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Taub DG, Woolf CJ. Age-dependent small fiber neuropathy: Mechanistic insights from animal models. Exp Neurol 2024; 377:114811. [PMID: 38723859 PMCID: PMC11131160 DOI: 10.1016/j.expneurol.2024.114811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/07/2024] [Accepted: 05/05/2024] [Indexed: 05/28/2024]
Abstract
Small fiber neuropathy (SFN) is a common and debilitating disease in which the terminals of small diameter sensory axons degenerate, producing sensory loss, and in many patients neuropathic pain. While a substantial number of cases are attributable to diabetes, almost 50% are idiopathic. An underappreciated aspect of the disease is its late onset in most patients. Animal models of human genetic mutations that produce SFN also display age-dependent phenotypes suggesting that aging is an important contributor to the risk of development of the disease. In this review we define how particular sensory neurons are affected in SFN and discuss how aging may drive the disease. We also evaluate how animal models of SFN can define disease mechanisms that will provide insight into early risk detection and suggest novel therapeutic interventions.
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Affiliation(s)
- Daniel G Taub
- F. M. Kirby Neurobiology Center and Department of Neurology, Boston Children's Hospital, Boston, MA, USA; Department of Neurobiology, Harvard Medical School, Boston, MA, USA.
| | - Clifford J Woolf
- F. M. Kirby Neurobiology Center and Department of Neurology, Boston Children's Hospital, Boston, MA, USA; Department of Neurobiology, Harvard Medical School, Boston, MA, USA
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2
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Peddareddygari LR, Grewal RP. A Patient With Charcot-Marie-Tooth Disease Type 4C (CMT4C) Presenting With Muscle Fasciculations and Motor Neuropathy. Cureus 2024; 16:e57550. [PMID: 38707135 PMCID: PMC11066706 DOI: 10.7759/cureus.57550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/07/2024] Open
Abstract
We report an unusual patient who, at age 47 years, had presented with complaints of muscle fasciculations. After neurological examination and electromyogram testing, he was diagnosed with motor neuropathy. Over the next 10 years, in addition to fasciculations, he developed numbness in his feet without any other symptoms. His current neurological examination at age 57 years was normal, except for mildly decreased light touch in the anterior portion of both feet. The nerve conduction studies performed repeatedly showed sensorimotor polyneuropathy with demyelination features. Blood tests, including anti-ganglioside antibodies, were normal. Genetic testing revealed two rare variants in trans in the SH3 domain and tetratricopeptide repeats 2gene, c.3413 G>A p.(S1138N) and c.3269 C>G p.(A1090G). Protein modeling suggests that these are disease-producing mutations and likely the cause of the neuropathy of our patient. Our study expands the clinical and genetic spectrum of patients with Charcot-Marie-Tooth disease type 4C.
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Affiliation(s)
| | - Raji P Grewal
- Neurosciences, Capital Health Institute for Neurosciences, Bordentown, USA
- Research and Development, Dynamic Biologics Inc., Monmouth Junction, USA
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Zirpoli GR, Farhad K, Klein MC, Downs S, Klein MM, Oaklander AL. Initial validation of the Mass. General Neuropathy Exam Tool (MAGNET) for evaluation of distal small-fiber neuropathy. Muscle Nerve 2024; 69:185-198. [PMID: 38112169 PMCID: PMC10842781 DOI: 10.1002/mus.28013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION/AIMS Diagnosis of small-fiber neuropathy (SFN) is hampered by its subjective symptoms and signs. Confirmatory testing is insufficiently available and expensive, so predictive examinations have value. However, few support the 2020 SFN consensus-case-definition requirements or were validated for non-diabetes neuropathies. Thus we developed the Massachusetts General Hospital Neuropathy Exam Tool (MAGNET) and measured diagnostic performance in 160 symptomatic patients evaluated for length-dependent SFN from any cause and 37 healthy volunteers. METHODS We compared prevalences of abnormalities (vital signs, pupil responses, lower-limb appearance, pin, light touch, vibration and position sensitivity, great-toe strength, muscle stretch reflexes), and validated diagnostic performance against objective SFN tests: lower-leg skin-biopsy epidermal neurite densities and autonomic function testing (AFT). Sensitivity/specificity, feasibility, test-retest and inter-rater reliability, and convergence with the Utah Early Neuropathy Scale were calculated. RESULTS Patients' ages averaged 48.5 ± 14.7 years and 70.6% were female. Causes of neuropathy varied, remaining unknown in 59.5%. Among the 46 with abnormal skin biopsies, the most prevalent abnormality was reduced pin sharpness at the toes (71.7%). Inter-rater reliability, test-retest reliability, and convergent validity excelled (range = 91.3-95.6%). Receiver operating characteristics comparing all symptomatic patients versus healthy controls indicated that a MAGNET threshold score of 14 maximized predictive accuracy for skin biopsies (0.74) and a 30 cut-off maximized accuracy for predicting AFT (0.60). Analyzing patients with any abnormal neuropathy-test results identified areas-under-the-curves of 0.87-0.89 for predicting a diagnostic result, accuracy = 0.80-0.89, and Youden's index = 0.62. Overall, MAGNET was 80%-85% accurate for stratifying patients with abnormal versus normal neuropathy test results. DISCUSSION MAGNET quickly generates research-quality metrics during clinical examinations.
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Affiliation(s)
- Gary R. Zirpoli
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Khosro Farhad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Madeleine C. Klein
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean Downs
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Max M. Klein
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA, USA
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Labib A, Burke O, Nichols A, Maderal AD. Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review. J Am Acad Dermatol 2023; 89:1192-1200. [PMID: 37517675 DOI: 10.1016/j.jaad.2023.06.063] [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: 10/29/2022] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.
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Affiliation(s)
- Angelina Labib
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Olivia Burke
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Anna Nichols
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Andrea D Maderal
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Ziegler D, Herder C, Papanas N. Neuropathy in prediabetes. Diabetes Metab Res Rev 2023; 39:e3693. [PMID: 37470302 DOI: 10.1002/dmrr.3693] [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: 02/23/2023] [Revised: 04/13/2023] [Accepted: 06/18/2023] [Indexed: 07/21/2023]
Abstract
Diabetic neuropathies are the most frequent complications of diabetes, contributing to high morbidity, excess mortality, reduced quality of life, and increased healthcare costs. Prediabetes is characterised by glucose levels within an intermediate range above normoglycaemia yet below the diagnostic threshold for diabetes. In 2021, 10.6% and 6.2% of adults worldwide were estimated to have impaired glucose tolerance and impaired fasting glucose, respectively, the majority of whom are unaware of having prediabetes. Evidence has accumulated suggesting that prediabetes is a predictor of cardiovascular disease (CVD) and increased mortality. The past 2 decades have witnessed an extensive debate, particularly among diabetologists and neurologists, as to whether prediabetes is associated with peripheral neuropathy. In this review, we elaborate on the current evidence, particularly from population-based studies supporting an increased risk of distal sensorimotor polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN) in people with prediabetes. Moreover, we discuss whether lifestyle interventions showing efficacy in preventing or delaying the transition from prediabetes to diabetes in persons with prediabetes may also exert favourable effects on the development and progression of DSPN and CAN. This review should help in raising the awareness of and translating the current knowledge on neuropathies in people with prediabetes into clinical practice and public health. The current recommendation that adults who are overweight or obese should be screened for prediabetes and referred to or offered preventive interventions should ultimately culminate in preventing not only CVD but also prediabetic neuropathy.
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Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Nikolaos Papanas
- Diabetes Centre, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Jin PH. Localization and Diagnostic Evaluation of Peripheral Nerve Disorders. Continuum (Minneap Minn) 2023; 29:1312-1326. [PMID: 37851032 DOI: 10.1212/con.0000000000001333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article provides a framework for the initial evaluation of patients with suspected peripheral nerve disease. The key clinical elements of peripheral nerve diseases can help the practicing neurologist differentiate among peripheral neuropathies with similar presentations. LATEST DEVELOPMENTS The wide range of peripheral nerve diseases with similar clinical presentations can pose a diagnostic challenge. The large array of available testing modalities (including imaging and electrodiagnostic, autonomic, laboratory, biopsy, and genetic testing) further complicates clinical decision making. Recent developments (eg, discovery of new autoantibodies, genetic variations, and histopathologic techniques) across the peripheral neuropathy spectrum have resulted in an increased need to evaluate patients logically and with a tailored diagnostic approach. ESSENTIAL POINTS A careful approach that focuses on key clinical elements combined with an understanding of purposeful diagnostic testing can lead to a successful diagnosis of peripheral nerve diseases.
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7
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Krämer HH, Bücker P, Jeibmann A, Richter H, Rosenbohm A, Jeske J, Baka P, Geber C, Wassenberg M, Fangerau T, Karst U, Schänzer A, van Thriel C. Gadolinium contrast agents: dermal deposits and potential effects on epidermal small nerve fibers. J Neurol 2023:10.1007/s00415-023-11740-z. [PMID: 37138180 DOI: 10.1007/s00415-023-11740-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/05/2023]
Abstract
Small fiber neuropathy (SFN) affects unmyelinated and thinly myelinated nerve fibers causing neuropathic pain with distal distribution and autonomic symptoms. In idiopathic SFN (iSFN), 30% of the cases, the underlying aetiology remains unknown. Gadolinium (Gd)-based contrast agents (GBCA) are widely used in magnetic resonance imaging (MRI). However, side-effects including musculoskeletal disorders and burning skin sensations were reported. We investigated if dermal Gd deposits are more prevalent in iSFN patients exposed to GBCAs, and if dermal nerve fiber density and clinical parameters are likewise affected. 28 patients (19 females) with confirmed or no GBCA exposure were recruited in three German neuromuscular centers. ISFN was confirmed by clinical, neurophysiological, laboratory and genetic investigations. Six volunteers (two females) served as controls. Distal leg skin biopsies were obtained according to European recommendations. In these samples Gd was quantified by elemental bioimaging and intraepidermal nerve fibers (IENF) density via immunofluorescence analysis. Pain phenotyping was performed in all patients, quantitative sensory testing (QST) only in a subset (15 patients; 54%). All patients reported neuropathic pain, described as burning (n = 17), jabbing (n = 16) and hot (n = 11) and five QST scores were significantly altered. Compared to an equal distribution significantly more patients reported GBCA exposures (82%), while 18% confirmed no exposures. Compared to unexposed patients/controls significantly increased Gd deposits and lower z-scores of the IENF density were confirmed in exposed patients. QST scores and pain characteristics were not affected. This study suggests that GBCA exposure might alter IENF density in iSFN patients. Our results pave the road for further studies investigating the possible role of GBCA in small fiber damage, but more investigations and larger samples are needed to draw firm conclusions.
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Affiliation(s)
- Heidrun H Krämer
- Department of Neurology, Justus Liebig University of Giessen, 35392, Giessen, Germany
| | - Patrick Bücker
- Institute of Inorganic and Analytical Chemistry, University of Münster, 48149, Münster, Germany
| | - Astrid Jeibmann
- Institute of Neuropathology, University Hospital Münster, 48149, Münster, Germany
| | - Henning Richter
- Clinic for Diagnostic Imaging, Diagnostic Imaging Research Unit (DIRU),Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, 8057, Zurich, Switzerland
| | | | - Johanna Jeske
- Department of Neurology, Justus Liebig University of Giessen, 35392, Giessen, Germany
| | - Panoraia Baka
- Department of Neurology, University Medical Center, 55101, Mainz, Germany
| | - Christian Geber
- Department of Neurology, University Medical Center, 55101, Mainz, Germany
- DRK Pain Center Mainz, 55131, Mainz, Germany
| | - Matthias Wassenberg
- Department of Neurology, Justus Liebig University of Giessen, 35392, Giessen, Germany
| | - Tanja Fangerau
- Department of Neurology, University of Ulm, 89081, Ulm, Germany
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, 48149, Münster, Germany
| | - Anne Schänzer
- Institute of Neuropathology, Justus Liebig University Giessen, 35392, Giessen, Germany.
| | - Christoph van Thriel
- IfADo-Leibniz Research Centre for Working Environment and Human Factors, 44139, Dortmund, Germany.
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Chan ACY, Kumar S, Tan G, Wong HY, Ong JJY, Chandra B, Huang H, Sharma VK, Lai PS. Expanding the genetic causes of small-fiber neuropathy: SCN genes and beyond. Muscle Nerve 2023; 67:259-271. [PMID: 36448457 DOI: 10.1002/mus.27752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 12/05/2022]
Abstract
Small-fiber neuropathy (SFN) is a disorder that exclusively affects the small nerve fibers, sparing the large nerve fibers. Thinly myelinated Aδ-fibers and unmyelinated C-fibers are damaged, leading to development of neuropathic pain, thermal dysfunction, sensory symptoms, and autonomic disturbances. Although many SFNs are secondary and due to immunological causes or metabolic disturbances, the etiology is unknown in up to half of the patients. Over the years, this proportion of "idiopathic SFN" has decreased, as familial and genetic causes have been discovered, thus shifting a proportion of once "idiopathic" cases to the genetic category. After the discovery of SCN9A-gene variants in 2012, SCN10A and SCN11A variants have been found to be pathogenic in SFN. With improved accessibility of SFN diagnostic tools and genetic tests, many non-SCN variants and genetically inherited systemic diseases involving the small nerve fibers have also been described, but only scattered throughout the literature. There are 80 SCN variants described as causing SFN, 8 genes causing hereditary sensory autonomic neuropathies (HSAN) described with pure SFN, and at least 7 genes involved in genetically inherited systemic diseases associated with SFN. This systematic review aims to consolidate and provide an updated overview on the genetic variants of SFN to date---SCN genes and beyond. Awareness of these genetic causes of SFN is imperative for providing treatment directions, prognostication, and management of expectations for patients and their health-care providers.
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Affiliation(s)
- Amanda C Y Chan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shivaram Kumar
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Grace Tan
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hiu Yi Wong
- Division of Life Science, State Key Laboratory of Molecular Neuroscience, Hong Kong University of Science and Technology, Hong Kong, China
- Hong Kong Center for Neurodegenerative Diseases, Hong Kong Science Park, Hong Kong, China
| | - Jonathan J Y Ong
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bharatendu Chandra
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Medical Genetics, University of Iowa, Iowa City, Iowa, USA
| | - Hua Huang
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
| | - Poh San Lai
- Yong Loo Ling School of Medicine, National University of Singapore, Singapore, Singapore
- Adjunct Faculty, Genome Institute of Singapore, Singapore, Singapore
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Sánchez-Tejerina D, Alvarez PF, Laínez E, Martinez VG, Santa-Cruz DI, Verdaguer L, Gratacòs M, Seoane JL, Raguer N, Hernández-Vara J, Llauradó A, Sotoca J, Salvado M, Arumi EG, Tizzano EF, Juntas R. RFC1 repeat expansions and cerebellar ataxia, neuropathy and vestibular areflexia syndrome: Experience and perspectives from a neuromuscular disorders unit. J Neurol Sci 2023; 446:120565. [PMID: 36753892 DOI: 10.1016/j.jns.2023.120565] [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: 06/30/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Pathogenic expansions in RFC1 have been described as a cause of a spectrum of disorders including late-onset ataxia, chronic cough, and cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). Sensory neuronopathy/neuropathy appears to be a major symptom of RFC1-disorder, and RFC1 expansions are common in patients with sensory chronic idiopathic axonal neuropathy or sensory ganglionopathy. We aimed to investigate RFC1 expansions in patients with suspected RFC1-related disease followed-up in a Neuromuscular Diseases Unit, with a particular interest in the involvement of the peripheral nervous system. METHODS We recruited twenty consecutive patients based on the presence of at least two of the following features: progressive ataxia, sensory neuropathy/neuronopathy, vestibulopathy and chronic cough. Medical records were retrospectively reviewed for a detailed clinical description. More extensive phenotyping of the RFC1-positive patients and clinical comparison between RFC1 positive and negative patients were performed. RESULTS Biallelic AAGGG repeat expansions were identified in 13 patients (65%). The most frequent symptoms were chronic cough and sensory disturbances in the lower extremities (12/13). Only 4 patients (31%) had complete CANVAS. The phenotypes were sensory ataxia and sensory symptoms in extremities in 4/13; sensory ataxia, sensory symptoms, and vestibulopathy in 3/13; sensory symptoms plus chronic cough in 2/13. Chronic cough and isolated sensory neuronopathy were significantly more prevalent in RFC1-positive patients. CONCLUSION Pathogenic RFC1 expansions are a common cause of sensory neuropathy/neuronopathy and should be considered in the approach to these patients. Identification of key symptoms or detailed interpretation of nerve conduction studies may improve patient selection for genetic testing.
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Affiliation(s)
- Daniel Sánchez-Tejerina
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain.
| | - Paula Fernandez Alvarez
- Department of Clinical and Molecular Genetics, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Elena Laínez
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Victoria Gonzalez Martinez
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Daniela Isabel Santa-Cruz
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Lena Verdaguer
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Margarida Gratacòs
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Jose Luis Seoane
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Núria Raguer
- Department of Clinical Neurophysiology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Jorge Hernández-Vara
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Arnau Llauradó
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Javier Sotoca
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Maria Salvado
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Elena Garcia Arumi
- Department of Clinical and Molecular Genetics, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain.; Biomedical Network Research Centre on Rare Diseases (CIBERER), Monforte de Lemos, 28029 Madrid, Spain
| | - Eduardo F Tizzano
- Department of Clinical and Molecular Genetics, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Raúl Juntas
- Department of Neurology, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
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Fouchard M, Brenaut E, Genestet S, Ficheux AS, Marcorelles P, Misery L. Observational case-control study of small-fiber neuropathies, with regards on smoking and vitamin D deficiency and other possible causes. Front Med (Lausanne) 2023; 9:1051967. [PMID: 36714112 PMCID: PMC9877604 DOI: 10.3389/fmed.2022.1051967] [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] [Received: 09/23/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Small fiber neuropathies (SFNs) are disorders of skin nerve endings inducing pruritus, burning pain, numbness, and paresthesia. The aims of this study were to search for putative etiologies of SFN and their occurrence in a cohort of patients and to compare patients with SFN to a group of patients without SFN to highlight potential factors associated with SFN. Methods This study was observational, retrospective, and monocentric. All patients with symptoms of SFN who underwent skin biopsies with intraepidermal nerve density counts were included. Patients with a count lower than 5 percentiles were considered to be in the SFN group. Other patients were considered to be the control group. Results A total of 162 patients with SFN and 161 controls were included. No cause was identified for 108 patients (61.7%). The established causes were autoimmune diseases (9.1%), diabetes or glucose intolerance (8%), medication (4%), liver disease (3.4%), and monoclonal gammopathy of undetermined significance (2.9%). Current or former smokers were more numerous in the SFN group (26.5%) than in the control group (16.1%), while vitamin D amounts were significantly lower in the SFN group than in the control group. Discussion Hence, tobacco smoking and vitamin D deficiency might be new putative causes of SFN.
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Affiliation(s)
- Maxime Fouchard
- Department of Dermatology, CHU Brest, Brest, France,Univ Brest, LIEN, Brest, France
| | - Emilie Brenaut
- Department of Dermatology, CHU Brest, Brest, France,Univ Brest, LIEN, Brest, France
| | - Steeve Genestet
- Department of Neurology, CHU Brest, Brest, France,Breton Competence Center of Rare Neuromuscular Diseases and Neuropathies With Cutaneous-Mucosal Symptoms, CHRU de Brest, Brest, France
| | | | - Pascale Marcorelles
- Univ Brest, LIEN, Brest, France,Breton Competence Center of Rare Neuromuscular Diseases and Neuropathies With Cutaneous-Mucosal Symptoms, CHRU de Brest, Brest, France,Department of Pathology, CHU Brest, Brest, France
| | - Laurent Misery
- Department of Dermatology, CHU Brest, Brest, France,Univ Brest, LIEN, Brest, France,Breton Competence Center of Rare Neuromuscular Diseases and Neuropathies With Cutaneous-Mucosal Symptoms, CHRU de Brest, Brest, France,*Correspondence: Laurent Misery,
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11
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Pelosi L, Coraci D, Mulroy E, Leadbetter R, Padua L, Roxburgh R. Ultrasound of peripheral nerves distinguishes inherited sensory neuronopathy of cerebellar ataxia with neuropathy and vestibular areflexia syndrome from inherited axonopathy. Muscle Nerve 2023; 67:33-38. [PMID: 36354069 DOI: 10.1002/mus.27751] [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: 05/19/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
Introduction/Aims Recent studies have shown that ultrasound of peripheral nerves can distinguish inherited sensory neuronopathy from acquired axonopathy with a high degree of accuracy. In this study we aimed to determine whether ultrasound can also distinguish inherited sensory neuronopathy from inherited axonopathy. Methods We compared the ultrasound cross-sectional areas (CSAs) of the median, ulnar, sural, and tibial nerves of retrospectively recruited patients with cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS), in whom sensory neuronopathy is a cardinal feature, with Charcot-Marie-Tooth type 2 (CMT2) disease patients, who have an inherited axonopathy, using the Kruskal-Wallis test and receiver-operating characteristic curves. Results There were 17 patients with CANVAS and 18 with CMT2. The upper limb nerve CSAs were significantly smaller in CANVAS than in CMT2 (P < .001), with the CSAs of the median nerve at mid-forearm and ulnar nerve at mid-arm being a third or less the size of those of the CMT2 patients. Nerve ultrasound reliably distinguished CANVAS from CMT2 with ROC areas under the curve between 0.97 and 0.99. The lower limb CSAs of the two patient groups were not significantly different. Discussion Ultrasound of the upper limb nerves distinguishes CANVAS sensory neuronopathy from inherited axonopathy with high accuracy and can therefore be proposed as a reliable additional tool in the investigation of these diseases.
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Affiliation(s)
- Luciana Pelosi
- Departments of Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, 829 Cameron Road, Tauranga, Tauranga, Bay of Plenty, 3112, New Zealand
| | - Daniele Coraci
- Department of Neuroscience, Section of Rehabilitation, University of Padua, Padua, Italy
| | - Eoin Mulroy
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Ruth Leadbetter
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Luca Padua
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Geriatrics and Orthopaedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Richard Roxburgh
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand.,Centre of Brain Research Neurogenetics Research Clinic, University of Auckland, New Zealand
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12
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Vilaça CDO, Souza FD, Barbato KBG. Profile of neurological disorders in a tertiary center of education in orthopedics. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:27-32. [PMID: 36918004 PMCID: PMC10014198 DOI: 10.1055/s-0042-1759763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Neurological conditions can cause secondary orthopedic disorders and can result from orthopedic surgical procedures. In addition, misdiagnosis and overtreatment involve both specialties. Epidemiological studies of neurological patients in tertiary units are often performed in emergency departments of general hospitals or rehabilitation centers. OBJECTIVE Describe the clinical and epidemiologic profile of neurological disorders in a Brazilian federal tertiary center and education hospital in orthopedics in Rio de Janeiro. METHODS We performed a retrospective study of the medical records of patients attended by neurology specialists of the internal medicine's department of the National Institute of Traumatology and Orthopedics from February 2014 to March 2020. RESULTS We reviewed neurological referrals in the medical records of 1,349 patients in the period. The mean age of patients was 49.67 years (standard deviation [SD] ± 18.99). There was a predominance of females, corresponding to 751 (55.7%) patients. Regarding ethnicity, 684 (50.7%) participants were white, 550 (40.8%) non-white, and 115 (8.5%) non-classified. Peripheral neuropathies (34.1%), osteoarticular diseases (10%), epilepsy (8.3%), developmental disorders (7.9%), and neuromuscular diseases (7.3%) were the 5 groups with the largest numbers of cases. CONCLUSION The sample consisted mostly of females and white individuals, and approximately one third of the cases were of peripheral neuropathies. Epidemiological studies in neurology from tertiary centers of another medical specialty can improve the professional development of both specialties. This interdisciplinary approach can also optimize resources, help avoid misdiagnosis, and reduce disability.
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Affiliation(s)
- Celmir de Oliveira Vilaça
- Universidade Federal do Rio de Janeiro, Serviço de Neurologia, Rio de Janeiro RJ, Brazil.,Universidade Federal Fluminense, Programa de Pós-Graduação em Neurologia/Neurociências, Rio de Janeiro RJ, Brazil.,Instituto de Traumatologia e Ortopedia Jammil Haddad, Rio de Janeiro RJ, Brazil
| | - Fabio de Souza
- Instituto de Traumatologia e Ortopedia Jammil Haddad, Rio de Janeiro RJ, Brazil.,Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro RJ, Brazil
| | - Kelly Biancardini Gomes Barbato
- Instituto de Traumatologia e Ortopedia Jammil Haddad, Rio de Janeiro RJ, Brazil.,Escola Médica Souza Marques, Rio de Janeiro RJ, Brazil
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13
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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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14
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Achenbach P, Block F, Dafotakis M. Medikamentös-induzierte Polyneuropathien jenseits von
Chemotherapeutika und Antiinfektiva. KLIN NEUROPHYSIOL 2022. [DOI: 10.1055/a-1869-3563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zahlreiche in der klinischen Routine eingesetzte Wirkstoffe jenseits von
Chemotherapeutika und Antiinfektiva können eine Polyneuropathie
verstärken oder hervorrufen. Kenntnis darüber, welche
Medikamente mit Polyneuropathien assoziiert sind sowie über
Risikofaktoren seitens der Patienten können die Häufigkeit
reduzieren. Bei entsprechendem Risiko sollten alternative Präparate
eingesetzt oder die Indikation zur Therapie generell überdacht
werden.
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15
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Controversies in treatment strategies in patients with foot drop due to peroneal nerve entrapment: Results of a survey among specialists. BRAIN AND SPINE 2022; 2:100887. [PMID: 36248140 PMCID: PMC9560709 DOI: 10.1016/j.bas.2022.100887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/13/2022] [Accepted: 03/29/2022] [Indexed: 12/26/2022]
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16
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Verdugo RJ, Matamala JM, Inui K, Kakigi R, Valls-Solé J, Hansson P, Bernhard Nilsen K, Lombardi R, Lauria G, Petropoulos IN, Malik RA, Treede RD, Baumgärtner U, Jara PA, Campero M. Review of techniques useful for the assessment of sensory small fiber neuropathies: Report from an IFCN expert group. Clin Neurophysiol 2022; 136:13-38. [DOI: 10.1016/j.clinph.2022.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/09/2023]
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17
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Corneal Confocal Microscopy in the Diagnosis of Small Fiber Neuropathy: Faster, Easier, and More Efficient Than Skin Biopsy? PATHOPHYSIOLOGY 2021; 29:1-8. [PMID: 35366285 PMCID: PMC8954271 DOI: 10.3390/pathophysiology29010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic pain may affect 30–50% of the world’s population and an important cause is small fiber neuropathy (SFN). Recent research suggests that autoimmune diseases may be one of the most common causes of small nerve fiber damage. There is low awareness of SFN among patients and clinicians and it is difficult to diagnose as routine electrophysiological methods only detect large fiber abnormalities, and specialized small fiber tests, like skin biopsy and quantitative sensory testing, are not routinely available. Corneal confocal microscopy (CCM) is a rapid, non-invasive, reproducible method for quantifying small nerve fiber degeneration and regeneration, and could be an important tool for diagnosing SFN. This review considers the advantages and disadvantages of CCM and highlights the evolution of this technique from a research tool to a diagnostic test for small fiber damage, which can be a valuable contribution to the study and management of autoimmune disease.
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18
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Malhotra A, Weaver J. Approach to Neuropathic Pain. Semin Neurol 2021; 41:744-759. [PMID: 34826876 DOI: 10.1055/s-0041-1726361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neuropathic pain is a common chief complaint encountered by neurologists and primary care providers. It is caused by disorders involving the somatosensory nervous system. The clinical evaluation of neuropathic pain is challenging and requires a multifaceted systematic approach with an emphasis on a thorough history and physical examination to identify characteristic signs and symptoms. Ancillary laboratory investigations, targeted imaging, and electrodiagnostic studies further help identify underlying etiologies to guide specific treatments. Management of neuropathic pain encompasses treating the underlying pathology as well as symptomatic control with nonpharmacological, pharmacological, and interventional therapies. Here, we present an approach to help evaluate patients with neuropathic pain.
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Affiliation(s)
- Ashwin Malhotra
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua Weaver
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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19
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Oosterbos C, Decramer T, Rummens S, Weyns F, Dubuisson A, Ceuppens J, Schuind S, Groen J, van Loon J, Rasulic L, Lemmens R, Theys T. Evidence in peroneal nerve entrapment: A scoping review. Eur J Neurol 2021; 29:665-679. [PMID: 34662481 DOI: 10.1111/ene.15145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/14/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Daily management of patients with foot drop due to peroneal nerve entrapment varies between a purely conservative treatment and early surgery, with no high-quality evidence to guide current practice. Electrodiagnostic (EDX) prognostic features and the value of imaging in establishing and supplementing the diagnosis have not been clearly established. METHODS We performed a literature search in the online databases MEDLINE, Embase, and the Cochrane Library. Of the 42 unique articles meeting the eligibility criteria, 10 discussed diagnostic performance of imaging, 11 reported EDX limits for abnormal values and/or the value of EDX in prognostication, and 26 focused on treatment outcome. RESULTS Studies report high sensitivity and specificity of both ultrasound (varying respectively from 47.1% to 91% and from 53% to 100%) and magnetic resonance imaging (MRI; varying respectively from 31% to 100% and from 73% to 100%). One comparative trial favoured ultrasound over MRI. Variable criteria for a conduction block (>20%-≥50) were reported. A motor conduction block and any baseline compound motor action potential response were identified as predictors of good outcome. Based predominantly on case series, the percentage of patients with good outcome ranged 0%-100% after conservative treatment and 40%-100% after neurolysis. No study compared both treatments. CONCLUSIONS Ultrasound and MRI have good accuracy, and introducing imaging in the standard diagnostic workup should be considered. Further research should focus on the role of EDX in prognostication. No recommendation on the optimal treatment strategy of peroneal nerve entrapment can be made, warranting future randomized controlled trials.
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Affiliation(s)
- Christophe Oosterbos
- Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Catholic University of Leuven, Leuven, Belgium.,Department of Neurosurgery, University Hospitals of Leuven, Leuven, Belgium
| | - Thomas Decramer
- Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Catholic University of Leuven, Leuven, Belgium.,Department of Neurosurgery, University Hospitals of Leuven, Leuven, Belgium
| | - Sofie Rummens
- Department of Physical Medicine and Rehabilitation, University Hospitals of Leuven, Leuven, Belgium.,Locomotor and Neurological Disorders, Catholic University of Leuven, Leuven, Belgium
| | - Frank Weyns
- Department of Neurosurgery, East Limburg Hospital, Genk, Belgium.,Neurosciences, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Annie Dubuisson
- Department of Neurosurgery, University Hospitals of Liège, Liège, Belgium
| | - Jeroen Ceuppens
- Department of Neurosurgery, Groeninge General Hospital, Kortrijk, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Brussels, Belgium
| | - Justus Groen
- Nerve Centre, University of Leiden, Leiden, the Netherlands
| | - Johannes van Loon
- Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Catholic University of Leuven, Leuven, Belgium.,Department of Neurosurgery, University Hospitals of Leuven, Leuven, Belgium
| | - Lukas Rasulic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, Catholic University of Leuven, Leuven, Belgium.,Centre for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium.,Department of Neurology, University Hospitals of Leuven, Leuven, Belgium
| | - Tom Theys
- Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Catholic University of Leuven, Leuven, Belgium.,Department of Neurosurgery, University Hospitals of Leuven, Leuven, Belgium
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20
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Esposito C, Ugo Garzarella E, Santarcangelo C, Di Minno A, Dacrema M, Sacchi R, Piccinocchi G, Piccinocchi R, Daglia M. Safety and efficacy of alpha-lipoic acid oral supplementation in the reduction of pain with unknown etiology: A monocentric, randomized, double-blind, placebo-controlled clinical trial. Biomed Pharmacother 2021; 144:112308. [PMID: 34649217 DOI: 10.1016/j.biopha.2021.112308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Extensive evidence suggests that alpha-lipoic acid (ALA) is effective in diabetic neuropathy pain management. However, little is known on its safety and efficacy in reducing idiopathic pain in normoglycemic subjects. The aim of this study was to evaluate ALA food supplement safety and efficacy in the reduction of different forms of idiopathic pain. METHODS Two-hundred and ten normoglycemic adults suffering from idiopathic pain (i.e. 57 subjects with primitive neuropathic pain, 141 subjects with arthralgia with unknown etiology, and 12 subjects with idiopathic myalgia) were randomized to receive placebo, 400 mg/day, or 800 mg/day of ALA. Participants underwent two visits (at baseline = t0, and after 2 months = t1) in which two validated questionaries for pain (numerical rating scale [NRS] and visual analogue scale [VAS]) were collected; fasting blood glucose assessment, adverse effects, and renal and hepatic toxicity were also monitored. RESULTS At t1, none of subjects treated with ALA reported a decreased glycemia or adverse effects. The treated subjects showed a significant reduction in NRS (p < 0.001) while the placebo group did not show any NRS reduction (p = 0.86). Similar results were also obtained for VAS. Statistical analysis aimed at detecting possible differences in NRS and VAS scores among treatment groups based on the source of pain did not reveal any significant effect. CONCLUSIONS Since the management of idiopathic pain is challenging for physicians, the use of ALA food supplements could be a feasible option, based on its safety and efficacy compared to commonly-used analgesic drugs.
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Affiliation(s)
- Cristina Esposito
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Emanuele Ugo Garzarella
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Cristina Santarcangelo
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Alessandro Di Minno
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy; CEINGE-Biotecnologie Avanzate, Via Gaetano Salvatore 486, 80145 Naples, Italy
| | - Marco Dacrema
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy
| | - Roberto Sacchi
- Applied Statistic Unit, Department of Earth and Environmental Sciences, University of Pavia, viale Taramelli 24, 27100 Pavia, Italy
| | - Gaetano Piccinocchi
- Comegen S.c.S., Società Cooperativa Sociale di Medici di Medicina Generale, Viale Maria Bakunin, 41, 80125 Naples, Italy
| | - Roberto Piccinocchi
- Level 1 Medical Director Anaesthesia and Resuscitation A. U. O. Luigi Vanvitelli, Via Santa Maria di Costantinopoli, 80138 Naples, Italy
| | - Maria Daglia
- Department of Pharmacy, University of Naples Federico II, via Domenico Montesano 49, 80131 Naples, Italy; International Research Center for Food Nutrition and Safety, Jiangsu University, 212013 Zhenjiang, China.
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21
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Ryan EC, Crisologo PA, La Fontaine J, Wukich DK, Oz OK, Bhavan K, Lavery LA. Clinical Outcomes of Foot Infections in Patients Without Diabetes. J Foot Ankle Surg 2021; 59:722-725. [PMID: 32061455 DOI: 10.1053/j.jfas.2019.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/25/2019] [Accepted: 07/31/2019] [Indexed: 02/03/2023]
Abstract
The aim of this study was to report clinical outcomes of moderate and severe foot infections in patients without diabetes. Medical records of 88 nondiabetic patients with foot infections treated at a safety net hospital were retrospectively reviewed. Patients were grouped by the presence of soft-tissue infection (STI) or osteomyelitis (OM). The diagnosis of OM was determined by positive bone culture or histopathology. STIs were defined by negative bone biopsy or negative imaging with magnetic resonance imaging or computed tomography/dual-modality radiolabeled white blood cell single-photon emission computed tomography. Patient outcomes were recorded ≤1 year after admission. Eighty-eight nondiabetic patients admitted to our institution for moderate or severe foot infections were included, 45 OM and 43 STI. No differences were noted in patient characteristics except that OM patients had a higher prevalence of neuropathy (66.7% versus 39.5%, p = .02). OM patients required surgery more often (97.8% versus 67.4%, p < .01), a greater number of surgeries (2.0 ± 1.2 versus 1.4 ± 1.3, p = .02), and more amputations (75.6% versus 11.6%, p < .01) than STI patients. OM patients had a higher proportion of wounds that healed (82.2% versus 62.8%, p = .04). There were no significant differences in reinfection (35.6% versus 25.6%, p = .36), foot-related readmission to hospital (35.6% versus 23.3%, p = .25), or total duration of antibiotics (13.9 ± 10.2 versus 13.5 ± 12.9, p = .87) between OM and STI patients. In conclusion, OM patients required more surgeries and amputations than patients with STIs; however, they had similar rates of reinfection and readmission within a year after the index hospitalization.
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Affiliation(s)
- Easton C Ryan
- Student, University of Texas Southwestern Medical School, Dallas, TX.
| | - Peter A Crisologo
- Fellow, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier La Fontaine
- Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dane K Wukich
- Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Orhan K Oz
- Professor, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kavita Bhavan
- Professor, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lawrence A Lavery
- Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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22
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Currò R, Salvalaggio A, Tozza S, Gemelli C, Dominik N, Galassi Deforie V, Magrinelli F, Castellani F, Vegezzi E, Businaro P, Callegari I, Pichiecchio A, Cosentino G, Alfonsi E, Marchioni E, Colnaghi S, Gana S, Valente EM, Tassorelli C, Efthymiou S, Facchini S, Carr A, Laura M, Rossor AM, Manji H, Lunn MP, Pegoraro E, Santoro L, Grandis M, Bellone E, Beauchamp NJ, Hadjivassiliou M, Kaski D, Bronstein AM, Houlden H, Reilly MM, Mandich P, Schenone A, Manganelli F, Briani C, Cortese A. RFC1 expansions are a common cause of idiopathic sensory neuropathy. Brain 2021; 144:1542-1550. [PMID: 33969391 PMCID: PMC8262986 DOI: 10.1093/brain/awab072] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/29/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022] Open
Abstract
After extensive evaluation, one-third of patients affected by polyneuropathy remain undiagnosed and are labelled as having chronic idiopathic axonal polyneuropathy, which refers to a sensory or sensory-motor, axonal, slowly progressive neuropathy of unknown origin. Since a sensory neuropathy/neuronopathy is identified in all patients with genetically confirmed RFC1 cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we speculated that RFC1 expansions could underlie a fraction of idiopathic sensory neuropathies also diagnosed as chronic idiopathic axonal polyneuropathy. We retrospectively identified 225 patients diagnosed with chronic idiopathic axonal polyneuropathy (125 sensory neuropathy, 100 sensory-motor neuropathy) from our general neuropathy clinics in Italy and the UK. All patients underwent full neurological evaluation and a blood sample was collected for RFC1 testing. Biallelic RFC1 expansions were identified in 43 patients (34%) with sensory neuropathy and in none with sensory-motor neuropathy. Forty-two per cent of RFC1-positive patients had isolated sensory neuropathy or sensory neuropathy with chronic cough, while vestibular and/or cerebellar involvement, often subclinical, were identified at examination in 58%. Although the sensory ganglia are the primary pathological target of the disease, the sensory impairment was typically worse distally and symmetric, while gait and limb ataxia were absent in two-thirds of the cases. Sensory amplitudes were either globally absent (26%) or reduced in a length-dependent (30%) or non-length dependent pattern (44%). A quarter of RFC1-positive patients had previously received an alternative diagnosis, including Sjögren's syndrome, sensory chronic inflammatory demyelinating polyneuropathy and paraneoplastic neuropathy, while three cases had been treated with immune therapies.
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Affiliation(s)
- Riccardo Currò
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Alessandro Salvalaggio
- Department of Neurosciences, ERN Neuromuscular Unit, University of Padova, Padova, Italy
| | - Stefano Tozza
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Chiara Gemelli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Natalia Dominik
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | | | - Francesca Magrinelli
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK.,Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Francesca Castellani
- Department of Neurosciences, ERN Neuromuscular Unit, University of Padova, Padova, Italy
| | - Elisa Vegezzi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Pietro Businaro
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Ilaria Callegari
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Anna Pichiecchio
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | | | | | | | | | - Enza Maria Valente
- IRCCS Mondino Foundation, Pavia, Italy.,Department of Molecular Medicine, Unit of Genetics, Università degli studi di Pavia, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,IRCCS Mondino Foundation, Pavia, Italy
| | - Stephanie Efthymiou
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Stefano Facchini
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Aisling Carr
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Matilde Laura
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Alexander M Rossor
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Hadi Manji
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Michael P Lunn
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Elena Pegoraro
- Department of Neurosciences, ERN Neuromuscular Unit, University of Padova, Padova, Italy
| | - Lucio Santoro
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Marina Grandis
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Emilia Bellone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy.,Medical Genetics Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Nicholas J Beauchamp
- Sheffield Diagnostic Genetics Service, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Trust and University of Sheffield, Sheffield, UK
| | - Diego Kaski
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK.,Department of Clinical and Motor Neurosciences, University College London, London, UK
| | - Adolfo M Bronstein
- Department of Brain Sciences, Neuro-otology Unit, Imperial College London, London, UK
| | - Henry Houlden
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Mary M Reilly
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Paola Mandich
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy.,Medical Genetics Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Angelo Schenone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Fiore Manganelli
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Chiara Briani
- Department of Neurosciences, ERN Neuromuscular Unit, University of Padova, Padova, Italy
| | - Andrea Cortese
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
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23
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Hadtstein F, Vrolijk M. Vitamin B-6-Induced Neuropathy: Exploring the Mechanisms of Pyridoxine Toxicity. Adv Nutr 2021; 12:1911-1929. [PMID: 33912895 PMCID: PMC8483950 DOI: 10.1093/advances/nmab033] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 12/26/2022] Open
Abstract
Vitamin B-6 in the form of pyridoxine (PN) is commonly used by the general population. The use of PN-containing supplements has gained lots of attention over the past years as they have been related to the development of peripheral neuropathy. In light of this, the number of reported cases of adverse health effects due to the use of vitamin B-6 have increased. Despite a long history of study, the pathogenic mechanisms associated with PN toxicity remain elusive. Therefore, the present review is focused on investigating the mechanistic link between PN supplementation and sensory peripheral neuropathy. Excessive PN intake induces neuropathy through the preferential injury of sensory neurons. Recent reports on hereditary neuropathy due to pyridoxal kinase (PDXK) mutations may provide some insight into the mechanism, as genetic deficiencies in PDXK lead to the development of axonal sensory neuropathy. High circulating concentrations of PN may lead to a similar condition via the inhibition of PDXK. The mechanism behind PDXK-induced neuropathy is unknown; however, there is reason to believe that it may be related to γ-aminobutyric acid (GABA) neurotransmission. Compounds that inhibit PDXK lead to convulsions and reductions in GABA biosynthesis. The absence of central nervous system-related symptoms in PDXK deficiency could be due to differences in the regulation of PDXK, where PDXK activity is preserved in the brain but not in peripheral tissues. As PN is relatively impermeable to the blood-brain barrier, PDXK inhibition would similarly be confined to the peripheries and, as a result, GABA signaling may be perturbed within peripheral tissues, such as sensory neurons. Perturbed GABA signaling within sensory neurons may lead to excitotoxicity, neurodegeneration, and ultimately, the development of peripheral neuropathy. For several reasons, we conclude that PDXK inhibition and consequently disrupted GABA neurotransmission is the most plausible mechanism of toxicity.
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Affiliation(s)
- Felix Hadtstein
- University College Venlo, Campus Venlo, Maastricht University, Maastricht, The Netherlands
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24
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Raasing LR, Vogels OJ, Veltkamp M, van Swol CF, Grutters JC. Current View of Diagnosing Small Fiber Neuropathy. J Neuromuscul Dis 2021; 8:185-207. [PMID: 33337383 PMCID: PMC8075405 DOI: 10.3233/jnd-200490] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Small fiber neuropathy (SFN) is a disorder of the small myelinated Aδ-fibers and unmyelinated C-fibers [5, 6]. SFN might affect small sensory fibers, autonomic fibers or both, resulting in sensory changes, autonomic dysfunction or combined symptoms [7]. As a consequence, the symptoms are potentially numerous and have a large impact on quality of life [8]. Since diagnostic methods for SFN are numerous and its pathophysiology complex, this extensive review focusses on categorizing all aspects of SFN as disease and its diagnosis. In this review, sensitivity in combination with specificity of different diagnostic methods are described using the areas under the curve. In the end, a diagnostic work-flow is suggested based on different phenotypes of SFN.
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Affiliation(s)
- Lisette R.M. Raasing
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Oscar J.M. Vogels
- Department of Neurology, St Antonius Hospital, CM, Nieuwegein, The Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
| | | | - Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology,St Antonius Hospital, CM, Nieuwegein, The Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, CX, Utrecht, The Netherlands
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25
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Contribution of Skin Biopsy in Peripheral Neuropathies. Brain Sci 2020; 10:brainsci10120989. [PMID: 33333929 PMCID: PMC7765344 DOI: 10.3390/brainsci10120989] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/30/2020] [Accepted: 12/11/2020] [Indexed: 12/18/2022] Open
Abstract
In the last three decades the study of cutaneous innervation through 3 mm-punch-biopsy has provided an important contribution to the knowledge of small fiber somatic and autonomic neuropathies but also of large fiber neuropathies. Skin biopsy is a minimally invasive technique with the advantage, compared to sural nerve biopsy, of being suitable to be applied to any site in our body, of being repeatable over time, of allowing the identification of each population of nerve fiber through its target. In patients with symptoms and signs of small fiber neuropathy the assessment of IntraEpidermal Nerve Fiber density is the gold standard to confirm the diagnosis while the quantification of sudomotor, pilomotor, and vasomotor nerve fibers allows to evaluate and characterize the autonomic involvement. All these parameters can be re-evaluated over time to monitor the disease process and to evaluate the effectiveness of the treatments. Myelinated fibers and their receptors can also be evaluated to detect a “dying back” neuropathy early when nerve conduction study is still normal. Furthermore, the morphometry of dermal myelinated fibers has provided new insight into pathophysiological mechanisms of different types of inherited and acquired large fibers neuropathies. In genetic neuropathies skin biopsy has become a surrogate for sural nerve biopsy, no longer necessary in the diagnostic process, to study genotype–phenotype correlations.
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26
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Freeman R, Gewandter JS, Faber CG, Gibbons C, Haroutounian S, Lauria G, Levine T, Malik RA, Singleton JR, Smith AG, Bell J, Dworkin RH, Feldman E, Herrmann DN, Hoke A, Kolb N, Mansikka H, Oaklander AL, Peltier A, Polydefkis M, Ritt E, Russell JW, Sainati S, Steiner D, Treister R, Üçeyler N. Idiopathic distal sensory polyneuropathy: ACTTION diagnostic criteria. Neurology 2020; 95:1005-1014. [PMID: 33055271 DOI: 10.1212/wnl.0000000000010988] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/21/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To present standardized diagnostic criteria for idiopathic distal sensory polyneuropathy (iDSP) and its subtypes: idiopathic mixed fiber sensory neuropathy (iMFN), idiopathic small fiber sensory neuropathy (iSFN), and idiopathic large fiber sensory neuropathy (iLFN) for use in research. METHODS The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities and Networks (ACTTION) public-private partnership with the Food and Drug Administration convened a meeting to develop consensus diagnostic criteria for iMFN, iSFN, and iLFN. After background presentations, a collaborative, iterative approach was used to develop expert consensus for new criteria. RESULTS An iDSP diagnosis requires at least 1 small fiber (SF) or large fiber (LF) symptom, at least 1 SF or LF sign, abnormalities in sensory nerve conduction studies (NCS) or distal intraepidermal nerve fiber density (IENFD), and exclusion of known etiologies. An iMFN diagnosis requires that at least 1 of the above clinical features is SF and 1 clinical feature is LF with abnormalities in sensory NCS or IENFD. Diagnostic criteria for iSFN require at least 1 SF symptom and at least 1 SF sign with abnormal IENFD, normal sensory NCS, and the absence of LF symptoms and signs. Diagnostic criteria for iLFN require at least 1 LF symptom and at least 1 LF sign with normal IENFD, abnormal sensory NCS, and absence of SF symptoms and signs. CONCLUSION Adoption of these standardized diagnostic criteria will advance research and clinical trials and spur development of novel therapies for iDSPs.
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Affiliation(s)
- Roy Freeman
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany.
| | - Jennifer S Gewandter
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Catharina G Faber
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Christopher Gibbons
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Simon Haroutounian
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Giuseppe Lauria
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Todd Levine
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Rayaz A Malik
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - J Robinson Singleton
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - A Gordon Smith
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Josh Bell
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Robert H Dworkin
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Eva Feldman
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - David N Herrmann
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Ahmet Hoke
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Noah Kolb
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Heikki Mansikka
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Anne Louise Oaklander
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Amanda Peltier
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Michael Polydefkis
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Elissa Ritt
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - James W Russell
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Stephen Sainati
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Deborah Steiner
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Roi Treister
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
| | - Nurcan Üçeyler
- From the Beth Israel Deaconess Medical Center (R.F., C.G.), Harvard Medical School, MA; University of Rochester Medical Center (J.S.G., R.H.D., D.N.H.), Rochester, NY; Department of Neurology (C.G.F.), School of Mental Health and Neuroscience, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Anesthesiology (S.H.), Washington University in St. Louis School of Medicine, St. Louis, MO; Neuroalgology Unit (G.L.), Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco" (G.L.), University of Milan,Milan, Italy; Phoenix Neurological Associates (T.L.), Phoenix, AZ; Weill Cornell Medicine-Qatar (R.A.M.), Qatar Foundation, Education City, Doha, Qatar; University of Utah (J.R.S.), Salt Lake City, UT; Virginia Commonwealth University (A.G.S.), Richmond, VA; Biogen (J.B.), Cambridge, MA; University of Michigan (E.F.), Ann Arbor, MI; Johns Hopkins School of Medicine (A.H., M.P.), Baltimore, MD; University of Vermont (N.K.), Burlington, VT; Chromocell Corp (H.M.), North Brunswick, NJ; Harvard Medical School (A.L.O.), Boston, MA; Departments of Neurology and Medicine (A.P.), and Vanderbilt Heart and Vascular Institute, Nashville, TN; NuFactor Specialty Pharmacy (E.R.), Temecula, CA; University of Maryland (J.W.R.), Baltimore, MD; Aptinyx (S.S.), INC., Evanston. IL; Amgen (D.S.), Cambridge, MA; University of Haifa (R.T.), Haifa, Israel; and University of Würzburg (N.Ü.), Würzburg, Germany
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27
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Abstract
There is an aging of the peripheral nervous system characterized by a decrease in sensory and motor nerve conduction, amplitudes of motor and above all sensory potentials, an abolition of the ankle jerk reflexes and an alteration of proprioceptive sensitivity in almost two-thirds of individuals over 65 years old. These anomalies tend to increase beyond 80 years. However, these signs of aging do not affect the quality of life of the subjects. The causes of peripheral neuropathies in the elderly differ little from those observed before age 65. Of course, hereditary causes are much less frequent, except cases with a late onset, now easily detectable, such as familial amyloidosis. In our climates and in the most developed countries, diabetes remains the most common cause, the prevalence of neuropathy increasing with age. The so-called idiopathic causes are also frequent and despite extensive investigations, nearly 20% of cases remain without etiological diagnosis, but this type of neuropathy is generally mild and not very progressive. The presence of peripheral neuropathy in the elderly can cause real problems in daily life, including the frequency of falls that can be responsible for deleterious bone damage.
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Affiliation(s)
- P Bouche
- Laboratory of Clinical Neurophysiology (Professor Lionel-Naccache), Salpetriere Hospital, 47, boulevard de l'hôpital, 75013 Paris, France.
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28
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Wajnsztajn Yungher F, Kim A, Boehme A, Kleyman I, Weimer LH, Maurer MS, Brannagan TH. Peripheral neuropathy symptoms in wild type transthyretin amyloidosis. J Peripher Nerv Syst 2020; 25:265-272. [PMID: 32627282 DOI: 10.1111/jns.12403] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/15/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
To propose a correlation between polyneuropathy and ATTRwt based on retrospective analysis of patients with ATTRwt. We reviewed 151 ATTRwt patients followed by the amyloid cardiac clinic (group A) for symptoms of neuropathy and 12 patients with ATTRwt evaluated in the Neurology Department (group B) with objective measures of neuropathy. Medical history, electrodiagnosis, laboratory and skin biopsies were assessed; 30.5% of group A had neuropathy symptoms. Alternative explanations for neuropathy symptoms were explored, including, age, gender, BMI, diabetes mellitus, B12 deficiency. No difference was observed for BMI, age, gender and spine disease for those with and without neuropathic symptoms (P > .05). All of group B (n = 12) were diagnosed with neuropathy, confirmed by electrodiagnostic testing or skin biopsy, while two patients had not yet developed cardiac symptoms. We observe a higher prevalence of neuropathic symptoms in ATTRwt patients than previously believed. Neuropathic symptoms may precede cardiac symptoms. Our findings suggest a possible causative relationship that requires further investigation.
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Affiliation(s)
- Fernanda Wajnsztajn Yungher
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA.,Department of Neurology, UConn Health, Farmington, Connecticut, USA
| | - Arreum Kim
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA
| | - Amelia Boehme
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA
| | - Inna Kleyman
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA
| | - Louis H Weimer
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA
| | - Mathew S Maurer
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Thomas H Brannagan
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, New York, New York, USA
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29
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Benavidez GA, Ylitalo KR, Lanning B, Asare M, Meyer A, Griggs JO. Peripheral neuropathy and depressive symptoms: examining the association in a primary health care setting among persons with and without diabetes mellitus. Qual Life Res 2020; 29:3297-3304. [PMID: 32651803 DOI: 10.1007/s11136-020-02579-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to measure the association between peripheral neuropathy symptoms and depressive symptoms among a sample of patients with and without diabetes mellitus (DM). METHODS Patients were administered the 15-item Michigan Neuropathy Screening Instrument (MNSI) and the patient health questionnaire depression scale (PHQ-8). Patients with an MNSI score ≥ 4 were categorized as having PN and patients with a PHQ-8 score ≥ 10 were considered to have current depression. Log-binomial regression was used to analyze the relationship between PN and depressive symptoms. RESULTS 406 patients were included in the final analysis. There were no statistically significant differences by diabetes status in PN symptoms (Diabetes = 61.8%; No diabetes = 55.4%; p = .20) or in depression status (Diabetes = 37.6%; No diabetes = 36.6%; p = .83). After adjustment for covariates, PN was associated with depression (aRR = 4.46; 95% CI 2.91,6.85) independent of diabetes status. CONCLUSIONS PN symptoms may be common among aging persons even in the absence of DM. Past literature and our study demonstrate that PN and depression are closely associated. More work is needed to understand the etiology and potential utility of intervention for depression symptoms among patients with neuropathy.
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Affiliation(s)
- Gabriel A Benavidez
- Department of Public Health, Baylor University, One Bear Place #97343, Waco, TX, 76798, USA.
| | - Kelly R Ylitalo
- Department of Public Health, Baylor University, One Bear Place #97343, Waco, TX, 76798, USA
| | - Beth Lanning
- Department of Public Health, Baylor University, One Bear Place #97343, Waco, TX, 76798, USA
| | - Matt Asare
- Department of Public Health, Baylor University, One Bear Place #97343, Waco, TX, 76798, USA
| | - Andrew Meyer
- Department of Health, Human Performance, and Recreation, Baylor University, One Bear Place #97313, Waco, TX, 76798, USA
| | - Jackson O Griggs
- Waco Family Health Center, 1600 Providence Dr, Waco, TX, 76707, USA
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Rauer S, Kastenbauer S, Hofmann H, Fingerle V, Huppertz HI, Hunfeld KP, Krause A, Ruf B, Dersch R. Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc03. [PMID: 32341686 PMCID: PMC7174852 DOI: 10.3205/000279] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 12/12/2022]
Abstract
Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis. This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults. Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany). The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.
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Affiliation(s)
| | | | | | - Volker Fingerle
- German Society for Hygiene and Microbiology (DGHM), Münster, Germany
| | - Hans-Iko Huppertz
- German Society of Paediatrics and Adolescent Medicine (DGKJ), Berlin, Germany.,German Society of Paediatric Infectology (DGPI), Berlin, Germany
| | - Klaus-Peter Hunfeld
- The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL), Bonn, Germany.,INSTAND e.V., Düsseldorf, Germany
| | | | - Bernhard Ruf
- German Society of Infectious Diseases (DGI), Berlin, Germany
| | - Rick Dersch
- German Society of Neurology (DGN), Berlin, Germany.,Cochrane Germany, Faculty of Medicine, University of Freiburg, Germany
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Kelley MA, Oaklander AL. Association of small-fiber polyneuropathy with three previously unassociated rare missense SCN9A variants. Can J Pain 2020; 4:19-29. [PMID: 32719824 PMCID: PMC7384751 DOI: 10.1080/24740527.2020.1712652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/27/2019] [Accepted: 01/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Small fiber polyneuropathy (SFN) involves ectopic firing and degeneration of small-diameter, somatic/autonomic peripheral axons. Causes include diabetes, inflammation and rare pathogenic mutations, including in SCN9-11 genes that encode small fiber sodium channels. AIMS The aim of this study is to associate a new phenotype-immunotherapy-responsive SFN-with rare amino acid-substituting SCN9A variants and present potential explanations. METHODS A retrospective chart review of two Caucasians with skin biopsy confirmed SFN and rare SCN9A single nucleotide polymorphisms not previously reported in neuropathy. RESULTS A 47-year-old with 4 years of disabling widespread neuropathic pain and exertional intolerance had nerve- and skin biopsy-confirmed SFN, with blood tests revealing only high-titer antinuclear antibodies and low complement C4 consistent with B cell dysimmunity. Six years of intravenous immunoglobulin (IVIg) therapy markedly improved sensory and autonomic symptoms and normalized his neurite density. After whole exome sequencing revealed a potentially pathogenic SCN9A-A3734G variant, sodium channel blockers were tried. Herpes zoster left a 32-year-old with disabling exertional intolerance ("chronic fatigue syndrome"), postural syncope and tachycardia, arm and leg paresthesias, reduced sweating, and distal hairloss. Screening revealed antinuclear and potassium channel autoantibodies, so prednisone and then IVIg were prescribed with great benefit. During 4 years of immunotherapy, his symptoms and function improved, and all abnormal biomarkers (autonomic testing and skin biopsies) normalized. Whole exome sequencing then revealed two nearby compound heterozygous SCN9A variants that were computer-predicted to be deleterious. CONCLUSIONS These cases newly associate three novel amino acid-substituting SCN9A variants with immunotherapy-responsive neuropathy. Only larger studies can determine whether these are contributory or coincidental, but they associate new variants with moderate or high likelihood of pathogenicity with a new highly related phenotype.
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Affiliation(s)
- Mary A. Kelley
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Dell Medical School at the University of Texas, Austin, Texas, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology (Neuropathology), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Toz H, Gozke E. Investigation of insulin resistance and vitamin E deficiency in chronic inflammatory demyelinatıng polyneuropathy: A 5-year retrospective study. NEUROL SCI NEUROPHYS 2020. [DOI: 10.4103/nsn.nsn_19_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Görlach J, Amsel D, Kölbel H, Grzybowsky M, Rutsch F, Schlierbach H, Vanlander A, Pogatzki‐Zahn E, Habig K, Garkisch S, Müller V, Fritz T, Ziegler A, Hahn A, Krämer HH, Van Coster R, Schänzer A. Diagnostic utility of small fiber analysis in skin biopsies from children with chronic pain. Muscle Nerve 2019; 61:173-181. [DOI: 10.1002/mus.26766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 11/13/2019] [Accepted: 11/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Jonas Görlach
- Institute of NeuropathologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Daniel Amsel
- Institute of NeuropathologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Heike Kölbel
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Children's HospitalUniversity Duisburg‐Essen Essen Germany
| | - Michelle Grzybowsky
- Department of Child NeurologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Frank Rutsch
- Department of General Pediatrics, Children's HospitalUniversity of Muenster Muenster Germany
| | - Hannah Schlierbach
- Institute of NeuropathologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Arnaud Vanlander
- Division of Child Neurology, Department of PediatricsUniversity Hospital Gent Gent Belgium
| | - Esther Pogatzki‐Zahn
- Department of Anesthesiology, Intensive Care and Pain MedicineUniversity Hospital Muenster Muenster Germany
| | - Kathrin Habig
- Department of NeurologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Stefanie Garkisch
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, Children's HospitalUniversity Duisburg‐Essen Essen Germany
| | | | - Thorsten Fritz
- Centre for Pain Therapy and Anaesthesiology at Schloss Butzbach Butzbach Germany
| | - Andreas Ziegler
- Department of General Pediatrics and Neuropediatrics, HeidelbergUniversity Hospital Heidelberg Germany
| | - Andreas Hahn
- Department of Child NeurologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Heidrun H. Krämer
- Department of NeurologyJustus‐Liebig‐University Giessen Giessen Germany
| | - Rudy Van Coster
- Division of Child Neurology, Department of PediatricsUniversity Hospital Gent Gent Belgium
| | - Anne Schänzer
- Institute of NeuropathologyJustus‐Liebig‐University Giessen Giessen Germany
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Oaklander AL, Nolano M. Scientific Advances in and Clinical Approaches to Small-Fiber Polyneuropathy: A Review. JAMA Neurol 2019; 76:1240-1251. [PMID: 31498378 PMCID: PMC10021074 DOI: 10.1001/jamaneurol.2019.2917] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Small-fiber polyneuropathy involves preferential damage to the thinly myelinated A-delta fibers, unmyelinated C sensory fibers, or autonomic or trophic fibers. Although this condition is common, most patients still remain undiagnosed and untreated because of lagging medical and public awareness of research advances. Chronic bilateral neuropathic pain, fatigue, and nausea are cardinal symptoms that can cause disability and dependence, including pain medication dependence. OBSERVATIONS Biomarker confirmation is recommended, given the nonspecificity of symptoms. The standard test involves measuring epidermal neurite density within a 3-mm protein gene product 9.5 (PGP9.5)-immunolabeled lower-leg skin biopsy. Biopsies and autonomic function testing confirm that small-fiber neuropathy not uncommonly affects otherwise healthy children and young adults, in whom it is often associated with inflammation or dysimmunity. A recent meta-analysis concluded that small-fiber neuropathy underlies 49% of illnesses labeled as fibromyalgia. Initially, patients with idiopathic small-fiber disorders should be screened by medical history and blood tests for potentially treatable causes, which are identifiable in one-third to one-half of patients. Then, secondary genetic testing is particularly important for familial and childhood cases. Treatable genetic causes include Fabry disease, transthyretin and primary systemic amyloidosis, hereditary sensory autonomic neuropathy-1, and ion-channel mutations. Immunohistopathologic evidence suggests that small-fiber dysfunction and denervation, especially of blood vessels, contributes to diverse symptoms, including postexertional malaise, postural orthostatic tachycardia, and functional gastrointestinal distress. Preliminary evidence implicates acute or chronic autoreactivity in some cases, particularly in female patients and otherwise healthy children and young adults. Different temporal patterns akin to Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy have been described; here, corticosteroids and immunoglobulins, which are often efficacious for inflammatory neuropathic conditions, are increasingly considered. CONCLUSIONS AND RELEVANCE Because small fibers normally grow throughout life, improving contributory conditions may permit regrowth, slow progression, and prevent permanent damage. The prognosis is often hopeful for improving quality of life and sometimes for abatement or resolution, particularly in the young and otherwise healthy individuals. Examples include diabetic, infectious, toxic, genetic, and inflammatory causes. The current standard of care requires prompt diagnosis and treatment, particularly in children and young adults, to restore life trajectory. Consensus diagnostic and tracking metrics should be established to facilitate treatment trials.
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Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston
| | - Maria Nolano
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University "Federico II" of Naples, Naples, Italy.,Skin Biopsy Laboratory, Department of Neurology, IRCCS, Istituti Clinici Scientifici Maugeri, SpA SB, Telese Terme, Italy
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Mangus LM, Rao DB, Ebenezer GJ. Intraepidermal Nerve Fiber Analysis in Human Patients and Animal Models of Peripheral Neuropathy: A Comparative Review. Toxicol Pathol 2019; 48:59-70. [PMID: 31221022 DOI: 10.1177/0192623319855969] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Analysis of intraepidermal nerve fibers (IENFs) in skin biopsy samples has become a standard clinical tool for diagnosing peripheral neuropathies in human patients. Compared to sural nerve biopsy, skin biopsy is safer, less invasive, and can be performed repeatedly to facilitate longitudinal assessment. Intraepidermal nerve fiber analysis is also more sensitive than conventional nerve histology or electrophysiological tests for detecting damage to small-diameter sensory nerve fibers. The techniques used for IENF analysis in humans have been adapted for large and small animal models and successfully used in studies of diabetic neuropathy, chemotherapy-induced peripheral neuropathy, HIV-associated sensory neuropathy, among others. Although IENF analysis has yet to become a routine end point in nonclinical safety testing, it has the potential to serve as a highly relevant indicator of sensory nerve fiber status in neurotoxicity studies, as well as development of neuroprotective and neuroregenerative therapies. Recently, there is also interest in the evaluation of IENF via skin biopsy as a biomarker of small fiber neuropathy in the regulatory setting. This article provides an overview of the anatomic and pathophysiologic principles behind IENF analysis, its use as a diagnostic tool in humans, and applications in animal models with focus on comparative methodology and considerations for study design.
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Affiliation(s)
- Lisa M Mangus
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Deepa B Rao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Gigi J Ebenezer
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Rowin J. Integrative neuromuscular medicine: Neuropathy and neuropathic pain: Consider the alternatives. Muscle Nerve 2019; 60:124-136. [DOI: 10.1002/mus.26510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Julie Rowin
- Wellness and Integrative Neurology, Advanced Pain and Anesthesia ConsultantsCenters for Pain Management Westchester Illinois USA
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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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Ricci L, Luigetti M, Florio L, Capone F, Di Lazzaro V. Causes of chronic neuropathies: a single-center experience. Neurol Sci 2019; 40:1611-1617. [PMID: 31001716 DOI: 10.1007/s10072-019-03899-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 04/12/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Chronic neuropathies are a common cause of neurological disability worldwide. However, few reports have evaluated, in real life, the prevalence of the several conditions which can cause it. PATIENTS AND METHODS The authors reviewed informatic database for outpatient office to confirm identification of chronic neuropathy in a 3-year interval period. RESULTS Among the 100 selected patients with chronic neuropathies, almost one fifth (19%) remained idiopathic. The most common etiologies were diabetes (17%), dysimmune neuropathies (38%), and vitamin B12 deficiency (9%). In the "dysimmune neuropathies" group, we distinguished various etiologies, including dysimmune neuropathies associated or not with systemic autoimmune diseases (7 and 3%, respectively), chronic inflammatory polyneuropathy (CIDP) (8%), multifocal motor neuropathy (MMN) (3%), paraproteinemic (8%), celiac disease-related (6%), and paraneoplastic (3%) neuropathies. CONCLUSIONS In this report from a single neurological center, treatable causes of chronic neuropathies, such as dysimmune neuropathies, including CIDP, and celiac disease-associated neuropathy, were common. These findings suggest the utility of routine screening with blood testing for dysimmune neuropathy and celiac disease for all patients presenting with idiopathic chronic polyneuropathy in whom primary diagnostic testings had failed to identify an etiology for the disease. SIGNIFICANCE Our results indicate that patients with peripheral neuropathy could receive a benefit from being evaluated routinely in a specialized neurological center, as many of the conditions that were discovered represented potentially treatable causes of neuropathy.
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Affiliation(s)
- Lorenzo Ricci
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy.
| | - Marco Luigetti
- IRCCS, UOC Neurologia, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy.,Università Cattolica del Sacro Cuore, Sede di Roma, Rome, Italy
| | - Lucia Florio
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
| | - Fioravante Capone
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128, Rome, Italy
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Electrodiagnosis in the Patient with Metabolic Syndrome: Adding Value to Patient Care. Phys Med Rehabil Clin N Am 2018; 29:735-749. [PMID: 30293627 DOI: 10.1016/j.pmr.2018.06.008] [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] [Indexed: 01/02/2023]
Abstract
Patients with metabolic syndrome are at increased risk of peripheral neuropathy; entrapment neuropathies, such as carpal tunnel syndrome; and spine disease that can lead to radiculopathy or spinal stenosis. Electrodiagnostic studies are a valuable part of patient care in this population. They can confirm suspected diagnoses, uncover additional conditions, and lead to the diagnosis of other causes of neuropathy that require treatment. By assessing the severity of neuropathy, patients at high risk for falls, functional decline, and foot ulcers are identified to guide prevention, treatment, and patient education.
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Clinical features affecting the patient-based outcome after minimal medial epicondylectomy for cubital tunnel syndrome. J Plast Reconstr Aesthet Surg 2018; 71:1446-1452. [DOI: 10.1016/j.bjps.2018.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/12/2018] [Accepted: 05/26/2018] [Indexed: 02/03/2023]
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Abstract
Peripheral neuropathy is commonly encountered in the primary care setting and is associated with significant morbidity, including neuropathic pain, falls, and disability. The clinical presentation of neuropathy is diverse, with possible symptoms including weakness, sensory abnormalities, and autonomic dysfunction. Accordingly, the primary care clinician must be comfortable using the neurologic examination-including the assessment of motor function, multiple sensory modalities, and deep tendon reflexes-to recognize and characterize neuropathy. Although the causes of peripheral neuropathy are numerous and diverse, careful review of the medical and family history coupled with limited, select laboratory testing can often efficiently lead to an etiologic diagnosis. This review offers an approach for evaluating suspected neuropathy in the primary care setting. It will describe the most common causes, suggest an evidence-based workup to aid in diagnosis, and highlight recent evidence that allows for selection of symptomatic treatment of patients with neuropathy.
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Abstract
PURPOSE OF REVIEW This article provides a conceptual framework for the evaluation of patients with suspected polyneuropathy to enhance the clinician's ability to localize and confirm peripheral nervous system pathology and, when possible, identify an etiologic diagnosis through use of rational clinical and judicious testing strategies. RECENT FINDINGS Although these strategies are largely time-honored, recent insights pertaining to the pathophysiology of certain immune-mediated neuropathies and to evolving genetic testing strategies may modify the way that select causes of neuropathy are conceptualized, evaluated, and managed. SUMMARY The strategies suggested in this article are intended to facilitate accurate bedside diagnosis in patients with suspected polyneuropathy and allow efficient and judicious use of supplementary testing and application of rational treatment when indicated.
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Zis P, Sarrigiannis PG, Rao DG, Hadjivassiliou M. Gluten neuropathy: prevalence of neuropathic pain and the role of gluten-free diet. J Neurol 2018; 265:2231-2236. [PMID: 30032386 DOI: 10.1007/s00415-018-8978-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/27/2018] [Accepted: 07/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Peripheral neuropathy is a common extraintestinal manifestation of gluten sensitivity (gluten neuropathy). We aimed to establish the prevalence of neuropathic pain in patients with otherwise idiopathic PN and gluten sensitivity (positive antigliadin, endomysial, and/or transglutaminase antibodies, with or without enteropathy) and to describe any contributory factors. METHODS All consecutive patients with gluten neuropathy (GN) attending a specialist gluten/neurology clinic were invited to participate. Pain was assessed via the DN4 questionnaire and the visual analog scale. Overall Neuropathy Limitations Scale was used to assess the severity of neuropathy. The Mental Health Index (MHI-5) was used to measure participants' general mental health status. RESULTS In total, 60 patients (76.7% males, mean age 69.9 ± 10.1 years) with GN were recruited. Neuropathic pain was present in 33 patients (55.0%). Comparison between groups of painful and not painful GN did not show significant differences regarding age, gender, neuropathy severity and neuropathy type. Patients with painless GN were more likely to be on a strict gluten-free diet (55.6 versus 21.2%, p = 0.006). Patients with painful GN presented with significantly worse MHI-5 score (75.9 ± 13.8 versus 87.4 ± 8.1, p < 0.001). Multivariate analysis showed that, after adjusting for age, gender and MHI-5, strict gluten-free diet was associated with lowering the odds of peripheral neuropathic pain by 88.7% (95% CI 47.2-97.6%, p = 0.006). CONCLUSION Neuropathic pain is very prevalent in GN and is associated with poorer mental health status. Strict gluten-free diet might be protective as it is associated with a significant reduction of the odds of peripheral neuropathic pain associated to GN.
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Affiliation(s)
- Panagiotis Zis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield, South Yorkshire, S10 2JF, UK.
| | - Ptolemaios Georgios Sarrigiannis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield, South Yorkshire, S10 2JF, UK
| | - Dasappaiah Ganesh Rao
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield, South Yorkshire, S10 2JF, UK
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Sheffield, South Yorkshire, S10 2JF, UK
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Abstract
Pyridoxine (vitamin B6) toxicity is a well-known cause of primary sensory, length-dependent, axonal polyneuropathy. Although sensory symptoms predominate, autonomic symptoms have also been reported in some cases. To date, there is no objective evidence of autonomic dysfunction reported in the literature. We present the case of a 41-year-old woman with 2 years of progressive burning pain, numbness, tingling, and weakness in a stocking-glove distribution who was found to have severe pyridoxine toxicity. Concurrent presence of large and small fiber nerve dysfunction was noted in the form of abnormal electromyography/nerve conduction study demonstrating a chronic sensory polyneuropathy and autonomic testing demonstrating abnormal responses to quantitative sweat testing and cardiovagal function testing. This case highlights the need for consideration of small fiber nerve damage by obtaining autonomic testing in cases of pyridoxine toxicity.
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Abraham A, Barnett C, Katzberg HD, Lovblom LE, Perkins BA, Bril V. Nerve function varies with hemoglobin A1c in controls and type 2 diabetes. J Diabetes Complications 2018; 32:424-428. [PMID: 29422233 DOI: 10.1016/j.jdiacomp.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/02/2017] [Accepted: 12/17/2017] [Indexed: 11/26/2022]
Abstract
AIMS To determine the cross-sectional threshold at which hemoglobin A1c (HbA1c) is associated with polyneuropathy in healthy controls, and the values associated with the most pronounced decline in nerve function in patients with diabetes. METHODS We used data from a cross-sectional cohort study of healthy controls and type 2 diabetes patients assessed between November 2010 and May 2013. Healthy controls and patients with diabetes were compared at different HbA1c ranges: <5.5%, 5.5-5.9%, and 6-6.4% for controls, and 6.5-7.4% and >7.5% for patients with diabetes. RESULTS The total cohort included 53 controls and 164 patients with diabetes. Subclinical small nerve fiber impairments were observed in controls at HbA1c levels of 5.5-6%, compared with HbA1c <5.5%, for example: lower Laser Doppler flare imaging area of 2.8 ± 1.4 versus 3.9 ± 2 mm2. The most prominent decline in both small and large nerve fiber function was seen with less impaired glycemic control and shorter duration of diabetes, i.e. at HbA1c levels of 6.5-7.4%, compared with >7.5%. CONCLUSIONS These findings underscore the importance of early treatment at the prediabetes and early diabetes stages to prevent nerve fiber decline that is likely irreversible.
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Affiliation(s)
- Alon Abraham
- Neuromuscular Service of the Department of Neurology, Tel Aviv Sourasky Medical Center, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Hans D Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Leif E Lovblom
- Division of Endocrinology and Metabolism, Department of Medicine, Sinai Health System, Lunenfeld Tanenbaum Research Institute, University of Toronto, Toronto, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, Sinai Health System, Lunenfeld Tanenbaum Research Institute, University of Toronto, Toronto, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.
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Valls-Solé J. Challenges in the diagnosis and treatment of small fiber neuropathies. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:129-130. [PMID: 29809233 DOI: 10.1590/0004-282x20180017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Josep Valls-Solé
- Neurology Department, EMG Unit, Institut d'Investigació Biomèdica August Pii Sunyer, Facultat de Medicina, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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Liu X, Treister R, Lang M, Oaklander AL. IVIg for apparently autoimmune small-fiber polyneuropathy: first analysis of efficacy and safety. Ther Adv Neurol Disord 2018; 11:1756285617744484. [PMID: 29403541 PMCID: PMC5791555 DOI: 10.1177/1756285617744484] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Small-fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. We have proposed a new cause; small-fiber-targeting autoimmune diseases akin to Guillain-Barré and chronic inflammatory demyelinating polyneuropathy (CIDP). There are no treatment studies yet for this 'apparently autoimmune SFPN' (aaSFPN), but intravenous immunoglobulin (IVIg), first-line for Guillain-Barré and CIDP, is prescribed off-label for aaSFPN despite very high cost. This project aimed to conduct the first systematic evaluation of IVIg's effectiveness for aaSFPN. METHODS With IRB approval, we extracted all available paper and electronic medical records of qualifying patients. Inclusion required having objectively confirmed SFPN, autoimmune attribution and other potential causes excluded. IVIg needed to have been dosed at ⩾1 g/kg/4 weeks for ⩾3 months. We chose two primary outcomes - changes in composite autonomic function testing (AFT) reports of SFPN and in ratings of pain severity - to capture objective as well as patient-prioritized outcomes. RESULTS Among all 55 eligible patients, SFPN had been confirmed by 3/3 nerve biopsies, 62% of skin biopsies, and 89% of composite AFT. Evidence of autoimmunity included 27% of patients having systemic autoimmune disorders, 20% having prior organ-specific autoimmune illnesses and 80% having ⩾1/5 abnormal blood-test markers associated with autoimmunity. A total of 73% had apparent small-fiber-restricted autoimmunity. IVIg treatment duration averaged 28 ± 25 months. The proportion of AFTs interpreted as indicating SFPN dropped from 89% at baseline to 55% (p ⩽ 0.001). Sweat production normalized (p = 0.039) and the other four domains all trended toward improvement. Among patients with pre-treatment pain ⩾3/10, severity averaging 6.3 ± 1.7 dropped to 5.2 ± 2.1 (p = 0.007). Overall, 74% of patients rated themselves 'improved' and their neurologists labeled 77% as 'IVIg responders'; 16% entered remissions that were sustained after IVIg withdrawal. All adverse events were expected; most were typical infusion reactions. The two moderate complications (3.6%) were vein thromboses not requiring discontinuation. The one severe event (1.8%), hemolytic anemia, remitted after IVIg discontinuation. CONCLUSION These results provide Class IV, real-world, proof-of-concept evidence suggesting that IVIg is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. They provide rationale for prospective trials, inform trial design and indirectly support the discovery of small-fiber-targeting autoimmune/inflammatory illnesses.
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Affiliation(s)
- Xiaolei Liu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Neurology, Dayi Hospital of Shanxi Medical University, China
| | - Roi Treister
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Magdalena Lang
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, 275 Charles Street/Warren Building 310, Boston, MA 02114, USA
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Van Eetvelde BLM, Cambier D, Vanden Wyngaert K, Celie B, Calders P. The Influence of Clinically Diagnosed Neuropathy on Respiratory Muscle Strength in Type 2 Diabetes Mellitus. J Diabetes Res 2018; 2018:8065938. [PMID: 30622971 PMCID: PMC6304822 DOI: 10.1155/2018/8065938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES This cross-sectional study investigated the influence of clinically diagnosed neuropathy (cdNP) on respiratory muscle strength in patients with type 2 diabetes mellitus (T2DM). METHODS 110 T2DM patients and 35 nondiabetic healthy controls (≥60 years) were allocated to one of three groups depending on the presence of cdNP: T2DM without cdNP (D-; n = 28), T2DM with cdNP (D+; n = 82), and controls without cdNP (C; n = 35). Clinical neurological diagnostic examination consisted of Vibration Perception Threshold and Diabetic Neuropathy Symptom score. Respiratory muscle strength was registered by maximal Inspiratory and Expiratory Pressures (PImax and PEmax), and respiratory function by Peak Expiratory Flow (PEF). Isometric Handgrip Strength and Short Physical Performance Battery were used to evaluate peripheral skeletal muscle strength and physical performance. Univariate analysis of covariance was used with age, level of physical activity, and body mass index as covariates. RESULTS PImax, PEmax, and PEF were higher in C compared to D- and D+. Exploring more in detail, PImax, PEmax, and PEF were significantly lower in D+ compared to C. PEmax and PEF were also significantly lower in D- versus C. Measures of peripheral muscle strength and physical performance showed less associations with cdNP and T2DM. CONCLUSIONS The presence of cdNP affects respiratory muscle strength in T2DM patients compared to healthy controls. Both cdNP and diabetes in themselves showed a distinctive impact on respiratory muscle strength and function; however, an accumulating effect could not be ascertained in this study. As commonly used measures of peripheral muscle strength and physical performance seemed to be less affected at the given time, the integration of PImax, PEmax, and PEF measurements in the assessment of respiratory muscle weakness could be of added value in the (early) screening for neuropathy in patients with T2DM.
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Affiliation(s)
| | - Dirk Cambier
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | | | - Bert Celie
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
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50
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A multicenter effort to improve comparability of vitamin B6 assays in whole blood. Clin Chem Lab Med 2017; 56:e23-e26. [DOI: 10.1515/cclm-2017-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/22/2017] [Indexed: 11/15/2022]
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