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Vazquez Do Campo R, Dyck PJB. Focal inflammatory neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:273-290. [PMID: 38697745 DOI: 10.1016/b978-0-323-90108-6.00009-0] [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: 05/05/2024]
Abstract
This chapter focuses on neuropathies that present with focal involvement of nerve roots, plexus, and/or peripheral nerves associated with autoimmune and inflammatory mechanisms that present with focal involvement of nerve roots, plexus and/or peripheral nerves. The clinical presentation, diagnosis, and treatment of focal autoimmune demyelinating neuropathies, focal nonsystemic vasculitic disorders (diabetic and nondiabetic radiculoplexus neuropathies, postsurgical inflammatory neuropathy, and neuralgic amyotrophy), and focal neuropathies associated with sarcoidosis and bacterial and viral infections are reviewed.
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Affiliation(s)
- Rocio Vazquez Do Campo
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - P James B Dyck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN, United States.
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Rahbar M, Dolatkhah N. Vasculitis presenting as carpal tunnel syndrome: a case report. J Med Case Rep 2023; 17:84. [PMID: 36872340 PMCID: PMC9987105 DOI: 10.1186/s13256-023-03801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/01/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Carpal tunnel syndrome is the most common focal mononeuropathy which presents with pain in the wrist and hand, paresthesia, loss of sensation in the distribution of the median nerve, and in more severe cases, weakness and atrophy of the thenar muscles. Meanwhile, carpal tunnel syndrome can present as an initial manifestation of underlying systemic vasculitis disorder and result in severe physical disabilities. CASE PRESENTATION A 27-year-old Iranian man was referred to our electrodiagnosis center with a clinical diagnosis of carpal tunnel syndrome in April 2020. Surgical intervention had been taken into account for him because of unsuccessful conservative therapies. On admission, thenar eminence was reduced. Electrodiagnostic findings were not compatible with median nerve entrapment at the wrist. All sensory modalities in the distribution of the right median nerve were decreased. Additionally, a mild increase in erythrocyte sedimentation rate was noted in laboratory tests. Because of the high vasculitis suspicion, we recommended the nerve biopsy and/or starting a high-dose corticosteroid. However, the surgery release was performed. After 6 months, the patient was referred for progressive weakness and numbness in the upper and lower limbs. After documentation of vasculitis neuropathy by biopsy, a diagnosis of non-systemic vasculitic neuropathy was confirmed. A rehabilitation program started immediately. Rehabilitation led to gradual improvement and recovery of function and muscle strength, and no complications remained, except mild leg paralysis. CONCLUSIONS Physicians should be suspicious of the median nerve vasculitis mononeuropathy in a patient with carpal tunnel syndrome-like symptoms. Median nerve vasculitis mononeuropathy as an initial presenting feature of vasculitis neuropathy can further result in severe physical impairments and disabilities.
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Affiliation(s)
- Mohammad Rahbar
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Dolatkhah
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Sen CK, Roy S, Khanna S. Diabetic Peripheral Neuropathy Associated with Foot Ulcer: One of a Kind. Antioxid Redox Signal 2023. [PMID: 35850520 DOI: 10.1089/ars.2022.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Significance: Diabetic peripheral neuropathy (DPN) associated with a diabetic foot ulcer (DFU) is likely to be complicated with critical factors such as biofilm infection and compromised skin barrier function of the diabetic skin. Repaired skin with a history of biofilm infection is known to be compromised in barrier function. Loss of barrier function is also observed in the oxidative stress affected diabetic and aged skin. Recent Advances: Loss of barrier function makes the skin prone to biofilm infection and cellulitis, which contributes to chronic inflammation and vasculopathy. Hyperglycemia favors biofilm formation as glucose lowering led to reduction in biofilm development. While vasculopathy limits oxygen supply, the O2 cost of inflammation is high increasing hypoxia severity. Critical Issues: The host nervous system can be inhabited by bacteria. Because electrical impulses are a part of microbial physiology, polymicrobial colonization of the host's neural circuit is likely to influence transmission of action potential. The identification of perineural apatite in diabetic patients with peripheral neuropathy suggests bacterial involvement. DPN starts in both feet at the same time. Future Directions: Pair-matched studies of DPN in the foot affected with DFU (i.e., DFU-DPN) compared with DPN in the without ulcer, and intact skin barrier function, are likely to provide critical insight that would help inform effective care strategies. This review characterizes DFU-DPN from a translational science point of view presenting a new paradigm that recognizes the current literature in the context of factors that are unique to DFU-DPN.
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Affiliation(s)
- Chandan K Sen
- Indiana Center for Regenerative Medicine & Engineering, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sashwati Roy
- Indiana Center for Regenerative Medicine & Engineering, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Savita Khanna
- Indiana Center for Regenerative Medicine & Engineering, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Aladawi M, Shelly S, Dyck PJB, Koster M, Engelstad J, Piccione EA, Naddaf E. Nitrofurantoin and Minocycline-Associated Vasculitic Neuropathy: Case Reports and Literature Review. J Clin Neuromuscul Dis 2022; 24:85-94. [PMID: 36409339 DOI: 10.1097/cnd.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Vasculitic neuropathies usually present acutely to subacutely, with an asymmetric pattern, involving multiple peripheral nerve territories. Drug-induced vasculitis is an often overlooked etiology of vasculitic neuropathy. METHODS We present the first reported case of nitrofurantoin-associated and an illustrative case of minocycline-associated vasculitic neuropathy, with a review of the literature. RESULTS The first patient is a 60-year-old woman who developed axonal sensorimotor peripheral neuropathy after nitrofurantoin use, with a superficial radial nerve biopsy confirming vasculitis. The second patient is a 23-year-old woman, with a history of acne vulgaris treated with minocycline, who presented with a subacute right common peroneal mononeuropathy followed by a left deep peroneal mononeuropathy, with elevated antinuclear, perinuclear-antineutrophil cytoplasmic, and myleoperoxidase antibodies, and MPO titers, and a sural nerve biopsy showing large arteriole vasculitis. Finally, we provide a comprehensive review of previously published cases. CONCLUSIONS Medications should be considered as a trigger for medication-induced vasculitic neuropathy. Accurate diagnosis would ensure timely treatment.
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Affiliation(s)
- Mohammad Aladawi
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Matthew Koster
- Deparmtent of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN; and
| | - JaNean Engelstad
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ezequiel A Piccione
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN
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Tulbă D, Popescu BO, Manole E, Băicuș C. Immune Axonal Neuropathies Associated With Systemic Autoimmune Rheumatic Diseases. Front Pharmacol 2021; 12:610585. [PMID: 33935704 PMCID: PMC8079948 DOI: 10.3389/fphar.2021.610585] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 03/10/2021] [Indexed: 01/19/2023] Open
Abstract
Immune axonal neuropathies are a particular group of immune-mediated neuropathies that occasionally accompany systemic autoimmune rheumatic diseases such as connective tissue dissorders and primary systemic vasculitides. Apart from vasculitis of vasa nervorum, various other mechanisms are involved in their pathogenesis, with possible therapeutic implications. Immune axonal neuropathies have highly heterogeneous clinical presentation and course, ranging from mild chronic distal sensorimotor polyneuropathy to severe subacute mononeuritis multiplex with rapid progression and constitutional symptoms such as fever, malaise, weight loss and night sweats, underpinning a vasculitic process. Sensory neuronopathy (ganglionopathy), small fiber neuropathy (sensory and/or autonomic), axonal variants of Guillain-Barré syndrome and cranial neuropathies have also been reported. In contrast to demyelinating neuropathies, immune axonal neuropathies show absent or reduced nerve amplitudes with normal latencies and conduction velocities on nerve conduction studies. Diagnosis and initiation of treatment are often delayed, leading to accumulating disability. Considering the lack of validated diagnostic criteria and evidence-based treatment protocols for immune axonal neuropathies, this review offers a comprehensive perspective on etiopathogenesis, clinical and paraclinical findings as well as therapy guidance for assisting the clinician in approaching these patients. High quality clinical research is required in order to provide indications and follow up rules for treatment in immune axonal neuropathies related to systemic autoimmune rheumatic diseases.
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Affiliation(s)
- Delia Tulbă
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,Colentina-Research and Development Center, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Laboratory of Cell Biology, Neurosciences and Experimental Myology, "Victor Babeș" National Institute of Pathology, Bucharest, Romania
| | - Emilia Manole
- Laboratory of Cell Biology, Neurosciences and Experimental Myology, "Victor Babeș" National Institute of Pathology, Bucharest, Romania
| | - Cristian Băicuș
- Colentina-Research and Development Center, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
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Nishi R, Koike H, Ohyama K, Fukami Y, Ikeda S, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Differential clinicopathologic features of EGPA-associated neuropathy with and without ANCA. Neurology 2020; 94:e1726-e1737. [PMID: 32217776 DOI: 10.1212/wnl.0000000000009309] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate the clinicopathologic features of eosinophilic granulomatosis with polyangiitis (EGPA)-associated neuropathy with a focus on the presence or absence of anti-neutrophil cytoplasmic antibodies (ANCAs). METHODS We examined the clinical features and pathologic findings of sural nerve biopsy specimens from 82 patients with EGPA-associated neuropathy. Of these patients, 32.9% were myeloperoxidase (MPO)-ANCA positive, and 67.1% were MPO-ANCA negative. PR3-ANCA was negative in all of 78 examined patients. RESULTS Upper limb symptoms were more frequently reported as initial neuropathic manifestations in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (44.4% vs 14.6%, p < 0.01). The serum levels of C-reactive protein were significantly higher in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (p < 0.05). Sural nerve biopsy specimens showed findings suggestive of vasculitis (i.e., destruction of vascular structures) in epineurial vessels; these results were seen more frequently in the MPO-ANCA-positive group than in the MPO-ANCA-negative group (p < 0.0001). Conversely, the numbers of eosinophils in the lumen of the epineurial vessels (p < 0.01) and epineurial vessels occluded by intraluminal eosinophils (p < 0.05) were higher in the MPO-ANCA-negative group than in the MPO-ANCA-positive group. Furthermore, the incidence of eosinophil infiltration in the endoneurium was higher in the MPO-ANCA-negative group than in the MPO-ANCA-positive group (p < 0.01). CONCLUSIONS This study suggests that the pathogenesis of EGPA comprises at least 2 distinct mechanisms: ANCA-associated vasculitis resulting in ischemic effects and inflammation, which is prominent in MPO-ANCA-positive patients, and eosinophil-associated vascular occlusion leading to ischemia and eosinophil-associated tissue damage, which is conspicuous in MPO-ANCA-negative patients.
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Affiliation(s)
- Ryoji Nishi
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Haruki Koike
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan.
| | - Ken Ohyama
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Yuki Fukami
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Shohei Ikeda
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Yuichi Kawagashira
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Masahiro Iijima
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Masahisa Katsuno
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan
| | - Gen Sobue
- From the Department of Neurology (R.N., H.K., K.O., Y.F., S.I., Y.K., M.I., M.K.) and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine; and Department of Neurology (K.O.), Okazaki City Hospital, Japan.
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Golovach IY, Yehudina YD. [Peripheral nervous system lesion in systemic vasculitis - issues of diagnosis and treatment]. TERAPEVT ARKH 2019; 91:63-69. [PMID: 32598591 DOI: 10.26442/00403660.2019.12.000206] [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: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Vasculitis is a clinically diverse group of diseases with histopathological signs of blood vessel inflammation, which contributes to vascular damage and ischemic damage to the affected tissues. Vasculitic neuropathy is a common complication of the primary systemic vasculitides, such as polyartertis nodosa and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, systemic diseases of the connective tissue - systemic lupus erythematosus and Sjogren syndrome, vasculitis associated with infection, most often viral hepatitis C and B and non - systemic vasculitis neuropathy. Vessels of medium and small caliber are involved in the pathological process in these diseases. With all vasculitis, except for those caused by the direct effect of the infectious trigger on the blood vessel walls, the main pathogenetic mechanism is an autoimmune process with the development of vasa nervorum vasculitis - small arteries and vessels that supply peripheral nerves, and the outcome - nerve ischemia. The classic clinical presentation is an acute or subacute painful multifocal neuropathy that has a predilection for the lower extremities, affects two or more named nerves, and progresses in a step wise manner. However, vasculitic neuropathy can manifest in a variety of ways, including asymmetric polyneuropathies and distal symmetric sensory neuropathies, and it also can be slowly progressive, particularly in cases of nonsystemic vasculitic neuropathy (NSVN), a form of vasculitis that clinically remains restricted to peripheral nerves. Nerve biopsy can help establish the diagnosis of a systemic vasculitis, particularly when other organ involvement is not clinically apparent, and is required for diagnosis of NSVN. Neuropathy due to systemic vasculitis should be treated in accordance with the recommendations for the treatment of the underlying disease. In NSVH, the main medicine of choice are glucocrticoids, and in severe/progressive cases, pulse therapy with cyclophosphamide.
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Affiliation(s)
- I Y Golovach
- Feofaniya Clinical hospital State Management of Affairs
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Younger DS. Cervical and Lumbosacral Radiculoplexus Neuropathy Following Influenza Vaccination. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/wjns.2019.94019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cruz S, Schaefer AM, Joshi A, Baker MR. Clinical Reasoning: A 71-year-old woman with subacute progressive distal weakness and paresthesia after vaccination. Neurology 2017; 88:e168-e173. [DOI: 10.1212/wnl.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Vasculitic Mononeuritis Multiplex May Be Misdiagnosed as Carpal Tunnel Syndrome. Am J Phys Med Rehabil 2016; 96:e44-e47. [PMID: 27362698 DOI: 10.1097/phm.0000000000000562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vasculitis is a group of disorders characterized by inflammation and destruction of blood vessels, resulting in ischemic injury to the involved tissue. Sometimes, peripheral neuropathy is one of the first symptoms of systemic vasculitis. Although the classic form of peripheral nervous system vasculitis is mononeuritis multiplex, it can also present as a mononeuritis. In this case report, the patient presented with progressive rapid onset numbness in her right hand for 2 months. She underwent carpal tunnel decompression surgery with initial diagnosis of acute carpal tunnel syndrome but failed to respond to the surgery, and two month later, she presented with foot drop. The final diagnosis was vasculitic mononeuritis multiplex. The present case report demonstrates the importance of identification of median mononeuritis as one of the first presentations of vasculitic disorders and distinction from acute carpal tunnel syndrome. The natural history of many of the systemic vasculitides is rapidly progressive, and they are likely to be fatal without early treatment. In this regard, timely diagnosis of vasculitis is critical because of the vital role of early immunosuppressive therapy in preventing multiorgan damage and decreasing mortality rate.
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