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Alberti C, Spagliardi J, Barbic F, Doneddu PE, Cutellè C, Furlan R, Nobile-Orazio E. Autonomic neuropathy improving after intravenous immunoglobulin therapy. Clin Auton Res 2024; 34:311-316. [PMID: 38733551 DOI: 10.1007/s10286-024-01034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Claudia Alberti
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jacopo Spagliardi
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Department of Internal Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy.
| | - Claudia Cutellè
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Department of Internal Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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Gavrilova N, Kamaeva E, Ignatova M, Ryabkova V, Lukashenko M, Churilov L, Shoenfeld Y. Intravenouse immunoglobuline in dysautonomia. Clin Immunol 2022; 240:109039. [DOI: 10.1016/j.clim.2022.109039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/01/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
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Murakami K, Koh J, Takahashi M, Ito H. [Acute-onset autoimmune autonomic ganglionopathy remarkably effective in intravenous high-dose immunoglobulin therapy]. Rinsho Shinkeigaku 2021; 61:687-691. [PMID: 34565756 DOI: 10.5692/clinicalneurol.cn-001631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A 77-year-old woman developed acute onset of orthostatic hypotension, urinary retention, and constipation. Neurological examination on admission showed severe orthostatic hypotension accompanied by syncope, mydriatic pupils, and attenuation of light reflexes with no abnormalities in other neurological systems. Autonomic testing revealed denervation hypersensitivity in norepinephrine (NE) intravenous infusion test and 0.125% pilocarpine instillation test, low NE in the serum, and decreased amount of sweating in quantitative sudomotor axon reflex test. These findings indicated dysfunction of postganglionic autonomic nerves. Autoimmune autonomic ganglionopathy (AAG) was diagnosed due to the presence of anti-ganglionic acetylcholine receptors. The patient was given intravenous high-dose immunoglobulin therapy (IVIg), improving orthostatic hypotension, urinary retention, and constipation. Previous reports indicated that the response to IVIg varied from case to case. Thus, this case suggests that IVIg is effective in acute-onset AAG cases.
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Affiliation(s)
| | - Jinsoo Koh
- Department of Neurology, Wakayama Medical University
| | | | - Hidefumi Ito
- Department of Neurology, Wakayama Medical University
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Gao CA, Weber UM, Peixoto AJ, Weiss SA. Seronegative autoimmune autonomic ganglionopathy from dual immune checkpoint inhibition in a patient with metastatic melanoma. J Immunother Cancer 2019; 7:262. [PMID: 31623673 PMCID: PMC6796437 DOI: 10.1186/s40425-019-0748-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have improved clinical outcomes including survival in several malignancies but have also been associated with a range of immune-related adverse events (irAEs). Neurological irAEs are rare compared to the more typical skin, gastrointestinal, and endocrine toxicities, and are often underrecognized and challenging to diagnose. Here, we report a case of seronegative autoimmune autonomic ganglionopathy (AAG) induced by dual immune checkpoint inhibitor therapy (ICI) in a patient with metastatic melanoma. CASE PRESENTATION A patient with metastatic melanoma was treated with ipilimumab and nivolumab. He developed a constellation of new symptoms including nausea, fatigue, and severe orthostatic hypotension refractory to fluid resuscitation. An infectious, cardiac, neurologic, and endocrine workup were unrevealing. Cardiovascular autonomic testing revealed poor sympathetic nervous system responses. He was diagnosed with seronegative AAG and significantly improved with immunomodulatory therapies including IVIG and steroids as well as varying doses of midodrine and fludrocortisone. He was able to restart nivolumab without recurrence of his symptoms. However, the AAG reoccurred when he was re-challenged with ipilimumab and nivolumab due to disease progression. While the AAG was manageable with steroids at that time, unfortunately his melanoma became resistant to ICI. CONCLUSIONS Immune checkpoint inhibitors can have a wide range of unusual, rare irAEs, including neurotoxicity such as AAG. Clinicians should maintain suspicion for this toxicity so that treatment can be rapidly provided to avoid disability.
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Affiliation(s)
- Catherine A Gao
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Urs M Weber
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Aldo J Peixoto
- Department of Medicine (Nephrology), Yale University School of Medicine, 330 Cedar Street, Boardman 114, New Haven, CT, 06520, USA
| | - Sarah A Weiss
- Department of Medicine (Medical Oncology), Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
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Golden EP, Vernino S. Autoimmune autonomic neuropathies and ganglionopathies: epidemiology, pathophysiology, and therapeutic advances. Clin Auton Res 2019; 29:277-288. [DOI: 10.1007/s10286-019-00611-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/03/2019] [Indexed: 12/12/2022]
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Bouxin M, Schvartz B, Mestrallet S, Debrumetz A, Hentzien M, Tabary T, Cohen R, Nicolas G, Bani-Sadr F. Rituximab treatment in seronegative autoimmune autonomic neuropathy and autoimmune autonomic ganglionopathy: Case-report and literature review. J Neuroimmunol 2018; 326:28-32. [PMID: 30468952 DOI: 10.1016/j.jneuroim.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune autonomic ganglionopathy (AAG) is a rare disease with no well-established treatment. Until recently, AAG could be seropositive (50 to 60% of patients) or seronegative for ganglionic (α3-type) nicotinic acetylcholine receptor (Gα3NAChR) antibodies. In early 2018, the two forms of the disease were distinguished, separating seropositive from seronegative ones, designating this latter form "seronegative autoimmune autonomic neuropathy" (SAAN). Most described treatments are plasma exchange (PE) and intravenous immunoglobulin (IVIG). However in some cases with no or small benefit, other immunomodulatory therapies, such as rituximab have been reported. We report the case of a 24-year-old female patient successfully treated for SAAN with rituximab and steroids after IVIG and PE failure. We also provide a review of case-reports reporting rituximab treatment for both SAAN and AAG. METHODS To identify articles reporting SAAN and AAG treatment with rituximab, we searched the PubMed database using the terms "autoimmune autonomic ganglionopathy", "autoimmune autonomic neuropathy" or "seronegative autoimmune autonomic neuropathy" and "rituximab". RESULTS Including our patient, nine cases have been described in the literature (4 SAAN and 5 AAG). Rituximab had a significant positive effect in 2 out of 4 SAAN and all 5 AAG cases, used alone or in association with other etiologic treatments. CONCLUSION Our study suggests rituximab (alone or in association with other treatments) could provide efficacy in both SAAN and AAG when PE and/or IVIG are not effective enough.
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Affiliation(s)
- M Bouxin
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - B Schvartz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - S Mestrallet
- Department of Internal Medicine and Infectious Diseases, CH de Charleville-Mézières, Charleville-Mézières, France
| | - A Debrumetz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - M Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - T Tabary
- Immunology Laboratory, Reims Teaching Hospitals, Reims, France
| | - R Cohen
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - G Nicolas
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - F Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France; University of Reims Champagne-Ardenne, EA-4684 / SFR CAP-SANTE, Reims F-51095, France.
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