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Silsby M, Yiannikas C, Fois AF, Kiernan MC, Fung VSC, Vucic S. Upper and lower limb tremor in inflammatory neuropathies. Clin Neurophysiol 2024; 158:69-78. [PMID: 38194761 DOI: 10.1016/j.clinph.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/23/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE The mechanisms underlying neuropathic tremor remain incompletely understood and a distinction has not been drawn between proximal and distal neuropathies. Lower limb tremor contributes to imbalance in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but this is unexplored in other neuropathies. We characterized upper and lower limb tremor in chronic immune sensory polyradiculopathy (CISP) and distal acquired demyelinating neuropathy with anti-MAG antibodies (DADS-MAG), contrasted to CIDP. METHODS This was a cross-sectional study of 38 patients (CIDP [n = 25], CISP [n = 7], DADS-MAG [n = 6]). Clinical assessment, tremor study recordings, nerve conduction studies, and somatosensory evoked potentials were performed. Balance was measured by force platform. RESULTS Upper limb tremor was prevalent (CIDP 66%, CISP 70%, DADS-MAG 100%). Peak frequencies followed a gradient along the upper limb, unchanged by weight-loading. Lower limb tremor was also present (CIDP 32%, CISP 29%, DADS-MAG 66%) and associated with imbalance. Nerve conduction parameters correlated with upper limb tremor in DADS-MAG and CISP, and imbalance in CISP. CONCLUSIONS Upper limb tremor is mediated by peripheral and central mechanisms regardless of distal or proximal pathology. Lower limb tremor correlates with peripheral nerve function and contributes to imbalance. SIGNIFICANCE This study contributes to the understanding of neuropathic tremor. Addressing lower limb tremor may be of therapeutic importance for neuropathy-associated imbalance.
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Affiliation(s)
- Matthew Silsby
- Neurology Department, Westmead Hospital; Westmead Clinical School, University of Sydney, Australia; Brain and Nerve Research Centre, University of Sydney, Australia; Neurology Department, Concord Hospital Sydney, Australia
| | - Con Yiannikas
- Neurology Department, Concord Hospital Sydney, Australia; Neurology Department, Royal North Shore Hospital Sydney, Australia
| | - Alessandro F Fois
- Neurology Department, Westmead Hospital; Westmead Clinical School, University of Sydney, Australia
| | - Matthew C Kiernan
- Neurology Department, Royal Prince Alfred Hospital Sydney, Australia; Brain and Mind Centre, University of Sydney, Australia
| | - Victor S C Fung
- Neurology Department, Westmead Hospital; Westmead Clinical School, University of Sydney, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney, Australia; Neurology Department, Concord Hospital Sydney, Australia.
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Silsby M, Yiannikas C, Fois AF, Ng K, Kiernan MC, Fung VSC, Vucic S. Imbalance and lower limb tremor in chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2023; 28:415-424. [PMID: 37314215 DOI: 10.1111/jns.12574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIMS Imbalance is a prominent symptom of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Although upper limb tremor in CIDP is described, lower limb tremor has not been assessed. The aim of this study was to determine whether lower limb tremor was present in CIDP and assess potential relationships with imbalance. METHODS This was a cross-sectional observational study of prospectively recruited consecutive patients with typical CIDP (N = 25). Clinical phenotyping, lower limb nerve conduction and tremor studies, and posturography analyses were performed. The Berg Balance Scale (BBS) divided CIDP patients into those with "good" and "poor" balance. RESULTS Lower limb tremor was evident in 32% of CIDP patients and associated with poor balance (BBSTremor 35 [23-46], BBSNo Tremor 52 [44-55], p = .035). Tremor frequency was 10.2-12.5 Hz with legs outstretched and on standing, apart from four patients with a lower frequency tremor (3.8-4.6 Hz) while standing. Posturography analysis revealed a high-frequency spectral peak in the vertical axis in 44% of CIDP patients (16.0 ± 0.4 Hz). This was more likely in those with "good" balance (40% vs. 4%, p = .013). INTERPRETATION Lower limb tremor is present in one third of CIDP patients and is associated with poor balance. A high-frequency peak on posturography is associated with better balance in CIDP. Lower limb tremor and posturography assessments could serve as important biomarkers of balance in a clinical setting.
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Affiliation(s)
- Matthew Silsby
- Neurology Department, Westmead Hospital Sydney & Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Brain and Nerve Research Centre, Concord Hospital, University of Sydney, Sydney, Australia
- Neurology Department, Concord Hospital Sydney, Sydney, Australia
| | - Con Yiannikas
- Neurology Department, Concord Hospital Sydney, Sydney, Australia
- Neurology Department, Royal North Shore Hospital Sydney & Sydney Medical School, University of Sydney, Sydney, Australia
| | - Alessandro F Fois
- Neurology Department, Westmead Hospital Sydney & Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Karl Ng
- Neurology Department, Royal North Shore Hospital Sydney & Sydney Medical School, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney & Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Victor S C Fung
- Neurology Department, Westmead Hospital Sydney & Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, Concord Hospital, University of Sydney, Sydney, Australia
- Neurology Department, Concord Hospital Sydney, Sydney, Australia
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Rajan R, Anandapadmanabhan R, Vishnoi A, Vishnu VY, Latorre A, Agarwal H, Ghosh T, Mangat N, Biswas D, Gupta A, Radhakrishnan DM, Singh MB, Bhatia R, Srivastava A, Srivastava MVP, Bhatia KP. Neuropathic Tremor in Guillain-Barré Syndrome. Mov Disord Clin Pract 2023; 10:1333-1340. [PMID: 37772292 PMCID: PMC10525049 DOI: 10.1002/mdc3.13807] [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: 12/06/2022] [Revised: 05/12/2023] [Accepted: 05/24/2023] [Indexed: 09/30/2023] Open
Abstract
Background Neuropathic Tremor (NT) is a postural/kinetic tremor of the upper extremity, often encountered in patients with chronic neuropathies such as paraprotein-associated and hereditary neuropathies. Objectives To describe the clinical and electrophysiological features of NT in a previously underrecognized setting- during recovery from Guillain-Barré Syndrome (GBS). Methods Patients with a documented diagnosis of GBS in the past, presenting with tremor were identified from review of clinical records. Participants underwent structured, videotaped neurological examination, and electrophysiological analysis using tri-axial accelerometry-surface electromyography. Tremor severity was assessed using the Fahn-Tolosa-Marin Tremor Rating Scale. Results We describe the clinical and electrophysiological features of 5 patients with GBS associated NT. Our cohort had a fine, fast, and slightly jerky postural tremor of frequency ranging from 8 to 10 Hz. Dystonic posturing and overflow movements were noted in 4/5 patients. Tremor appeared 3 months-5 years after the onset of GBS, when patients had regained near normal muscle strength and deep tendon jerks were well elicitable. Electrophysiological analysis of tremor strongly suggested the presence of a central oscillator in all patients. Conclusion NT is not limited to chronic inflammatory or hereditary neuropathies and may occur in the recovery phase of GBS. The tremor is characterized by a high frequency, jerky postural tremor with dystonic posturing. Electrophysiological evaluation suggests the presence of a central oscillator, hypothetically the cerebellum driven by impaired sensorimotor feedback.
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Affiliation(s)
- Roopa Rajan
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | | | - Aayushi Vishnoi
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | | | - Anna Latorre
- Sobell Department of Motor Neuroscience and Movement DisordersUniversity College London (UCL) Institute of NeurologyLondonUnited Kingdom
| | - Harsh Agarwal
- All Indian Institute of Medical SciencesNew DelhiIndia
| | | | - Navtej Mangat
- All Indian Institute of Medical SciencesNew DelhiIndia
| | - Deblina Biswas
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Anu Gupta
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | | | - Mamta Bhushan Singh
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Rohit Bhatia
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Achal Srivastava
- Department of NeurologyAll India Institute of Medical SciencesNew DelhiIndia
| | | | - Kailash P. Bhatia
- Sobell Department of Motor Neuroscience and Movement DisordersUniversity College London (UCL) Institute of NeurologyLondonUnited Kingdom
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Silsby M, Fois AF, Yiannikas C, Ng K, Kiernan MC, Fung VSC, Vucic S. Chronic inflammatory demyelinating polyradiculoneuropathy-associated tremor: Phenotype and pathogenesis. Eur J Neurol 2023; 30:1059-1068. [PMID: 36692234 DOI: 10.1111/ene.15693] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/16/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Tremor in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is underrecognized, and the pathophysiology remains incompletely understood. This study evaluated tremor in CIDP and tested the hypothesis, established in other demyelinating neuropathies, that tremor occurs due to mistimed peripheral inputs affecting central motor processing. Additionally, the tremor stability index (TSI) was calculated with the hypothesis that CIDP-related tremor is more variable than other tremor disorders. METHODS Consecutive patients with typical CIDP were prospectively recruited from neuromuscular clinics. Alternative causes of neuropathy and tremor were excluded. Cross-sectional clinical assessment and extensive tremor study recordings were undertaken. Pearson correlation coefficient was used to compare nerve conduction studies and tremor characteristics, and t-test was used for comparisons between groups. RESULTS Twenty-four patients with CIDP were included. Upper limb postural and action tremor was present in 66% and was mild according to the Essential Tremor Rating Assessment Scale. Tremor did not significantly impact disability. Surface electromyography (EMG) found high-frequency spectral peaks in deltoid (13.73 ± 0.66 Hz), biceps brachii (11.82 ± 0.91 Hz), and extensor carpi radialis (11.87 ± 0.91 Hz) muscles, with lower peaks in abductor pollicis brevis EMG (6.07 ± 0.45 Hz) and index finger accelerometry (6.53 ± 0.42 Hz). Tremor was unchanged by weight loading but correlated with ulnar nerve F-wave latency and median nerve sensory amplitude. TSI (2.3 ± 0.1) was significantly higher than essential tremor. CONCLUSIONS Postural tremor is a common feature in CIDP. Tremor was unaffected by weight loading, typical of centrally generated tremors, although there was a correlation with peripheral nerve abnormalities. The high beat-to-beat variability on TSI and gradation of peak frequencies further suggest a complex pathophysiology. These findings may assist clinicians with the diagnosis of neuropathic tremor.
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Affiliation(s)
- Matthew Silsby
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
| | - Alessandro F Fois
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Con Yiannikas
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
- Neurology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karl Ng
- Neurology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Matthew C Kiernan
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Brain and Mind Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Victor S C Fung
- Neurology Department, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Neurology Department, Concord Hospital, Sydney, New South Wales, Australia
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van Veen R, Pallada G, Wieske L, Ten Holter SEM, van Rootselaar AF, Verhamme C, de Bie RMA, van Schaik IN, Merkies ISJ, Dijk JM, Eftimov F. The effect of tremor on disability assessment in chronic inflammatory demyelinating polyradiculoneuropathy. J Peripher Nerv Syst 2023; 28:58-68. [PMID: 36571466 DOI: 10.1111/jns.12528] [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: 10/15/2022] [Revised: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 12/27/2022]
Abstract
Tremor in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is common, often unresponsive to treatment, and may contribute to disability. We aim to investigate whether tremor is associated with disability as measured in daily practice and clinical trials, independent of other impairments. We included 76 CIDP patients in this cross-sectional study. We assessed tremor with the Tremor Research Group essential tremor rating assessment scale (TETRAS) and the Fahn-Tolosa-Marin clinical rating scale (FTM). Disability was measured with the inflammatory Rasch-built overall disability scale (I-RODS) and the adjusted Inflammatory Neuropathy Cause and Treatment disability scale (INCAT-DS, categorized separately in arm score, or total score). Impairments including strength, sensory impairment, and fatigue were measured using specific impairment scales. We tested whether "the presence of a clinically relevant tremor" (based on TETRAS and FTM) or "tremor severity" (FTM part B sum score) was associated with disability scores (I-RODS, INCAT-DS total score, and INCAT-DS arm score), independent of the impairment scores, using multivariate regression. Both "the presence of a clinically relevant tremor" and "tremor severity" were significantly associated with disability measured by the INCAT-DS (arm score and total score), but not the I-RODS, independent of strength, sensory impairment, and fatigue. The explained variances were low. Clinically relevant tremor can (partly) explain disability in CIDP, as measured with the INCAT-DS, independent of muscle strength, sensory deficits, and fatigue. To assess disease activity in CIDP patients with tremor, both impairment and disability outcomes should be assessed, as disability is caused partly by tremor while the effect of immunotherapy on tremor seems limited.
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Affiliation(s)
- R van Veen
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neuroinfection and inflammation, Amsterdam, The Netherlands
| | - G Pallada
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neuroinfection and inflammation, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - L Wieske
- Amsterdam Neuroscience, Neuroinfection and inflammation, Amsterdam, The Netherlands.,Department of Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - S E M Ten Holter
- Department of Neurology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A F van Rootselaar
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands.,Department of Neurology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - C Verhamme
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neuroinfection and inflammation, Amsterdam, The Netherlands.,Department of Clinical Neurophysiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - R M A de Bie
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | | | - I S J Merkies
- Department of Neurology, Maastricht Academic Medical Centre, Maastricht, the Netherlands.,Curaçao Medical Centre, Willemstad, Curacao
| | - J M Dijk
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neuroinfection and inflammation, Amsterdam, The Netherlands
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Çetinkaya Tezer D, Tutuncu M, Akalin MA, Uzun N, Karaali Savrun F, E Kiziltan M, Gunduz A. Myoclonus and tremor in chronic inflammatory demyelinating polyneuropathy: a multichannel electromyography analysis. Acta Neurol Belg 2022; 122:1289-1296. [PMID: 35750953 DOI: 10.1007/s13760-022-01992-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 05/25/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Information regarding involuntary movements in chronic inflammatory polyneuropathy (CIDP) is gradually increasing. Our goal is to identify the types of involuntary movements in CIDP. METHODS All patients who were followed with the diagnosis of CIDP were invited for clinical and electrophysiological evaluations. Demographic and clinical findings (age, gender, duration of illness, diagnosis, treatments) were noted. Clinical examination and multichannel surface electromyography were done. We also performed routine upper and lower extremity peripheral nerve conduction studies, F-waves, long latency reflexes, blink reflex, mixed nerve silent period and cutaneous silent period in all patients. RESULTS Twenty-two patients accepted the invitation. Eleven patients with CIDP had involuntary movements. Ten (45.5%) patients with CIDP had tremor and seven (31.8%) had short-duration and high-amplitude myoclonus. Regarding demographic, clinical and electrophysiological features, there was no significant difference between patients with and without tremor. The latencies of R1, R2 and R2c components of BR were longer among CIDP patients without tremor compared to CIDP patients with tremor. Presence of myoclonus (p = 0.007) and delayed F-waves (p = 0.008) were associated with the presence of tremor. CONCLUSION Tremor and myoclonus were frequent in CIDP. The fact that myoclonus was detected in the majority of patients only by multichannel surface EMG who were clinically evaluated as pure tremor suggests that a more detailed electrophysiological evaluation is required. There was no difference in the medications used or other clinical features between patients with and without tremor.
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Affiliation(s)
- Damla Çetinkaya Tezer
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Melih Tutuncu
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mehmet Ali Akalin
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nurten Uzun
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Feray Karaali Savrun
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Meral E Kiziltan
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Aysegul Gunduz
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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Rajabally YA. Contemporary challenges in the diagnosis and management of chronic inflammatory demyelinating polyneuropathy. Expert Rev Neurother 2022; 22:89-99. [PMID: 35098847 DOI: 10.1080/14737175.2022.2036125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite extensive research, multiple inter-related diagnostic and management challenges remain for chronic inflammatory demyelinating polyneuropathy (CIDP). AREAS COVERED A literature review was performed on diagnosis and treatment in CIDP. The clinical features and disease course were evaluated. Investigative techniques, including electrophysiology, cerebrospinal fluid examination, neuropathology, imaging and neuroimmunology, were considered in relation to technical aspects, sensitivity, specificity, availability and cost. Available evidenced-based treatments and those with possible efficacy despite lack of evidence, were considered, as well as current methods for evaluation of treatment effects. EXPERT OPINION CIDP remains a clinical diagnosis, supported first and foremost by electrophysiology. Other investigative techniques have limited impact. Most patients with CIDP respond to available first-line treatments and immunosuppression may be efficacious in those who do not. Consideration of the natural history and of the high reported remission rate, of under-recognised associated disabling features, of treatment administration modalities and assessment methods, require enhanced attention.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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8
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Cox SZ, Gwathmey KG. Chronic Immune-Mediated Polyneuropathies. Clin Geriatr Med 2021; 37:327-345. [PMID: 33858614 DOI: 10.1016/j.cger.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article discusses the chronic immune-mediated polyneuropathies, a broad category of acquired polyneuropathies that encompasses chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), the most common immune-mediated neuropathy, the CIDP variants, and the vasculitic neuropathies. Polyneuropathies associated with rheumatological diseases and systemic inflammatory diseases, such as sarcoidosis, will also be briefly covered. These patients' history, examination, serum studies, and electrodiagnostic studies, as well as histopathological findings in the case of vasculitis, confirm the diagnosis and differentiate them from the more common length-dependent polyneuropathies. Prompt identification and initiation of treatment is imperative for these chronic immune-mediated polyneuropathies to prevent disability and even death.
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Affiliation(s)
- Stephen Zachary Cox
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA.
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Malik A, Berry R, Fung BM, Tabibian JH. Association between chronic inflammatory demyelinating polyneuropathy and gastrointestinal malignancies. Clin J Gastroenterol 2020; 14:1-13. [PMID: 33146871 DOI: 10.1007/s12328-020-01281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon and under-recognized immune-mediated disorder of the peripheral nervous system. It is associated with both infectious and non-infectious etiologies and presents in several variant forms. In rare instances, CIDP has been reported in association with gastrointestinal (esophageal, hepatic, colorectal, and pancreatic) malignancies. The diagnosis of malignancy is typically preceded by weeks to months by that of CIDP, though the inverse may also be seen. As with other etiologies of CIDP, cases associated with gastrointestinal malignancies are often treated with corticosteroids, intravenous immunoglobulins, and/or plasma exchange, with improvement or resolution of neurological symptoms in the majority of cases. In this review, we provide a practical overview of CIDP, with an emphasis on recognizing the clinical association between CIDP and gastrointestinal malignancies.
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Affiliation(s)
- Adnan Malik
- Division of Hepatology, Loyola University Medical Center, Maywood, IL, USA
| | - Rani Berry
- Department of Internal Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA
| | - Brian M Fung
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA, 2B-182, USA. .,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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10
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Gwathmey K. Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants. Continuum (Minneap Minn) 2020; 26:1205-1223. [PMID: 33002999 DOI: 10.1212/con.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and its variants comprise a group of immune-mediated neuropathies with distinctive clinical presentations and electrodiagnostic features. Prompt recognition of these treatable disorders is mandatory as delays result in significant disability and morbidity. This article highlights the clinical presentation, pathophysiology, diagnostic evaluation, and treatment approach of these polyneuropathies. RECENT FINDINGS The spectrum of CIDP is expanding with the recent characterization of neuropathies associated with nodal and paranodal antibodies. These neuropathies are distinguished by their unique presentations and are often refractory to IV immunoglobulin (IVIg) therapy. Subcutaneous immunoglobulins have recently been approved as a treatment option for CIDP and join corticosteroids, IVIg, and plasma exchange as first-line treatment. SUMMARY CIDP is characterized by progressive symmetric proximal and distal weakness, large fiber sensory loss, and areflexia, with clinical nadir reached more than 8 weeks after symptom onset. Autoimmune demyelinating neuropathies fall on a continuum, with differences in the type of nerve fibers affected and pattern of deficits. Distinguishing between typical CIDP and its variants allows for selection of the most appropriate treatment.
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11
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Kiziltan ME, Gunduz A, Tutuncu M, Ertan S, Apaydin H, Kiziltan G. Myoclonus in the elderly: A retrospective analysis of clinical and electrophysiological characteristics of patients referred to an electrophysiology laboratory. Parkinsonism Relat Disord 2018; 49:22-27. [PMID: 29326035 DOI: 10.1016/j.parkreldis.2017.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 12/09/2017] [Accepted: 12/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Late-onset myoclonus in the elderly is mainly related to dementia or systemic disease. In this report, we aimed to investigate the clinical and electrophysiological features of patients with late-onset myoclonus. PATIENTS AND METHOD We retrospectively assessed the medical records of patients who were referred to our electromyography laboratory. From these records, we included all patients who had myoclonus which started after the age of 60 years and in whom it was confirmed by polymyography. Demographic, clinical and electrophysiological findings were retrieved from the medical records. RESULTS There were 63 patients with myoclonus. Types of myoclonus were spinal segmental (n = 2), cortical (n = 25) and probable cortico-subcortical involving upper extremities (n = 36). The latter two types displayed reflex sensitivity. Four patients (one with multifocal cortical myoclonus and others with probable cortico-subcortical myoclonus) were diagnosed with probable CJD. Other diagnoses were Parkinsons's disease, Parkinson-plus or dementia syndromes, vascular parkinsonism, polyneuropathy, Celiac disease and post-hypoxic encephalopathy. Eleven patients did not have a specific diagnosis. CONCLUSIONS Myoclonus in our cohort was mostly associated with parkinsonism. Cortical myoclonus is not rare in the elderly age group. Myoclonus in polyneuropathy is irregular, tremor-like with electrophysiological characteristics similar to the cortical subtype.
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Affiliation(s)
- Meral E Kiziltan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Aysegul Gunduz
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey.
| | - Melih Tutuncu
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Sibel Ertan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Hulya Apaydin
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
| | - Gunes Kiziltan
- Department of Neurology, Cerrahpaşa School of Medicine, Istanbul University, Turkey
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