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Pascual-Goñi E, Collet R, Tejada-Illa C, Martín-Aguilar L, Caballero-Ávila M, Lleixà C, Novelli S, López-Pardo J, Sanfeliu AE, Mariscal A, Álvaro Gargallo Y, Martínez-Hernández E, Cocho D, Querol L. Excellent response to anti-CD38 therapy with daratumumab in a patient with severe refractory CANOMAD. J Neurol Neurosurg Psychiatry 2024; 95:609-611. [PMID: 38341197 DOI: 10.1136/jnnp-2023-332443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/01/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIG) and rituximab are considered the first-line and second-line treatments for Chronic Ataxic Neuropathy and Ophthalmoplegia with IgM-paraprotein, cold Agglutinins, and anti-Disialosyl antibodies (CANOMAD), with an overall clinical response around 50%. New anti-CD38 daratumumab, targeting long-lived plasma cells, has been reported as a promising therapy for treatment-refractory antibody-mediated disorders. We report the first case of a severe refractory CANOMAD, successfully treated with daratumumab. METHODS A patient in their 70s with severe relapsing CANOMAD, refractory to IVIG, steroids, rituximab and ibrutinib developed severe tetraparesis and respiratory failure. Plasma exchange (PE) improved motor and ventilatory function; however, after 6 weeks, patient remained PE dependent. Intravenous daratumumab was initiated at 16 mg/kg weekly for 3 weeks, every 2 weeks for the second and third month, and monthly afterwards. RESULTS After 3 weeks of starting daratumumab, PE was discontinued and, since then, the patient evolved to complete recovery. Antidisialosyl antibody titres decreased after PE and remained stable during daratumumab. Serum neurofilament light-chain levels were elevated in the exacerbation phase and normalised after daratumumab. The patient remains in clinical remission under monthly daratumumab, 12 months after initiation. CONCLUSIONS The first patient with aggressive treatment-refractory CANOMAD treated with daratumumab provides proof-of-principle evidence that daratumumab may be an effective treatment in IgM-related neuropathies.
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Affiliation(s)
- Elba Pascual-Goñi
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Roger Collet
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Clara Tejada-Illa
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lorena Martín-Aguilar
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marta Caballero-Ávila
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Silvana Novelli
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi López-Pardo
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Esquirol Sanfeliu
- Department of Haematology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anais Mariscal
- Immunology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yolanda Álvaro Gargallo
- Immunology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Dolores Cocho
- Department of Neurology, Hospital General de Granollers, Granollers, Spain
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Balestro G, Picelli A, Ortolani L, Marcante A. Combined effect of medical therapy and rehabilitation in Chronic Ataxic Neuropathy with anti-Disialosyl IgM Antibodies (CANDA): a case report. Eur J Transl Myol 2023; 33:11557. [PMID: 37522810 PMCID: PMC10583142 DOI: 10.4081/ejtm.2023.11557] [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: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023] Open
Abstract
Chronic Ataxic Neuropathy with anti-Disialosyl IgM Antibodies (CANDA) is a rare form of immune-mediated sensory ataxic neuropathy. We describe the case of a 45-year-old man, who was diagnosed with CANDA in October 2018. Since then, he has been treated with monthly courses of intravenous immunoglobulin administration (IV Ig) and, in October 2022, he underwent plasmapheresis, reporting a sudden worsening of clinical and motor picture. After a new IV Ig cycle admission, the patient was hospitalized to perform intensive rehabilitation, involving two individual sessions per day (90 minutes each) for 5 days a week. During hospitalization it was registered a relevant improvement in the muscle strength of the lower limbs (LLs). Furthermore, progressive improvements were recorded both in patient's motor performance and in his level of autonomy in activities of daily living. These results had a positive impact on his quality of life and made it possible to reduce the frequency of IV Ig treatments. This is the first case in literature reporting the combined effect of rehabilitation treatment and medical therapy in CANDA neuropathy.
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Affiliation(s)
- Giulio Balestro
- Unit of Neurorehabilitation, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital of Verona, University of Verona, Verona.
| | - Alessandro Picelli
- Unit of Neurorehabilitation, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital of Verona, University of Verona, Verona.
| | - Luca Ortolani
- U.O.C. Recovery and Functional Rehabilitation - Lonigo, Ulss8 Berica.
| | - Andrea Marcante
- U.O.C. Recovery and Functional Rehabilitation - Lonigo, Ulss8 Berica.
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Aguirre AS, Vivanco RA, Ortiz JF, Rozen V, InsuastI WE, Fiallos J, Gallegos C, Villavicencio A, Salazar K, Duenas F, Singla R. Efficacy of Rituximab in CANOMAD: A Systematic Review. Cureus 2023; 15:e39237. [PMID: 37337500 PMCID: PMC10277167 DOI: 10.7759/cureus.39237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/21/2023] Open
Abstract
CANOMAD, characterized by chronic ataxic neuropathy, ophthalmoplegia, immunoglobulin M (IgM) paraprotein, cold agglutinins, and disialosyl antibodies, encompasses a clinical, radiological, and laboratory diagnosis. CANOMAD is a rare condition, with fewer than 100 cases reported in the literature. The understanding and diagnosis of the disease have improved in the last few years, but the treatment of CANOMAD is mainly unknown, and there is not a clear consensus about it. We conducted a systematic review regarding the efficacy of rituximab in CANOMAD's treatment to investigate the clinical and biological response of CANOMAD in patients treated with rituximab. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines for this systematic review. To analyze the bias of the study, we used the Joanna Briggs Institute's (JBI) Critical Appraisal Checklist to analyze the bias of the case reports, and we used the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for the observational studies. We only included case reports, case series, and observational studies written in English with patients formally diagnosed with CANOMAD and treated with rituximab. We excluded systematic reviews, literature reviews, and meta-analyses. We investigated the clinical and biological responses of the patients to rituximab. The clinical response was classified as complete recovery (CR), partial response (PR), stable disease (SD), and non-response (NR). We gathered 34 patients. The literature uses a modified Rankin score to define complete improvement (CR), partial response (PR), stable disease (SD), and progression. Clinically, there were three patients with CR, five with PR, 15 with SD, and 11 with progression. The biological response was assessed by measuring the decrease in antibody titers in 27 patients. Among those, six patients had CR, 12 had PR, eight had SD, and one had progression. Among 15 patients with neurological evaluation, 10 had ocular symptoms, and two presented with bulbar symptoms. Seven of the ten patients with ocular symptoms had SD, two had PR, and one had progression. Only 14 patients had a report of demyelinating features. Three had an axonal pattern, six had a demyelinating pattern, and five had a mixed pattern. Among patients with an axonal pattern, three had an SD. Among patients with a demyelinating pattern, three had a PR, two had an SD, and one had progression. Among patients with a mixed pattern, four had SD, and one had progression. We concluded that patients with CR have a shorter disease duration than patients with PR, SD, or progression. In addition, patients with CR had longer follow-ups than the other groups, suggesting that being treated early with rituximab improves the clinical outcome and has a sustained effect. There were no differences in the frequency of ocular and bulbar symptoms among patients with CANOMAD. The axonal pattern is more common in patients with SD, suggesting that axonal and mixed patterns could be markers of a bad prognosis.
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Affiliation(s)
- Alex S Aguirre
- School of Medicine, Universidad San Francisco de Quito, Quito, ECU
| | - Ricardo A Vivanco
- Faculty of Health Sciences, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | | | - Valery Rozen
- School of Medicine, Michigan State University College of Human Medicine, Grand Rapids, USA
| | - Walter E InsuastI
- Division of Research and Academic Affairs, Larkin Health System, South Miami, USA
| | - John Fiallos
- Faculty of Health Sciences, Universidad de Guayaquil, Guayaquil, ECU
| | - Camila Gallegos
- School of Medicine, Universidad San Francisco de Quito, Quito, ECU
| | | | - Kevin Salazar
- Division of Research and Academic Affairs, Larkin Health System, Miami, USA
| | - Francisco Duenas
- Faculty of Health Sciences, Universidad Católica de Santiago de Guayaquil, Guayaquil, ECU
| | - Ramit Singla
- Department of Vascular Neurology, University of Tennessee Health Science Centre, Memphis, USA
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Min YG, Ju W, Ha YE, Ban JJ, Shin JY, Kim SM, Hong YH, Park SH, Sung JJ. Skin Biopsy as a Novel Diagnostic Aid in Immune-Mediated Neuropathies. J Neuropathol Exp Neurol 2022; 81:1018-1025. [PMID: 36137254 PMCID: PMC9677240 DOI: 10.1093/jnen/nlac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Immune-mediated neuropathies are a heterogenous group of inflammatory peripheral nerve disorders. They can be classified according to the domain where the autoimmune process begins: the internode, paranode, or node. However, conventional diagnostic tools, electrodiagnosis (EDX), and autoantibody testing do not fully address this issue. In this institutional cohort study, we investigated the value of dermal myelinated fiber analysis for target domain-based classification. Twenty-seven consecutive patients with immune-mediated neuropathies underwent skin biopsies. The sections were stained with antibodies representative of myelinated fiber domains and were scanned using a confocal microscope. Clinical and pathological features of each patient were reviewed comprehensively. Quantitative morphometric parameters were subjected to clustering analysis, which stratified patients into 3 groups. Cluster 1 ("internodopathy") was characterized by prominent internodal disruption, intact nodes and paranodes, demyelinating EDX pattern, and absence of nodal-paranodal antibodies. Cluster 2 ("paranodopathy") was characterized by paranodal disruption and corresponding antibodies. Morphological changes were restricted to the nodes in cluster 3; we designated this cluster as "nodopathy." This report highlights the utility of skin biopsy as a diagnostic aid to gain pathogenic insight and classify patients with immune-mediated neuropathies.
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Affiliation(s)
- Young Gi Min
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woohee Ju
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Ye-Eun Ha
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Jae-Jun Ban
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Neuroscience Research Institute, Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Je-Young Shin
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul National University Seoul Metropolitan Government Boramae Hospital, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Soul, Korea
| | - Jung-Joon Sung
- Send correspondence to: Jung-Joon Sung, MD, PhD, Department of Neurology, Seoul National University Hospital, Department of Translational Medicine, Seoul National University College of Medicine, 101 Daehangno, Jongnogu, Seoul 03080, Korea; E-mail:
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