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Conceição I. Early diagnosis in ATTRv amyloidosis, how early is enough? How early is possible? Med Clin (Barc) 2024; 162:e70-e73. [PMID: 38614903 DOI: 10.1016/j.medcli.2024.02.013] [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: 10/03/2023] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 04/15/2024]
Abstract
Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is a rare, progressive, and debilitating genetic disorder characterized by the deposition of abnormal transthyretin (TTR) protein aggregates in various tissues, leading to organ dysfunction. Early diagnosis of ATTRv amyloidosis is critical for starting timely interventions and improving patient outcomes. This review explores the concepts of "how early is enough" and "how early is possible" in the context of diagnosing ATTRv amyloidosis, highlighting the challenges and opportunities for early recognition.
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Affiliation(s)
- Isabel Conceição
- Departamento de Neurociências e Saúde Mental, Unidade Local de Saúde de Santa Maria, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal.
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2
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Beauvais D, Labeyrie C, Cauquil C, Francou B, Eliahou L, Not A, Echaniz-Laguna A, Adam C, Slama MS, Benmalek A, Leonardi L, Rouzet F, Adams D, Algalarrondo V, Beaudonnet G. Detailed clinical, physiological and pathological phenotyping can impact access to disease-modifying treatments in ATTR carriers. J Neurol Neurosurg Psychiatry 2024; 95:489-499. [PMID: 37875336 PMCID: PMC11103288 DOI: 10.1136/jnnp-2023-332180] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/27/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis is a life-threatening autosomal dominant systemic disease due to pathogenic TTR variants (ATTRv), mostly affecting the peripheral nerves and heart. The disease is characterised by a combination of symptoms, organ involvement and histological amyloid deposition. The available disease-modifying ATTRv treatments (DMTs) are more effective if initiated early. Pathological nerve conduction studies (NCS) results are the cornerstone of large-fibre polyneuropathy diagnosis, but this anomaly occurs late in the disease. We investigated the utility of a multimodal neurological and cardiac evaluation for detecting early disease onset in ATTRv carriers. METHODS We retrospectively analysed a cohort of ATTRv carriers with normal NCS results regardless of symptoms. Multimodal denervation and infiltration evaluations included a clinical questionnaire (Lauria and New York Heart Association (NYHA)) and examination, intra-epidermal nerve fibre density assessment, autonomic assessment based on heart rate variability, Sudoscan, meta-iodo-benzyl-guanidine scintigraphy, cardiac biomarkers, echocardiography, MRI and searches for amyloidosis on skin biopsy and bone scintigraphy. RESULTS We included 130 ATTRv carriers (40.8% men, age: 43.6±13.5 years), with 18 amyloidogenic TTR gene mutations, the majority of which was the late-onset Val30Met variant (42.3%). Amyloidosis was detected in 16.9% of mutation carriers, including 9 (6.9%) with overt disease (Lauria>2 or NYHA>1) and 13 asymptomatic carriers (10%) with organ involvement (small-fibre neuropathy or cardiomyopathy). Most of these patients received DMT. Abnormal test results of unknown significance were obtained for 105 carriers (80.8%). Investigations were normal in only three carriers (2.3%). CONCLUSIONS Multimodal neurological and cardiac investigation of TTRv carriers is crucial for the early detection of ATTRv amyloidosis and initiation of DMT.
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Affiliation(s)
- Diane Beauvais
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Department of Neurology (Nerve-Muscle Unit), AOC National Reference Center for Neuromuscular Disorders, University Hospital of Bordeaux (CHU Pellegrin), Bordeaux, France
| | - Céline Labeyrie
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Cécile Cauquil
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Bruno Francou
- AP-HP, Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Adeline Not
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
| | - Andoni Echaniz-Laguna
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Université de Paris-Saclay, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Clovis Adam
- AP-HP, Service d'Anatomopathologie Clinique, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Michel S Slama
- AP-HP, Département de Cardiologie, CHU Bichat, Paris, France
| | - Anouar Benmalek
- Faculté de Pharmacie, Université Paris-Saclay, Gif-sur-Yvette, France
| | - Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sant'Andrea Hospital, Sapienza University of Rome, Roma, Italy
| | - François Rouzet
- AP-HP, Service de Médecine nucléaire, CHU Bichat, Paris, France
| | - David Adams
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- Université de Paris-Saclay, INSERM U1195, Le Kremlin-Bicêtre, France
| | - Vincent Algalarrondo
- AP-HP, Département de Cardiologie, CHU Bichat, Paris, France
- Université Paris Cité, Paris, France
| | - Guillemette Beaudonnet
- AP-HP, Service de neurologie, CHU Bicêtre, Centre de référence national des neuropathies amyloïdes familiales et autres neuropathies périphériques rares, CERAMIC, FILNEMUS Network, Le Kremlin-Bicêtre, France
- AP-HP, Unité de Neurophysiologie Clinique et Epileptologie (UNCE), CHU Bicêtre, Le Kremlin-Bicêtre, France
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Karam C, Mauermann ML, Gonzalez-Duarte A, Kaku MC, Ajroud-Driss S, Brannagan TH, Polydefkis M. Diagnosis and treatment of hereditary transthyretin amyloidosis with polyneuropathy in the United States: Recommendations from a panel of experts. Muscle Nerve 2024; 69:273-287. [PMID: 38174864 DOI: 10.1002/mus.28026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024]
Abstract
Hereditary transthyretin (ATTRv; v for variant) amyloidosis is a rare, multisystem, progressive, and fatal disease in which polyneuropathy is a cardinal manifestation. Due to a lack of United States (US)-specific guidance on ATTRv amyloidosis with polyneuropathy, a panel of US-based expert clinicians convened to address identification, monitoring, and treatment of this disease. ATTRv amyloidosis with polyneuropathy should be suspected in unexplained progressive neuropathy, especially if associated with systemic symptoms or family history. The diagnosis is confirmed through genetic testing, biopsy, or cardiac technetium-based scintigraphy. Treatment should be initiated as soon as possible after diagnosis, with gene-silencing therapeutics recommended as a first-line option. Consensus is lacking on what represents "disease progression" during treatment; however, the aggressive natural history of this disease should be considered when evaluating the effectiveness of any therapy.
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Affiliation(s)
- Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Alejandra Gonzalez-Duarte
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| | - Michelle C Kaku
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Senda Ajroud-Driss
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Thomas H Brannagan
- Department of Neurology, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Michael Polydefkis
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Thimm A, Carpinteiro A, Oubari S, Papathanasiou M, Kessler L, Rischpler C, Malik RA, Herrmann K, Reinhardt HC, Rassaf T, Kleinschnitz C, Hagenacker T, Stettner M. Corneal confocal microscopy identifies corneal nerve loss and increased Langerhans cells in presymptomatic carriers and patients with hereditary transthyretin amyloidosis. J Neurol 2023:10.1007/s00415-023-11689-z. [PMID: 37014422 DOI: 10.1007/s00415-023-11689-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is a rare, but life-threatening protein misfolding disorder due to TTR gene mutations. Cardiomyopathy (ATTRv-CM) and polyneuropathy (ATTRv-PN) with early small nerve fibre involvement are the most common manifestations. Timely diagnosis and treatment initiation are key to limiting progression of disease. Corneal confocal microscopy (CCM) is a non-invasive method to quantify corneal small nerve fibres and immune cell infiltrates in vivo. METHODS This cross-sectional study investigated the utility of CCM in 20 patients with ATTRv amyloidosis (ATTRv-CM, n = 6; ATTRv-PN, n = 14) and presymptomatic carriers (n = 5) compared to 20 age- and sex-matched healthy controls. Corneal nerve fibre density, corneal nerve fibre length, corneal nerve branch density, and cell infiltrates were assessed. RESULTS Corneal nerve fibre density and nerve fibre length were significantly lower in patients with ATTRv amyloidosis compared to healthy controls regardless of the clinical phenotype (ATTRv-CM, ATTRv-PN) and corneal nerve fibre density was significantly lower in presymptomatic carriers. Immune cell infiltrates were only evident in patients with ATTRv amyloidosis, which correlated with reduced corneal nerve fibre density. CONCLUSIONS CCM identifies small nerve fibre damage in presymptomatic carriers and symptomatic patients with ATTRv amyloidosis and may serve as a predictive surrogate marker to identify individuals at risk of developing symptomatic amyloidosis. Furthermore, increased corneal cell infiltration suggests an immune-mediated mechanism in the pathogenesis of amyloid neuropathy.
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Affiliation(s)
- Andreas Thimm
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany.
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
- Institute of Molecular Biology, University of Duisburg-Essen, Essen, Germany
| | - Sara Oubari
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | | | - Rayaz Ahmed Malik
- Institute of Cardiovascular Science, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
- Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Hans Christian Reinhardt
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
| | - Mark Stettner
- Department of Neurology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Center for Translational Neuro- and Behavioral Scienes (C-TNBS), University Hospital Essen, Essen, Germany
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Tozza S, Severi D, Palumbo G, Provitera V, Ruggiero L, Dubbioso R, Iodice R, Nolano M, Manganelli F. Quantitative Sensory Testing in Late-Onset ATTRv Presymptomatic Subjects: A Single Center Experience. Biomedicines 2022; 10:2877. [PMID: 36359398 PMCID: PMC9687694 DOI: 10.3390/biomedicines10112877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2023] Open
Abstract
Backgrounds Hereditary transthyretin amyloidosis (ATTRv) presymptomatic subjects undergo multidisciplinary evaluation to detect, as early as possible, a subclinical involvement of multisystem disease. Quantitative sensory testing (QST) that investigates and discriminates the function of C, Aδ and Aβ fibers is included as an instrumental test to monitor nerve fiber function. The purpose of this study was to evaluate the role of QST in the context of the multidisciplinary evaluation in late onset carriers. Methods Four-teen presymptomatic (namely carriers) were enrolled. Subjects underwent thermal [cold and warm detection threshold (CDT, WDT), cold and heat pain (CP and HP)] and tactile QST in four body sites: foot dorsum, distal lateral leg, distal thigh, hand dorsum. Results Overall, presymptomatic subject showed a significant difference in all thermal QST findings compared to the control group. All subjects had at least one altered thermal QST finding; the sites more frequently altered were foot and leg, whilst the thermal modalities which were more frequently abnormal were CDT, WDT and CP. Conclusions Our study highlights the importance of performing thermal QST in subjects carrying TTR mutation, given the high frequency of abnormal findings. Notably, performing both innocuous and painful stimulation in foot and/or leg increases the chance of detecting nerve fiber dysfunction. Moreover, the investigation of the hand may provide useful information in monitoring disease progression before the Predicted Age of Disease Onset (PADO).
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Affiliation(s)
- Stefano Tozza
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Daniele Severi
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Giovanni Palumbo
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Vincenzo Provitera
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, 82037 Telese Terme, Italy
| | - Lucia Ruggiero
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Raffaele Dubbioso
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Rosa Iodice
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
| | - Maria Nolano
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, 82037 Telese Terme, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Science and Odonstomatology, University “Federico II”, 80131 Naples, Italy
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Leonardi L, Adam C, Beaudonnet G, Beauvais D, Cauquil C, Not A, Morassi O, Benmalek A, Trassard O, Echaniz-Laguna A, Adams D, Labeyrie C. Skin amyloid deposits and nerve fiber loss as markers of neuropathy onset and progression in hereditary transthyretin amyloidosis. Eur J Neurol 2022; 29:1477-1487. [PMID: 35100482 DOI: 10.1111/ene.15268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess skin biopsy as marker of disease onset and severity in hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN), a treatable disease. METHODS In this single center retrospective study, skin Congo red staining and intraepidermal nerve fiber density (IENFD) were evaluated in symptomatic ATTRv-PN patients and asymptomatic TTR gene mutation carriers between 2012 and 2019. Non-ATTRv subjects with small fiber neuropathy suspicion who underwent skin biopsy in the same timespan were used as controls. RESULTS One-hundred-eighty-three symptomatic ATTRv-PN, 36 asymptomatic carriers, and 537 non-ATTRv patients were included. Skin biopsy demonstrated amyloid depositions in 80% of the 183 symptomatic cases. Skin amyloid deposits were found in 75% of early-stage ATTRv-PN patients, and in 14% of asymptomatic carriers. All 183 symptomatic and 34/36 asymptomatic patients displayed decreased ankle IENFD with a proximal-distal gradient distribution, and reduced IEFND correlated with disease severity and duration. CONCLUSIONS Our study demonstrates skin amyloid deposits are a marker of ATTRv-PN disease onset, and decreased IENFD a marker of disease progression. These results are of major importance for the early identification of ATTRv-PN patients in need of disease-modifying treatments.
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Affiliation(s)
- Luca Leonardi
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Clovis Adam
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,University Paris-Saclay, INSERM U 1195, 94270, Le Kremlin Bicêtre, France.,Pathology Department, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Guillemette Beaudonnet
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,Neurophysiology and Epileptology Department, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Diane Beauvais
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Cécile Cauquil
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Adeline Not
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Olivier Morassi
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Anouar Benmalek
- School of Pharmacy, University Paris-Saclay, Châtenay-Malabry, France
| | - Olivier Trassard
- Pathology Department, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
| | - Andoni Echaniz-Laguna
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,University Paris-Saclay, INSERM U 1195, 94270, Le Kremlin Bicêtre, France
| | - David Adams
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,University Paris-Saclay, INSERM U 1195, 94270, Le Kremlin Bicêtre, France
| | - Céline Labeyrie
- Referral Center for Familial Amyloid Polyneuropathy and other rare peripheral neuropathies (NNERF), Department of Neurology, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France.,University Paris-Saclay, INSERM U 1195, 94270, Le Kremlin Bicêtre, France.,Pathology Department, Bicêtre University Hospital, AP-HP, 94270, Le Kremlin Bicêtre, France
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Bekircan-Kurt CE, Yilmaz E, Arslan D, Yildiz FG, Dikmetas Ö, Ergul-Ulger Z, Kocabeyoglu S, Irkec M, Hekimsoy V, Tokgozoglu L, Tan E, Erdem-Ozdamar S. The functional and structural evaluation of small fibers in asymptomatic carriers of p.Val50Met (Val30Met) mutation. Neuromuscul Disord 2021; 32:50-56. [PMID: 34980537 DOI: 10.1016/j.nmd.2021.11.013] [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] [Received: 07/09/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 01/14/2023]
Abstract
Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-PN patients' family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.
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Affiliation(s)
- Can Ebru Bekircan-Kurt
- Hacettepe University, Department of Neurology, Neuromuscular Diseases Research Laboratory, Ankara, Turkey.
| | - Ezgi Yilmaz
- Hacettepe University, Department of Neurology, Ankara, Turkey
| | - Doruk Arslan
- Hacettepe University, Department of Neurology, Ankara, Turkey
| | | | - Özlem Dikmetas
- Hacettepe University, Department of Ophthalmology, Ankara, Turkey
| | - Zeynep Ergul-Ulger
- Hacettepe University, Department of Neurology, Neuromuscular Diseases Research Laboratory, Ankara, Turkey
| | | | - Murat Irkec
- Hacettepe University, Department of Ophthalmology, Ankara, Turkey
| | - Vedat Hekimsoy
- Hacettepe University, Department of Cardiology, Ankara, Turkey
| | - Lale Tokgozoglu
- Hacettepe University, Department of Cardiology, Ankara, Turkey
| | - Ersin Tan
- Hacettepe University, Department of Neurology, Neuromuscular Diseases Research Laboratory, Ankara, Turkey
| | - Sevim Erdem-Ozdamar
- Hacettepe University, Department of Neurology, Neuromuscular Diseases Research Laboratory, Ankara, Turkey
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8
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A circulating, disease-specific, mechanism-linked biomarker for ATTR polyneuropathy diagnosis and response to therapy prediction. Proc Natl Acad Sci U S A 2021; 118:2016072118. [PMID: 33597308 DOI: 10.1073/pnas.2016072118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The transthyretin (TTR) amyloidoses (ATTR) are progressive, degenerative diseases resulting from dissociation of the TTR tetramer to monomers, which subsequently misfold and aggregate, forming a spectrum of aggregate structures including oligomers and amyloid fibrils. To determine whether circulating nonnative TTR (NNTTR) levels correlate with the clinical status of patients with V30M TTR familial amyloid polyneuropathy (FAP), we quantified plasma NNTTR using a newly developed sandwich enzyme-linked immunosorbent assay. The assay detected significant plasma levels of NNTTR in most presymptomatic V30M TTR carriers and in all FAP patients. NNTTR was not detected in age-matched control plasmas or in subjects with other peripheral neuropathies, suggesting NNTTR can be useful in diagnosing FAP. NNTTR levels were substantially reduced in patients receiving approved FAP disease-modifying therapies (e.g., the TTR stabilizer tafamidis, 20 mg once daily). This NNTTR decrease was seen in both the responders (average reduction 56.4 ± 4.2%; n = 49) and nonresponders (average reduction of 63.3 ± 4.8%; n = 32) at 12 mo posttreatment. Notably, high pretreatment NNTTR levels were associated with a significantly lower likelihood of clinical response to tafamidis. Our data suggest that NNTTR is a disease driver whose reduction is sufficient to ameliorate FAP so long as pretreatment NNTTR levels are below a critical clinical threshold.
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9
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Akinboboye O, Shah K, Warner AL, Damy T, Taylor HA, Gollob J, Powell C, Karsten V, Vest J, Maurer MS. DISCOVERY: prevalence of transthyretin ( TTR) mutations in a US-centric patient population suspected of having cardiac amyloidosis. Amyloid 2020; 27:223-230. [PMID: 32456532 DOI: 10.1080/13506129.2020.1764928] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hereditary transthyretin-mediated amyloidosis (hATTR amyloidosis) is a multisystem disease that presents with polyneuropathy and/or cardiomyopathy. METHODS DISCOVERY, a multicenter screening study, enrolled patients with clinically suspected cardiac amyloidosis to determine the frequency of transthyretin (TTR) mutations and assess disease characteristics. RESULTS Of 1007 patients, the majority were from the US (84%), Black/African American (56%), male (63%), and with a mean (standard deviation) age of 65 (13) years. Among 1001 patients with genotyping results, 74 (7%) had a pathogenic TTR mutation (71/836 [8%] from the US). Val122Ile was the most common mutation, found in 11% of Black/African American patients overall; Black/African American ethnicity was an independent predictor of having a pathogenic TTR mutation. Additional independent predictors of such mutations in the total population and Black/African American group were interventricular septum thickness, low electrocardiogram voltage, and age. CONCLUSIONS Pathogenic TTR mutations occurred in 8% of US patients with suspected cardiac amyloidosis. Most mutations were Val122Ile, almost exclusively found in Black/African American patients. Disease often remains undetected until advanced and difficult to treat, therefore, clinicians should assess at-risk patients for hATTR amyloidosis as early as possible.
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Affiliation(s)
| | - Keyur Shah
- Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Alberta L Warner
- VA Greater Los Angeles Health Care System, University of California, Los Angeles, CA, USA
| | - Thibaud Damy
- Mondor Amyloidosis Network and GRC Amyloid Research Institute and Department of Cardiology at AP-HP Henri-Mondor Teaching Hospital and UPEC, Créteil, France
| | - Herman A Taylor
- Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA, USA
| | | | | | | | - John Vest
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Mathew S Maurer
- Cardiovascular Research Lab for the Elderly at New York-Presbyterian/Columbia Allen Hospital, Columbia University Medical Center, New York, NY, USA
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Maia LF, Maceski A, Conceição I, Obici L, Magalhães R, Cortese A, Leppert D, Merlini G, Kuhle J, Saraiva MJ. Plasma neurofilament light chain: an early biomarker for hereditary ATTR amyloid polyneuropathy. Amyloid 2020; 27:97-102. [PMID: 31906707 DOI: 10.1080/13506129.2019.1708716] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Transthyretin amyloidosis due to V30M mutation (ATTR-V30M) is the most frequent hereditary ATTR amyloidosis. Besides neurophysiological measures, there are no biomarkers to detect preclinical disease or monitor disease progression. CSF or plasma neurofilament light chain (pNfL) have recently been considered sensitive biomarkers to quantitate neuro-axonal damage in several disorders of the peripheral and central nervous system.Objective: Characterise plasma NfL levels in a series of untreated ATTR-V30M patients stratified by clinical severity using a cross-sectional retrospective study design.Methods: Sixty ATTR-V30M patients and 16 controls from 2 independent cohorts were analysed for pNfL by single-molecule array assay (SIMOA) technique. Disease severity was assessed with Polyneuropathy Disability Score.Results: pNfL is elevated in ATTR-V30M patients as a function of disease severity in both cohorts. Moreover, pNfL discriminates asymptomatic mutation carriers from early symptomatic patients (AUC = 0.97; p < .001) with high sensitivity (92.3%) and specificity (93.8%). pNfL elevation (>66.9 pg/mL) also discriminates patients with sensory neuropathy from patients with motor neuropathy (AUC = 0.91; p < .01) with a sensitivity of 61.5% and a specificity of 92.3%.Conclusion: pNfL is an easily accessible biomarker to establish ATTR-V30M disease conversion and to monitor disease progression. pNfL could be used as efficacy measure of disease-oriented therapies in clinical and pre-clinical trials.
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Affiliation(s)
- Luis F Maia
- Molecular Neurobiology Group, Instituto de Biologia Molecular e Celular (IBMC) - Instituto de Investigação e Inovação em Saúde (i3S) da Universidade do Porto, Porto, Portugal.,Neurology Department, Centro Hospitalar Universitário do Porto (CHUP), Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Aleksandra Maceski
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabel Conceição
- Neurology Department, Centro Hospitalar Universitário Lisboa Norte (CHULN) and Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Andreas Cortese
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - David Leppert
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Maria João Saraiva
- Molecular Neurobiology Group, Instituto de Biologia Molecular e Celular (IBMC) - Instituto de Investigação e Inovação em Saúde (i3S) da Universidade do Porto, Porto, Portugal
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Expert consensus recommendations to improve diagnosis of ATTR amyloidosis with polyneuropathy. J Neurol 2020; 268:2109-2122. [PMID: 31907599 PMCID: PMC8179912 DOI: 10.1007/s00415-019-09688-0] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
Amyloid transthyretin (ATTR) amyloidosis with polyneuropathy (PN) is a progressive, debilitating, systemic disease wherein transthyretin protein misfolds to form amyloid, which is deposited in the endoneurium. ATTR amyloidosis with PN is the most serious hereditary polyneuropathy of adult onset. It arises from a hereditary mutation in the TTR gene and may involve the heart as well as other organs. It is critical to identify and diagnose the disease earlier because treatments are available to help slow the progression of neuropathy. Early diagnosis is complicated, however, because presentation may vary and family history is not always known. Symptoms may be mistakenly attributed to other diseases such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), idiopathic axonal polyneuropathy, lumbar spinal stenosis, and, more rarely, diabetic neuropathy and AL amyloidosis. In endemic countries (e.g., Portugal, Japan, Sweden, Brazil), ATTR amyloidosis with PN should be suspected in any patient who has length-dependent small-fiber PN with autonomic dysfunction and a family history of ATTR amyloidosis, unexplained weight loss, heart rhythm disorders, vitreous opacities, or renal abnormalities. In nonendemic countries, the disease may present as idiopathic rapidly progressive sensory motor axonal neuropathy or atypical CIDP with any of the above symptoms or with bilateral carpal tunnel syndrome, gait disorders, or cardiac hypertrophy. Diagnosis should include DNA testing, biopsy, and amyloid typing. Patients should be followed up every 6–12 months, depending on the severity of the disease and response to therapy. This review outlines detailed recommendations to improve the diagnosis of ATTR amyloidosis with PN.
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12
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González-Duarte A, Cárdenas-Soto K, Fueyo O, Bañuelos CE, Gibbons C, Freeman R. Small fibre neuropathy assessments in early stages of hATTR amyloidosis. Amyloid 2019; 26:55-56. [PMID: 31343296 DOI: 10.1080/13506129.2019.1600852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Karla Cárdenas-Soto
- a Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Omar Fueyo
- a Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Carlo-Enrico Bañuelos
- a Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | | | - Roy Freeman
- b Beth Israel Deaconess Medical Centre , Mexico City , Mexico
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13
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Kopishinskaya SV. [Transthyretin familial amyloid polyneuropathy]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:82-89. [PMID: 30499502 DOI: 10.17116/jnevro201811810182] [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: 11/18/2022]
Abstract
Transthyretin family amyloid polyneuropathy (TTR-FAP) is a progressive, ultimately fatal disease. It manifests itself primarily with sensory, motor and autonomic polyneuropathy and/or cardiomyopathy and is caused by extracellular deposition of insoluble amyloid fibrils in the endoneurium. The cause of TTR-FAP is the mutation in the gene encoding transthyretin, more than 100 types of mutations are known. Given the phenotypic diversity of TTR-FAP, it is difficult for clinicians to make this diagnosis. An erroneous diagnosis is a frequent occurrence, risking the onset of an organ pathology. The paper addresses the issues of the pathogenesis, diagnosis and treatment of TTR-FAP.
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Affiliation(s)
- S V Kopishinskaya
- Federal State Budget Educational Establishment of Higher Education Nizhny Novgorod State Medical Academy of the Ministry of Public Health of the Russian Federation, Nizhny Novgorod, Russia
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Guasp M, Köhler AA, Campolo M, Casanova-Molla J, Valls-Sole J. Evidence of neurophysiological improvement of early manifestations of small-fiber dysfunction after liver transplantation in a patient with familial amyloid neuropathy. Clin Neurophysiol Pract 2018; 3:40-44. [PMID: 30215006 PMCID: PMC6133776 DOI: 10.1016/j.cnp.2018.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/13/2018] [Accepted: 01/23/2018] [Indexed: 01/28/2023] Open
Abstract
Detecting signs of neuropathy helps therapeutic decisions in familial amyloidosis. Psychophysical thermal testing may be the only test showing damage in small fibers. Quantitative signs of improvement may remain a few years after liver transplantation.
Introduction Small fiber polyneuropathy (SFP) is a common heralding clinical manifestation of damage to the nervous system in patients with familial amyloidosis. The diagnosis of SFP is a significant factor in the decision to treat a previously asymptomatic gene carrier, as treatment would prevent irreversible nerve damage. This requires detection of the earliest but unequivocal signs of peripheral nerve involvement. Case report We present the case of a young female who was diagnosed of SFP, supported by data from quantitative sensory testing. She had preserved sensory nerve action potentials in the distalmost nerves of her feet and recordable nociceptive evoked potentials. She was successfully transplanted the liver from a previously healthy donor, and recovered fully of her symptoms and signs. Improvement was documented with repeated psychophysical and electrodiagnostic testing in the course of 4 years after transplantation. Significance This case illustrates the utility of psychophysical testing to support the diagnosis of SFP.
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Affiliation(s)
- Mar Guasp
- EMG and Motor Control Section, Neurology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Michela Campolo
- EMG and Motor Control Section, Neurology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jordi Casanova-Molla
- EMG and Motor Control Section, Neurology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josep Valls-Sole
- EMG and Motor Control Section, Neurology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Abstract
Small fiber neuropathy, which affects the sensory Aδ and C fibers, is now a major diagnostic and therapeutic challenge. Nearly 7% of the general population have chronic neuropathic pain responsible for severe quality-of-life impairments. Awareness must therefore be raised among clinicians of the somatosensory and autonomic symptoms that can reveal small fiber neuropathy, appropriate diagnostic investigations, most common causes, and best treatment options for each patient profile. To help achieve this goal, the present review article discusses the clinical presentation of neuropathic pain and paresthesia and/or autonomic dysfunction due to involvement of nerves supplying exocrine glands and smooth muscle; normal findings from standard electrophysiological investigations; most informative diagnostic tests (epidermal nerve fiber density in a skin biopsy, laser-evoked potentials, heat- and cold-detection thresholds, electrochemical skin conductance); main causes, which consist chiefly of metabolic diseases (diabetes mellitus, glucose intolerance), dysimmunity syndromes (Sjögren's syndrome, sarcoidosis, monoclonal gammopathy), and genetic abnormalities (familial amyloidosis due to a transthyretin mutation, Fabry disease, sodium channel diseases); and the available symptomatic and etiological treatments.
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