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Malhotra A, Weaver J. Approach to Neuropathic Pain. Semin Neurol 2021; 41:744-759. [PMID: 34826876 DOI: 10.1055/s-0041-1726361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Neuropathic pain is a common chief complaint encountered by neurologists and primary care providers. It is caused by disorders involving the somatosensory nervous system. The clinical evaluation of neuropathic pain is challenging and requires a multifaceted systematic approach with an emphasis on a thorough history and physical examination to identify characteristic signs and symptoms. Ancillary laboratory investigations, targeted imaging, and electrodiagnostic studies further help identify underlying etiologies to guide specific treatments. Management of neuropathic pain encompasses treating the underlying pathology as well as symptomatic control with nonpharmacological, pharmacological, and interventional therapies. Here, we present an approach to help evaluate patients with neuropathic pain.
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Affiliation(s)
- Ashwin Malhotra
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua Weaver
- Department of Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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2
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Gondim FDAA, Barreira AA, Claudino R, Cruz MW, Cunha FMBD, Freitas MRGD, França MC, Gonçalves MVM, Marques W, Nascimento OJM, Oliveira ASB, Pereira RC, Pupe C, Rotta FT, Schestatsky P. Definition and diagnosis of small fiber neuropathy: consensus from the Peripheral Neuropathy Scientific Department of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:200-208. [PMID: 29809227 DOI: 10.1590/0004-282x20180015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/15/2018] [Indexed: 01/20/2023]
Abstract
The aim of this study was to describe the results of a Brazilian Consensus on Small Fiber Neuropathy (SFN). Fifteen neurologists (members of the Brazilian Academy of Neurology) reviewed a preliminary draft. Eleven panelists got together in the city of Fortaleza to discuss and finish the text for the manuscript submission. Small fiber neuropathy can be defined as a subtype of neuropathy characterized by selective involvement of unmyelinated or thinly myelinated sensory fibers. Its clinical picture includes both negative and positive manifestations: sensory (pain/dysesthesias/pruritus) or combined sensory and autonomic complaints, associated with an almost entirely normal neurological examination. Standard electromyography is normal. A growing list of medical conditions is associated with SFN. The classification of SFN may also serve as a useful terminology to uncover minor discrepancies in the normal values from different neurophysiology laboratories. Several techniques may disclose sensory and/or autonomic impairment. Further studies are necessary to refine these techniques and develop specific therapies.
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Affiliation(s)
| | - Amilton Antunes Barreira
- Departamento de Neurociências e Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Rinaldo Claudino
- Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Márcia Waddington Cruz
- Departamento de Neurologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | | | | | | | | | - Wilson Marques
- Departamento de Neurociências e Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | | | | | | | - Camila Pupe
- Departamento de Neurologia, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
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3
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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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4
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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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5
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Glavey SV, Leung N. Monoclonal gammopathy: The good, the bad and the ugly. Blood Rev 2015; 30:223-31. [PMID: 26732417 DOI: 10.1016/j.blre.2015.12.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a condition characterized by the presence of a monoclonal gammopathy (MG) in which the clonal mass has not reached a predefined state in which the condition is considered malignant. It is a precursor to conditions such as multiple myeloma or lymphoma at a rate of ~1%/year. Thus, from a hematologic standpoint, MGUS is a fairly benign condition. However, it is now recognized that organ damage resulting from just the MG without the need MM or lymphoma can occur. One of the most recognized is nephropathy secondary to monoclonal gammopathy of renal significance (MGRS). Other well-recognized conditions include neuropathies, oculopathies and dermopathies. Some conditions such as autoimmune diseases and coagulopathies are less common and recognized. Finally, systemic involvement of multiple organs is well described in several entities. In all of these conditions, the role of the MG is no longer insignificant. Thus, the term MGUS should be avoided when describing these entities.
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Affiliation(s)
- Siobhan V Glavey
- Department of Hematology, National University of Ireland, Galway, Ireland
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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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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Rojas-García R, Gallardo E, Illa I. Paraproteinemic neuropathies. Presse Med 2013; 42:e225-34. [PMID: 23618626 DOI: 10.1016/j.lpm.2013.02.329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 02/04/2013] [Accepted: 02/12/2013] [Indexed: 12/13/2022] Open
Abstract
The term paraproteinemic neuropathy refers to a heterogeneous group of neuropathies, which share the common feature of a homogeneous immunoglobulin in the serum. The presence of a monoclonal gammopathy indicates an underlying clonal B-cell expansion, which may appear in the context of a lymphoproliferative disorder. If a neoplastic origin of the gammopathy is identified, the treatment should be targeted to the neoplasm. In most patients, however, the monoclonal gammopathy is not associated with malignant haematological disorders, and is defined as monoclonal gammopathy of undetermined significance.
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Affiliation(s)
- Ricard Rojas-García
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Abstract
Chronic sensory or sensorimotor polyneuropathy is a common cause for referral to neurologists. Despite extensive diagnostic testing, up to one-third of these patients remain without a known cause, and are referred to as having cryptogenic sensory peripheral neuropathy. Symptoms progress slowly. On examination, there may be additional mild toe flexion and extension weakness. Electrophysiologic testing and histology reveals axonal neuropathy. Prognosis is usually favorable, as most patients maintain independent ambulation. Besides patient education and reassurance, management is focused on pharmacotherapy for neuropathic pain and physical therapy for balance training, and, occasionally, assistive devices.
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Affiliation(s)
- Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Boulevard, Kansas City, KS 66160, USA.
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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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10
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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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11
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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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12
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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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13
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Bida JP, Kyle RA, Therneau TM, Melton LJ, Plevak MF, Larson DR, Dispenzieri A, Katzmann JA, Rajkumar SV. Disease associations with monoclonal gammopathy of undetermined significance: a population-based study of 17,398 patients. Mayo Clin Proc 2009; 84:685-93. [PMID: 19648385 PMCID: PMC2719521 DOI: 10.1016/s0025-6196(11)60518-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To systematically study the association of monoclonal gammopathy of undetermined significance (MGUS) with all diseases in a population-based cohort of 17,398 patients, all of whom were uniformly tested for the presence or absence of MGUS. PATIENTS AND METHODS Serum samples were obtained from 77% (21,463) of the 28,038 enumerated residents in Olmsted County, Minnesota. Informed consent was obtained from patients to study 17,398 samples. Among 17,398 samples tested, 605 cases of MGUS and 16,793 negative controls were identified. The computerized Mayo Medical Index was used to obtain information on all diagnoses entered between January 1, 1975, and May 31, 2006, for a total of 422,663 person-years of observations. To identify and confirm previously reported associations, these diagnostic codes were analyzed using stratified Poisson regression, adjusting for age, sex, and total person-years of observation. RESULTS We confirmed a significant association in 14 (19%) of 75 previously reported disease associations with MGUS, including vertebral and hip fractures and osteoporosis. Systematic analysis of all 16,062 diagnostic disease codes found additional previously unreported associations, including mycobacterium infection and superficial thrombophlebitis. CONCLUSION These results have major implications both for confirmed associations and for 61 diseases in which the association with MGUS is likely coincidental.
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Affiliation(s)
| | | | | | | | | | | | | | | | - S. Vincent Rajkumar
- Individual reprints of this article are not available. Address correspondence to S. Vincent Rajkumar, MD, Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Bida JP, Kyle RA, Therneau TM, Melton LJ, Plevak MF, Larson DR, Dispenzieri A, Katzmann JA, Rajkumar SV. Disease associations with monoclonal gammopathy of undetermined significance: a population-based study of 17,398 patients. Mayo Clin Proc 2009; 84:685-93. [PMID: 19648385 PMCID: PMC2719521 DOI: 10.4065/84.8.685] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To systematically study the association of monoclonal gammopathy of undetermined significance (MGUS) with all diseases in a population-based cohort of 17,398 patients, all of whom were uniformly tested for the presence or absence of MGUS. PATIENTS AND METHODS Serum samples were obtained from 77% (21,463) of the 28,038 enumerated residents in Olmsted County, Minnesota. Informed consent was obtained from patients to study 17,398 samples. Among 17,398 samples tested, 605 cases of MGUS and 16,793 negative controls were identified. The computerized Mayo Medical Index was used to obtain information on all diagnoses entered between January 1, 1975, and May 31, 2006, for a total of 422,663 person-years of observations. To identify and confirm previously reported associations, these diagnostic codes were analyzed using stratified Poisson regression, adjusting for age, sex, and total person-years of observation. RESULTS We confirmed a significant association in 14 (19%) of 75 previously reported disease associations with MGUS, including vertebral and hip fractures and osteoporosis. Systematic analysis of all 16,062 diagnostic disease codes found additional previously unreported associations, including mycobacterium infection and superficial thrombophlebitis. CONCLUSION These results have major implications both for confirmed associations and for 61 diseases in which the association with MGUS is likely coincidental.
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Affiliation(s)
| | | | | | | | | | | | | | | | - S. Vincent Rajkumar
- From the Department of Biochemistry and Molecular Biology (J.P. B., S.V.R.), Division of Hematology (R.A.K., A.D., S.V.R.), Division of Biomedical Informatics and Biostatistics (T.M.T., M.F.P., D.R.L.), Division of Epidemiology (L.J.M.), and Department of Laboratory Medicine and Pathology (J.A.K.), Mayo Clinic, Rochester, MN
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Hoffman-Snyder C, Smith BE. Neuromuscular Disorders Associated with Paraproteinemia. Phys Med Rehabil Clin N Am 2008; 19:61-79, vi. [DOI: 10.1016/j.pmr.2007.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Abstract
The occurrence of a peripheral neuropathy (PN) in association with a monoclonal gammopathy is quite common and suggests that monoclonal proteins may play a pathogenetic role in peripheral nervous system damage. In fact, paraproteinemic PN constitute an heterogeneous group of disorders related to various pathogenetic factors, and the histopathologic features in peripheral nerve biopsies differ from one condition to another. In several well defined disorders, the responsibility of the monoclonal component in the development of the PN has been evidenced. This is the case for most of the PN associated with an IgM monoclonal gammopathy, either a monoclonal gammopathy of undetermined significance (MGUS) or Waldenstrom's macroglobulinemia. The responsibility of the monoclonal protein in the occurrence of amyloid neuropathy related to multiple myeloma is also recognized. However, most IgG or IgA MGUS, as well as the monoclonal component in POEMS syndrome, have an uncertain causal relationship with the neuropathy. PN associated with monoclonal cryoglobulin (type 1) are occasional and differ from those associated with mixed cryoglobulins (types 2 or 3).
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Affiliation(s)
- A Vital
- Department of Neuropathology, Victor Ségalen University, Bordeaux, France.
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17
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Abstract
Small-fiber neuropathy is a peripheral nerve disease that most commonly presents in middle-aged and older people, who develop burning pain in their feet. Although it can be caused by disorders of metabolism such as diabetes, chronic infections (such as with human immunodeficiency virus), genetic abnormalities, toxicity from various drugs, and autoimmune diseases, the cause often remains a mystery because standard electrophysiologic tests for nerve injury do not detect small-fiber function. Inadequate ability to test for and diagnose small-fiber neuropathies has impeded patient care and research, but new tools offer promise. Infrequently, the underlying cause of small-fiber dysfunction is identified and disease-modifying therapy can be instituted. More commonly, the treatments for small-fiber neuropathy involve symptomatic treatment of neuropathic pain.
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Affiliation(s)
- Ezekiel Fink
- Department of Anesthesiology, Neurology, and Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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18
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Hoitsma E, Reulen JPH, de Baets M, Drent M, Spaans F, Faber CG. Small fiber neuropathy: a common and important clinical disorder. J Neurol Sci 2004; 227:119-30. [PMID: 15546602 DOI: 10.1016/j.jns.2004.08.012] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Revised: 08/27/2004] [Accepted: 08/30/2004] [Indexed: 11/21/2022]
Abstract
Small fiber neuropathy (SFN) is a neuropathy selectively involving small diameter myelinated and unmyelinated nerve fibers. Interest in this disorder has considerably increased during the past few years. It is often idiopathic and typically presents with peripheral pain and/or symptoms of autonomic dysfunction. Diagnosis is made on the basis of the clinical features, normal nerve conduction studies (NCS) and abnormal specialized tests of small nerve fibers. Among others, these tests include assessment of epidermal nerve fiber density, temperature sensation tests for sensory fibers and sudomotor and cardiovagal testing (QSART) for autonomic fibers. Unless an underlying disease is identified, treatment is usually symptomatic and directed towards alleviation of neuropathic pain.
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Affiliation(s)
- E Hoitsma
- Department of Clinical Neurophysiology, Maastricht University Hospital, Maastricht, The Netherlands.
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Abstract
Recent advances in neuroimmunology have led to improvements in the pathogenesis, diagnosis, prognosis, and treatment of many neuromuscular disorders. The value of autoantibody testing is increasing steadily in neurologic practice. Not all antibodies have a high yield in diagnosis. In some disorders, such as generalized adult onset of myasthenia gravis, Lambert-Eaton myasthenic syndrome,Miller Fisher syndrome, and multifocal motor neuropathy,autoantibody tests provide accurate diagnosis and can be considered biologic markers of these disorders.
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Affiliation(s)
- Rahman Pourmand
- State University of New York, Stony Brook, NY 11794-8121, USA.
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20
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Magy L, Chassande B, Maisonobe T, Bouche P, Vallat JM, Léger JM. Polyneuropathy associated with IgG/IgA monoclonal gammopathy: a clinical and electrophysiological study of 15 cases. Eur J Neurol 2004; 10:677-85. [PMID: 14641513 DOI: 10.1046/j.1468-1331.2003.00687.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peripheral neuropathy has been widely reported in patients with monoclonal gammopathy (MG), more frequently immunoglobulin M (IgM) or IgG than IgA. Nevertheless, it remains unclear whether this association has clinical or pathogenic relevance. In order to clarify the possible role of IgG/IgA MG in neuropathy, we studied the clinical and electrophysiological features of 15 consecutive patients with polyneuropathy and IgG/IgA-MG, and compared them to those of 40 patients with polyneuropathy associated with IgM-MG, previously reported. Nine middle-aged patients (60%) had a chronic progressive or relapsing demyelinating polyneuropathy (DP) that was clinically and electrophysiologically indistinguishable from classic chronic inflammatory demyelinating polyneuropathy (CIDP) and frequently responded to immunosuppressive treatments, both characteristics supporting a dysimmune process. Six older patients (40%) had a chronic axonal distal polyneuropathy similar to the so-called chronic cryptogenic sensory polyneuropathy: there was no clear relationship with the MG in these patients and the response to immunosuppressive treatments was poor. Several features allowed us to distinguish between polyneuropathies associated with IgG/IgA-MG (IgG/IgA-PN) considered together and polyneuropathies associated with IgM-MG (IgM-PN). In the first group, the proportion of patients with a predominantly sensory clinical picture (27%) was less than that in the second group (75%), and there were fewer changes in nerve conduction studies. In addition, we found that the nine patients with DP associated with IgG/IgA-MG (IgG/IgA-DP) differed from the 31 with DP associated with IgM-MG (IgM-DP): clinical and electrophysiological studies clearly showed that the demyelinating pattern was more heterogeneous in IgG/IgA-DP than in IgM-DP. The spectrum of polyneuropathies associated with IgG/IgA-MG is heterogeneous, including DP, which is similar to classic CIDP, and axonal polyneuropathy, in which the pathogenic role of the MG remains elusive. In addition, IgG/IgA-DP differ from IgM-DP on clinical and electrophysiological grounds, suggesting probable different physiopathological mechanisms.
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Affiliation(s)
- L Magy
- Service de Neurologie, CHU Dupuytren, Limoges, France
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21
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Bertorini T, Narayanaswami P. Autoimmune neuropathies. COMPREHENSIVE THERAPY 2003; 29:194-209. [PMID: 14989041 DOI: 10.1007/s12019-003-0023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Autoimmune neuropathies are common and treatable disorders of the peripheral nerves, which should be properly recognized. This article discusses their diagnosis, differential diagnosis and proper treatment.
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Affiliation(s)
- Tulio Bertorini
- Department of Neurology, University of Tennessee, Memphis, Health Science Center, College of Medicine, 855 Monroe Avenue, Room 406, Memphis, TN 38163, USA
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22
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Abstract
Monoclonal gammopathy of undetermined significance (MGUS) denotes the presence of a monoclonal protein (M-protein) in patients without evidence of multiple myeloma (MM), macroglobulinemia, amyloidosis (AL), or a related plasma cell proliferative disorder. MGUS is found in approximately 3% of persons older than 70 years and in about 1% of those older than 50 years. In a series of 1384 patients from south-eastern Minnesota in whom MGUS was diagnosed at Mayo Clinic from 1960 through 1994, the risk of progression was 1% per year. Patients were at risk of progression even after 25 years or more of a stable monoclonal gammopathy. The risk of development of MM was increased by 25-fold, the risk of macroglobulinemia was 46-fold, and the risk of primary AL was 8.4-fold when compared with a similar population (Surveillance, Epidemiology and End Results). The concentration of the serum M-protein was the major independent predictor of progression. Patients with an immunoglobulin M (IgM) or an IgA monoclonal gammopathy had a higher risk of progression than those with an IgG monoclonal gammopathy. The presence of a urine M-protein or the reduction of one or more uninvolved Igs was not a risk factor for progression. MGUS may be associated with many different disorders, including lymphoproliferative diseases, leukemia, connective tissue disorders, dermatologic diseases, and neurologic disorders.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Neriishi K, Nakashima E, Suzuki G. Monoclonal gammopathy of undetermined significance in atomic bomb survivors: incidence and transformation to multiple myeloma. Br J Haematol 2003; 121:405-10. [PMID: 12716362 DOI: 10.1046/j.1365-2141.2003.04287.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Among 6737 atomic bomb survivors who did not have monoclonal gammopathy at the first examination, 112 developed monoclonal gammopathy of undetermined significance (MGUS) between 1985 and 2001. The crude incidence rate was 164 per 100 000 person-years in the overall study population, with a sharp increase in incidence after age 60 years. The incidence was not significantly associated with radiation dose (P = 0.91), although the incidence at less than 80 years of age showed a marginally significant association (P = 0.05). Among 75 patients with MGUS detected in 1985, 50 patients (67%) had died by 2001, 16 (21%) of these deaths were due to multiple myeloma (MM). MM mortality among MGUS patients was 2284 per 100 000 person-years while the rate in the total population was 14.6 per 100 000 person-years. The risk of MM mortality was greater in the older generation. The transformation from MGUS to MM was faster in exposed persons than in non-exposed persons, but this was not statistically significant.
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Affiliation(s)
- Kazuo Neriishi
- Department of Clinical Studies, Radiation Effects Research Foundation, Minami-ku, Hiroshima, Japan.
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Abstract
Neuromuscular complications of cancer are common and can affect any component of the peripheral nervous system from peripheral nerve cell body to muscle. Perhaps the most common complication is a length-dependent symmetric axonal polyneuropathy that is often multifactorial in etiology, resulting from metabolic and treatment effects of the primary malignancy. However, neuromuscular disorders may also be the presenting complaint in many conditions, including disorders caused by malignant infiltration of nerve and disorders cause by paraneoplastic syndromes. Although many of the paraneoplastic conditions are poorly responsive to treatment, not all are, and one hopes that prompt diagnosis of the underlying malignancy will lead to improved patient outcome. Recognition of iatrogenic neuromuscular complications is also important to modify treatment protocols when possible and thus decrease the risk of long-term neurologic disability.
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Affiliation(s)
- Hannah R Briemberg
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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25
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Saperstein DS, Barohn RJ. Current concepts and controversy in chronic inflammatory demyelinating polyneuropathy. Curr Neurol Neurosci Rep 2003; 3:57-63. [PMID: 12507413 DOI: 10.1007/s11910-003-0039-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired, immune-mediated demyelinating neuropathy. It is the most common treatable acquired polyneuropathy and represents a significant number of initially undiagnosed neuropathy patients. This article reviews the common clinical, laboratory, and electrodiagnostic features of CIDP. In addition, current areas of uncertainty are discussed.
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Affiliation(s)
- David S Saperstein
- Department of Neurology, The University of Kansas Medical Center, 1005B Wescoe, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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26
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Drew MJ. Plasmapheresis in the dysproteinemias. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 2002; 6:45-52. [PMID: 11886576 DOI: 10.1046/j.1526-0968.2002.00393.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The dysproteinemias consist of a broad range of serious disease states with the common thread of excessive production of an abnormal, or para-protein. Various clinical syndromes may arise, either from the underlying disease process, the excess paraprotein, or both. Clinical presentation depends upon the organ system(s) affected by the abnormal protein. Diseases included under the classification of dysproteinemias include cryoprotein-related diseases, Waldenström's macroglobulinemia, hyperviscosity syndrome, monoclonal gammopathy, multiple myeloma, light chain disease, and amyloidosis. Plasmapheresis, often in conjunction with other therapies, has been widely used to treat the dysproteinemias and their resulting clinical syndromes. Automated plasmapheresis, which separates plasma from the cellular blood elements by centrifugation, is used most commonly in the United States. Membrane separation and immunoadsorption techniques are more commonly used in Europe and Japan. In automated plasmapheresis, the plasma is removed from the patient's circulation and replaced with a protein-based fluid such as 5% human albumin solution or plasma protein fraction or with fresh frozen plasma. Membrane separation and immunoadsorption allow the offending proteins to be removed more selectively from the patient's plasma prior to the plasma being returned to the patient. This review article presents a description of each disease, the rationale for plasmapheresis therapy, recommended schedules of plasmapheresis, and the use of adjunctive therapies. Results of published studies, case reports, and the author's experience in treating these diseases will serve as the foundation for discussion.
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Affiliation(s)
- Mary Jo Drew
- Transfusion medicine, Henry Ford Hospital Blood Bank, Detroit, Michigan 48202, USA
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Eurelings M, Notermans NC, Franssen H, Van Es HW, Ramos LM, Wokke JH, van den Berg LH. MRI of the brachial plexus in polyneuropathy associated with monoclonal gammopathy. Muscle Nerve 2001; 24:1312-8. [PMID: 11562910 DOI: 10.1002/mus.1149] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
On magnetic resonance (MR) imaging of the brachial plexus increased signal intensity and swelling of the brachial plexus has been found in chronic inflammatory demyelinating polyneuropathy (CIDP). Whether these proximal abnormalities are also present in the distal polyneuropathy associated with monoclonal gammopathy is unknown. Therefore, we performed MR imaging of the brachial plexus in 21 patients with polyneuropathy associated with IgM monoclonal gammopathy (11 IgM with anti-MAG antibodies, 10 IgM without anti-MAG antibodies). For comparison we studied 9 patients with polyneuropathy associated with IgG monoclonal gammopathy and 8 patients with CIDP. Among the 30 patients with monoclonal gammopathy, 24 patients had demyelinating polyneuropathy. Among these 24 patients, there was increased signal intensity of the brachial plexus on the T2-weighted images regardless of whether clinical deficits were generalized or purely distal in location. No association was found with the isotype of the monoclonal gammopathy. Of the 8 patients with CIDP, 5 had brachial plexus abnormalities. None of the 6 patients with axonal polyneuropathy associated with monoclonal gammopathy had such abnormalities. Thus, MR imaging of the brachial plexus shows that the distal demyelinating polyneuropathy associated with monoclonal gammopathy is more generalized than presumed.
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Affiliation(s)
- M Eurelings
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, G03.228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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28
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Eurelings M, Notermans NC, Van de Donk NW, Lokhorst HM. Risk factors for hematological malignancy in polyneuropathy associated with monoclonal gammopathy. Muscle Nerve 2001; 24:1295-302. [PMID: 11562908 DOI: 10.1002/mus.1147] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Polyneuropathy associated with monoclonal gammopathy of undetermined significance (MGUS) is a well-known disease entity. Of the patients with monoclonal gammopathy without neuropathy, 25% develop a hematological malignancy during long-term follow-up. Whether the frequency of hematological malignancy is similar in patients with polyneuropathy associated with monoclonal gammopathy and whether hematological screening is necessary in these patients is unknown. To determine the frequency of and risk factors for a hematological malignancy, we investigated 104 patients with polyneuropathy and monoclonal gammopathy. Potential diagnostic variables were obtained from medical history, physical and neurological examination, and laboratory analysis. The associations between potential diagnostic variables and outcome, hematological malignancy, were evaluated by univariable and multivariable logistic-regression analysis. Among our patients, 23 had a hematological malignancy (8 multiple myeloma, 10 low-grade lymphoma, 3 plasmacytoma, 1 Castleman's disease and 1 POEMS syndrome [polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes]). Weight loss, progression of the neuropathy, and an M-protein level > 1 g/L were independent risk factors for malignancy. Extensive screening is indicated in patients with these features.
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Affiliation(s)
- M Eurelings
- Department of Neurology, University Medical Center Utrecht, G03.228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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29
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Abstract
Few prospective, randomized, placebo-controlled trials have been performed to guide clinicians in the management of neuropathies seen in the setting of monoclonal gammopathies (paraproteins). Recommendations must be made on the basis of clinical experience and information gleaned from various uncontrolled and open-label trials. In every instance, decisions concerning therapy must be based on the clinical setting in which the paraprotein occurs. Treatment of paraproteinemic neuropathies associated with multiple myeloma, amyloidosis, and Waldenström's macroglobulinemia should be directed at the treatment of the underlying disease. These neuropathies often remain recalcitrant to therapy. If the paraprotein results from cryoglobulinemia due to hepatitis C virus infection, interferon-alpha (with or without ribavirin) provides optimal subjective and objective relief from symptoms. For neuropathy associated with osteosclerotic myeloma (POEMS syndrome) and solitary bone lesions, radiation therapy is the most effective and least toxic initial therapy. In those patients with monoclonal gammopathies of undetermined significance (MGUS), consideration of the clinical syndrome may be very helpful in selecting appropriate treatment. Patients who fulfill diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are best treated in a manner similar to that used for idiopathic CIDP (ie, with intravenous immunoglobulin, plasma exchange, and corticosteroids). Class I evidence documents plasma exchange to be effective in peripheral neuropathies associated with MGUS of the IgG and IgA, but not IgM, types. The most difficult cases to treat are those with peripheral neuropathies associated with IgM monoclonal gammopathies, with or without reactivity to myelin-associated glycoprotein (MAG). A number of published case series propose therapeutic regimens for these conditions, yet optimal treatment remains to be established. In many cases, mildly symptomatic patients should not be subjected to the morbidity associated with current treatment regimens. In those patients requiring treatment, this author initially tries plasma exchange, followed by a course of chlorambucil if the symptoms and signs are predominantly sensory. For cases with rapid progression or significant disability, a regimen of monthly pulses with prednisone and cyclophosphamide is recommended. If improvement does not ensue, a trial of a newer agent, such as rituximab, is recommended. Supportive treatment with physical therapy, orthotics, and ambulatory aids enhances patient independence at a relatively low cost.
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Affiliation(s)
- Matthew P. Wicklund
- Department of Neurology, Division of Neuromuscular Disease, The Ohio State University, 1654 Upham Drive, Columbus, OH 43210, USA.
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Abstract
A number of presentations of chronic demyelinating polyneuropathy have been identified, each distinguished by its phenotypic pattern. In addition to classic chronic inflammatory demyelinating polyneuropathy (CIDP), which is characterized clinically by symmetric proximal and distal weakness and sensory loss, several regional variants can be recognized: multifocal motor neuropathy (MMN: asymmetric and pure motor), multifocal acquired demyelinating sensory and motor (MADSAM) neuropathy (asymmetric, sensory, and motor), and distal acquired demyelinating symmetric (DADS) neuropathy (symmetric, distal, sensory, and motor). There are also temporal, pathological, and disease-associated variants. This review describes a clinical scheme for approaching the chronic acquired demyelinating polyneuropathies that leads to a rational use of supportive laboratory studies and treatment options. In addition, we propose new diagnostic criteria for CIDP that more accurately reflect current clinical practice.
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Affiliation(s)
- D S Saperstein
- Department of Neurology, Wilford Hall Medical Center, 2200 Bergquist Drive, Suite 1 (MMCN), San Antonio, Texas 78236-5300, USA.
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31
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Abstract
Polyneuropathy with monoclonal gammopathy usually is considered a nosological entity different from chronic inflammatory demyelinating polyneuropathy (CIDP). Criteria proposed by the American Academy of Neurology AIDS Task Force (1991), however, show monoclonal gammopathy to be a condition concurrent with CIDP. The purpose of this study was to clarify the nosological relationship between CIDP and IgM anti-myelin-associated glycoprotein (MAG)/sulfated glucuronyl paragloboside (SGPG)-associated polyneuropathy. We investigated IgM anti-MAG/SGPG antibody in 85 CIDP patients by various methods, then examined the relation of M-protein to the presence of IgM anti-MAG/SGPG antibody. In our large study, 17 (20%) of 85 CIDP patients had high IgM anti-SGPG antibody titers in the enzyme-linked immunosorbent assay. This was confirmed by thin-layer chromatography-immunostaining for IgM anti-SGPG antibody and immunoblotting for IgM anti-MAG antibody. Immunoelectrophoresis and immunofixation, respectively, detected IgM M-protein in 6 (35%) and 13 (76%) of the 17 CIDP patients. We conclude that some patients with IgM anti-MAG/SGPG antibody with or without monoclonal gammopathy may be diagnosed as having CIDP, when patients are diagnosed according to the current CIDP criteria.
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Affiliation(s)
- Y Tagawa
- Department of Neurology, Dokkyo University School of Medicine, Kitakobayashi 880, Mibu, Shimotsuga, Tochigi 321-0293, Japan
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Gorson KC. Clinical features, evaluation, and treatment of patients with polyneuropathy associated with monoclonal gammopathy of undetermined significance (MGUS). J Clin Apher 1999; 14:149-53. [PMID: 10540371 DOI: 10.1002/(sici)1098-1101(1999)14:3<149::aid-jca8>3.0.co;2-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A number of common disorders of the peripheral nervous system are closely linked to a monoclonal gammopathy. In a minority of patients, the neuropathy represents the sentinel feature of a malignant plasma cell dyscrasia, such as multiple myeloma or its osteosclerotic variant, Waldenstrom's disease, amyloidosis, cryoglobulinemia or lymphoma; the vast majority have so-called "monoclonal gammopathy of undetermined significance" (MGUS). Sensory symptoms predominate with paresthesias, numbness, imbalance, and gait ataxia. Electrodiagnostic studies show mixed demyelinating and axonal features and often may be indistinguishable from findings in chronic inflammatory demyelinating polyneuropathy. Some have a pure axonal polyneuropathy, and in these patients the relationship to the paraprotein is less certain. With limited success, correlations have been made between the immunoglobulin type (IgM, IgG, or IgA) and the clinical and electromyographic characteristics of the neuropathy. The treatment of MGUS neuropathies poses a considerable challenge. Patients with IgG/IgA-MGUS have improved with corticosteroids or intravenous immune globulin. Only the benefit of plasma exchange has been substantiated in a controlled trial. The IgM neuropathies tend to be more refractory but often improve with similar regimens, particularly if cytotoxic agents are added in doses sufficient to reduce the amount of the M-protein. In addition to plasma exchange, chlorambucil, and cyclophosphamide, interferon-alpha is a novel therapy that holds promise for patients with IgM neuropathies associated with anti-myelin associated antibodies.
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Affiliation(s)
- K C Gorson
- Neurology Service, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02135, USA.
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Siami GA, Siami FS. Plasmapheresis and paraproteinemia: cryoprotein-induced diseases, monoclonal gammopathy, Waldenström's macroglobulinemia, hyperviscosity syndrome, multiple myeloma, light chain disease, and amyloidosis. THERAPEUTIC APHERESIS : OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY FOR APHERESIS AND THE JAPANESE SOCIETY FOR APHERESIS 1999; 3:8-19. [PMID: 10079800 DOI: 10.1046/j.1526-0968.1999.00146.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Therapeutic plasmapheresis has been in widespread use as either a primary or adjunctive therapy in the United States since the 1960s. There are several types of plasmapheresis procedures used to treat various diseases. Plasma exchange with a centrifugal plasma separator using replacement fluid such as human albumin solution is the most widely used method in the United States. Other forms of plasmapheresis include membrane plasma separation, membrane fractionation, cryofiltration apheresis, immunoadsorption, and chemical affinity column pheresis. Therapeutic plasmapheresis has been used for the treatment of paraproteinemia to remove harmful paraproteins. Paraproteinemia is a disease classification in which abnormal or large amounts of plasma proteins such as cryoproteins or immunoglobulins are produced. In most cases, plasmapheresis is used in combination with corticosteroids and immunosuppressive drugs to prevent production of abnormal proteins or to treat the underlying disease. Cryoprotein-induced diseases, which include cryoglobulinemia, cryofibrinogenemia, and cold IgM antibody agglutinin with cryoglobulin properties, are a subclass of paraproteinemia. Other categories of paraproteinemia include monoclonal gammopathy, Waldenström's macroglobulinemia, hyperviscosity syndrome, multiple myeloma, light chain disease, and amyloidosis. Some of these diseases may be interrelated, and they may be associated with one another. In this review paper, we discuss the role of plasmapheresis in the specific classes of paraproteinemia in the United States, including our own experience.
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Affiliation(s)
- G A Siami
- Vanderbilt University Medical Center, Department of Medicine, Veterans Administration Medical Center, Nashville, TN 37212-2637, USA
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Affiliation(s)
- A H Ropper
- Neurology Service, St. Elizabeth's Medical Center, and Tufts University School of Medicine, Boston, MA 02135, USA
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35
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Abstract
OBJECTIVE To compare the clinical and electrodiagnostic features and response to treatment in patients with IgM-MGUS and IgG-MGUS associated polyneuropathy. MATERIAL AND METHODS Retrospective review of 34 consecutive patients with MGUS associated neuropathy evaluated over 5 years. RESULTS There were 19 patients with IgM-MGUS and 15 with IgG-MGUS. There were no differences in age, duration of symptoms, or distribution of motor and sensory symptoms or signs. IgM-MGUS patients had prolonged distal latencies of the median and ulnar motor potentials, greater slowing of the peroneal nerve conduction velocity and more often absent ulnar sensory potentials. Half of the patients in both groups improved following immunotherapy. CONCLUSION IgM-MGUS patients had more severe demyelination on the nerve conduction studies, but there were no clinical features that differentiated the 2 groups. IgM and IgG-MGUS patients improved with plasma exchange and other immune therapies. Anti-MAG antibodies failed to distinguish a subgroup of patients with IgM-MGUS neuropathy.
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Affiliation(s)
- D Simovic
- Neurology Service, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA 02135, USA
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36
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Abstract
We prospectively evaluated patients with idiopathic polyneuropathy (PN) and motor neuron disease (MND) with commercial antibody (Ab) panels. Patients with sensorimotor PN received a "sensorimotor neuropathy profile" [3-sulfated glucuronyl paragloboside (SGPG)/myelin-associated glycoprotein (MAG), GM1, asialo-GM1, GD1b, Hu, sulfatide]. Motor neuropathy or MND patients underwent a "motor neuropathy profile" (SGPG/MAG, GM1, asialo-GM1). Seven of 78 patients (9.0%) with sensorimotor PN and 3 of 44 patients (6.8%) with MND had abnormal panels. None of 60 patients with axonal sensory or sensorimotor PN had antisulfatide Ab. Seven of 13 patients (54%) with multifocal motor neuropathy had abnormal panels, with 6 seropositive to GM1. We found abnormal Ab panels in fewer than 10% of patients with idiopathic sensorimotor PN and MND. Moreover, abnormal Ab tests often did not relate to the clinical context. Our data do not support the use of commercial Ab panels in the evaluation of patients with idiopathic PN or MND.
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Affiliation(s)
- G I Wolfe
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas 75235-8897, USA
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37
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Gorson KC, Ropper AH. Axonal neuropathy associated with monoclonal gammopathy of undetermined significance. J Neurol Neurosurg Psychiatry 1997; 63:163-8. [PMID: 9285452 PMCID: PMC2169654 DOI: 10.1136/jnnp.63.2.163] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The neuropathy associated with monoclonal gammopathy of undetermined significance (MGUS) is typically a predominantly demyelinating process that may have additional features of axonal degeneration. Sixteen patients with MGUS and a pure or predominantly axonal neuropathy are reported and compared with 20 consecutive patients with demyelinating neuropathy and MGUS who were seen during the same period. METHODS Retrospective review of a consecutive series of patients with neuropathy and MGUS evaluated during a five year period. RESULTS The axonal group had mild, symmetric, slowly progressive, predominantly sensory neuropathy, usually limited to the legs. There were no differences in the age of onset or duration of symptoms at the time of presentation, initial symptoms, or the severity of weakness between the axonal and demyelinating cases. However, the axonal process was associated with less vibration and proprioceptive loss, did not include leg ataxia (present in 55% of patients with demyelinating type), less often had generalised areflexia (19% v 70%), IgM gammopathy (19% v 80%), and anti-MAG antibodies (0% v 40%), and had lower CSF protein concentrations (mean, 49 v 100 mg/dl). The illness was also generally milder with less disability (mean Rankin score 2.1 v 2.8). Fewer patients with axonal neuropathy improved with immunomodulating therapy (27% v 75%). CONCLUSION There is an axonal neuropathy associated with MGUS that is clinically and electrophysiologically distinct from the more typical demyelinating pattern.
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Affiliation(s)
- K C Gorson
- Neurology Service, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA 02135, USA
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