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El Sadaney AO, Dutta A, Cook J, Baffour FI. Monoclonal Gammopathy of Clinical Significance (MGCS) and Related Disorders: A Review and the Role of Imaging. Diagnostics (Basel) 2024; 14:1907. [PMID: 39272692 PMCID: PMC11394483 DOI: 10.3390/diagnostics14171907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
The term monoclonal gammopathy of clinical significance (MGCS) refers to a group of symptomatic monoclonal gammopathies that do not meet the diagnostic criteria for malignant plasma cell disorders, such as multiple myeloma or Waldenström macroglobulinemia. These symptoms are attributable to the paraneoplastic effects of monoclonal immunoglobulins that occur through diverse mechanisms. The presence of symptoms distinguishes MGCS from monoclonal gammopathy of undetermined significance, which lacks significant symptomatic presentation. The presentations of MGCS are manifold, adding to the diagnostic challenge. Clinical suspicion is key for accurate and timely diagnosis. Radiologic imaging can provide pivotal information to guide the diagnosis. In this review, we discuss MGCS from a radiology perspective and highlight pertinent imaging features associated with the disorders.
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Affiliation(s)
| | - Anika Dutta
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Joselle Cook
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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2
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Bellanti R, Keddie S, Lunn MP, Rinaldi S. Ultrasensitive assay technology and fluid biomarkers for the evaluation of peripheral nerve disease. J Neurol Neurosurg Psychiatry 2024; 95:114-124. [PMID: 37821222 DOI: 10.1136/jnnp-2023-332031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/22/2023] [Indexed: 10/13/2023]
Abstract
The field of biomarker discovery is rapidly expanding. The introduction of ultrasensitive immunoassays and the growing precision of genetic technologies are poised to revolutionise the assessment and monitoring of many diseases. Given the difficulties in imaging and tissue diagnosis, there is mounting interest in serum and cerebrospinal fluid biomarkers of peripheral neuropathy. Realised and potential fluid biomarkers of peripheral nerve disease include neuronal biomarkers of axonal degeneration, glial biomarkers for peripheral demyelinating disorders, immunopathogenic biomarkers (such as the presence and titre of antibodies or the levels of cytokines) and genetic biomarkers. Several are already starting to inform clinical practice, whereas others remain under evaluation as potential indicators of disease activity and treatment response. As more biomarkers become available for clinical use, it has become increasingly difficult for clinicians and researchers to keep up-to-date with the most recent discovery and interpretation. In this review, we aim to inform practising neurologists, neuroscientists and other clinicians about recent advances in fluid biomarker technology, with a focus on single molecule arrays (Simoa), chemiluminescent enzyme immunoassays (CLEIA), electrochemiluminescence (ECL), proximity extension assays (PEA), and microfluidic technology. We discuss established and emerging fluid biomarkers of peripheral neuropathy, their clinical applications, limitations and potential future developments.
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Affiliation(s)
- Roberto Bellanti
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
| | - Stephen Keddie
- Department of Neuromuscular Diseases, The Royal London Hospital, London, UK
| | - Michael P Lunn
- Department of Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London, UK
- Department of Neuroinflammation, National Hospital for Neurology and Neurosurgery, London, UK
| | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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3
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Mariotto S, de Gaspari P, Jäger D, Hahn S, Forni C, Saschenbrecker S, Lattwein E, Dinoto A, Ferrari S. A novel cell-based immunofluorescence assay for the detection of autoantibodies to myelin-associated glycoprotein. Front Neurol 2023; 14:1289810. [PMID: 38169815 PMCID: PMC10758835 DOI: 10.3389/fneur.2023.1289810] [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: 09/06/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
Peripheral neuropathy with antibodies to myelin-associated glycoprotein (MAG) is an autoimmune demyelinating disorder of the peripheral nervous system caused by pathogenic IgM recognizing the human natural killer-1 glycoepitope expressed on MAG. This study aimed to analyze the performance of a new indirect immunofluorescence cell-based assay (CBA, EUROIMMUN) for the detection of anti-MAG IgM. Antibody reactivity was determined in sera from 95 patients with clinical and neurophysiological evidence of anti-MAG-associated neuropathy and in control samples from 55 patients with other forms of peripheral neuropathy. Compared to the results of the gold standard method (ELISA, Bühlmann) and using samples at a dilution of 1:100, the CBA had a sensitivity of 98.9% and a specificity of 100% (PPV 100%, NPV 98.2%). In conclusion, the CBA allows the detection of antibodies to MAG using an easy and standardized technique, and it presents a sensitive and specific alternative to the more time-consuming ELISA. Larger studies are needed to address anti-MAG titer monitoring in parallel with clinical activity.
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Affiliation(s)
- Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Piera de Gaspari
- Neuroimmunology Group, Pediatric Research Institute, Padua, Italy
| | - Dominik Jäger
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Stefanie Hahn
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Cindy Forni
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Sandra Saschenbrecker
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Erik Lattwein
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Alessandro Dinoto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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4
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Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
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Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
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5
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Naum R, Gwathmey KG. Autoimmune polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:587-608. [PMID: 37562888 DOI: 10.1016/b978-0-323-98818-6.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.
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Affiliation(s)
- Ryan Naum
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kelly Graham Gwathmey
- Neuromuscular Division, Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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Parisi M, Dogliotti I, Clerico M, Bertuzzo D, Benevolo G, Orsucci L, Schiavetti I, Cavallo R, Cavallo F, Ragaini S, Di Liberto A, Ferrante M, Bondielli G, Artusi CA, Drandi D, Lopiano L, Ferrero B, Ferrero S. Efficacy of rituximab in anti-myelin-associated glycoprotein demyelinating polyneuropathy: Clinical, hematological and neurophysiological correlations during 2 years of follow-up. Eur J Neurol 2022; 29:3611-3622. [PMID: 36083713 PMCID: PMC9825860 DOI: 10.1111/ene.15553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/11/2022] [Accepted: 08/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE We evaluated the clinical and neurophysiological efficacy of rituximab (RTX) in a neurophysiologically homogeneous group of patients with monoclonal gammopathy and immunoglobulin M (IgM) anti-myelin-associated glycoprotein antibody (anti-MAG) demyelinating polyneuropathy. METHODS Twenty three anti-MAG-positive polyneuropathic patients were prospectively evaluated before and for 2 years after treatment with RTX 375 mg/m2 . The Inflammatory Neuropathy Cause and Treatment (INCAT) disability scale (INCAT-ds), modified INCAT sensory score (mISS), Medical Research Council sum score, Patients' Global Impression of Change scale were used, IgM levels were assessed and extensive electrophysiological examinations were performed before (T0) and 1 year (T1) and 2 years (T2) after RTX treatment. RESULTS At T1 and T2 there was a significant reduction from T0 both in mISS and in INCAT-ds, with a p value < 0.001 in the inferential Friedman's test overall analysis. Ulnar nerve Terminal Latency Index and distal motor latency significantly changed from T0 to T1 and in the overall analysis (p = 0.001 and p = 0.002), and ulnar nerve sensory nerve action potential (SNAP) amplitude was significantly increased at T2 from T1, with a p value < 0.001 in the overall analysis. Analysis of the receiver-operating characteristic curves showed that a 41.8% increase in SNAP amplitude in the ulnar nerve at T2 from T0 was a fair predictor of a mISS reduction of ≥2 points (area under the curve 0.85; p = 0.005; sensitivity: 90.9%, specificity: 83.3%). CONCLUSIONS This study suggests that RTX is effective in patients with clinically active demyelinating anti-MAG neuropathy over 2 years of follow-up, and that some neurophysiological variables might be useful for monitoring this efficacy.
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Affiliation(s)
- Mattia Parisi
- Department of NeurosciencesUniversity of TurinTurinItaly
| | - Irene Dogliotti
- Stem Cell Transplant UnitUniversity Hospital A.O.U. “Città della Salute e della Scienza di Torino”TurinItaly
| | - Michele Clerico
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly,SSD Myeloma Unit and Clinical Trial, University HaematologyA.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
| | | | - Giulia Benevolo
- SSD Myeloma Unit and Clinical Trial, University HaematologyA.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
| | - Lorella Orsucci
- Division of Hematology 2A.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
| | - Irene Schiavetti
- Section of Biostatistics, Department of Health SciencesUniversity of GenoaGenoaItaly
| | - Roberto Cavallo
- Department of NeurologyOspedale San Giovanni BoscoTurinItaly
| | - Federica Cavallo
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly,SSD Myeloma Unit and Clinical Trial, University HaematologyA.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
| | - Simone Ragaini
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly,SSD Myeloma Unit and Clinical Trial, University HaematologyA.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
| | | | - Martina Ferrante
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly
| | - Giulia Bondielli
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly
| | | | - Daniela Drandi
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly
| | | | - Bruno Ferrero
- Department of NeurosciencesUniversity of TurinTurinItaly
| | - Simone Ferrero
- Department of Molecular Biotechnologies and Health SciencesUniversity of TurinTurinItaly,SSD Myeloma Unit and Clinical Trial, University HaematologyA.O.U. "Città della Salute e della Scienza di Torino"TurinItaly
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7
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Lino AMM, Castelli JB, Szor RS, Fernandes F, Aiello VD. Diagnostic challenges in systemic amyloidosis: a case report with clinical and laboratorial pitfalls. AUTOPSY AND CASE REPORTS 2021; 11:e2021326. [PMID: 34631606 PMCID: PMC8489187 DOI: 10.4322/acr.2021.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/22/2021] [Indexed: 12/02/2022] Open
Abstract
Currently, there is growing evidence in the literature warning of misdiagnosis involving amyloidosis and chronic inflammatory demyelinating polyneuropathy (CIDP). Although inducing clinical manifestations outside the peripheral nervous system, light chain and transthyretin amyloidosis may initially present with peripheral neuropathy, which can be indistinguishable from CIDP, leading to a delay in the correct diagnosis. Besides, the precise identification of the amyloid subtype is often challenging. This case report exemplifies clinical and laboratory pitfalls in diagnosing amyloidosis and subtyping amyloid, exposing the patient to potentially harmful procedures.
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Affiliation(s)
- Angelina Maria Martins Lino
- Universidade de São Paulo (USP), Hospital das Clínicas, Department of Neurology, Clinical Peripheral Nerve Group, São Paulo, SP, Brasil
| | - Jussara Bianchi Castelli
- Universidade de São Paulo (USP), Instituto do Coração, Laboratory of Pathology, São Paulo, SP, Brasil.,Grupo Fleury, Department of Pathology, São Paulo, SP, Brasil
| | - Roberta Shcolnik Szor
- Universidade de São Paulo (USP), Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | - Fabio Fernandes
- Universidade de São Paulo (USP), Instituto do Coração, Cardiomiopathy Group, São Paulo, SP, Brasil
| | - Vera Demarchi Aiello
- Universidade de São Paulo (USP), Instituto do Coração, Laboratory of Pathology, São Paulo, SP, Brasil
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8
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Ruiz M, Puthenparampil M, Campagnolo M, Castellani F, Salvalaggio A, Ruggero S, Toffanin E, Cacciavillani M, Gallo P, Franciotta D, Briani C. Oligoclonal IgG bands in chronic inflammatory polyradiculoneuropathies. J Neurol Neurosurg Psychiatry 2021; 92:969-974. [PMID: 33850000 DOI: 10.1136/jnnp-2020-325868] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) albumincytologic dissociation represents a supportive diagnostic criterion of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).Few studies have investigated possible systemic or intrathecal humoral immune response activation in CIDP.Aim of our study was to investigate whether the search of oligoclonal IgG bands (OCBs) might provide additional data helpful in CIDP diagnostic work-up. METHODS Forty-eight consecutive patients with CIDP (34 men, mean age 59.4, range 16-83) were recruited. CSF analysis included nephelometric measurement of albumin and IgG concentrations, calculation of QALB, QAlbLIM and intrathecal IgG synthesis, and OCBs detection with isoelectric focusing. Data were compared with those from CSF and serum of 32 patients with Guillain-Barré syndrome (GBS), 18 patients with anti-myelin associated glycoprotein (MAG) antibody neuropathy, 4 patients with multifocal motor neuropathy and 32 patients with non-inflammatory neuropathies (NINPs). RESULTS Patients with CIDP and anti-MAG antibody neuropathy had significantly higher CSF albumin concentrations and QALB values than NINPs (p=0.0003 and p=0.0095, respectively). A total of 9 (19%) patients with CIDP presented identical serum and CSF OCBs ('mirror pattern') versus 3 patients (16.6%) with anti-MAG antibody neuropathy, 13 patients (40.6%) with GBS and 12.5% patients with NINPs. Only one patient with CIDP showed unique-to-CSF OCBs. First-line therapy was effective in 80.4% of patients with CIDP, irrespective of CSF findings. CONCLUSIONS Compared with NINP, CIDP, GBS and anti-MAG antibody neuropathies had a significantly increased CSF protein and blood-spinal nerve root barrier damage. Intrathecal humoral immune response is rare in our patients with CIDP. Systemic oligoclonal activation is more frequent, but not significantly different from what was detected in the control groups.
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Affiliation(s)
- Marta Ruiz
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Marta Campagnolo
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Alessandro Salvalaggio
- Department of Neurosciences (DNS), University of Padova, Padova, Italy.,Padova Neuroscience Center (PNC), Padova, Italy
| | - Susanna Ruggero
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | | | - Paolo Gallo
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | | | - Chiara Briani
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
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9
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Abstract
Paraproteinaemic neuropathies comprise a heterogeneous group of neuro-haematological conditions with some distinct neurological, haematological and systemic phenotypes. The spectrum of disease varies from mild to severe, indolent to rapidly progressive and from small fibre sensory involvement to dramatic sensorimotor deficits. The haematological association may be overlooked, resulting in delayed treatment, disability, impaired quality of life and increased mortality. However, the presence of an irrelevant benign paraprotein can sometimes lead to inappropriate treatment. In this review, we outline our practical approach to paraproteinaemic disorders, discuss the utility and limitations of diagnostic tests and the distinctive clinical phenotypes and touch on the complex multidisciplinary management approaches.
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Affiliation(s)
- Antonia S Carroll
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,National Hospital for Neurology and Neurosurgery, London, UK
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10
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Castillo JJ, Callander NS, Baljevic M, Sborov DW, Kumar S. The evaluation and management of monoclonal gammopathy of renal significance and monoclonal gammopathy of neurological significance. Am J Hematol 2021; 96:846-853. [PMID: 33709474 PMCID: PMC8252623 DOI: 10.1002/ajh.26155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 12/24/2022]
Abstract
Despite the benign nature of monoclonal gammopathy of undetermined significance (MGUS), mounting data are associating MGUS with the development of organ dysfunction, specifically monoclonal gammopathy of renal significance (MGRS) and monoclonal gammopathy of neurological significance (MGNS), which could be associated with substantial morbidity. Emerging evidence suggests that patients with MGRS and MGNS could benefit from treatments used for myeloma, Waldenström macroglobulinemia, or chronic lymphocytic leukemia, depending on the underlying pathology. However, the treatment of MGRS and MGNS is not standardized, and potentially effective therapies might not be reimbursed because these conditions do not formally meet the criteria for malignant processes. The present review aims at establishing standards for the evaluation and management of MGRS and MGNS, which can facilitate the diagnosis of and provide therapeutic options for treating practitioners and patients affected by these conditions. The careful design and execution of clinical trials for patients with MGRS and MGNS are positively encouraged.
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Affiliation(s)
- Jorge J. Castillo
- Dana‐Farber Cancer Institute Harvard Medical School Boston Massachusetts
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11
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Simkhada N, Adhikari P, Baral N, Dhakal B, Mahat K. Multiple Myeloma and Vasculitic Neuropathy: An Unusual Presentation. Cureus 2021; 13:e13776. [PMID: 33842152 PMCID: PMC8025791 DOI: 10.7759/cureus.13776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma (MM) is a clonal proliferation of plasma cells in the bone marrow resulting in the production of paraproteins. It is more common in elderly adults and presents with nonspecific symptoms like bone pain, pathological fracture, fatigue, and signs of hypercalcemia. Peripheral neuropathy is an atypical presentation. We present a rare case of vasculitic neuropathy (VN) who was also diagnosed with MM at the same time. Nerve conduction study and biopsy showed findings suggestive of demyelinating VN. His serum protein electrophoresis and bone marrow aspirate were consistent with MM. The association between these two conditions remains understudied. So far there is no strong evidence suggesting an association between MM and VN. If VN was just coincidental or a presenting symptom of MM remains a question and warrants further studies.
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Affiliation(s)
- Nabin Simkhada
- Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, NPL
| | - Prakash Adhikari
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Nisha Baral
- Microbiology, Manipal College of Medical Sciences, Pokhara, NPL
| | - Bishal Dhakal
- Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, NPL
| | - Krish Mahat
- Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, NPL
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12
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Yang Y, Canepa C. IgM paraprotein and anti-MAG sensory polyneuropathy associated with Waldenstrom's macroglobulinaemia and medullary carcinoma of the thyroid. BMJ Case Rep 2021; 14:14/2/e240242. [PMID: 33622752 PMCID: PMC7907858 DOI: 10.1136/bcr-2020-240242] [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: 11/03/2022] Open
Abstract
A previously fit and well 76-year-old man, presented with distal lower limb sensory symptoms suggestive of peripheral sensory neuropathy, associated with positive anti-MAG antibodies (myelin associated glycoprotein) and IgM paraprotein. Bone marrow biopsy showed lymphoplasmocytoid lymphoma (Waldenstrom's macroglobulinaemia, WM), consequently positive for MYD88 mutation. He subsequently developed medullary carcinoma of the thyroid, most likely secondary to WM. He underwent a successful total thyroidectomy and four treatment doses of rituximab, which proved beneficial. He is currently stable and under multidisciplinary monitoring. His sensory symptoms have improved following rituximab treatment and his WM is under control.
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Affiliation(s)
- Yunfei Yang
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carlo Canepa
- Department of Neurology, James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK
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13
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Lomas OC, Mouhieddine TH, Tahri S, Ghobrial IM. Monoclonal Gammopathy of Undetermined Significance (MGUS)-Not So Asymptomatic after All. Cancers (Basel) 2020; 12:E1554. [PMID: 32545521 PMCID: PMC7352603 DOI: 10.3390/cancers12061554] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is considered to be a benign precursor condition that may progress to a lymphoproliferative disease or multiple myeloma. Most patients do not progress to an overt condition, but nevertheless, MGUS is associated with a shortened life expectancy and, in a minority of cases, a number of co-morbid conditions that include an increased fracture risk, renal impairment, peripheral neuropathy, secondary immunodeficiency, and cardiovascular disease. This review aims to consolidate current evidence for the significance of these co-morbidities before considering how best to approach these symptoms and signs, which are often encountered in primary care or within a number of specialties in secondary care.
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Affiliation(s)
- Oliver C. Lomas
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
| | - Tarek H. Mouhieddine
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sabrin Tahri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
| | - Irene M. Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
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14
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Byun JM, Kwon YN, Koh Y, Yoon SS, Sung JJ, Kim I. Distinctive patterns of peripheral neuropathy across the spectrum of plasma cell disorders. Sci Rep 2019; 9:16769. [PMID: 31727997 PMCID: PMC6856063 DOI: 10.1038/s41598-019-53289-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/25/2019] [Indexed: 11/11/2022] Open
Abstract
Many patients with plasma cell disorders suffer from peripheral neuropathy, but differential diagnosis with chronic inflammatory demyelinating polyneuropathy (CIDP) is difficult. We aimed to (1) identify factors useful for differential diagnosis between peripheral neuropathy associated with plasma cell disorders versus CIDP and (2) determine whether neuropathy presentations and severity varied across the spectrum of different plasma cell disorders. A retrospective chart review of 18 monoclonal gammopathy of unknown significance (MGUS) patients, 15 POEMS syndrome patients and 34 CIDP patients between January 2005 and December 2016 was conducted. The peripheral neuropathy associated with plasma cell disorders seemed to be more sensory oriented compared to CIDP. MGUS patients were significantly older than CIDP patients (median age 70 vs. 59, respectively, p = 0.027). POEMS syndrome patients showed significantly higher platelet count at the time of neuropathy presentation compared to CIDP (p = 0.028). Lambda type MGUS patients were associated with less severe symptoms compared to POEMS syndrome patients despite harboring lambda monoclonal gammopathy as a common denominator. Kappa type MGUS patients showed predominantly axonal type neuropathy compared to its counterpart and POEMS syndrome. Careful inspection of clinical profiles and symptoms of patients presenting with neuropathy can help to discriminate those with underlying plasma cell disorders. The phenotype of neuropathy, platelet count and age at presentation seem to be the most useful indicators.
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Affiliation(s)
- Ja Min Byun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Young Nam Kwon
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
| | - Inho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea.
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Tang MAH, Mathis S, Duffau P, Cazenave P, Solé G, Duval F, Soulages A, Le Masson G. Prognostic factor of poor outcome in anti-MAG neuropathy: clinical and electrophysiological analysis of a French Cohort. J Neurol 2019; 267:561-571. [PMID: 31705291 DOI: 10.1007/s00415-019-09618-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/01/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-MAG polyneuropathy (anti-MAG PN) is an immune-mediated peripheral sensorimotor neuropathy characterized by distal demyelination and ataxia. However, this disorder, unlike other immune-mediated neuropathies, is difficult to treat in most cases. METHOD We retrospectively collected all anti-MAG PN patients followed in two hospitals for a period of 12 years to determine prognostic factors, especially those that indicated a good response to the various therapeutic strategies used. RESULTS Forty-seven patients were included in the study; of these, 61% had a classical 'distal demyelinating pattern', 34.2% had a 'CIDP-like pattern', and the others had an 'axonal pattern'. The most commonly used treatments were intravenous immunoglobulin (IVIg) as the first-line treatment and rituximab as the second- or third-line treatment. No prognostic factor was identified for IVIg, but electrophysiological parameters at onset were better in patients with a good response to rituximab than in non-responder patients, even though mild or high disability was observed in nearly half the patients at last examination. CONCLUSION Even though disability seems to progress in most cases despite the treatments used, our results suggest that an early electrophysiological reduction in sensory nerves could be considered a 'red flag' for the prompt initiation of rituximab to try to delay long-term disability.
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Affiliation(s)
- Marie-Ange Hoang Tang
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Philippe Cazenave
- Department of Neurology, Robert Boulin Hospital, 112 rue de la Marne, 33505, Libourne, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Antoine Soulages
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France. .,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.
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16
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Canepa C. Waldenstrom-associated anti-MAG paraprotein polyneuropathy with neurogenic tremor. BMJ Case Rep 2019; 12:12/3/e228376. [PMID: 30936346 DOI: 10.1136/bcr-2018-228376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 71-year-old female patient presented with a 14-year history of slowly progressive distal limb numbness, paraesthesia and reduced vibration perception, ataxic gait and intentional tremor. Examination revealed with a length-dependent sensory neuropathy. Nerve conduction studies showed a chronic sensorimotor inflammatory demyelinating polyneuropathy. Intravenous immunoglobulin treatment (on two occasions) proved ineffective. Serum electrophoresis showed increased monoclonal IgM with kappa light chains. Anti-myelin-associated glycoprotein (MAG) levels were extremely elevated, >70 000 BTU. Bone marrow biopsy revealed 15%-20% small B cells and positive MYD88 mutation, indicative of Waldenstrom macroglobulinaemia. A diagnosis of Waldenstrom-associated anti-MAG paraprotein neuropathy with intentional (neurogenic) tremor was made. Repeat nerve conduction study showed a severe sensory demyelinating neuropathy with no axonal lesion. Treatment with rituximab was given for 1 month with minimal improvement. Repeat anti-MAG levels dropped to 53 670 BTU, with minimal clinical improvement.
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Affiliation(s)
- Carlo Canepa
- Department of Neurology, James Paget University Hospital, Great Yarmouth, UK
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17
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Are neurological complications of monoclonal gammopathy of undetermined significance underestimated? Oncotarget 2018; 8:5081-5091. [PMID: 27974705 PMCID: PMC5354894 DOI: 10.18632/oncotarget.13861] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/21/2016] [Indexed: 11/30/2022] Open
Abstract
Objectives Monoclonal gammopathy of undetermined significance (MGUS) is a premalignancy preceding multiple myeloma (MM) or related disorders. Neurological symptoms caused by the monoclonal immunoglobulins or free light-chains are often associated with a high morbidity. We analyzed the prevalence of neuropathy, clinical features and the long-term outcome in 223 patients (pts.) with MGUS. Patients and Methods Between 1/2005 and 3/2015, 223 adult pts. with MGUS were identified in our database. Results In36/223 pts. (16%) a neuropathy was diagnosed (MGUS associated neuropathy, MGUS-N). 20 pts. (55%) had a distal symmetric axonal neuropathy, 10 pts. (28%) had a chronic inflammatory demyelinating polyneuropathy and 6 pts (17%) a distal acquired demyelinating symmetric polyneuropathy. In MGUS-NN (without neuropathy) and in MGUS-N, progression to smoldering MM, MM or Waldenstrom's macroglobulinemia (WM) occurred in 17% of the pts. The Immunoglobulin subtype was predominantly IgG in MGUS-NN and IgM in MGUS-N and ≥5.5% plasma cells in the bone-marrow predicted progression to MM and AL-amyloidosis in MGUS-NN and to WM in MGUS-N (p<0.05). Conclusion Due to the substantial prevalence of neuropathies, MGUS pts. should be monitored carefully and referred to a specialized center if neurological symptoms occur.
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18
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Nobile-Orazio E, Bianco M, Nozza A. Advances in the Treatment of Paraproteinemic Neuropathy. Curr Treat Options Neurol 2017; 19:43. [DOI: 10.1007/s11940-017-0479-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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19
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Chaudhry HM, Mauermann ML, Rajkumar SV. Monoclonal Gammopathy-Associated Peripheral Neuropathy: Diagnosis and Management. Mayo Clin Proc 2017; 92:838-850. [PMID: 28473042 PMCID: PMC5573223 DOI: 10.1016/j.mayocp.2017.02.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/31/2017] [Accepted: 02/03/2017] [Indexed: 11/25/2022]
Abstract
Monoclonal gammopathies comprise a spectrum of clonal plasma cell disorders that include monoclonal gammopathy of undetermined significance, multiple myeloma, and Waldenström macroglobulinemia. In this review, we outline the epidemiology, etiology, classification, diagnosis, and treatment of monoclonal gammopathy-associated peripheral neuropathy. Monoclonal gammopathy of undetermined significance is relatively common in the general population, with a prevalence of 3% to 4% among individuals older than age 50 years. Therefore, the presence of M protein in a patient with neuropathy does not automatically indicate a causal relationship. Monoclonal gammopathy-associated peripheral neuropathy is often a difficult diagnosis with limited treatment options. Studies addressing the optimal approach to diagnosis and management of this entity are limited. In addition to a review of the literature, we present a diagnostic approach to patients with monoclonal gammopathy-associated peripheral neuropathy and discuss available data and options for treatment.
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20
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Rosenbaum E, Marks D, Raza S. Diagnosis and management of neuropathies associated with plasma cell dyscrasias. Hematol Oncol 2017; 36:3-14. [PMID: 28397326 DOI: 10.1002/hon.2417] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
Abstract
Neuropathies associated with plasma cell dyscrasias are a major cause of morbidity for patients managed by medical oncologists. Because of similarities in clinical presentation and on nerve conduction studies, identifying the underlying disease leading to a paraproteinemic neuropathy can often be difficult. In addition, the degree of neurologic deficit does not strictly correlate with the extent of abnormalities on common clinical laboratory testing. Fortunately, with increasing understanding into the biologic mechanisms of underlying hematologic diseases, additional biomarkers have recently been developed, thus improving our diagnostic capacity. Neuropathies associated with plasma cells dyscrasias are seen with Monoclonal gammopathy of undetermined significance (MGUS) particularly IgM subtype, followed by IgG and IgA MGUS, multiple myeloma, Waldenström's macroglobulinemia, amyloid, Castleman's disease, and POEMS syndrome. The mechanisms of neuronal injury associated with plasma cell dyscrasia vary based on underlying diagnosis and include malignant infiltration, immune-mediated antibody deposition, or local compression of nerve roots. The polyneuropathies are frequently demyelinating, although axonal and mixed neuropathies can also be seen. As demonstrated by the cases included in this review, patients frequently present with symmetric sensory disturbance, followed by progressive motor weakness. Unfortunately, because of the complexity of diagnostic testing, patients are frequently examined late, often after receiving several ineffective therapies. The aim of this case-based review is to provide clinicians with insight on how to properly recognize these atypical neuropathies and send the appropriate diagnostic work, increasing the likelihood of accurately classify the patient's underlying hematologic disorder.
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Affiliation(s)
- Evan Rosenbaum
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
| | - Douglas Marks
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
| | - Shahzad Raza
- Division of Hematology & Oncology, Columbia University Medical Center, New York, NY, USA
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21
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D'Sa S, Kersten MJ, Castillo JJ, Dimopoulos M, Kastritis E, Laane E, Leblond V, Merlini G, Treon SP, Vos JM, Lunn MP. Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel. Br J Haematol 2017; 176:728-742. [PMID: 28198999 DOI: 10.1111/bjh.14492] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Paraproteinaemic neuropathies are a heterogeneous group of disorders most frequently associated with IgM monoclonal gammopathies including Waldenström macroglobulinaemia (WM). Their consequences are significant for affected patients, and their management challenging for their physicians. The variability in clinical presentation and time course hamper classification and management. The indications for invasive investigations such as cerebrospinal fluid analysis, nerve conduction tests and sensory nerve biopsies are unclear, and the optimum way to measure clinical response to treatment unknown. When to intervene and and how to treat, also present challenges to physicians. As part of its latest deliberations at the International Workshops on WM (IWWM) in London, UK (August 2014), the IWWM8 panel have proposed a consensus approach to the diagnosis and management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM. Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.
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Affiliation(s)
- Shirley D'Sa
- Waldenström Clinic, Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie José Kersten
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Edward Laane
- Department of Haematology, North Estonia Medical Centre, Tallinn, Estonia
| | - Véronique Leblond
- AP-HP Hôpital Pitié Salpêtrière, UPMC Univ. Paris 6 GRC-11, Grechy, Paris, France
| | - Giampaolo Merlini
- Centre for Research and Treatment of Systemic Amyloidosis, University of Pavia, Pavia, Italy
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Josephine M Vos
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands.,Cancer Centre, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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22
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Lunn MPT, Nobile‐Orazio E. Immunotherapy for IgM anti-myelin-associated glycoprotein paraprotein-associated peripheral neuropathies. Cochrane Database Syst Rev 2016; 10:CD002827. [PMID: 27701752 PMCID: PMC6457998 DOI: 10.1002/14651858.cd002827.pub4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Serum monoclonal anti-myelin-associated glycoprotein (anti-MAG) antibodies may be pathogenic in some people with immunoglobulin M (IgM) paraprotein and demyelinating neuropathy. Immunotherapies aimed at reducing the level of these antibodies might be expected to be beneficial. This is an update of a review first published in 2003 and previously updated in 2006 and 2012. OBJECTIVES To assess the effects of immunotherapy for IgM anti-MAG paraprotein-associated demyelinating peripheral neuropathy. SEARCH METHODS On 1 February 2016 we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase for randomised controlled trials (RCTs). We also checked trials registers and bibliographies, and contacted authors and experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs involving participants of any age treated with any type of immunotherapy for anti-MAG antibody-associated demyelinating peripheral neuropathy with monoclonal gammopathy of undetermined significance and of any severity.Our primary outcome measures were numbers of participants improved in disability assessed with either or both of the Neuropathy Impairment Scale (NIS) or the modified Rankin Scale (mRS) at six months after randomisation. Secondary outcome measures were: mean improvement in disability, assessed with either the NIS or the mRS, 12 months after randomisation; change in impairment as measured by improvement in the 10-metre walk time, change in a validated linear disability measure such as the Rasch-built Overall Disability Scale (R-ODS) at six and 12 months after randomisation, change in subjective clinical scores and electrophysiological parameters at six and 12 months after randomisation; change in serum IgM paraprotein concentration or anti-MAG antibody titre at six months after randomisation; and adverse effects of treatments. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures expected by Cochrane. MAIN RESULTS We identified eight eligible trials (236 participants), which tested intravenous immunoglobulin (IVIg), interferon alfa-2a, plasma exchange, cyclophosphamide and steroids, and rituximab. Two trials of IVIg (22 and 11 participants, including 20 with antibodies against MAG), had comparable interventions and outcomes, but both were short-term trials. We also included two trials of rituximab with comparable interventions and outcomes.There were very few clinical or statistically significant benefits of the treatments used on the outcomes predefined for this review, but not all the predefined outcomes were used in every included trial and more responsive outcomes are being developed. A well-performed trial of IVIg, which was at low risk of bias, showed a statistical benefit in terms of improvement in mRS at two weeks and 10-metre walk time at four weeks, but these short-term outcomes are of questionable clinical significance. Cyclophosphamide failed to show any benefit in the single trial's primary outcome, and showed a barely significant benefit in the primary outcome specified here, but some toxic adverse events were identified.Two trials of rituximab (80 participants) have been published, one of which (26 participants) was at high risk of bias. In the meta-analysis, although the data are of low quality, rituximab is beneficial in improving disability scales (Inflammatory Neuropathy Cause and Treatment (INCAT) improved at eight to 12 months (risk ratio (RR) 3.51, 95% confidence interval (CI) 1.30 to 9.45; 73 participants)) and significantly more participants improve in the global impression of change score (RR 1.86, 95% CI 1.27 to 2.71; 70 participants). Other measures did not improve significantly, but wide CIs do not preclude some effect. Reported adverse effects of rituximab were few, and mostly minor.There were few serious adverse events in the other trials. AUTHORS' CONCLUSIONS There is inadequate reliable evidence from trials of immunotherapies in anti-MAG paraproteinaemic neuropathy to form an evidence base supporting any particular immunotherapy treatment. IVIg has a statistically but probably not clinically significant benefit in the short term. The meta-analysis of two trials of rituximab provides, however, low-quality evidence of a benefit from this agent. The conclusions of this meta-analysis await confirmation, as one of the two included studies is of very low quality. We require large well-designed randomised trials of at least 12 months' duration to assess existing or novel therapies, preferably employing unified, consistent, well-designed, responsive, and valid outcome measures.
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Affiliation(s)
- Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Eduardo Nobile‐Orazio
- Milan UniversityIRCCS Humanitas Clinical Institute, Neurology 2Istituto Clinico HumanitasVia Manzoni 56, RozzanoMilanItaly20089
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23
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Rison RA, Beydoun SR. Paraproteinemic neuropathy: a practical review. BMC Neurol 2016; 16:13. [PMID: 26821540 PMCID: PMC4731930 DOI: 10.1186/s12883-016-0532-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/16/2016] [Indexed: 12/14/2022] Open
Abstract
The term paraproteinemic neuropathy describes a heterogeneous set of neuropathies characterized by the presence of homogeneous immunoglobulin in the serum. An abnormal clonal proliferation of B-lymphocytes or plasma cells, which may or may not occur in the context of a hematologic malignancy, produces the immunoglobulins in excess. If malignancy is identified, treatment should be targeted to the neoplasm. Most cases, however, occur as monoclonal gammopathy of undetermined significance. Few prospective, randomized, placebo-controlled trials are available to inform the management of paraproteinemic neuropathies. Clinical experience combined with data from smaller, uncontrolled studies provide a basis for recommendations, which depend on the specific clinical setting in which the paraprotein occurs. In this review, we provide a clinically practical approach to diagnosis and management of such patients.
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Affiliation(s)
- Richard A Rison
- University of Southern California, Keck School of Medicine, Los Angeles County Medical Center, Medical Director PIH Health-Whittier Stroke Program, Neurology Consultants Medical Group, 12401 Washington Blvd., Whittier, CA, 90602, USA.
| | - Said R Beydoun
- University of Southern California, Keck School of Medicine, Los Angeles County Medical Center, 1520 San Pablo Street Suite 3000, Los Angeles, CA, 90033, USA.
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Analyzing Relationship Between Monoclonal Gammopathy of Undetermined Significance (MGUS) with Different Types of Neuropathy: An Observational Study. Indian J Hematol Blood Transfus 2015; 32:186-92. [PMID: 27065581 DOI: 10.1007/s12288-015-0547-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022] Open
Abstract
To analyze multiple variables, including immunoglobulin subtypes in patients with monoclonal gammopathy of undetermined significance (MGUS) and different types of neuropathy. This was a retrospective, single center study done in a tertiary care hospital in the United States. The data was collected for years 2001-2011. Inclusion criteria were the presence of MGUS and neuropathy. Exclusion criteria were the presence of other factors such as diabetes, vitamin B12 deficiency, alcoholism etc. which can cause neuropathy. Patients with IgM MGUS were compared with patients having Non-IgM MGUS. A total of 281 patients were analyzed in this study. The average age at the time of diagnosis of MGUS and neuropathy was 68 years. The most common type of neuropathy was sensorimotor peripheral neuropathy (46 %). The most common location of neuropathy was the lower extremities (68 %). Among our patients, 52 % had their neuropathy symptoms for 1-5 years before presenting to the clinic. When IgM MGUS was compared with Non-IgM MGUS, a statistically significant difference was found in terms of race (White vs. Others, OR 4.43, 95 % CI 2.13, 9.19, p < 0.001) and survival status (OR 1.98, 95 % CI 1.01, 3.90, p = 0.046). Patients with MGUS are prone to develop different types of neuropathies. Caucasians are more likely to have IgM MGUS as compared to other races. IgM MGUS is generally related to worse outcomes as compared to Non-IgM MGUS. Medical therapies, including gabapentin and pregabalin are effective treatments and the response rate can be as high as 80-90 % with these medications.
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25
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Stork ACJ, Lunn MPT, Nobile‐Orazio E, Notermans NC. Treatment for IgG and IgA paraproteinaemic neuropathy. Cochrane Database Syst Rev 2015; 2015:CD005376. [PMID: 25803231 PMCID: PMC6781839 DOI: 10.1002/14651858.cd005376.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Paraproteinaemic neuropathy refers to those neuropathies associated with a monoclonal gammopathy or paraprotein. The most common of these present with a chronic, predominantly sensory, symmetrical neuropathy, similar to chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) but with relatively more sensory involvement, both clinically and neurophysiologically. The optimal treatment for neuropathies associated with IgG and IgA monoclonal gammopathy of uncertain significance is not known. This is an update of a review first published in 2007. OBJECTIVES To assess the effects of any treatment for IgG or IgA paraproteinaemic peripheral neuropathy. SEARCH METHODS On 18 January 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, MEDLINE and EMBASE. We also checked bibliographies for controlled trials of treatments for IgG or IgA paraproteinaemic peripheral neuropathy. We checked clinical trials registries for ongoing studies in November 2014. SELECTION CRITERIA We considered for inclusion randomised controlled trials (RCTs) and quasi-RCTs using any treatment for IgG or IgA paraproteinaemic peripheral neuropathy. We excluded people with IgM paraproteins. We excluded people where the monoclonal gammopathy was considered secondary to an underlying disorder. We included participants of any age with a diagnosis of monoclonal gammopathy of uncertain significance with a paraprotein of the IgG or IgA class and a neuropathy. Included participants were not required to fulfil specific electrophysiological diagnostic criteria. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to select studies, extract data and analyse results. One trial author provided additional data and clarification. MAIN RESULTS We identified one RCT, with 18 participants, that fulfilled the predetermined inclusion criteria. The trial compared plasma exchange to sham plasma exchange in participants with IgG or IgA paraproteinaemic neuropathy over a three-week follow-up period. We identified four other studies but these were not RCTs or quasi-RCTs. The included RCT did not report our predefined primary outcome measure, change in disability six months after randomisation. The trial revealed a modest benefit of plasma exchange in the weakness component of the Neuropathy Disability Score (NDS, now the Neuropathy Impairment Score); the mean improvement with plasma exchange was 17 points (95% confidence interval (CI) 5.2 to 28.8 points) versus 1 point (95% CI -7.7 to 9.7 points) in the sham exchange group at three weeks' follow-up (mean difference (MD) 16.00; 95% CI 1.37 to 30.63, low quality evidence). There was no statistically significant difference in the overall NDS (MD 18.00; 95% CI -2.03 to 38.03, low quality evidence), vibration thresholds or neurophysiological indices. Adverse events were not reported. The trial was at low risk of bias overall, although limitations of trial size and duration reduce the quality of the evidence in support of its conclusions. AUTHORS' CONCLUSIONS The evidence from RCTs for the treatment of IgG or IgA paraproteinaemic neuropathy is currently inadequate. More RCTs of treatments are required. These should have adequate follow-up periods and contain larger numbers of participants, perhaps through multicentre collaboration, considering the relative infrequency of this condition. Observational or open trial data provide limited support for the use of treatments such as plasma exchange, cyclophosphamide combined with prednisolone, intravenous immunoglobulin, and corticosteroids. These interventions show potential therapeutic promise but the potential benefits must be weighed against adverse effects. Their optimal use and the long-term benefits need to be considered and validated with well-designed RCTs.
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Affiliation(s)
- Abraham CJ Stork
- University Medical Center UtrechtBrain Center Rudolf MagnusUtrechtNetherlands
| | - Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Eduardo Nobile‐Orazio
- Milan UniversityIRCCS Humanitas Clinical Institute, Neurology 2Istituto Clinico HumanitasVia Manzoni 56, RozzanoMilanItaly20089
| | - Nicolette C Notermans
- Brain Center Rudolf Magnus, University Medical Center UtrechtDepartment of NeurologyHeidelberglaan 100UtrechtUtrechtNetherlands3584 CX
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Al-Zuhairy A, Schrøder HD, Plesner T, Abildgaard N, Sindrup SH. Immunostaining of skin biopsy adds no diagnostic value in MGUS-associated peripheral neuropathy. J Neurol Sci 2015; 349:60-4. [DOI: 10.1016/j.jns.2014.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/24/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
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Talamo G, Mir MA, Pandey MK, Sivik JK, Raheja D. IgM MGUS associated with anti-MAG neuropathy: a single institution experience. Ann Hematol 2015; 94:1011-6. [DOI: 10.1007/s00277-014-2294-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 12/23/2014] [Indexed: 11/24/2022]
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Raheja D, Specht C, Simmons Z. Paraproteinemic neuropathies. Muscle Nerve 2014; 51:1-13. [DOI: 10.1002/mus.24471] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Divisha Raheja
- Department of Neurology; Penn State Hershey Medical Center; EC 037, 30 Hope Drive Hershey Pennsylvania 17033 USA
| | - Charles Specht
- Department of Neurology; Penn State Hershey Medical Center; EC 037, 30 Hope Drive Hershey Pennsylvania 17033 USA
- Department of Pathology; Penn State Hershey Medical Center; Hershey Pennsylvania USA
- Department of Ophthalmology; Penn State Hershey Medical Center; Hershey Pennsylvania USA
- Department of Neurosurgery; Penn State Hershey Medical Center; Hershey Pennsylvania USA
| | - Zachary Simmons
- Department of Neurology; Penn State Hershey Medical Center; EC 037, 30 Hope Drive Hershey Pennsylvania 17033 USA
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Gwathmey K, Balogun RA, Burns T. Neurologic indications for therapeutic plasma exchange: 2013 update. J Clin Apher 2014; 29:211-9. [DOI: 10.1002/jca.21331] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Kelly Gwathmey
- Department of Neurology; The University of Virginia; Charlottesville Virginia
| | - Rasheed A. Balogun
- Division of Nephrology; Department of Medicine; University of Virginia Health System; Charlottesville Virginia
| | - Ted Burns
- Department of Neurology; The University of Virginia; Charlottesville Virginia
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Comparison of monoclonal gammopathy of undetermined significance-associated neuropathy and chronic inflammatory demyelinating polyneuropathy patients. J Neurol 2014; 261:1485-91. [PMID: 24801490 PMCID: PMC4119250 DOI: 10.1007/s00415-014-7357-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 10/29/2022]
Abstract
OBJECTIVES There are varying reports on whether monoclonal gammopathy of undetermined significance-associated neuropathy (MGUSN) patients are distinguishable from those with chronic inflammatory demyelinating polyneuropathy (CIDP) and whether specific MGUSN subclasses are associated with specific clinical phenotypes. METHODS We performed a retrospective chart review of MGUSN (n = 56) and CIDP (n = 67) patients. Data extracted included: demographics, neurological examination, and nerve conduction studies (NCS) at baseline and last visit. Clinical status was rated as 0 = worse, 1 = unchanged, 2 = stabilized after a declining course, or 3 = improved. The electrophysiology data were rated as 0 = worse, 1 = stable, or 2 = improved. Statistical analyses were performed using JMP (version 9.0.2 for Macintosh, from SAS). RESULTS Seventy percent were males, aged 68.1 ± 12.6 years with neuropathy for 9.8 ± 6.8 years and follow-up of 4.0 ± 3.2 years. CIDP patients had more severe neuropathy, and were more likely to receive treatment and to respond. The clinical neuropathy status remained unchanged in 52.8 % of the MGUSN and 24.2 % of the CIDP patients, and stabilized in 7.6 % of MGUSN and 30.3 % of CIDP patients. IgM-MGUSN patients did not differ from other immunoglobulin subclasses in response to treatment. The clinical severity and the number of abnormal NCS parameters were greater in the demyelinating MGUSN in comparison to the axonal group. CONCLUSION MGUSN patients have less severe neuropathy than CIDP patients, but among the MGUSN patients the severity is greater in the demyelinating and the IgM groups. MGUSN patients may do well without treatment and exposure to potential adverse effects.
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Clinical spectrum and evolution of monoclonal gammopathy-associated neuropathy: an observational study. Neurologist 2013; 18:378-84. [PMID: 23114670 DOI: 10.1097/nrl.0b013e31826a99e9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paraproteinemic neuropathy (PPN) is often under-diagnosed because of its clinical and electrophysiological variability. Progression of neuropathy is considered an alarm bell for possible malignant conversion of underlying monoclonal gammopathy (MG). OBJECTIVE To report clinical presentation, course, and evolution in a group of patients with PPN in order to identify findings useful for achieving the diagnosis, suspecting progression, and recognizing the underlying hematological conditions. PATIENTS AND METHODS Thirty-nine patients with PPN underwent clinical examination, electrodiagnostic studies, cerebrospinal fluid analysis, and laboratory tests. These parameters were compared between the different peak groups. RESULTS IgM MG was found in 51.4%, IgG MG in 33.3%, and IgA MG in 10.3% of our cohort. PPN appeared as mainly sensory, demyelinating, mildly progressive neuropathy, regardless of the type of peak or light chain. However, axonal findings were present in many IgG patients and in part of the IgM patients and a small number of the IgG patients may have presented with motor symptoms at the onset. The IgM patients had a significant tendency toward clinical worsening and IgG subjects had a more elevated rate of malignancy. IgA-related neuropathies were rare, heterogenous, and with a high tendency to evolution and malignancy. CONCLUSIONS Most of PPN often present a relatively monomorphic clinical picture but they can be clinically heterogenous and must be suspected even if sensory impairment and demyelination are not the dominant features. Tendency to malignancy seems globally elevated and needs intensive follow-up. Diagnostic approach to patients presenting with peripheral neuropathy should always include the typing of monoclonal immunoglobulins in serum and urine. In contrast, patients presenting with MG should be submitted to nerve conduction study/electroneurography and neurological evaluation.
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Multifocal motor neuropathy, multifocal acquired demyelinating sensory and motor neuropathy, and other chronic acquired demyelinating polyneuropathy variants. Neurol Clin 2013; 31:533-55. [PMID: 23642723 DOI: 10.1016/j.ncl.2013.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic acquired demyelinating neuropathies (CADP) constitute an important group of immune neuromuscular disorders affecting myelin. This article discusses CADP with emphasis on multifocal motor neuropathy, multifocal acquired demyelinating sensory and motor neuropathy, distal acquired demyelinating symmetric neuropathy, and less common variants. Although each of these entities has distinctive laboratory and electrodiagnostic features that aid in their diagnosis, clinical characteristics are of paramount importance in diagnosing specific conditions and determining the most appropriate therapies. Knowledge regarding pathogenesis, diagnosis, and management of these disorders continues to expand, resulting in improved opportunities for identification and treatment.
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Abstract
The association of neuropathy with monoclonal gammopathy has been known for several years, even if the clinical and pathogenetic relevance of this association is not completely defined. This is not a marginal problem since monoclonal gammopathy is present in 1-3% of the population above 50 years in whom it is often asymptomatic, and in at least 8% of patients is associated with a symptomatic neuropathy, representing one of the leading causes of neuropathy in aged people. Monoclonal gammopathy may result from malignant lymphoproliferative diseases including multiple myeloma or solitary plasmocytoma, Waldenström's macroglobulinemia (WM), other IgM-secreting lymphoma or chronic lymphocytic leukemia, and primary systemic amyloidosis (AL). In most instances it is not associated with any of these disorders and is defined monoclonal gammopathy of undetermined significance (MGUS) for its possible, though infrequent, evolution into malignant forms. Several data support the pathogenetic role of the monoclonal gammopathy in the neuropathy particularly when of IgM isotype where IgM reactivity to several neural antigens has been reported. Increased levels of VEGF have been implicated in POEMS syndrome. However, there are as yet no defined therapies for these neuropathies, as their efficacy has not been confirmed in randomized trials.
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Affiliation(s)
- Eduardo Nobile-Orazio
- 2nd Neurology, Department of Translational Medicine, Milan University, IRCCS Humanitas Clinical Institute, Rozzano, Milan, Italy.
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Pihan M, Decaux O, Marcorelles P, Bahon-Riedinger I, Lemercier S, Gainche-Salmon A, Doncker AV. Neuropathies associées à une IgM monoclonale anti-MAG. Rev Med Interne 2012; 33:686-92. [DOI: 10.1016/j.revmed.2012.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 05/14/2012] [Indexed: 12/23/2022]
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Lunn MPT, Nobile-Orazio E. Immunotherapy for IgM anti-myelin-associated glycoprotein paraprotein-associated peripheral neuropathies. Cochrane Database Syst Rev 2012:CD002827. [PMID: 22592686 DOI: 10.1002/14651858.cd002827.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Serum monoclonal anti-myelin-associated glycoprotein antibodies may be pathogenic in some people with immunoglobulin M (IgM) paraprotein and demyelinating neuropathy. Immunotherapies aimed at reducing the level of these antibodies might be expected to be beneficial. This is an update of a review first published in 2003 and previously updated in 2006. OBJECTIVES To assess the effects of immunotherapy for IgM anti-myelin-associated glycoprotein paraprotein-associated demyelinating peripheral neuropathy. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register 6 June 2011), CENTRAL (2011, Issue 2), MEDLINE (January 1966 to May 2011) and EMBASE (January 1980 to May 2011) for controlled trials. We also checked bibliographies and contacted authors and experts in the field. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials involving participants of any age treated with any type of immunotherapy for anti-myelin-associated glycoprotein antibody-associated demyelinating peripheral neuropathy with monoclonal gammopathy of undetermined significance and of any severity.Our primary outcome measure was change in the Neuropathy Impairment Scale or Modified Rankin Scale at six months after randomisation. Secondary outcome measures were: Neuropathy Impairment Scale or the Modified Rankin Score at 12 months after randomisation; 10-metre walk time, subjective clinical scores and electrophysiological parameters at six and 12 months after randomisation; IgM paraprotein levels and anti-myelin-associated glycoprotein antibody titres at six months after randomisation; and adverse effects of treatments. DATA COLLECTION AND ANALYSIS The two authors independently selected studies. Two authors independently assessed the risk of bias in included studies. MAIN RESULTS We identified seven eligible trials (182 participants), which tested intravenous immunoglobulin, alfa interferon alfa-2a, plasma exchange, cyclophosphamide and steroids, and rituximab. Only two trials, of intravenous immunoglobulin (with 33 participants, including 20 with antibodies against myelin-associated glycoprotein), had comparable interventions and outcomes, but both were short-term trials.There were no clinical or statistically significant benefits of the treatments used on the outcomes predefined for this review, but not all the predefined outcomes were used in every included trial. Intravenous immunoglobulin showed a statistical benefit in terms of improvement in Modified Rankin Scale at two weeks and 10-metre walk time at four weeks. Cyclophosphamide failed to show any benefit in the trial's primary outcome, and showed a barely significant benefit in the primary outcome specified here, but some toxic adverse events were identified. A trial of rituximab was of poor methodological quality with a high risk of bias and a further larger study is awaited. Serious adverse events were few in the other trials. AUTHORS' CONCLUSIONS There is inadequate reliable evidence from trials of immunotherapies in anti-myelin-associated glycoprotein paraproteinaemic neuropathy to form an evidence base supporting any particular immunotherapy treatment. There is very low quality evidence of benefit from rituximab. Large well designed randomised trials of at least six to 12 months duration are required to assess existing or novel therapies, preferably employing unified, consistent, well designed, responsive and valid outcome measures.
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Affiliation(s)
- Michael P T Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.
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Gwathmey K, Balogun RA, Burns T. Neurologic indications for therapeutic plasma exchange: 2011 update. J Clin Apher 2012; 27:138-45. [DOI: 10.1002/jca.21219] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 02/21/2012] [Indexed: 12/17/2022]
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Bayat E, Kelly JJ. Neurological complications in plasma cell dyscrasias. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:731-46. [PMID: 22230530 DOI: 10.1016/b978-0-444-53502-3.00020-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Elham Bayat
- Department of Neurology, The George Washington University, Washington, DC, USA
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Gwathmey K, Balogun RA, Burns T. Neurologic indications for therapeutic plasma exchange: An update. J Clin Apher 2011; 26:261-8. [DOI: 10.1002/jca.20298] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/05/2011] [Indexed: 12/18/2022]
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Adams D, Lozeron P, Théaudin M, Adam C, Lacroix C. Neuropatie periferiche nel corso delle disglobulinemie. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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European Federation of Neurological Societies/Peripheral Nerve Society Guideline* on management of paraproteinemic demyelinating neuropathies. Report of a Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Socie. J Peripher Nerv Syst 2010; 15:185-95. [DOI: 10.1111/j.1529-8027.2010.00278.x] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sommer CL, Brandner S, Dyck PJ, Harati Y, LaCroix C, Lammens M, Magy L, Mellgren SI, Morbin M, Navarro C, Powell HC, Schenone AE, Tan E, Urtizberea A, Weis J. Peripheral Nerve Society Guideline on processing and evaluation of nerve biopsies. J Peripher Nerv Syst 2010; 15:164-75. [DOI: 10.1111/j.1529-8027.2010.00276.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, Sarode R, Schwartz J, Weinstein R, Shaz BH. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2010; 25:83-177. [PMID: 20568098 DOI: 10.1002/jca.20240] [Citation(s) in RCA: 352] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.
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Affiliation(s)
- Zbigniew M Szczepiorkowski
- Transfusion Medicine Service, Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Kawagashira Y, Kondo N, Atsuta N, Iijima M, Koike H, Katsuno M, Tanaka F, Kusunoki S, Sobue G. IgM MGUS anti-MAG neuropathy with predominant muscle weakness and extensive muscle atrophy. Muscle Nerve 2010; 42:433-5. [DOI: 10.1002/mus.21741] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vrethem M, Reiser N, Lauermann C, Svanborg E. Polyneuropathy associated with IgM vs IgG monoclonal gammopathy: comparison between clinical and electrophysiological findings. Acta Neurol Scand 2010; 122:52-7. [PMID: 20003083 DOI: 10.1111/j.1600-0404.2009.01259.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The neuropathy associated with IgM monoclonal gammopathy (IgM-MG) is regarded as a sensorimotor, mainly demyelinating neuropathy. It is not fully known whether the neuropathy in IgG-MG is caused by the same mechanisms and shows the same electrophysiological characteristics. We aimed at making a comparison between clinical and neurophysiological findings in these two conditions. PATIENTS AND METHODS Twenty-seven patients with IgM-associated neuropathy [18 with anti-myelin-associated glycoprotein (anti-MAG) antibodies] were compared with 15 age-matched patients with IgG-associated neuropathy. RESULTS Patients with IgM-associated neuropathy (especially those with anti-MAG antibodies) had significantly clinically more severe disabilities with involvement of both motor and sensory functions compared with patients with IgG-associated neuropathy in whom clinical sensory disturbances were more prominent than motor dysfunction. Motor and sensory conduction velocities were significantly lower and distal latencies significantly longer in the IgM group than in the IgG group concerning the median, ulnar and peroneal nerves. Fifty-four per cent of the patients in the IgM group did not present a sensory response of the median nerve vs 13% in the IgG group. There was also a significant difference concerning absent responses from the peroneal and sural nerves in the IgM vs IgG group (peroneal: 48% vs 13%, sural: 88% vs 27%). CONCLUSION Polyneuropathy associated with IgM-MG, especially when associated with anti-MAG antibodies, appears to have more of a demyelinating involvement that meets the criteria for demyelination. This was not as clear in those associated with IgG. The IgG neuropathy showed less and milder deficit in the electrophysiological studies.
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Berenson JR, Anderson KC, Audell RA, Boccia RV, Coleman M, Dimopoulos MA, Drake MT, Fonseca R, Harousseau JL, Joshua D, Lonial S, Niesvizky R, Palumbo A, Roodman GD, San-Miguel JF, Singhal S, Weber DM, Zangari M, Wirtschafter E, Yellin O, Kyle RA. Monoclonal gammopathy of undetermined significance: a consensus statement. Br J Haematol 2010; 150:28-38. [PMID: 20507313 DOI: 10.1111/j.1365-2141.2010.08207.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
On February 25, 2009, a panel of international experts on plasma cell dyscrasia and skeletal disease met to discuss monoclonal gammopathy of undetermined significance (MGUS). This non-malignant B-cell disorder is the most common plasma cell dyscrasia and is associated with an increased risk of developing serious B-cell disorders. Individuals with MGUS also have an increased risk of osteoporosis and osteopenia associated with an increased likelihood of developing fractures especially in the vertebral column, peripheral neuropathy and thromboembolic events. The goal of the meeting was to develop a consensus statement regarding the appropriate tests to screen, evaluate and follow-up patients with MGUS. The panel also addressed the identification and treatment of MGUS-related skeletal problems, thromboembolic events and neurological complications. The following consensus statement outlines the conclusions and marks the first time that a consensus statement for the screening and treatment of MGUS has been clearly stated.
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Affiliation(s)
- James R Berenson
- Institute for Myeloma & Bone Cancer Research, West Hollywood, CA 90069, USA.
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Hellqvist E, Kvarnström M, Söderberg A, Vrethem M, Ernerudh J, Rosén A. Myelin protein zero is naturally processed in the B cells of monoclonal gammopathy of undetermined significance of immunoglobulin M isotype: aberrant triggering of a patient's T cells. Haematologica 2009; 95:627-36. [PMID: 20015874 DOI: 10.3324/haematol.2009.015123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Monoclonal gammopathy of undetermined significance of immunoglobulin M isotype is a condition with clonally expanded B cells, recently suggested to have an infectious origin. This monoclonal gammopathy is frequently associated with polyneuropathy and antibodies against myelin protein zero, whereas the role of the T cells remains largely unknown. We analyzed protein zero-specific B cells, as antigen-presenting cells, and their capacity to activate T helper cells. DESIGN AND METHODS We used a well-characterized monoclonal gammopathy of undetermined significance-derived B-cell line, TJ2, expressing anti-protein zero immunoglobulin M. The ability of TJ2 cells to bind, endocytose, process, and present protein zero was investigated by receptor-clustering and immunofluorescence. The activation of protein zero-specific autologous T cells was studied by measuring interleukin-2 and interferon-gamma with flow cytometry, immunobeads, and enzyme-linked immunospot assays. RESULTS Surface-receptor clustering and endocytosis of receptor-ligand (immunoglobulin M/protein zero) complexes were pronounced after exposure to protein zero. Naturally processed or synthetic protein zero peptide (194-208)-pulsed TJ2 cells significantly induced interleukin-2 secretion from autologous T cells compared to control antigen-pulsed cells (P<0.001). The numbers of interferon-gamma-producing T helper cells, including CD4(+)/CD8(+) cells, were also significantly increased (P=0.0152). Affinity-isolated naturally processed myelin peptides were potent interferon-gamma stimulators for autologous peripheral blood mononuclear cells, but not for control peripheral blood mononuclear cells. CONCLUSIONS We show for the first time that myelin protein zero is naturally processed in B cells from monoclonal gammopathy of undetermined significance of immunoglobulin M isotype, acting as aberrant antigen-presenting cells in activation of a patient's T helper cells. Our findings cast new light on the important role of autoreactive protein zero-specific B cells in the induction of the pathogenic T-cell responses found in nerve lesions of patients with monoclonal gammopathy of undetermined significance with peripheral neuropathy.
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Affiliation(s)
- Eva Hellqvist
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, SE-581 85 Linköping, Sweden
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Tremor associated with chronic inflammatory demyelinating peripheral neuropathy: treatment with pregabalin. Clin Neuropharmacol 2008; 31:241-4. [PMID: 18670249 DOI: 10.1097/wnf.0b013e3181585b71] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report a case of a patient with tremor associated with chronic inflammatory demyelinating neuropathy (CIDP) that improved after treatment with pregabalin. CASE REPORT A 68-year-old man diagnosed as having CIDP at age 63 years developed postural and kinetic tremor in both hands at age 64 years. Tremor did not improve with propranolol, primidone, phenobarbital, clonazepam, alprazolam, gabapentin, and topiramate, but improved markedly with pregabalin. Tremor worsened after pregabalin withdrawal and improved again after its reintroduction. CONCLUSIONS Pregabalin could be useful in the treatment of postural tremor associated with CIDP resistant to other therapies.
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Cai Z, Cash K, Swift J, Sutton-Smith P, Robinson M, Thompson PD, Blumbergs PC. Focal myelin swellings and tomacula in anti-MAG IgM paraproteinaemic neuropathy: Novel teased nerve fiber studies. J Peripher Nerv Syst 2008. [DOI: 10.1111/j.1529-8027.2001.01013.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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