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Kapoor M, Reddel SW. Ways to think about vasculitic neuropathy. Curr Opin Neurol 2024:00019052-990000000-00185. [PMID: 39046107 DOI: 10.1097/wco.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
PURPOSE OF REVIEW Vasculitis as a pathomechanism for neuropathy can be isolated to the peripheral nervous system, a part of a systemic autoimmune condition or a component of another syndrome. This review aims to discuss the broad range of diagnoses in which vasculitic neuropathy can be encountered, highlight the progress in imaging techniques in identifying vasculitis, and the new drugs developed for other autoimmune diseases that may be applied to neurological conditions. RECENT FINDINGS Advances in imaging modalities, ultrasound, MRI and FDG-PET scanning for neuromuscular applications has redefined many aspects of vasculitic neuropathies. The benefit of dividing vasculitides by vessel size is becoming less absolute as diagnostic approaches advance. MRI and FDG-PET are widely used in diagnosis, defining extent of involvement of disease and monitoring. In neuralgic amyotrophy, the identification of hourglass-like constrictions on imaging has changed the treatment paradigm to include surgical interventions. These diagnostic approaches are supported by new immunomodulating and immunosuppression techniques. SUMMARY Vasculitic neuropathies are a broad group of conditions with a range of causes and associations. Increased use of imaging techniques impacts our traditional definitions and classifications. The growth in treatment options for other autoimmune conditions are likely to infiltrate the neurological landscape.
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Affiliation(s)
- Mahima Kapoor
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Centre, Melbourne, Victoria
| | - Stephen W Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, Australia
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2
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Baima JPS, Silva BCG, Vieira VL, Meireles LP, Arai MH, Lino AMM. A great simulator in clinical practice: mononeuritis multiplex in HIV infection. Autops Case Rep 2024; 14:e2024493. [PMID: 39021464 PMCID: PMC11253905 DOI: 10.4322/acr.2024.493] [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] [Received: 08/05/2023] [Accepted: 04/21/2024] [Indexed: 07/20/2024]
Abstract
HIV infection is a chameleon, mimicking several diseases. Herein, we report a previously healthy 39-year-old woman who, over 2 months, developed arthritis, weight loss, and confluent multiple mononeuropathy. Extensive laboratory investigation showed positive serology for HIV, with a CD4 count of 100 cells, and necrotizing vasculitis on a nerve biopsy not associated with CMV co-infection, allowing the diagnosis of polyarteritis nodosa-like vasculitis in an HIV-infected patient. Apart from the infection, HIV-related autoimmunity can affect any organ and contribute to the complexity of the clinical presentation of HIV infection.
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Affiliation(s)
- José Pedro Soares Baima
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
| | - Beatriz Carneiro Gondim Silva
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
| | - Vanessa Lopes Vieira
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Luiz Pedro Meireles
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Milton Hideaki Arai
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Angelina Maria Martins Lino
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
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Mohamed AA, Caussat T, Mouhawasse E, Ali R, Johansen PM, Lucke-Wold B. Neurosurgical Intervention for Nerve and Muscle Biopsies. Diagnostics (Basel) 2024; 14:1169. [PMID: 38893695 PMCID: PMC11172125 DOI: 10.3390/diagnostics14111169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
(1) Background: Neurologic and musculoskeletal diseases represent a considerable portion of the underlying etiologies responsible for the widely prevalent symptoms of pain, weakness, numbness, and paresthesia. Because of the subjective and often nonspecific nature of these symptoms, different diagnostic modalities have been explored and utilized. (2) Methods: Literature review. (3) Results: Nerve and muscle biopsy remains the gold standard for diagnosing many of the responsible neurological and musculoskeletal conditions. However, the need for invasive tissue sampling is diminishing as more investigations explore alternative diagnostic modalities. Because of this, it is important to explore the current role of neurosurgical intervention for nerve and muscle biopsies and its current relevance in the diagnostic landscape of neurological and musculoskeletal disorders. With consideration of the role of nerve and muscle biopsy, it is also important to explore innovations and emerging techniques for conducting these procedures. This review explores the indications and emerging techniques for neurological intervention for nerve and muscle biopsies. (4) Conclusions: The role of neurosurgical intervention for nerve and muscle biopsy remains relevant in diagnosing many neurological and musculoskeletal disorders. Biopsy is especially relevant as a supportive point of evidence for diagnosis in atypical cases. Additionally, emerging techniques have been explored to guide diagnostics and biopsy, conduct less invasive biopsies, and reduce risks of worsening neurologic function and other symptoms secondary to biopsy.
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Affiliation(s)
- Ali A. Mohamed
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Thomas Caussat
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Edwin Mouhawasse
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Rifa Ali
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Phillip M. Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33613, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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4
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Wang S, A. A, Feinstein D, Traisak P, Eid H, Karpoff M. An Unusual Case of Peripheral Nerve Vasculitis. Case Rep Rheumatol 2024; 2024:3469182. [PMID: 38317741 PMCID: PMC10843867 DOI: 10.1155/2024/3469182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/08/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
Peripheral neuropathy is a common manifestation of systemic vasculitis. The etiology of vasculitic peripheral neuropathy is generally classified into two groups: systemic and nonsystemic. In systemic vasculitic neuropathy (SVN), neuropathy is a consequence of a systemic disease, most commonly involving medium and small vessels throughout the body. There are three main clinical presentations: multifocal neuropathy, distal symmetric polyneuropathy, and overlapping multifocal neuropathy. Specifically, distal symmetric polyneuropathy affects multiple somatic nerves diffusely in a symmetric and length-dependent pattern (also known as the classic stocking-glove pattern). This case represents an atypical presentation of SVN, presenting with widespread symmetric polyneuropathy.A 73-year-old woman presented with distal acute on chronic bilateral upper and lower extremity weakness, sensory changes, and widespread pain. Symptoms started about three months prior and gradually worsened with progressive difficulty with ambulation and required assistive devices. Elevated ESR is at 70 mm/hour, CRP at 25.66 mg/dL, elevated c-ANCA titers at 1 : 320 and PR3 at 5.0 AI, and elevated creatine kinase (CK) at 500-600 U/L. A muscle biopsy of the left vastus showed neurogenic atrophy without myositis. Initial improvement was with oral prednisone, but was stopped on discharge. Many purpuric and petechial lesions were developed on distal legs/feet and right fourth digit distal gangrene. EMG showed distal, symmetric, and axonal polyneuropathy affecting the upper and lower extremities and acute denervation in more distal muscles. The patient received pulse dose steroids and two doses of rituximab induction therapy and was discharged with an oral steroid taper. The patient's symptoms started as distal symmetric neuropathy at the onset and progressively worsened over the course of 3 months. Neuropathy, both on the exam and on EMG, seemed to have developed more rapidly than expected, regardless of its distribution. The EMG showed severe peripheral nerve damage and denervation, which is unusual for ANCA-associated systemic vasculitis.
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Affiliation(s)
- S. Wang
- Cooper University Health Care, Camden, NJ, USA
| | - Arsany A.
- Care Point Health, Jersey City, NJ, USA
| | - D. Feinstein
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - P. Traisak
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - H. Eid
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - M. Karpoff
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
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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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Kyle K, Hutto SK, Reda H, Zonozi R, Farhad K, Jeyabalan A, Chwalisz BK. Small fiber neuropathy associated with ANCA positivity: a case series and brief literature review. Neurol Sci 2023; 44:4473-4479. [PMID: 37453951 DOI: 10.1007/s10072-023-06954-y] [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] [Received: 03/02/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Small fiber neuropathy [SFN] is a common peripheral neurologic disorder with a vast array of implicated etiologies. It has previously been proposed that some forms of immune-mediated small fiber neuropathy are driven by vasculitis, though antinuclear cytoplasmic antibodies [ANCA] antibodies have not commonly been reported in association with SFN, thus far. We present this case series to discuss the observation of a possible novel association between ANCA and SFN. METHODS This is a retrospective case series of 6 patients with SFN and ANCA positivity, with and without systemic manifestations. Patients included were diagnosed with SFN by skin biopsy or autonomic function testing and were seropositive for ANCA by ELISA. RESULTS Six patients are outlined, including 4 females and 2 males. Antigen specific antibodies were MPO alone in 4 cases, PR3 alone in 1 case and both MPO and PR3 in 1 case. Systemic vasculitis was noted in 2 patients. Five patients received immunosuppression. Three patients experienced partial improvement, while symptoms stabilized in 3 patients. DISCUSSION This is the first series of patients with suspected immune-mediated SFN and ANCA antibody positivity, raising the possibility of ANCA mediated isolated SFN. This is in contradistinction to the more typical ANCA-mediated peripheral neuropathy manifestations of mononeuropathy multiplex or axonal sensorimotor neuropathy. We cannot unequivocally prove ANCA-associated vasculitis [AAV] causality in these cases; however, the stabilization in SFN symptomatology and associated improvement in ANCA antibody titer, after AAV treatment, may be indicative of an association.
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Affiliation(s)
- Kevin Kyle
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA.
| | - Spencer K Hutto
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Haatem Reda
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Reza Zonozi
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Khosro Farhad
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Boston, MA, 02114, USA
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Collins MP, Hadden RDM, Shahnoor N. Primary perineuritis, a rare but treatable neuropathy: Review of perineurial anatomy, clinicopathological features, and differential diagnosis. Muscle Nerve 2023; 68:696-713. [PMID: 37602939 DOI: 10.1002/mus.27949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 08/22/2023]
Abstract
The perineurium surrounds each fascicle in peripheral nerves, forming part of the blood-nerve barrier. We describe its normal anatomy and function. "Perineuritis" refers to both a nonspecific histopathological finding and more specific clinicopathological entity, primary perineuritis (PP). Patients with PP are often assumed to have nonsystemic vasculitic neuropathy until nerve biopsy is performed. We systematically reviewed the literature on PP and developed a differential diagnosis for histopathologically defined perineuritis. We searched PubMed, Embase, Scopus, and Web of Science for "perineuritis." We identified 20 cases (11 M/9F) of PP: progressive, unexplained neuropathy with biopsy showing perineuritis without vasculitis or other known predisposing condition. Patients ranged in age from 18 to 75 (mean 53.7) y and had symptoms 2-24 (median 4.5) mo before diagnosis. Neuropathy was usually sensory-motor (15/20), painful (18/19), multifocal (16/20), and distal-predominant (16/17) with legs more affected than arms. Truncal numbness occurred in 6/17; 10/18 had elevated cerebrospinal fluid (CSF) protein. Electromyography (EMG) and nerve conduction studies (NCS) demonstrated primarily axonal changes. Nerve biopsies showed T-cell-predominant inflammation, widening, and fibrosis of perineurium; infiltrates in epineurium in 10/20 and endoneurium in 7/20; and non-uniform axonal degeneration. Six had epithelioid cells. 19/20 received corticosteroids, 8 with additional immunomodulators; 18/19 improved. Two patients did not respond to intravenous immunoglobulin (IVIg). At final follow-up, 13/16 patients had mild and 2/16 moderate disability; 1/16 died. Secondary causes of perineuritis include leprosy, vasculitis, neurosarcoidosis, neuroborreliosis, neurolymphomatosis, toxic oil syndrome, eosinophilia-myalgia syndrome, and rarer conditions. PP appears to be an immune-mediated, corticosteroid-responsive disorder. It mimics nonsystemic vasculitic neuropathy. Cases with epithelioid cells might represent peripheral nervous system (PNS)-restricted forms of sarcoidosis.
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Affiliation(s)
- Michael P Collins
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Nazima Shahnoor
- Neuromuscular Pathology Laboratory, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Mansueto G, Lanza G, Falleti J, Orabona P, Alaouieh D, Hong E, Girolami S, Montella M, Fisicaro F, Galdieri A, Singh P, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes from Pathology to Bedside: Part 2-Peripheral Nervous System. Curr Neurol Neurosci Rep 2023; 23:83-107. [PMID: 36820992 PMCID: PMC9947450 DOI: 10.1007/s11910-023-01249-3] [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: 01/18/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Peripheral nervous system vasculitides (PNSV) are a heterogeneous group of disorders with a clinical subset that may differ in prognosis and therapy. We provide a comprehensive update on the clinical assessment, diagnosis, complications, treatment, and follow-up of PNSV. RECENT FINDINGS Progress in neuroimaging, molecular testing, and peripheral nerve biopsy has improved clinical assessment and decision-making of PNSV, also providing novel insights on how to prevent misdiagnosis and increase diagnostic certainty. Advances in imaging techniques, allowing to clearly display the vessel walls, have also enhanced the possibility to differentiate inflammatory from non-inflammatory vascular lesions, while recent histopathology data have identified the main morphological criteria for more accurate diagnosis and differential diagnoses. Overall, the identification of peculiar morphological findings tends to improve diagnostic accuracy by defining a clearer boundary between systemic and non-systemic neuropathies. Therefore, the definition of epineurium vessel wall damage, type of vascular lesion, characterization of lymphocyte populations, antibodies, and inflammatory factors, as well as the identification of direct nerve damage or degeneration, are the common goals for pathologists and clinicians, who will both benefit for data integration and findings translation. Nevertheless, to date, treatment is still largely empiric and, in some cases, unsatisfactory, thus often precluding precise prognostic prediction. In this context, new diagnostic techniques and multidisciplinary management will be essential in the proper diagnosis and prompt management of PNSV, as highlighted in the present review. Thirty to fifty percent of all patients with vasculitis have signs of polyneuropathy. Neuropathies associated with systemic vasculitis are best managed according to the guidelines of the underlying disease because appropriate workup and initiation of treatment can reduce morbidity. Steroids, or in severe or progressive cases, cyclophosphamide pulse therapy is the standard therapy in non-systemic vasculitic neuropathies. Some patients need long-term immunosuppression. The use of novel technologies for high-throughput genotyping will permit to determine the genetic influence of related phenotypes in patients with PNSV.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Piazza L. Miraglia 2, 80138, Naples, Italy.,Clinical Department of Laboratory Services and Public Health-Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy.,Pathology-Unit of Federico II University, Via S. Pansini 3, 80131, Naples, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.,Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Jessica Falleti
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | - Pasquale Orabona
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | | | - Emily Hong
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sara Girolami
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy
| | - Marco Montella
- Mental and Physical Health and Preventive Medicine Department, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Anna Galdieri
- AOU "Luigi Vanvitelli", Via Santa Maria Di Costantinopoli 104, 80138, Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, 147002, Punjab, India
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy.
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Duchesne M. [Nerve biopsy in the diagnosis of peripheral neuropathies]. Ann Pathol 2023; 43:83-95. [PMID: 36522247 DOI: 10.1016/j.annpat.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/22/2022] [Accepted: 11/01/2022] [Indexed: 12/15/2022]
Abstract
The indications for nerve biopsy have diminished in recent years. This examination nevertheless remains essential in certain cases of peripheral neuropathies, making it possible to specify the diagnosis or the mechanism of injury for a therapeutic purpose. It is a simple but "invasive" procedure, which can only be performed once on the same nerve. The indications are thus discussed on a case-by-case basis and based on a range of clinical, electrophysiological, biological or even genetic arguments. This involves close collaboration between clinical physicians and pathologists. The main difficulty of this biopsy concerns the fragility of the sample and the techniques necessary for its interpretation, requiring it to be carried out in expert centers. Nerve biopsy is closely related to skin biopsy in the search for small fiber neuropathy. It is a particular technique, but very well codified. The purpose of this review is to recall the indications and contraindications of nerve biopsy, and to explain what the contributions are but also the limits of this examination as well as of skin biopsy.
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Affiliation(s)
- Mathilde Duchesne
- Laboratoire de neurologie, CHU de Limoges, CHU de Dupuytren, Centre de référence neuropathies périphérique rares, 2, avenue Martin-Luther-King, 87000 Limoges, France; Service d'anatomo-pathologie, CHU de Dupuytren, bâtiment CBRS, rue du Professeur Descottes, 87000 Limoges, France.
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10
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [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: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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11
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Gisslander K, Dahlin LB, Smith R, Jayne D, O'Donovan DG, Mohammad AJ. The role of sural nerve biopsy in diagnosis of vasculitis. J Rheumatol 2022; 49:1031-1036. [PMID: 35649553 DOI: 10.3899/jrheum.211406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The diagnostic yield of sural nerve biopsy (SNB) in vasculitis is uncertain. Our aim was to document relevant characteristics of patients undergoing sural nerve biopsy in the investigation of vasculitis; determine the diagnostic yield; relate positive biopsy findings to patient demographic, laboratory, and clinical parameters; and to calculate the rate of surgical complications. METHODS Patients with suspected vasculitis that underwent SNB as part of diagnostic evaluation at academic medical centres in Sweden and the United Kingdom were identified by searching local pathology databases and clinic registers. A structured review of medical case records and pathology reports was conducted. Histological findings were categorized as definite, probable, or no vasculitis in accordance with the 2015 Brighton Collaboration reinterpretation and update of the Peripheral Nerve Society Guidelines for Vasculitic Neuropathy. Definite and probable findings were considered positive for vasculitis. RESULTS Ninety-one patients that underwent SNB were identified (45% female). Forty (44%) showed histological evidence of vasculitis: 14 definite and 26 probable. A concomitant muscle biopsy conducted in 10 patients did not contribute to the diagnostic yield. Positive antineutrophil cytoplasmic antibody test, organ involvement other than the nervous system, and a longer biopsy sample were associated with a positive biopsy. The reported surgical complication rate was 15%. CONCLUSION Sural nerve biopsy of sufficient length is an expedient procedure to confirm a diagnosis of vasculitis.
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Affiliation(s)
- Karl Gisslander
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Lars B Dahlin
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Rona Smith
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - David Jayne
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Dominic G O'Donovan
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Aladdin J Mohammad
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
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Mansueto G, Lanza G, Fisicaro F, Alaouieh D, Hong E, Girolami S, Montella M, Feola A, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes From Pathology to Bedside: Part 1-Central Nervous System. Curr Neurol Neurosci Rep 2022; 22:47-69. [PMID: 35138587 PMCID: PMC9056593 DOI: 10.1007/s11910-022-01172-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide a comprehensive update on the clinical assessment, diagnosis, complications, and treatment of primary central nervous system vasculitis (PCNSV). RECENT FINDINGS The developments in neuroimaging, molecular testing, and cerebral biopsy have enhanced clinical assessment and decision making, providing novel insights to prevent misdiagnosis increasing diagnostic certainty. Advances in imaging techniques visualizing the wall of intracranial vessels have improved the possibility to distinguish inflammatory from non-inflammatory vascular lesions. Large recent studies have revealed a more varied histopathological pictures and disclosed an association with amyloid angiopathy. Unfortunately, therapy remains largely empiric. PCNSV is a heterogeneous group of disorders encompassing different clinical subsets that may differ in terms of prognosis and therapy. Recent evidence has described a more benign course, with good response to therapy. New diagnostic techniques will play soon a pivotal role in the appropriate diagnosis and prompt management of PCNSV.
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Affiliation(s)
- Gelsomina Mansueto
- grid.9841.40000 0001 2200 8888Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania “Luigi Vanvitelli”, Piazza L. Miraglia 2, 80138 Naples, Italy
- grid.9841.40000 0001 2200 8888Clinical Department of Laboratory Services and Public Health—Legal Medicine Unit, University of Campania “Luigi Vanvitelli”, via Luciano Armanni 5, 80138 Naples, Italy
- grid.4691.a0000 0001 0790 385XPathology-Unit of Federico II University, via S. Pansini 3, 80131 Naples, Italy
| | - Giuseppe Lanza
- grid.8158.40000 0004 1757 1969Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
- grid.419843.30000 0001 1250 7659Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy
| | - Francesco Fisicaro
- grid.8158.40000 0004 1757 1969Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy
| | - Danielle Alaouieh
- grid.266832.b0000 0001 2188 8502School of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Emily Hong
- grid.266832.b0000 0001 2188 8502School of Medicine, University of New Mexico, Albuquerque, NM USA
| | - Sara Girolami
- grid.413811.eNeurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039 Sulmona, L’Aquila, Italy
| | - Marco Montella
- grid.9841.40000 0001 2200 8888Mental and Physical Health and Preventive Medicine Department, University of Campania “Luigi Vanvitelli”, via Luciano Armanni 5, 80138 Naples, Italy
| | - Alessandro Feola
- Department Experimental Medicine, University of Campania, 80138 Naples, Italy
| | - Mario Di Napoli
- grid.413811.eNeurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039 Sulmona, L’Aquila, Italy
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Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
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Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
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14
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Doherty L, Chaudhry V. Inpatient Diagnosis and Management of Neuromuscular Disorders. Semin Neurol 2021; 41:493-510. [PMID: 34619777 DOI: 10.1055/s-0041-1733794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although many neuromuscular conditions are evaluated on an outpatient basis owing to their chronic or progressive nature, more urgent evaluation and management is often required for the inpatient presenting with acute to subacute focal or generalized numbness or weakness. This review focuses on clinical pattern recognition and basic anatomic localization principles to aid in the identification of common, as well as some less frequently encountered, neuromuscular disorders in hospitalized patients. The characteristic clinical and diagnostic features, associated complications, and recommended treatments of key neuromuscular conditions with acute and subacute manifestations are discussed. These conditions can be life-threatening in some cases, such as in Guillain-Barré syndrome, owing to associated oropharyngeal weakness, respiratory failure, or marked dysautonomia. Prompt recognition of the clinical and pathologic features is therefore necessary to reduce associated morbidity and mortality.
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Affiliation(s)
- Leana Doherty
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vinay Chaudhry
- Department of Neurology, Division of Neuromuscular Medicine, University of North Carolina School of Medicine Chapel Hill, North Carolina
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15
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Nathani D, Spies J, Barnett MH, Pollard J, Wang M, Sommer C, Kiernan MC. Nerve biopsy: Current indications and decision tools. Muscle Nerve 2021; 64:125-139. [PMID: 33629393 PMCID: PMC8359441 DOI: 10.1002/mus.27201] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023]
Abstract
After initial investigation of patients presenting with symptoms suggestive of neuropathy, a clinical decision is made for a minority of patients to undergo further assessment with nerve biopsy. Many nerve biopsies do not demonstrate a definitive pathological diagnosis and there is considerable cost and morbidity associated with the procedure. This highlights the need for appropriate selection of patients, nerves and neuropathology techniques. Additionally, concomitant muscle and skin biopsies may improve the diagnostic yield in some cases. Several advances have been made in diagnostics in recent years, particularly in genomics. The indications for nerve biopsy have consequently changed over time. This review explores the current indications for nerve biopsies and some of the issues surrounding its use. Also included are comments on alternative diagnostic modalities that may help to supplant or reduce the use of nerve biopsy as a diagnostic test. These primarily include extraneural biopsy and neuroimaging techniques such as magnetic resonance neurography and nerve ultrasound. Finally, we propose an algorithm to assist in deciding when to perform nerve biopsies.
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Affiliation(s)
- Dev Nathani
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Judith Spies
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Michael H. Barnett
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - John Pollard
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Min‐Xia Wang
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Claudia Sommer
- Neurologische KlinikUniversitätsklinikum WürzburgWürzburgGermany
| | - Matthew C. Kiernan
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
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16
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London ZN. A Structured Approach to the Diagnosis of Peripheral Nervous System Disorders. ACTA ACUST UNITED AC 2021; 26:1130-1160. [PMID: 33002996 DOI: 10.1212/con.0000000000000922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Neuroanatomic localization and pattern recognition can be used to diagnose both focal lesions and generalized disorders of the peripheral nervous system. This article describes the nature and pattern of sensory and motor deficits associated with lesions of specific spinal nerve roots, plexus, or peripheral nerves. It also describes the patterns of sensory and motor deficits that suggest multifocal or generalized disorders of the motor neurons, sensory neurons, and peripheral nerves. RECENT FINDINGS The pattern of sensory and motor deficits may be used to distinguish lesions of the peripheral nervous system from those of the central nervous system. The spinal roots, nerve plexus, and peripheral nerves supply specific muscles and receive sensory input from distinctive cutaneous regions. Focal lesions of these structures therefore produce characteristic patterns of sensory and motor deficits. Multifocal or generalized disorders of the peripheral nervous system may be distinguished by categorizing their sensory and motor involvement, proximal and distal predominance, and degree of symmetry. Serum tests, CSF analysis, electrodiagnostic studies, MRI, ultrasound, nerve biopsy, and skin biopsy have unique roles in the diagnosis of suspected neuromuscular disorders. SUMMARY A structured approach to the diagnosis of nerve and motor neuron disorders can lead to hypothesis-driven diagnostic testing. Ancillary tests should be reserved for cases in which confirming or refuting a diagnosis will change patient management.
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Chang SH, Wang J, Zhang X, Zhao N, Jia K, Yi M, Zhang QX, Zhai H, Li XW, Yang CS, Yang L, Zhang LJ. The prevalence of anti-neurofascin-155 antibodies in patients with neuromyelitis optica spectrum disorders. Clin Exp Immunol 2021; 206:1-11. [PMID: 33998675 DOI: 10.1111/cei.13617] [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: 12/23/2020] [Revised: 04/23/2021] [Accepted: 05/12/2021] [Indexed: 12/30/2022] Open
Abstract
Anti-neurofascin-155 (NF155) antibodies have been observed in two cases with neuromyelitis optica spectrum disorders (NMOSD). This study investigated the prevalence of anti-NF155 antibodies in patients with NMOSD and the clinical features of anti-NF155 antibody-positive patients. Sera from 129 patients with NMOSD were screened with anti-NF155 antibodies by cell-based assay (CBA) and re-examined using immunostaining of teased mouse sciatic nerve fibres. Fifty-six patients with multiple sclerosis (MS) and 50 healthy controls (HC) were also enrolled for detecting anti-NF155 antibodies. A total of 12.40% (16 of 129) of patients with NMOSD were positive for anti-NF155 antibodies confirmed by both CBA and immunostaining. Immunoglobulin (Ig) G1 was the predominant subclass. However, none of 56 MS patients or 50 HC were positive for anti-NF155 antibodies. Anti-NF155 antibody-positive NMOSD patients had a higher proportion of co-existing with autoimmune diseases (p < 0.001) and higher positive rates of serum non-organ-specific autoantibodies, including anti-SSA antibodies (p < 0.001), anti-SSB antibodies (p = 0.008), anti-Ro-52 antibodies (p < 0.001) and rheumatoid factor (p < 0.001). Five anti-NF155 antibody-positive NMOSD patients who took part in the nerve conduction study showed mildly abnormal results. Differences in some nerve conduction study parameters were observed between anti-NF155 antibody-positive and negative patients. Anti-NF155 antibodies occurred in a small proportion of NMOSD patients. Anti-NF155 antibody-positive NMOSD patients tended to co-exist with autoimmune diseases.
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Affiliation(s)
- Sheng-Hui Chang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing Wang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xu Zhang
- Translational Neuroscience Center, Graduate School of Medicine, International University of Health and Welfare, Okawa, Japan
| | - Ning Zhao
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Kun Jia
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Ming Yi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiu-Xia Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Hui Zhai
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiao-Wen Li
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Chun-Sheng Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Li Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lin-Jie Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
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Trikamji B, Pestronk A. Treatable, motor-sensory, axonal neuropathies with C5b-9 complement on endoneurial microvessels. Muscle Nerve 2021; 63:506-515. [PMID: 33346931 DOI: 10.1002/mus.27155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Identification and treatment of immune-mediated polyneuropathies may lead to improved strength and function. We studied the clinical and laboratory features, and treatment response, in patients with motor-sensory axonal polyneuropathies who were found to have C5b-9 complement staining on endoneurial microvessels. METHODS Retrospective review of 16 consecutive adults with motor-sensory axonal polyneuropathies who were then found to have C5b-9 staining of endoneurial microvessels on nerve biopsy, and subsequently treated with intravenous corticosteroids (1 g methylprednisolone for 5 consecutive days, and then weekly). Strength measurements were done using quantitative handheld dynamometry. Nerve biopsy analysis included frozen and fixed tissue. RESULTS Patients (mean onset age, 59 ± 4 years; range, 34-83 years; 12 of 16 were males; 9 of 16 had diabetes) had progressive (median duration, 2 years), asymmetric, distal weakness, in the lower extremities (16 of 16) and/or upper extremities (7 of 16), and panmodal sensory loss. Electrodiagnostic studies showed axon loss. Nerve pathology showed abnormal C5b-9 staining on endoneurial microvessels. Axon loss was present in all nerves, often varied among fascicles. Inflammation was uncommon. Distal strength usually improved (mean improvement of 34 ± 6% of normal strength; P = .0003) with corticosteroid treatment. DISCUSSION Motor-sensory axonal polyneuropathies having noninflammatory, humoral immune pathology with C5b-9 staining of endoneurial microvessels (HIEM) frequently manifest progressive asymmetric, distal, lower extremity with or without upper extremity weakness that improves rapidly during corticosteroid treatment. HIEM may represent a new class of noninflammatory-vasculopathic, treatable axonal motor-sensory neuropathies.
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Affiliation(s)
- Bhavesh Trikamji
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Alan Pestronk
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri, USA
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19
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Chkheidze R, Pytel P. What Every Neuropathologist Needs to Know: Peripheral Nerve Biopsy. J Neuropathol Exp Neurol 2020; 79:355-364. [PMID: 32167544 DOI: 10.1093/jnen/nlaa012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Peripheral neuropathy is a common disorder with many possible etiologies including metabolic diseases, inflammatory conditions, infections, malignancy, inherited diseases, drugs, and toxins. In most instances, diagnosis and treatment plan can be established based on clinical presentation, family history, laboratory results, genetic testing, and electrophysiological studies. But in some situations, a peripheral nerve biopsy remains a valuable tool. This is especially true in patients with rapidly progressive disease, with atypical presentation or for whom other approaches fail to yield a definitive diagnosis. The pathologic examination starts with basic decisions about specimen triage. A few basic questions help to provide an initial framework for the assessment of a nerve biopsy-is the specimen adequate; are there inflammatory changes; are there vascular changes; is there amyloid; are there changes to axonal density and the Schwann cell-myelin-axon unit. In the appropriate context and with such an approach peripheral nerve biopsies can still represent a clinically helpful test.
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Affiliation(s)
- Rati Chkheidze
- From the Department of Pathology, UT Southwestern Medical Center, Dallas, Texas
| | - Peter Pytel
- Department of Pathology, University of Chicago, Chicago, Illinois
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20
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Abstract
The immune-mediated neuropathies are a broad category of diseases differentiated by time course, affected nerve fibers, and disease associations. This article spans the common, well-defined inflammatory demyelinating polyradiculoneuropathies (Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy) to the rarer, acquired demyelinating neuropathy variants (Miller-Fisher syndrome and multifocal motor neuropathy), vasculitic neuropathies, and sensory neuronopathies (dorsal root ganglionopathies). These case studies illustrate the characteristic clinical patterns of the immune-mediated neuropathies encountered in neurologic practice. Recommendations for diagnostic evaluation and treatment approach accompany each case. Prompt recognition of these disorders is imperative; delays in treatment may result in prolonged morbidity and permanent disability.
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Nichols L, Karivelil MJ. Vasculitis with a neuromuscular presentation and associated cancer revealed by autopsy. AUTOPSY AND CASE REPORTS 2020; 10:e2020175. [PMID: 33344289 PMCID: PMC7703305 DOI: 10.4322/acr.2020.175] [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: 11/23/2022] Open
Abstract
Peripheral neuropathy is common, but rarely due to vasculitis. This report is the case of a 74-year-old woman with systemic vasculitis who presented with progressive arm and leg weakness associated with numbness. Autopsy revealed a colon cancer, which may have triggered the vasculitis. This case illustrates the association between vasculitis and malignancy. The best treatment of vasculitis in patients with cancer-associated vasculitis is usually treatment of the cancer, which often yields remission of the vasculitis. This case also illustrates the difficulty of suspecting vasculitis since the symptoms and signs are nonspecific and protean. It is important not to miss a diagnosis of vasculitis. It is often life-threatening. It is treatable. The critical step in the diagnosis of vasculitis is to think of it.
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Affiliation(s)
- Larry Nichols
- Mercer University School of Medicine, Department of Pathology. Macon, GA, United States of America
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22
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[Polyneuropathies in vasculitis and connective tissue diseases : Clinical manifestations and diagnostic recommendations]. Internist (Berl) 2020; 61:261-269. [PMID: 32072188 DOI: 10.1007/s00108-020-00755-7] [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: 10/25/2022]
Abstract
Vasculitic neuropathies result from inflammation of the vasa nervorum followed by ischemia and destruction of the peripheral nerve. The inflammation can be systemic or localized, i.e. non-systemic. Systemic vasculitis can be divided into primary and secondary forms. The latter is associated with, e.g. connective tissue diseases, infections, cancer or induced by certain drugs. Around two thirds of patients with systemic vasculitis develop vasculitic neuropathy presenting as characteristic painful, multifocal mononeuropathy of acute onset. The group of non-systemic neuropathies has grown in recent years with the addition of diabetic and non-diabetic lumbosacral radiculoplexus neuropathies, among others. Within the group of connective tissue diseases, other non-vasculitic neuropathies can occur as nerve-entrapment syndromes and sensory ataxic neuropathy. The aim of this article is to present a condensed overview of neuropathies associated with vasculitis and connective tissue diseases and to communicate characteristic clinical symptoms supporting rapid diagnostic and therapeutic procedures.
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Mullin E, Aristotelidou V, Blackburn D, Jenkins T, Hadjivassiliou M. Cognitive deficits in vasculitis of the nervous system: a cross-sectional study. Postgrad Med 2019; 131:546-549. [PMID: 31483199 DOI: 10.1080/00325481.2019.1664256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: To identify the cognitive and functional deficits in a well-characterized group of patients with vasculitis of the nervous system. Methods: Sixty-seven patients diagnosed with Central Nervous System (CNS) or Peripheral nervous System (PNS) vasculitis over a 14-year period were retrospectively identified. Data on clinical presentation, laboratory, radiographic and tissue biopsy investigations, and treatment were collated. Cognitive, functional and quality of life evaluation assessments were performed in 31 patients who agreed to participate and included Addenbrooke's Cognitive Examination-revised (ACE-R), Nottingham Extended Activities of Daily Living (NEADL) and EQ-5D-3L quality of life questionnaires. Results: CNS vasculitis patients exhibited cognitive impairment, with a mean ACE-R score of 74/100 (standard deviation (SD) 16). NEADL and EQ-5D-3L scores were in the impaired range at 41/66 (SD 21) and 57/81 (SD 22), respectively. Patients with just PNS vasculitis exhibited fewer cognitive deficits with ACE-R and NEADL scores of 87 (SD 8) and 46 (SD 16) respectively. EQ-5D-3L score was in the impaired range of 65 (SD 22). Conclusions: Vasculitis of the nervous system and, in particular, CNS vasculitis causes cognitive impairment and deficits in functional ability. Such patients should be targeted for cognitive rehabilitation.
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Affiliation(s)
- Edward Mullin
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK
| | | | - Daniel Blackburn
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
| | - Thomas Jenkins
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
| | - Marios Hadjivassiliou
- Sheffield Institute for Translational Neuroscience and Department of Neurosciences, University of Sheffield , Sheffield , UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital , Sheffield , UK
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