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Lanman T, Wu C, Cheung H, Goyal N, Greene M. Response to "Polyradiculitis Complicating SARS-CoV-2 Vaccinations is Not Infrequent". Neurohospitalist 2023; 13:210-211. [PMID: 37064923 PMCID: PMC10091430 DOI: 10.1177/19418744221138634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Connie Wu
- Neurology, Stanford University School of
Medicine, CA, USA
| | | | | | - Maxwell Greene
- Neurology, Stanford University School of
Medicine, CA, USA
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Lanman TA, Wu C, Cheung H, Goyal N, Greene M. Guillain-Barré Syndrome with Rapid Onset and Autonomic Dysfunction Following First Dose of Pfizer-BioNTech COVID-19 Vaccine: A Case Report. Neurohospitalist 2022; 12:388-390. [PMID: 35401916 PMCID: PMC8977423 DOI: 10.1177/19418744211065242] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Guillain-Barre syndrome (GBS) is an immune-mediated, often post-infectious illness
manifesting as an acute, characteristically monophasic, polyradiculoneuropathy. We present
a case of GBS with autonomic involvement following an mRNA-based vaccine against SARS-COV2
(Pfizer/BioNTech mRNA-BNT162b2). A 58-year-old woman presented with fatigue, distal
extremity paresthesias, and severe back pain within 3 days after receiving her first
vaccine dose. She developed worsening back pain and paresthesias in distal extremities
which prompted her initial presentation to the hospital. By the third week post-vaccine,
she developed increasing gait unsteadiness, progression of paresthesias, and new autonomic
symptoms including presyncopal episodes and constipation. Neurological exam showed
bilateral distal predominant lower extremity weakness, decreased sensation in a
length-dependent pattern, and areflexia. EMG/NCS showed a diffuse sensorimotor
polyneuropathy with mixed demyelinating and axonal features consistent with GBS. She was
treated with 2 g/kg of IVIG over 3 days and also received prednisone 60 mg daily for
3 days for severe back pain, with improvement of symptoms. This possible association with
mRNA-based vaccination expands the potential triggers for an autoimmune-based attack on
the peripheral nervous system.
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Affiliation(s)
- Tyler Ashford Lanman
- Neurology Department, Stanford Medicine, Stanford, CA, USA
- Neuromuscular Department, Stanford Medicine, Stanford, CA, USA
| | - Connie Wu
- Neurology Department, Stanford Medicine, Stanford, CA, USA
| | - Helen Cheung
- Neuromuscular Department, Stanford Medicine, Stanford, CA, USA
| | - Neelam Goyal
- Neuromuscular Department, Stanford Medicine, Stanford, CA, USA
| | - Maxwell Greene
- Neuromuscular Department, Stanford Medicine, Stanford, CA, USA
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Apetse K, Dongmo Tajeuna J, Kumako V, Waklatsi K, Kombate D, Assogba K, Balogou A. [Guillain-Barré syndrome in hospitals in Togo]. MEDECINE TROPICALE ET SANTE INTERNATIONALE 2021; 1:mtsibulletin.2021.124. [PMID: 35686169 PMCID: PMC9128467 DOI: 10.48327/mtsibulletin.2021.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 08/19/2021] [Indexed: 11/18/2022]
Abstract
Introduction In sub-Saharan Africa characterized by limited resources especially in health facilities and a relatively higher frequency of infectious diseases, studies on Guillain-Barré syndrome (GBS) are rare. Objectives The objectives of this work are to describe the characteristics of GBS in Togo through a cohort of patients followed in the neurology unit of the Campus University Hospital of Lomé. Methodology The study took place from May 2015 to July 2019. Patients with GBS of levels 1 to 3 of the Brighton criteria for diagnostic certainty were included consecutively and assessed at admission, at 6 months and at 1 year with the GBS disability score and the MRC sum score. Qualitative and quantitative variables were expressed, respectively, in frequency and median (interquartile range). Results Out of 7012 hospitalized patients, 28 (0.39%) including 20 women (71%) with a median age of 40 (27-53) years, presented GBS. The clinical presentation mainly consisted of bilateral sensory-motor disorders predominantly in the lower limbs associated with facial diplegia and preceded by an infectious event. On admission, 39% of patients (n=11) were able to walk (GBS score 0 to 3) and the median MRC sum score was 28 (12-38). Cytoalbuminologic dissociation was present in 654% of patients (13 of 20 patients who underwent lumbar puncture). The demyelinating and axonal subtypes each accounted for 47% (9 of 19 patients who underwent an electroneuromyography examination). Immunoglobulins and intravenous corticosteroid therapy were administered in 18% (n=5) and 50% (n=14) of patients, respectively. Lethality rate during hospitalization was 11% (n=3). The median MRC sum score at 6 and 12 month-outcome were 40 (38-49) and 51 (46-58), respectively. After one year of evolution, case fatality rate was 18% (n=5), and 78% of survivors (n=14) could walk without assistance, of which 17% (n=3) were asymptomatic. Conclusion In Togo, GBS, with a low hospital prevalence, remains a serious condition due to its high morbidity and lethality related to non-optimal treatment and delayed management.
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Affiliation(s)
- K. Apetse
- Faculté des sciences de la santé, Université de Lomé, Lomé, Togo,Service de neurologie, CHU CAMPUS de Lomé, Lomé, Togo,*
| | | | - V.K. Kumako
- Faculté des sciences de la santé, Université de Kara, Kara, Togo,Service de neurologie, CHU Kara, Kara, Togo
| | - K.P. Waklatsi
- Service de neurologie, CHU CAMPUS de Lomé, Lomé, Togo
| | - D. Kombate
- Faculté des sciences de la santé, Université de Lomé, Lomé, Togo,Service de neurologie, CHU CAMPUS de Lomé, Lomé, Togo
| | - K. Assogba
- Faculté des sciences de la santé, Université de Lomé, Lomé, Togo,Service de neurologie, CHU CAMPUS de Lomé, Lomé, Togo
| | - A.K. Balogou
- Faculté des sciences de la santé, Université de Lomé, Lomé, Togo,Service de neurologie, CHU CAMPUS de Lomé, Lomé, Togo
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Longitudinal study of neuropathic pain in patients with Guillain-Barré syndrome. Ir J Med Sci 2020; 190:1137-1142. [PMID: 33057880 DOI: 10.1007/s11845-020-02395-0] [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: 07/09/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to analyze neuropathic pain (NeP) and its therapy in patients with Guillain-Barré syndrome (GBS) during a 6-month follow-up period. METHOD This longitudinal multicenter study included 69 newly diagnosed adult GBS patients. NeP diagnosis was based on the criteria of Finnerup and confirmed by the PainDETECT Questionnaire (PD-Q). Severity of GBS was assessed by GBS disability scale (GDS). Patients were assessed: on day 14 (D14), day 28 (D28), month 3 (M3), and month 6 (M6) from the disease onset. RESULTS At D14, pain was present in 85.5% of patients, while 26.4% had NeP. At M6, 72.5% of patients had pain, 20.0% of them NeP. In acute GBS, pain intensity was higher in patients with NeP compared to those with non-NeP (p < 0.01). Pain intensity in patients with NeP did not change during time, but it decreased in patients with non-NeP at M6 (p < 0.05). Around 20% of GBS patients were on specific NeP medication throughout the observed period. One quarter of patients with NeP were not on specific NeP drug in the acute phase. Up to one third of patients with NeP were on NeP medication but still had significant NeP. Pooled PD-Q score was in correlation with pooled GDS score (rho = + 0.43, p < 0.01). CONCLUSIONS NeP is a common and potentially severe symptom in GBS that may persist for months. It is important to recognize NeP, start specific treatment on time, in adequate doses, and for prolonged period of time.
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Proximal nerve lesions in early Guillain-Barré syndrome: implications for pathogenesis and disease classification. J Neurol 2016; 264:221-236. [PMID: 27314967 DOI: 10.1007/s00415-016-8204-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/10/2016] [Accepted: 06/10/2016] [Indexed: 12/13/2022]
Abstract
Guillain-Barré syndrome (GBS) is an acute-onset, immune-mediated disorder of the peripheral nervous system. In early GBS, arbitrarily established up to 10 days of disease onset, patients could exhibit selective manifestations due to involvement of the proximal nerves, including nerve roots, spinal nerves and plexuses. Such manifestations are proximal weakness, inaugural nerve trunk pain, and atypical electrophysiological patterns, which may lead to delayed diagnosis. The aim of this paper was to analyze the nosology of early GBS reviewing electrophysiological, autopsy and imaging studies, both in acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor/motor-sensory axonal neuropathy (AMAN/AMSAN). Early electrophysiology showed either well-defined demyelinating or axonal patterns, or a non-diagnostic pattern with abnormal late responses; there may be attenuated M responses upon lumbar root stimulation as the only finding. Pathological changes predominated in proximal nerves, in some studies, most prominent at the sides where the spinal roots unite to form the spinal nerves; on very early GBS endoneurial inflammatory edema was the outstanding feature. In the far majority of cases, spinal magnetic resonance imaging showed contrast enhancement of cauda equina, selectively involving anterior roots in AMAN. Both in AIDP and AMAN/AMSAN, ultrasonography has demonstrated frequent enlargement of ventral rami of C5-C7 nerves with blurred boundaries, whereas sonograms of upper and lower extremity peripheral nerves exhibited variable and less frequent abnormalities. We provide new insights into the pathogenesis and classification of early GBS.
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Use of natural compounds in the management of diabetic peripheral neuropathy. Molecules 2014; 19:2877-95. [PMID: 24603557 PMCID: PMC6271156 DOI: 10.3390/molecules19032877] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/20/2014] [Accepted: 02/26/2014] [Indexed: 11/18/2022] Open
Abstract
Nephropathy, retinopathy cardiomyopathy and peripheral neuropathy are all recognized as important complications in about 50% of diabetes mellitus (DM) patients, mostly related to a poor glycemic control or to an improper management of this pathology. In any case, amongst others, diabetic peripheral neuropathy (DPN) seems the leading and most painful complication usually affecting many DM patients. For this reason, this work was conceived to review the large variety of strategies adopted for management of DPN, starting from the most conventional therapies to arrive at alternative approaches. From this perspective, both the most popular pharmacological treatments used to respond to the poorly effect of common analgesics—non-steroidal anti-inflammatory drugs (NSAIDS) and opioids—understood as gabapentin vs. pregabalin clinical use, and the guidelines provided by Oriental Medicine as well as by a long list of natural compounds that many authors identify as possible therapeutic or alternative agents to replace or to combine with the existing therapies will be included. Moreover, in the effort to provide the widest panel of remedies, the most antique techniques of acupuncture and electrostimulation will be considered as alternative, which are useful approaches to take into account in any non-pharmacological strategy for DPN management.
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Endo K, Yasui K, Hasegawa Y, Yanagi T. [An adult Guillain-Barré syndrome patient with enhancement of anterior roots on spinal MRI and severe radicular pain relieved by intravenous methylprednisolone pulse therapy: A case report]. Rinsho Shinkeigaku 2013; 53:543-550. [PMID: 23892966 DOI: 10.5692/clinicalneurol.53.543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 37-year-old man was admitted to our hospital because of progressive abnormal gait and severe pain in the low back and lower extremities, more severe on the right side, especially in his right posterior thigh. The pain appeared one week after he suffered from slight fever and diarrhea. On admission, a neurological examination revealed mild distal weakness of the all extremities and loss of Achilles tendon reflex, associated with positive Lasègue sign. However, sensation was intact except for slightly impaired vibratory sensation on the trunk. An electrophysiological study showed diminished amplitude of compound muscle action potential and loss of F-wave of the posterior tibial nerves. Finding of cerebrospinal fluid was normal at the time of admission, although 12 days later albuminocytologic dissociation was found. Cervical and lumbar magnetic resonance images showed gadolinium enhancement of the anterior nerve roots and the cauda equina, more prominent on the right side, correlating with the prominent side of the patient's leg pain. Because of neurological features, electrophysiological abnormalities and CSF findings, we diagnosed his illness as Guillain-Barré syndrome (GBS) characterized by severe back and leg pain. The character of pain was deep and aching, suggesting myalgic pain caused by the affected anterior roots. A short course high-dose intravenous immunoglobulin (IVIg) therapy was not effective against the radicular pain although minimal improvement of limb weakness occurred. Non-steroidal anti-inflammatory drugs and carbamazepine were unsuccessful for pain relief. Thereafter, intravenous methylprednisolone (IVMP) pulse therapy was introduced. On the day IVMP pulse therapy started, severe radicular pain began to decrease and became gradually milder without any marked effect on the other symptoms and signs of GBS.Moderate to severe pain is a common and early symptom of GBS and requires aggressive treatment. IVMP pulse therapy may be one of treatments for refractory and intolerable pain of GBS.
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Affiliation(s)
- Kuniyuki Endo
- Department of Neurology, Nagoya Daini Red Cross Hospital
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Abstract
The latest estimation for the frequency of Guillain-Barré syndrome (GBS) is 1.1 to 1.8 per 100000 persons per year. Guillain-Barré syndrome is today divided into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and the axonal subtypes, acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). The axonal forms of GBS are caused by certain autoimmune mechanisms, due to a molecular mimicry between antecedent bacterial infection (particularly Campylobacter jejuni) and human peripheral nerve gangliosides. Improvements in patient management in intensive care units has permitted a dramatic drop in mortality rates. Immunotherapy, including plasma exchange (PE) or intravenous immunoglobulin (IVIg), seems to shorten the time to recovery, but their effect remains limited. Further clinical investigations are needed to assess the effect of PE or IVIg on the GBS patients with mild affection, no response, or relapse.
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Affiliation(s)
- Harutoshi Fujimura
- Department of Neurology, Toneyama National Hospital, Toneyama, Toyonaka, Japan.
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van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome. Lancet Neurol 2008; 7:939-50. [PMID: 18848313 DOI: 10.1016/s1474-4422(08)70215-1] [Citation(s) in RCA: 496] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guillain-Barré syndrome (GBS) is an important cause of acute neuromuscular paralysis. Molecular mimicry and a cross-reactive immune response play a crucial part in its pathogenesis, at least in those cases with a preceding Campylobacter jejuni infection and with antibodies to gangliosides. The type of preceding infection and patient-related host factors seem to determine the form and severity of the disease. Intravenous immunoglobulin (IVIg) and plasma exchange are effective treatments in GBS; mainly for practical reasons, IVIg is the preferred treatment. Whether mildly affected patients or patients with Miller Fisher syndrome also benefit from IVIg is unclear. Despite medical treatment, GBS often remains a severe disease; 3-10% of patients die and 20% are still unable to walk after 6 months. In addition, many patients have pain and fatigue that can persist for months or years. Advances in prognostic modelling have resulted in the development of a new and simple prognostic outcome scale that might also help to guide new treatment options, particularly in patients with GBS who have a poor prognosis.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus Medical Centre, Rotterdam, Netherlands.
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Ruts L, van Koningsveld R, Jacobs BC, van Doorn PA. Determination of pain and response to methylprednisolone in Guillain-Barré syndrome. J Neurol 2007; 254:1318-22. [PMID: 17426908 PMCID: PMC2778673 DOI: 10.1007/s00415-006-0515-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2006] [Revised: 11/29/2006] [Accepted: 12/03/2006] [Indexed: 11/24/2022]
Abstract
Pain can be a serious problem in patients with Guillain-Barré syndrome (GBS). Different pain symptoms and the effect of methylprednisolone on pain are evaluated.
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Affiliation(s)
- Liselotte Ruts
- Dept. of Neurology, Erasmus MC, Room number Ee-2230, P.O. BOX 1738, 3000 DR, Rotterdam, The Netherlands.
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Boukhris S, Magy L, Khalil M, Sindou P, Vallat JM. Pain as the presenting symptom of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). J Neurol Sci 2007; 254:33-8. [PMID: 17286985 DOI: 10.1016/j.jns.2006.12.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 12/08/2006] [Accepted: 12/12/2006] [Indexed: 11/29/2022]
Abstract
Numerous clinical forms of CIDP have been described, but pain is generally considered a rare or secondary sign. We describe here the clinical, electrophysiological and neuropathological characteristics of five patients with CIDP and pain as the main presenting symptom, and their course with treatment. Between January 2003 and December 2004, we selected five patients with prominent or isolated pain among 27 patients diagnosed with CIDP. All patients were subjected to clinical and electrophysiological examinations, and had a complete laboratory work up to exclude other causes of neuropathy. In view of the atypical clinical presentation, all five patients underwent nerve biopsy. There were two men and three women. The mean age at onset of neuropathy was 70+/-7.39 years. All patients initially presented with pain in the lower limbs associated with modest motor impairment (1 case), distal paresthesia (4 cases), cramps (1 case) and fatigue (2 cases). CSF was normal in three cases. On electrophysiological examination, three patients had nerve conduction abnormalities with subtle or clear signs of demyelination: three (case 1, 2 and 4) fulfilled the criteria of Rotta et al. and two (case 2 and 4) the criteria of both Nicolas et al and the INCAT group. Patients were all given symptomatic treatment and four patients received an immunomodulatory treatment, which was constantly effective. Pain may be a major and disabling symptom in patients with CIDP, so this diagnosis has to be considered in patients referred for a painful polyneuropathy. Moreover, immunomodulatory treatment has to be considered in such patients as symptomatic therapy may be ineffective.
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Affiliation(s)
- S Boukhris
- Department of Neurology, University Hospital, 2 Avenue Martin Luther King, 87042 Limoges Cedex, France
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Abstract
This review focuses on the actual status and recent advances in the treatment of immune-mediated neuropathies, including: Guillain-Barre syndrome (GBS) with its subtypes acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute motor and sensory axonal neuropathy, Miller Fisher syndrome, and acute pandysautonomia; chronic inflammatory demyelinating polyneuropathy (CIDP) with its subtypes classical CIDP, CIDP with diabetes, CIDP/monoclonal gammopathy of undetermined significance (MGUS), sensory CIDP, multifocal motor neuropathy (MMN), multifocal acquired demyelinating sensory and motor neuropathy or Lewis-Sumner syndrome, multifocal acquired sensory and motor neuropathy, and distal acquired demyelinating sensory neuropathy; IgM monoclonal gammopathies with its subtypes Waldenstrom's macroglobulinemia, myelin-associated glycoprotein-associated gammopathy, polyneuropathy, organomegaly, endocrinopathy, M-protein, skin changes syndrome, mixed cryoglobulinemia, gait ataxia, late-onset polyneuropathy syndrome, and MGUS. Concerning the treatment of GBS, there is no significant difference between intravenous immunoglobulins (IVIG), plasma exchange or plasma exchange followed by IVIG. Because of convenience and absent invasiveness, IVIG are usually preferred. In treating CIDP corticosteroids, IVIG, or plasma exchange are equally effective. Despite the high costs and relative lack of availability, IVIG are preferentially used. For the one-third of patients, who does not respond, other immunosuppressive options are available. In MMN IVIG are the treatment of choice. Inadequate response in 20% of the patients requires adjunctive immunosuppressive therapies. Neuropathies with IgM monoclonal gammopathy may respond to various chemotherapeutic agents, although the long-term effects are unknown. In addition, such treatment may be associated with serious side effects. Recent data support the use of rituximab, a monoclonal antibody against the B-cell surface-membrane-marker CD20.
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Affiliation(s)
- J Finsterer
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria.
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Abstract
Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating poly-(radiculo)neuropathy (CIDP) are immune-mediated disorders with a variable duration of progression and a range in severity of weakness. Infections can trigger GBS and exacerbate CIDP. Anti-ganglioside antibodies are important, but there is debate on the role of genetic factors in the pathogenesis of these disorders. Randomized controlled trials (RCT) have shown that intravenous immunoglobulin (IVIg) and plasma exchange (PE) are effective in both GBS and CIDP. Most CIDP patients also improve after steroid therapy. Despite current treatment options, many patients have residual deficits or need to be treated for a long period of time. Therefore, new treatment trials are highly indicated. This review focuses on the current and possible new treatment options that could be guided by recent results from laboratory experiments.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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