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Chung SA, Huang AJ, Murali MR, Chwalisz BK, Wallace ZS, Kozanno LN. Case 11-2024: An 82-Year-Old Woman with Falls and Cognitive Decline. N Engl J Med 2024; 390:1312-1322. [PMID: 38598798 DOI: 10.1056/nejmcpc2312725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Sharon A Chung
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Ambrose J Huang
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Mandakolathur R Murali
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Bart K Chwalisz
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Zachary S Wallace
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
| | - Liana N Kozanno
- From the Department of Medicine, University of California, San Francisco, San Francisco (S.A.C.); and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Massachusetts General Hospital, and the Departments of Radiology (A.J.H.), Medicine (M.R.M., Z.S.W.), Neurology (B.K.C.), and Pathology (M.R.M., L.N.K.), Harvard Medical School - both in Boston
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2
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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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Wu P, Liu X, Dai Q, Yu J, Zhao J, Yu F, Liu Y, Gao Y, Li H, Li W. Diagnosing the benign paroxysmal positional vertigo via 1D and deep-learning composite model. J Neurol 2023:10.1007/s00415-023-11662-w. [PMID: 37076600 DOI: 10.1007/s00415-023-11662-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Benign Paroxysmal Positional Vertigo (BPPV) is the leading cause of vertigo, and its characteristic nystagmus induced by positional maneuvers makes it a good model for Artificial Intelligence (AI) diagnosis. However, during the testing procedure, up to 10 min of indivisible long-range temporal correlation data are produced, making the AI-informed real-time diagnosing unlikely in clinical practice. METHODS A combined 1D and Deep-Learning (DL) composite model was proposed. Two separate cohorts were recruited, with one for model generation and the other for evaluation of model's real-world generalizability. Eight features, including two head traces and three eye traces and their corresponding slow phase velocity (SPV) value, were served as the inputs. Three candidate models were tested, and a sensitivity study was conducted to determine the saliently important features. RESULTS The study included 2671 patients in the training cohort and 703 in the test cohort. A hybrid DL model achieved a micro-area under the receiver operating curve (AUROC) of 0.982 (95% CI 0.965, 0.994) and macro-AUROC of 0.965 (95% CI 0.898, 0.999) for overall classification. The highest accuracy was observed for right posterior BPPV, with an AUROC of 0.991 (95% CI 0.972, 1.000), followed by left posterior BPPV, with an AUROC of 0.979 (95% CI 0.940, 0.998), the lowest AUROC was 0.928 (95% CI 0.878, 0.966) for lateral BPPV. The SPV was consistently identified as the most predictive feature in the models. If the model process is carried out 100 times for a 10-min data, one single running takes 0.79 ± 0.06 s. CONCLUSION This study designed DL models which can accurately detect and categorize the subtype of BPPV, enabling a quick and straightforward diagnosis of BPPV in clinical setting. The critical feature identified in the model helps expand our understanding of this disorder.
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Affiliation(s)
- Peixia Wu
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
- Nursing Department, Eye and ENT Hospital, Fudan University, Shanghai, China
| | - Xuebing Liu
- Department of Computer Science and Engineering, Jeonbuk National University, Jeonju, South Korea
| | - Qi Dai
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Jiaoda Yu
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Jieli Zhao
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
- Nursing Department, Eye and ENT Hospital, Fudan University, Shanghai, China
| | - Fangzhou Yu
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Yaoqian Liu
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China
| | - Yongbin Gao
- School of Electronic and Electronics Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Huawei Li
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China.
- Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China.
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, 20003, China.
- The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, 200032, China.
| | - Wenyan Li
- ENT Institute and Otorhinolaryngology Department of Eye and ENT Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China.
- Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, China.
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, 20003, China.
- The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, 200032, China.
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4
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Masuda Y, Matsuda S, Kotani T, Nishioka D, Ota S, Hosokawa T, Ishida S, Takeuchi T. Association between Serum Biomarkers and Peripheral Neuropathy in Microscopic Polyangiitis. Int J Mol Sci 2022; 23:13374. [PMID: 36362162 PMCID: PMC9658745 DOI: 10.3390/ijms232113374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2023] Open
Abstract
This study aimed to elucidate the pathomechanism of peripheral neuropathy (PN) in microscopic polyangiitis (MPA) and to identify biomarkers useful for diagnosis and severity assessment. Patients with MPA (n = 37) and other non-inflammatory neurological diseases (ONDs; n = 12) were enrolled, and the peripheral nerves of all patients were evaluated using nerve conduction studies. We compared the clinical characteristics and 14 serum biomarker profiles among patients with MPA and PN, MPA without PN, and ONDs. Patients with MPA had a higher prevalence of motor neuropathy than patients with ONDs. Among the patients with MPA, those with motor neuropathy had significantly higher total Birmingham Vasculitis Activity Scores and serum levels of C-reactive protein (CRP), tissue inhibitor of metalloproteinase-1 (TIMP-1), and interleukin-6 than patients without motor neuropathy. Multivariable analyses adjusted for age, serum CRP level, and diabetes mellitus showed that high serum levels of TIMP-1 were independently related to a diagnosis of motor neuropathy in MPA. Additionally, there were significant negative correlations between the serum levels of TIMP-1 and compound muscle action potential amplitudes. Serum levels of TIMP-1 may be associated with the pathomechanism of motor neuropathy in MPA and could be a useful biomarker for diagnosing and evaluating the severity of motor neuropathy in MPA.
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Affiliation(s)
- Yuichi Masuda
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shogo Matsuda
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Takuya Kotani
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Daisuke Nishioka
- Research & Development Center, Department of Medical Statistics, Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shin Ota
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Takafumi Hosokawa
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shimon Ishida
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Tohru Takeuchi
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
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Martins-Martinho J, Dourado E, Khmelinskii N, Espinosa P, Ponte C. Localized Forms of Vasculitis. Curr Rheumatol Rep 2021; 23:49. [PMID: 34196889 PMCID: PMC8247627 DOI: 10.1007/s11926-021-01012-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/26/2022]
Abstract
Purpose of Review To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis. Recent Findings Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment. Summary Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.
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Affiliation(s)
- Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal. .,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pablo Espinosa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
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6
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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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Gwathmey KG, Satkowiak K. Peripheral nervous system manifestations of rheumatological diseases. J Neurol Sci 2021; 424:117421. [PMID: 33824004 DOI: 10.1016/j.jns.2021.117421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/02/2020] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
Rheumatological diseases result in immune-mediated injury to not only connective tissue, but often components of the peripheral nervous system. These overlap conditions can be broadly categorized as peripheral neuropathies and overlap myositis. The peripheral neuropathies are distinctive as many have unusual presentations such as non-length-dependent, small fiber neuropathies and sensory neuronopathies (both due to dorsal root ganglia dysfunction), multiple mononeuropathies (e.g. vasculitic neuropathies), and even cranial neuropathies. Overlap myositis is increasingly recognized and is often associated with specific autoantibodies. Sarcoidosis also has widespread neurological manifestations and impacts both the peripheral nerves and muscle. Much work is needed to fully characterize the vast presentations of these overlap diseases. Given the rarity of these disorders, they are understudied, resulting in significant knowledge gaps with regards to their underlying pathophysiology and the best treatment approach. A basic knowledge of these disorders is mandatory for both practicing rheumatologists and neurologists as prompt recognition and early initiation of immunotherapy may prevent significant morbidity and permanent disability.
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Affiliation(s)
- Kelly G Gwathmey
- Virginia Commonwealth University, Department of Neurology, 1101 E Marshall St., PO Box 980599, Richmond, VA 23298, USA.
| | - Kelsey Satkowiak
- University of Virginia, Department of Neurology, Charlottesville, VA, USA
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8
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Cox SZ, Gwathmey KG. Chronic Immune-Mediated Polyneuropathies. Clin Geriatr Med 2021; 37:327-345. [PMID: 33858614 DOI: 10.1016/j.cger.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article discusses the chronic immune-mediated polyneuropathies, a broad category of acquired polyneuropathies that encompasses chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), the most common immune-mediated neuropathy, the CIDP variants, and the vasculitic neuropathies. Polyneuropathies associated with rheumatological diseases and systemic inflammatory diseases, such as sarcoidosis, will also be briefly covered. These patients' history, examination, serum studies, and electrodiagnostic studies, as well as histopathological findings in the case of vasculitis, confirm the diagnosis and differentiate them from the more common length-dependent polyneuropathies. Prompt identification and initiation of treatment is imperative for these chronic immune-mediated polyneuropathies to prevent disability and even death.
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Affiliation(s)
- Stephen Zachary Cox
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA.
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Rodrigues R, Branco M, Silva R, Ruano L, Fontão L, Lopes M, Scigliano H, Taipa R, Pires MM, Santos C. Peripheral neuropathy in systemic vasculitis and other autoimmune diseases - a report of five cases emphasizing the importance of etiologic characterization. eNeurologicalSci 2020; 21:100272. [PMID: 32995578 PMCID: PMC7502409 DOI: 10.1016/j.ensci.2020.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/24/2020] [Accepted: 09/09/2020] [Indexed: 10/24/2022] Open
Abstract
Introduction Peripheral neuropathies may present in the context of systemic vasculitis and other autoimmune diseases. The etiologic characterization is crucial to define the treatment and prognosis in secondary vasculitis. The purpose of this study is to describe the pathway of etiologic investigation including the role of nerve biopsy. Methods Retrospective analysis of patients seen in the neuromuscular outpatient clinic during the last four years with peripheral neuropathy in the context of systemic vasculitis or other autoimmune diseases. Results We present five patients with stepwise progressive sensorimotor deficits of upper and lower limbs. All patients presented with systemic features and one of them had an established diagnosis of systemic vasculitis. They underwent an extended blood panel, including autoimmune and serologic tests. Electromyography and nerve conduction studies revealed asymmetric axonal sensorimotor polyneuropathies in four patients, and an axonal sensorimotor multiple mononeuropathy in one. Four patients underwent nerve biopsy and the other performed a skin biopsy, with findings suggestive of possible vasculitic processes. The etiologies identified included microscopic polyangiitis, HBV-related polyarteritis nodosa and two eosinophilic granulomatosis with polyangiitis. In the last patient a specific etiology could not be established. Conclusion This series reveals the etiologic and phenotypic diversity of peripheral neuropathies related with systemic vasculitis. The therapeutic approach and prognosis were distinct in each patient, emphasizing the importance of a prompt diagnosis and appropriate treatment.
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Affiliation(s)
- Rita Rodrigues
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Mariana Branco
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Renata Silva
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Luís Ruano
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal.,Public Health and Forensic Sciences and Medical Education Department, Faculty of Medicine of Porto University, Porto, Portugal
| | - Luís Fontão
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Marta Lopes
- Neurology Department, Hospital Privado de Braga Sul, Trofa Saúde Hospitais, Braga, Portugal
| | | | - Ricardo Taipa
- Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Manuel Melo Pires
- Neuropathology Unit, Department of Neurosciences, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Catarina Santos
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
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Abstract
AbstractDisorders of sudomotor function are common and diverse in their presentations. Hyperhidrosis or hypohidrosis in generalized or regional neuroanatomical patterns can provide clues to neurologic localization and inform neurologic diagnosis. Conditions that impair sudomotor function include small fiber peripheral neuropathy, sudomotor neuropathy, myelopathy, α-synucleinopathies, autoimmune autonomic ganglionopathy, antibody-mediated hyperexcitability syndromes, and a host of medications. Particularly relevant to neurologic practice is the detection of postganglionic sudomotor deficits as a diagnostic marker of small fiber neuropathies. Extensive anhidrosis is important to recognize, as it not only correlates with symptoms of heat intolerance but may also place the patient at risk for heat stroke when under conditions of heat stress. Methods for assessing sudomotor dysfunction include the thermoregulatory sweat test, the quantitative sudomotor axon reflex test, silicone impressions, and the sympathetic skin response.
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Update on classification, epidemiology, clinical phenotype and imaging of the nonsystemic vasculitic neuropathies. Curr Opin Neurol 2020; 32:684-695. [PMID: 31313704 DOI: 10.1097/wco.0000000000000727] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Single-organ vasculitis of the peripheral nervous system (PNS) is often designated nonsystemic vasculitic neuropathy (NSVN). Several variants or subtypes have been distinguished, including migratory sensory neuropathy, postsurgical inflammatory neuropathy, diabetic radiculoplexus neuropathies, skin-nerve vasculitides, and, arguably, neuralgic amyotrophy. NSVN often presents as nondiabetic lumbosacral radiculoplexus neuropathy (LRPN). This review updates classification, clinical features, epidemiology, and imaging of these disorders. RECENT FINDINGS A recent study showed the annual incidence of LRPN in Olmstead County, Minnesota to be 4.16/100 000:2.79/100 000 diabetic and 1.27/100 000 nondiabetic. This study was the first to determine the incidence or prevalence of any vasculitic neuropathy. In NSVN, ultrasonography shows multifocal enlargement of proximal and distal nerves. In neuralgic amyotrophy, MRI and ultrasound reveal multifocal enlargements and focal constrictions in nerves derived from the brachial plexus. Histopathology of these chronic lesions shows inflammation and rare vasculitis. Diffusion tensor imaging of tibial nerves in NSVN revealed decreased fractional anisotropy in one study. SUMMARY Single-organ PNS vasculitides are the most common inflammatory neuropathies. Neuralgic amyotrophy might result from PNS vasculitis, but further study is necessary. The usefulness of focal nerve enlargements or constrictions in understanding pathological mechanisms, directing biopsies, and monitoring disease activity in NSVN should be further investigated.
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12
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Biology of the human blood-nerve barrier in health and disease. Exp Neurol 2020; 328:113272. [PMID: 32142802 DOI: 10.1016/j.expneurol.2020.113272] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 12/13/2022]
Abstract
A highly regulated endoneurial microenvironment is required for normal axonal function in peripheral nerves and nerve roots, which structurally consist of an outer collagenous epineurium, inner perineurium consisting of multiple concentric layers of specialized epithelioid myofibroblasts that surround the innermost endoneurium, which consists of myelinated and unmyelinated axons embedded in a looser mesh of collagen fibers. Endoneurial homeostasis is achieved by tight junction-forming endoneurial microvessels that control ion, solute, water, nutrient, macromolecule and leukocyte influx and efflux between the bloodstream and endoneurium, and the innermost layers of the perineurium that control interstitial fluid component flux between the freely permeable epineurium and endoneurium. Strictly speaking, endoneurial microvascular endothelium should be considered the blood-nerve barrier (BNB) due to direct communication with circulating blood. The mammalian BNB is considered the second most restrictive vascular system after the blood-brain barrier (BBB) based on classic in situ permeability studies. Structural alterations in endoneurial microvessels or interactions with hematogenous leukocytes have been described in several human peripheral neuropathies; however major advances in BNB biology in health and disease have been limited over the past 50 years. Guided by transcriptome and proteome studies of normal and pathologic human peripheral nerves, purified primary and immortalized human endoneurial endothelial cells that form the BNB and leukocytes from patients with well-characterized peripheral neuropathies, validated by in situ or ex vivo protein expression studies, data are emerging on the molecular and functional characteristics of the human BNB in health and in specific peripheral neuropathies, as well as chronic neuropathic pain. These early advancements have the potential to not only increase our understanding of how the BNB works and adapts or fails to adapt to varying insult, but provide insights relevant to pathogenic leukocyte trafficking, with translational potential and specific therapeutic application for chronic peripheral neuropathies and neuropathic pain.
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Bischof A, Jaeger VK, Hadden RDM, Luqmani RA, Pröbstel AK, Merkel PA, Suppiah R, Craven A, Collins MP, Daikeler T. Peripheral neuropathy in antineutrophil cytoplasmic antibody-associated vasculitides: Insights from the DCVAS study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2019; 6:6/6/e615. [PMID: 31540965 PMCID: PMC6807658 DOI: 10.1212/nxi.0000000000000615] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/08/2019] [Indexed: 11/16/2022]
Abstract
Objective Reported prevalence of vasculitic neuropathy (VN) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is highly variable, and associations with other organ manifestations have not been studied systematically while accounting for diagnostic certainty of VN. Methods Data of all patients with AAV within the Diagnostic and Classification criteria for primary systemic VASculitis study were analyzed cross-sectionally. VN was categorized as definite (histology proven), probable (multiple mononeuropathy or nerve biopsy consistent with vasculitis), or possible (all others). Associations with other organ manifestations were compared in patients with and without VN. Results Nine hundred fifty-five patients (mean age 57 years, range 18–91 years, 51% female) were identified. Of these, 572 had granulomatosis with polyangiitis (GPA), 218 microscopic polyangiitis (MPA), and 165 eosinophilic granulomatosis with polyangiitis (EGPA). The prevalence of VN was 65% in EGPA, 23% in MPA, and 19% in GPA. Nerve biopsy was performed in 32/269 (12%) patients, demonstrating definite vasculitis in 17/32 (53%) of patients. VN was associated with myeloperoxidase-ANCA positivity (p = 0.004) and skin (p < 0.001), musculoskeletal, (p < 0.001) and cardiovascular (p = 0.005) involvement. Patients with VN were less likely to have renal (p < 0.001), eye (p < 0.001), and gastrointestinal (p = 0.023) involvement. Conclusions Our study provides comprehensive insights into the prevalence and organ associations of VN in a large, systematically collected AAV cohort. VN is most commonly associated with skin, musculoskeletal, and cardiovascular manifestations. In routine clinical practice, diagnosis of VN is infrequently confirmed by the gold standard of nerve biopsy but rather supported by the clinical setting of active systemic AAV.
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Affiliation(s)
- Antje Bischof
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI.
| | - Veronika K Jaeger
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Robert D M Hadden
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Raashid A Luqmani
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Anne-Katrin Pröbstel
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Peter A Merkel
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Ravi Suppiah
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Anthea Craven
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Michael P Collins
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
| | - Thomas Daikeler
- From the Immunology Clinic and Department of Neurology (A.B.), Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel; Department of Rheumatology (V.K.J., T.D.), University Hospital Basel, Switzerland; Department of Neurology (R.D.M.H.), King's College Hospital, London; Nuffield Department of Orthopedics (R.A.L., A.C.), Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, United Kingdom; Department of Neurology (A.-K.P.), University Hospital Basel & Clinical Neuroimmunology; Department of Biomedicine (A.-K.P.), University of Basel, Switzerland; Division of Rheumatology and Department of Biostatistics, Epidemiology, and Informatics (P.A.M.), University of Pennsylvania, Philadelphia; Department of Rheumatology (R.S.), Auckland District Health Board, New Zealand; and Department of Neurology (M.P.C.), Medical College of Wisconsin, Milwaukee, WI
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Hui M, Meena AK, Rajasekhar L, Sireesha Y, Afshan J, Mridula R, Borgohain R, Uppin MS. Vasculitic Neuropathy: A Retrospective Analysis of Nerve Biopsies and Clinical Features from a Single Tertiary Care Center. Ann Indian Acad Neurol 2019; 22:180-186. [PMID: 31007430 PMCID: PMC6472243 DOI: 10.4103/aian.aian_47_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Vasculitic neuropathy can be either restricted to the peripheral nerves or associated with systemic involvement of other organs. The objective of this study was to analyze the nerve biopsies reported as "vasculitic neuropathy" with clinical features. Materials and Methods All cases diagnosed with vasculitic neuropathy were retrospectively analyzed and categorized as systemic vasculitis and nonsystemic vasculitic neuropathy based on the clinical features. The histological features were further evaluated and classified according to the Peripheral Nerve Society Guidelines. Results Of the 126 cases, there were 65 nonsystemic vasculitis, 45 secondary systemic vasculitis, and 16 primary systemic vasculitis. Definite vasculitis was more common in the systemic vasculitis group. The epineurial vessels were predominantly involved with chronic axonal changes. Conclusion The sensitivity of definite vasculitis on nerve biopsy was 54.76%. The sensitivity increases when the diagnostic criteria of definite and probable vasculitis were applied taking into account perivascular inflammation accompanied by vascular changes and axonopathy.
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Affiliation(s)
- Monalisa Hui
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - A K Meena
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Yareeda Sireesha
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jabeen Afshan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rukmini Mridula
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rupam Borgohain
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Stein AA, Vrionis F, Espinosa PS, Moskowitz S. Report of an Isolated L5 Radiculopathy Caused by an L2-3 Disc Herniation and Review of the Literature. Cureus 2018; 10:e2552. [PMID: 30410818 PMCID: PMC6218189 DOI: 10.7759/cureus.2552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Intervertebral disc herniation is a common cause of radiculopathy. Disc herniations occurring in the lumbar spine typically affect the nerve root exiting under the pedicle of the vertebral body, one level caudal. However, in rare cases, a disc herniation can cause remote isolated radicular symptoms. The authors present the case of a 70-year-old male who presented with an acute, new-onset, left-sided foot drop, low back pain, and a classic L5 monoradiculopathy. Imaging revealed a large, left-sided paracentral extruded L2-3 disc and the absence of any pathology at the L4/5 level. Although the patient’s clinical presentation and imaging did not classically correlate, it was felt that the L2-L3 disc was the etiology of the patient’s L5 radiculopathy and a left L2-3 microsurgical discectomy was performed. At the six-week follow-up, his foot drop was near normal, sensation was intact with minimal paresthesias, and he remained pain-free. At the one-year follow-up, he experienced full resolution of his foot drop and remained symptom-free. Although rare, disc herniations may cause isolated, remote, painful mononeuropathies not related to the direct level of nerve root compression and should be considered along with other etiologies of peripheral neuropathies.
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Affiliation(s)
- Alan A Stein
- Boca Raton Regional Hospital, Marcus Neuroscience Institute, Boca Raton, USA
| | - Frank Vrionis
- Neurological Surgery, Marcus Neuroscience Institute, Boca Raton, USA
| | - Patricio S Espinosa
- Neurology, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, USA
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Vasculitic Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
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Mitchell CH, Fayad LM, Ahlawat S. Magnetic Resonance Imaging of the Digital Nerves of the Hand: Anatomy and Spectrum of Pathology. Curr Probl Diagn Radiol 2017; 47:42-50. [PMID: 28438411 DOI: 10.1067/j.cpradiol.2017.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 01/20/2023]
Abstract
Digital nerves are intrinsic to the sensory and motor function of the hand. These nerves represent the terminal ramifications of the ulnar, median, and radial nerves and are located distal to the carpal tunnel and Guyon canal. With magnetic resonance imaging, traumatic and nontraumatic abnormalities of the digital nerves can be shown with high contrast as well as high spatial resolution. Digital nerve abnormalities are most commonly posttraumatic in nature; however, infection, inflammatory, vascular malformations, and neoplasms can rarely occur. Magnetic resonance imaging is playing an increasing role in the assessment of peripheral nerve injury throughout the body, and in the hand, which can accurately identify the extent and character of digital nerve abnormalities before operative intervention.
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Affiliation(s)
- Charles H Mitchell
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Laura M Fayad
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Shivani Ahlawat
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, MD.
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Callaghan BC, Price RS, Chen KS, Feldman EL. The Importance of Rare Subtypes in Diagnosis and Treatment of Peripheral Neuropathy: A Review. JAMA Neurol 2016; 72:1510-8. [PMID: 26437251 DOI: 10.1001/jamaneurol.2015.2347] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare localizations of peripheral neuropathy often require more extensive diagnostic testing and different treatments. OBJECTIVE To describe rare localizations of peripheral neuropathy, including the appropriate diagnostic evaluation and available treatments. EVIDENCE REVIEW References were identified from PubMed searches conducted on May 29, 2015, with an emphasis on systematic reviews and randomized clinical trials. Articles were also identified through the use of the authors' own files. Search terms included common rare neuropathy localizations and their causes, as well as epidemiology, pathophysiology, diagnosis, and treatment. FINDINGS Diffuse, nonlength-dependent neuropathies, multiple mononeuropathies, polyradiculopathies, plexopathies, and radiculoplexus neuropathies are rare peripheral neuropathy localizations that often require extensive diagnostic testing. Atypical neuropathy features, such as acute/subacute onset, asymmetry, and/or motor predominant signs, are frequently present. The most common diffuse, nonlength-dependent neuropathies are Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and amyotrophic lateral sclerosis. Effective disease-modifying therapies exist for many diffuse, nonlength-dependent neuropathies including Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and some paraprotein-associated demyelinating neuropathies. Vasculitic neuropathy (multiple mononeuropathy) also has efficacious treatment options, but definitive evidence of a treatment effect for IgM anti-MAG neuropathy and diabetic amyotrophy (radiculoplexus neuropathy) is lacking. CONCLUSIONS AND RELEVANCE Recognition of rare localizations of peripheral neuropathy is essential given the implications for diagnostic testing and treatment. Electrodiagnostic studies are an important early step in the diagnostic evaluation and provide information on the localization and pathophysiology of nerve injury.
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Affiliation(s)
| | - Raymond S Price
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Kevin S Chen
- Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor
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The utility of electrodiagnostic tests for the assessment of medically unexplained weakness and sensory deficit. Clin Neurophysiol Pract 2016; 1:2-8. [PMID: 30214953 PMCID: PMC6123842 DOI: 10.1016/j.cnp.2016.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/10/2016] [Indexed: 12/14/2022] Open
Abstract
Medically unexplained symptoms (MUS) are challenge for electrodiagnostic testing. Weakness and sensory deficit can be manifestations of psychogenic disorders. This is a review of electrodiagnostic methods used for the assessment of MUS.
Patients with suspected medically unexplained symptoms or psychogenic disorders are frequently requested to undergo an EMG exam. However, the suspected diagnosis is not always told to the electromyography practitioner, who must be able to recognize such a condition to avoid false positive diagnosis without dismissing the possibility to uncover any true dysfunction. There are many clinical manoeuvers to assess the consistency of the patients’ reported weakness or sensory deficit. The electrodiagnostic practitioner should be aware of those clinical tricks and interpret the electrodiagnostic findings in the clinical context. There are many electrodiagnostic tests that the practitioner can use for the assessment of motor and sensory functions but these tests have also important drawbacks and limitations. Only after a good clinical evaluation would the practitioner be able to give his/her opinion on the clinical relevance of the electrodiagnostic findings. Here we review some of the tests that can help the practitioner to define the electrophysiological characteristics of a suspected functional disorder presenting with weakness or sensory deficit.
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Hadden RDM, Collins MP, Živković SA, Hsieh ST, Bonetto C, Felicetti P, Marchione P, Santuccio C, Bonhoeffer J. Vasculitic peripheral neuropathy: Case definition and guidelines for collection, analysis, and presentation of immunisation safety data. Vaccine 2015; 35:1567-1578. [PMID: 26655629 DOI: 10.1016/j.vaccine.2015.11.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 11/16/2015] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Saša A Živković
- Department of Neurology, University of Pittsburgh Medical Center, USA
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taiwan
| | | | | | | | | | - Jan Bonhoeffer
- Brighton Collaboration Foundation, Basel, Switzerland; University of Basel Children's Hospital, Basel, Switzerland
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Neuropatie delle vasculiti. Neurologia 2015. [DOI: 10.1016/s1634-7072(15)73992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Inflammatory neuropathies: pathology, molecular markers and targets for specific therapeutic intervention. Acta Neuropathol 2015; 130:445-68. [PMID: 26264608 DOI: 10.1007/s00401-015-1466-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 08/01/2015] [Accepted: 08/02/2015] [Indexed: 12/21/2022]
Abstract
Inflammatory neuropathies encompass groups of heterogeneous disorders characterized by pathogenic immune-mediated hematogenous leukocyte infiltration of peripheral nerves, nerve roots or both, with resultant demyelination or axonal degeneration or both. Inflammatory neuropathies may be divided into three major disease categories: Guillain-Barré syndrome (particularly the acute inflammatory demyelinating polyradiculoneuropathy variant), chronic inflammatory demyelinating polyradiculoneuropathy and nonsystemic vasculitic neuropathy (or peripheral nerve vasculitis). Despite major advances in molecular biology, pathology and genetics, the pathogenesis of these disorders remains elusive. There is insufficient knowledge on the mechanisms of hematogenous leukocyte trafficking into the peripheral nervous system to guide the development of specific molecular therapies for immune-mediated inflammatory neuropathies compared to disorders such as psoriasis, inflammatory bowel disease, rheumatoid arthritis or multiple sclerosis. The recent isolation and characterization of human endoneurial endothelial cells that form the blood-nerve barrier provides an opportunity to elucidate leukocyte-endothelial cell interactions critical to the pathogenesis of inflammatory neuropathies at the interface between the systemic circulation and peripheral nerve endoneurium. This review discusses our current knowledge of the classic pathological features of inflammatory neuropathies, attempts at molecular classification and genetic determinants, the utilization of in vitro and in vivo animal models to determine pathogenic mechanisms at the interface between the systemic circulation and the peripheral nervous system relevant to these disorders and prospects for future potential molecular pathology biomarkers and targets for specific therapeutic intervention.
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Grimm A, Décard BF, Axer H, Fuhr P. The Ultrasound pattern sum score - UPSS. A new method to differentiate acute and subacute neuropathies using ultrasound of the peripheral nerves. Clin Neurophysiol 2015; 126:2216-25. [PMID: 25691156 DOI: 10.1016/j.clinph.2015.01.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 12/21/2014] [Accepted: 01/27/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Ultrasound differentiation of neuropathies is a great challenge. We, therefore, suggest a standardized score to operationalize differentiation between several acute and subacute onset neuropathies. METHOD We retrospectively analyzed the ultrasound data of 61 patients with acute or subacute neuropathies, e.g. chronic immune-mediated neuropathies, Guillain-Barré syndrome (GBS), and axonal/vasculitic neuropathies. We compared these data to 28 healthy controls. Based on these results an ultrasound pattern sum score (UPSS) with three sub-scores (UPS-A for the sensorimotor nerves, UPS-B for the cervical roots and the vagal nerve and UPS-C for the sural nerve) was developed. Afterwards, the applicability of the score was prospectively validated in 10 patients with chronic neuropathies and in 14 patients with unknown acute and subacute PNP before performing additional tests. RESULTS UPS-A and UPSS were significantly higher in CIDP than in other neuropathies and controls (p<0.001). UPS-B was significantly more often pathologic in GBS than in CIDP and other neuropathies (p<0.001). Using receiver operation characteristics curve analysis boundary values for each score were defined. Positive predictive value (PPV) of these scores for CIDP and GBS was >85%. Vasculitic neuropathies showed an intermediate type of UPSS compared to other axonal neuropathies (p<0.001). In the prospective application the pattern score could be used with good accuracy in several types of neuropathy. CONCLUSION UPS-A and UPSS operationalize to diagnose acute and subacute-onset CIDP and its variants with high sensitivity, specificity, and PPV. An increased UPS-B with normal UPSS and other sub scores may point to the diagnosis of GBS with high PPV and enables the differentiation from CIDP. SIGNIFICANCE Using the UPSS and its sub-scores gives a new diagnostic power to the method of the peripheral nerve ultrasound.
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Affiliation(s)
- Alexander Grimm
- Department of Neurology, Basel University Hospital, Basel, Switzerland.
| | - Bernhard F Décard
- Department of Neurology, Basel University Hospital, Basel, Switzerland
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Peter Fuhr
- Department of Neurology, Basel University Hospital, Basel, Switzerland
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Grimm A, Décard BF, Bischof A, Axer H. Ultrasound of the peripheral nerves in systemic vasculitic neuropathies. J Neurol Sci 2014; 347:44-9. [PMID: 25262016 DOI: 10.1016/j.jns.2014.09.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/05/2014] [Accepted: 09/12/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Ultrasound of the peripheral nerves (PNUS) can be used to visualize nerve pathologies in polyneuropathies (PNP). The aim of this study was to investigate, whether PNUS provides additional information in patients with proven systemic vasculitic neuropathies (VN). MATERIAL AND METHODS Systematic ultrasound measurements of several peripheral nerves, the vagal nerve and the 6th cervical nerve root were performed in 14 patients and 22 healthy controls. Nerve conduction studies of the corresponding nerves were undertaken. Finally, the measured results were compared to a study population of demyelinating immune-mediated and axonal neuropathies. RESULTS Patients with VN displayed significant smaller amplitudes of compound muscle action potentials (CMAP) (p<0.05) and sensory nerve action potentials (SNAP) compared to healthy controls, while conduction velocity did not differ between groups. The mean nerve cross-sectional areas (CSA) were increased in several peripheral nerves compared to the controls, most prominent in tibial and fibular nerve (p<0.01). PNUS revealed nerve enlargement in most of the clinically and electrophysiologically affected nerves (22 out of 31) in VN. Nerve enlargement was more often seen in vasculitic neuropathies than in other axonal neuropathies, but significantly rarer than in demyelinating neuropathies. CONCLUSION Focal CSA enlargement in one or more nerves in electrophysiologically axonal neuropathies can be a hint for VN and thus facilitate diagnostic and therapeutic procedures.
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Affiliation(s)
- Alexander Grimm
- Department of Neurology, Basel University Hospital, Switzerland; Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
| | | | - Antje Bischof
- Department of Neurology, Basel University Hospital, Switzerland; Clinical Immunology, Basel University Hospital Basel, Switzerland
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Sepsis Control and Care (CSCC), Jena University Hospital, Germany
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Ripellino P, Varrasi C, Maldi E, Cantello R. Peroneal nerve involvement as initial manifestation of primary systemic vasculitis. BMJ Case Rep 2014; 2014:bcr-2014-204084. [PMID: 24686810 DOI: 10.1136/bcr-2014-204084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of two patients with foot drop due to peroneal nerve infarct as early sign of two different forms of primary systemic vasculitides: a predominantly small-vessel p-antineutrophil cytoplasmic antibody-positive vasculitis (microscopic polyangiitis) and a predominantly medium-vessel vasculitis (polyarteritis nodosa).
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Affiliation(s)
- Paolo Ripellino
- Department of Neurology, University of Turin, AOU maggiore della Carità, Novara, Italy
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Abstract
The vasculitic neuropathies are a diverse group of disorders characterised by the acute-to-subacute onset of painful sensory and motor deficits that result from inflammatory destruction of nerve blood vessels and subsequent ischaemic injury. They are common in patients with primary systemic vasculitis and are seen in vasculitis secondary to disorders such as rheumatoid arthritis, viral infections, and diabetic inflammatory neuropathies. It is imperative that neurologists recognise these disorders to initiate treatment promptly and thereby prevent morbidity and mortality. To simplify the approach to patients with vasculitis of the peripheral nerves, a straightforward, dichotomous classification scheme can be used in which the vasculitic neuropathies are divided into two groups-nerve large arteriole vasculitis and nerve microvasculitis-on the basis of the size of the involved vessels. The size of the affected blood vessels correlates with the clinical course and prognosis in patients with vasculitic neuropathy.
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Abstract
Neuropathic disorders encompass those that affect the neuron's cell body or neuronopathies, those affecting the peripheral process, or peripheral neuropathies. The peripheral neuropathies can be broadly subdivided into the myelinopathies and axonopathies, conditions which can be hereditary or acquired. Each of these disorders has distinct clinical features that enable neurologists to recognize the various patterns of presentation. Once a particular pattern is established, further laboratory studies can be performed to support the clinical impression.
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Affiliation(s)
- Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 2012, Kansas City, KS 66160, USA.
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