurological impairment improved dramatically. He currently remains in complete remission without a flare-up of the polyneuropathy. Based upon our experience and other case reports of lymphoma with immune-mediated neuropathy caused by anti-disialosyl ganglioside IgM antibodies, we conclude that determining the anti-ganglioside antibody profile and beginning early treatment should be considered promptly for patients with malignant lymphoma who develop polyneuropathy.
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Affiliation(s)
- Gen Shihashi
- Department of Neurology, Keio University School of Medicine, Japan
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40
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Peripheral nerve proteins as potential autoantigens in acute and chronic inflammatory demyelinating polyneuropathies. Autoimmun Rev 2014; 13:1070-8. [DOI: 10.1016/j.autrev.2014.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 06/27/2014] [Indexed: 01/06/2023]
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41
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Yagi Y, Yokote H, Watanabe Y, Amino T, Kamata T, Kusunoki S. Taste impairment in Miller Fisher syndrome. Neurol Sci 2014; 36:809-10. [PMID: 25116259 DOI: 10.1007/s10072-014-1916-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/04/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Yohsuke Yagi
- Department of Neurology, Musashino Red Cross Hospital, Kyonancho 1-26-1, Musashino, Tokyo, 180-8610, Japan,
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42
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Wakerley BR, Uncini A, Yuki N. Guillain-Barré and Miller Fisher syndromes--new diagnostic classification. Nat Rev Neurol 2014; 10:537-44. [PMID: 25072194 DOI: 10.1038/nrneurol.2014.138] [Citation(s) in RCA: 365] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Guillain-Barré syndrome (GBS) and its variant, Miller Fisher syndrome (MFS), exist as several clinical subtypes with different neurological features and presentations. Although the typical clinical features of GBS and MFS are well recognized, current classification systems do not comprehensively describe the full spectrum of either syndrome. In this Perspectives article, GBS and MFS are classified on the basis of current understanding of the common pathophysiological profiles of each disease phenotype. GBS is subclassified into classic and localized forms (for example, pharyngeal-cervical-brachial weakness and bifacial weakness with paraesthesias), and MFS is divided into incomplete (for example, acute ophthalmoparesis, acute ataxic neuropathy) and CNS subtypes (Bickerstaff brainstem encephalitis). Diagnostic criteria based on clinical characteristics are suggested for each condition. We believe this approach to be more inclusive than existing systems, and argue that it could facilitate early clinical diagnosis and initiation of appropriate immunotherapy.
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Affiliation(s)
- Benjamin R Wakerley
- Department of Neurology, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - Antonino Uncini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio, Via dei Vestini 31, Chieti 66013, Italy
| | - Nobuhiro Yuki
- Departments of Medicine and Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Unit 09-01, Centre for Translational Medicine, 14 Medical Drive, Singapore 117599, Singapore
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