Chronic Idiopathic Demyelinating Polyradiculoneuropathy. Guillain-Barré Syndrome. London: Springer; 1990. pp. 205-46. [DOI: 10.1007/978-1-4471-3175-5_10]

Pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy

The acute lesions of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consist of endoneurial foci of chemokine and chemokine receptor expression and T cell and macrophage activation. The myelin protein antigens, P2, P0, and PMP22, each induce experimental autoimmune neuritis in rodent models and might be autoantigens in CIDP. The strongest evidence incriminates P0, to which antibodies have been found in 20% of cases. Failure of regulatory T-cell mechanism is thought to underlie persistent or recurrent disease, differentiating CIDP from the acute inflammatory demyelinating polyradiculoneuropathy form of Guillain-Barré syndrome. Corticosteroids, intravenous immunoglobulin and plasma exchange each provide short term benefit but the possible long-term benefits of immunosuppressive drugs have yet to be confirmed in randomised, controlled trials.

Asymmetrical polyneuropathy with a stepwise progressive course and well-demarcated areas of demyelination

A female patient was 12 years old when she presented with hemiatrophy and muscle weakness on the right side of her body. Then a stepwise worsening occurred, and at 19 years of age sensory symptoms were also noticed, as well as a mild involvement of the left part of her body. The cerebrospinal fluid (CSF) protein level was elevated without cells. The main electrophysiological abnormality was a marked temporal dispersion of the compound muscle action potentials (CMAPs). Motor nerve conduction velocities were moderately reduced. A superficial peroneal nerve biopsy revealed well-demarcated areas of demyelination with prominent Schwann cell hyperplasia. Neither deletion nor duplication of the PMP22 gene nor mutation of the P0 or connexin 32 genes was found by molecular genetic investigations. Immunotherapy was administered, and over the next 6 years the symptomatology fluctuated. This unusual disorder seems to be a variant of chronic acquired demyelinating polyneuropathy and may be immunologically mediated.

Chronic Inflammatory Demyelinating Polyneuropathy

Treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) requires long-term immunomodulatory therapy, which has potential side effects. Before such therapy is instituted, a firm diagnosis of CIDP must be established. Prednisone, plasma exchange (PE), and intravenous immunoglobulin (IVIG) are all proven first-line therapies for CIDP that are of similar efficacy. The choice of treatment should be individualized based on costs, availability, and potential adverse effects. Except in the elderly and in those with complicating medical illnesses, IVIG is well tolerated and easy to administer; hence, it should be the initial therapy for most patients with CIDP. Because of its prohibitive costs and limited availability, however, it is not ideal for long-term administration. In the elderly and in those with complicating medical illnesses (eg, diabetes, obesity, or hypertension), PE may be used as the first-line therapy. Because the effects of PE are transient and because it is expensive, requires vascular access, and can only be performed in specialized centers, long-term therapy with PE alone is problematic. Prednisone is inexpensive, easily available, and of proven efficacy. It is the preferred treatment in young, otherwise healthy persons either as a first-line therapy or in association with IVIG or PE. Patients who require repeated treatment with IVIG or PE and cannot tolerate prednisone or those who require high-dose prednisone should be administered azathioprine, cyclosporin A, or cyclophosphamide, usually in combination with one of the first-line therapies.

A novel trial design to study the effect of intravenous immunoglobulin in chronic inflammatory demyelinating polyradiculoneuropathy

Using a novel trial design, we prospectively examined the effect of intravenous immunoglobulin in seven patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in a double-blind, placebo-controlled cross-over study. We suggest that the commonly used manual muscle testing and Rankin scale are not sufficiently sensitive to measure changes in CIDP and should not be used as isolated outcome measures. We propose a timed 10-m walk, the Nine-Hole Peg Test, the Hammersmith Motor Ability Score, and myometry as alternative measures which are valid, reliable and sensitive. Our trial design permitted the measurement of a treatment response in three responders despite different patterns of disability typical of the broad clinical picture seen in CIDP.

Extensive demyelinating changes in the peripheral nerves of Crow-Fukase syndrome: a pathological study of one autopsied case

Pathological changes of the peripheral nervous system in one autopsied case of Crow-Fukase syndrome (POEMS syndrome) was systemically examined. Distally accentuated myelinated axon loss was observed in the peripheral nerve trunks, ventral and dorsal spinal roots, but was not observed in the fasciculus gracilis. Segmental demyelination and remyelination associated with focal excessive myelin outfolds were the most characteristic features, the distribution of which was more prominent in the proximal nerve trunks and the spinal nerve roots. Endoneurial edema was present, and focal perivascular T lymphocyte accumulation was occasionally observed in the spinal nerve roots and proximal nerve trunks. Neurons in the sympathetic ganglia, dorsal root ganglia and ventral horns were well preserved.