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George DS, Jayaraj ND, Pacifico P, Ren D, Sriram N, Miller RE, Malfait AM, Miller RJ, Menichella DM. The Mas-related G protein-coupled receptor d (Mrgprd) mediates pain hypersensitivity in painful diabetic neuropathy. Pain 2024; 165:1154-1168. [PMID: 38147415 PMCID: PMC11017747 DOI: 10.1097/j.pain.0000000000003120] [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: 04/18/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 12/28/2023]
Abstract
ABSTRACT Painful diabetic neuropathy (PDN) is one of the most common and intractable complications of diabetes. Painful diabetic neuropathy is characterized by neuropathic pain accompanied by dorsal root ganglion (DRG) nociceptor hyperexcitability, axonal degeneration, and changes in cutaneous innervation. However, the complete molecular profile underlying the hyperexcitable cellular phenotype of DRG nociceptors in PDN has not been elucidated. This gap in our knowledge is a critical barrier to developing effective, mechanism-based, and disease-modifying therapeutic approaches that are urgently needed to relieve the symptoms of PDN. Using single-cell RNA sequencing of DRGs, we demonstrated an increased expression of the Mas-related G protein-coupled receptor d (Mrgprd) in a subpopulation of DRG neurons in the well-established high-fat diet (HFD) mouse model of PDN. Importantly, limiting Mrgprd signaling reversed mechanical allodynia in the HFD mouse model of PDN. Furthermore, in vivo calcium imaging allowed us to demonstrate that activation of Mrgprd-positive cutaneous afferents that persist in diabetic mice skin resulted in an increased intracellular calcium influx into DRG nociceptors that we assess in vivo as a readout of nociceptors hyperexcitability. Taken together, our data highlight a key role of Mrgprd-mediated DRG neuron excitability in the generation and maintenance of neuropathic pain in a mouse model of PDN. Hence, we propose Mrgprd as a promising and accessible target for developing effective therapeutics currently unavailable for treating neuropathic pain in PDN.
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Affiliation(s)
| | | | | | - Dongjun Ren
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | | | - Rachel E. Miller
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | - Anne-Marie Malfait
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | - Richard J. Miller
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniela Maria Menichella
- Departments of Neurology and
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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2
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Machado-Costa MC, Mitne-Neto M, Costa LHD, Alves LM, Oliveira ASB, Zatz M, Silva HCA. Small-fibre Neuropathy in Patients with Familial Amyotrophic Lateral Sclerosis Type 8. Can J Neurol Sci 2023; 50:885-890. [PMID: 36457144 DOI: 10.1017/cjn.2022.331] [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: 12/03/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a degenerative disease of the nervous system that primarily affects motor neurons. ALS type 8 (ALS8) is a familiar form with predominant involvement of lower motor neurons, tremor, and slow progression. OBJECTIVE The aim of this study was to describe sensory involvement in a cohort of ALS8 patients and compare it with the characteristics of sporadic ALS (sALS) patients and controls. METHODS We compared data from 40 ALS8 and 10 sALS patients assessed by neurological evaluation and electrophysiological study. Skin biopsies were performed in these patients and 12 controls for analysis of intraepidermal nerve fiber (IENF) density by protein gene product 9.5 (PGP 9.5) immunohistochemistry. RESULTS The ALS8 group was younger than the sALS group at the onset of symptoms (p < 0.05) and had a longer disease evolution (p < 0.01). Sensory abnormalities were evident in 35% of the ALS8 and 30% of the sALS patients by neurological examination, and all ALS patients presented normal sensory nerve action potentials. Despite being similar in the ALS8 and sALS groups, IENF density in the ALS8 group was lower than that in the controls (p < 0.0005). In the ALS8 group, IENF density was significantly lower in patients with impairment of vibratory sensation than in those without this finding (p < 0.05) and in females than in males (p < 0.05). CONCLUSION Sensory impairment and decreased IENF density are present in ALS8 patients at a frequency and intensity similar to that in the sALS group.
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Affiliation(s)
| | - Miguel Mitne-Neto
- Department of Research and Development, Fleury Group, São Paulo, Brazil
| | | | - Luciana Moura Alves
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Acary Souza Bulle Oliveira
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Mayana Zatz
- Human Genome and Research Centre, University of São Paulo, São Paulo, Brazil
| | - Helga Cristina Almeida Silva
- Discipline of Anaesthesiology, Pain and Intensive Care, Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
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3
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Bouhassira D, Attal N. Personalized treatment of neuropathic pain: Where are we now? Eur J Pain 2023; 27:1084-1098. [PMID: 37114461 DOI: 10.1002/ejp.2120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/07/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The treatment of neuropathic pain remains a major unmet need that the development of personalized and refined treatment strategies may contribute to address. DATABASE In this narrative review, we summarize the various approaches based on objective biomarkers or clinical markers that could be used. RESULTS In principle, the validation of objective biomarkers would be the most robust approach. However, although promising results have been reported demonstrating a potential value of genomics, anatomical or functional markers, the clinical validation of these markers has only just begun. Thus, most of the strategies documented to date have been based on the development of clinical markers. In particular, many studies have suggested that the identification of specific subgroups of patients presenting with specific combinations of symptoms and signs would be a relevant approach. Two main approaches have been used to identify relevant sensory profiles: quantitative sensory testing and specific patients reported outcomes based on description of pain qualities. CONCLUSION We discuss here the advantages and limitations of these approaches, which are not mutually exclusive. SIGNIFICANCE Recent data indicate that various new treatment strategies based on predictive biological and/or clinical markers could be helpful to better personalized and therefore improve the management of neuropathic pain.
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Affiliation(s)
- Didier Bouhassira
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
| | - Nadine Attal
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
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4
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Amato AA, De Girolami U. Neuromuscular pathology. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:287-300. [PMID: 37562873 DOI: 10.1016/b978-0-323-98818-6.00005-4] [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
In this chapter, we discuss the indications for muscle, nerve, and skin biopsies, the techniques and normal processing of biopsy specimens, normal histological appearance, and the commonest histopathological abnormalities of different myopathies and neuropathies.
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Affiliation(s)
- Anthony A Amato
- Department of Neurology, Division of Neuromuscular Diseases, Neuropathology Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Umberto De Girolami
- Department of Pathology, Neuropathology Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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5
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Raicher I, Ravagnani LHC, Correa SG, Dobo C, Mangueira CLP, Macarenco RSES. Investigation of nerve fibers in the skin by biopsy: technical aspects, indications, and contribution to diagnosis of small-fiber neuropathy. EINSTEIN-SAO PAULO 2022; 20:eMD8044. [PMID: 35830153 PMCID: PMC9262281 DOI: 10.31744/einstein_journal/2022md8044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/06/2022] [Indexed: 11/05/2022] Open
Abstract
Skin biopsy with investigation of small-diameter nerve fibers in human epidermis and dermis has been proven to be a useful method for confirming small-fiber neuropathy. In medical practice, small-fiber neuropathy is increasingly recognized as a leading cause of neuropathic pain. It is a prevalent complaint in medical offices, brought by patients often as a “painful burning sensation”. The prevalence of neuropathic pain is high in small-fiber neuropathies of different etiologies, especially in the elderly; 7% of population in this age group present peripheral neuropathy. Pain and paresthesia are symptoms which might cause disability and impair quality of life of patients. The early detection of small-fiber neuropathy can contribute to reducing unhealthy lifestyles, associated to higher incidence of the disease.
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6
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Strand N, Wie C, Peck J, Maita M, Singh N, Dumbroff J, Tieppo Francio V, Murphy M, Chang K, Dickerson DM, Maloney J. Small Fiber Neuropathy. Curr Pain Headache Rep 2022; 26:429-438. [PMID: 35384587 DOI: 10.1007/s11916-022-01044-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This narrative review aims to summarize advances in the field of small fiber neuropathy made over the last decade, with emphasis on novel research highlighting the distinctive features of SFN. RECENT FINDINGS While the management of SFNs is ideally aimed at treating the underlying cause, most patients will require pain control via multiple, concurrent therapies. Herein, we highlight the most up-to-date information for diagnosis, medication management, interventional management, and novel therapies on the horizon. Despite the prevalence of small fiber neuropathies, there is no clear consensus on guidelines specific for the treatment of SFN. Despite the lack of specific guidelines for SFN treatment, the most recent general neuropathic pain guidelines are based on Cochrane studies and randomized controlled trials (RCTs) which have individually examined therapies used for the more commonly studied SFNs, such as painful diabetic neuropathy and HIV neuropathy. The recommendations from current guidelines are based on variables such as number needed to treat (NNT), safety, ease of use, and effect on quality of life.
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Affiliation(s)
- N Strand
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA.
| | - C Wie
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - J Peck
- Performing Arts Medicine Department, Shenandoah University, Winchester, USA
| | - M Maita
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - N Singh
- OrthoAlabama Spine and Sports, Birmingham, AL, USA
| | - J Dumbroff
- Mount Sinai Morningside and West Department of Anesthesiology, New York, NY, USA
| | - V Tieppo Francio
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - M Murphy
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - K Chang
- Department of Anesthesiology and Critical Care, Emory University, Atlanta, GA, USA
| | - D M Dickerson
- NorthShore University HealthSystem, Evanston, IL, USA
- University of Chicago Medicine, Chicago,, IL, USA
| | - J Maloney
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
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7
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George DS, Hackelberg S, Jayaraj ND, Ren D, Edassery SL, Rathwell CA, Miller RE, Malfait AM, Savas JN, Miller RJ, Menichella DM. Mitochondrial calcium uniporter deletion prevents painful diabetic neuropathy by restoring mitochondrial morphology and dynamics. Pain 2022; 163:560-578. [PMID: 34232927 PMCID: PMC8720329 DOI: 10.1097/j.pain.0000000000002391] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/25/2021] [Accepted: 06/18/2021] [Indexed: 01/11/2023]
Abstract
ABSTRACT Painful diabetic neuropathy (PDN) is an intractable complication affecting 25% of diabetic patients. Painful diabetic neuropathy is characterized by neuropathic pain accompanied by dorsal root ganglion (DRG) nociceptor hyperexcitability, resulting in calcium overload, axonal degeneration, and loss of cutaneous innervation. The molecular pathways underlying these effects are unknown. Using high-throughput and deep-proteome profiling, we found that mitochondrial fission proteins were elevated in DRG neurons from mice with PDN induced by a high-fat diet (HFD). In vivo calcium imaging revealed increased calcium signaling in DRG nociceptors from mice with PDN. Furthermore, using electron microscopy, we showed that mitochondria in DRG nociceptors had fragmented morphology as early as 2 weeks after starting HFD, preceding the onset of mechanical allodynia and small-fiber degeneration. Moreover, preventing calcium entry into the mitochondria, by selectively deleting the mitochondrial calcium uniporter from these neurons, restored normal mitochondrial morphology, prevented axonal degeneration, and reversed mechanical allodynia in the HFD mouse model of PDN. These studies suggest a molecular cascade linking neuropathic pain to axonal degeneration in PDN. In particular, nociceptor hyperexcitability and the associated increased intracellular calcium concentrations could lead to excessive calcium entry into mitochondria mediated by the mitochondrial calcium uniporter, resulting in increased calcium-dependent mitochondrial fission and ultimately contributing to small-fiber degeneration and neuropathic pain in PDN. Hence, we propose that targeting calcium entry into nociceptor mitochondria may represent a promising effective and disease-modifying therapeutic approach for this currently intractable and widespread affliction. Moreover, these results are likely to inform studies of other neurodegenerative disease involving similar underlying events.
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Affiliation(s)
| | | | | | - Dongjun Ren
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | | | - Craig A. Rathwell
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Rachel E. Miller
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | - Anne-Marie Malfait
- Department of Internal Medicine, Rush Medical College, Chicago, IL, United States
| | | | - Richard J. Miller
- Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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8
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Middleton SJ, Barry AM, Comini M, Li Y, Ray PR, Shiers S, Themistocleous AC, Uhelski ML, Yang X, Dougherty PM, Price TJ, Bennett DL. Studying human nociceptors: from fundamentals to clinic. Brain 2021; 144:1312-1335. [PMID: 34128530 PMCID: PMC8219361 DOI: 10.1093/brain/awab048] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022] Open
Abstract
Chronic pain affects one in five of the general population and is the third most important cause of disability-adjusted life-years globally. Unfortunately, treatment remains inadequate due to poor efficacy and tolerability. There has been a failure in translating promising preclinical drug targets into clinic use. This reflects challenges across the whole drug development pathway, from preclinical models to trial design. Nociceptors remain an attractive therapeutic target: their sensitization makes an important contribution to many chronic pain states, they are located outside the blood-brain barrier, and they are relatively specific. The past decade has seen significant advances in the techniques available to study human nociceptors, including: the use of corneal confocal microscopy and biopsy samples to observe nociceptor morphology, the culture of human nociceptors (either from surgical or post-mortem tissue or using human induced pluripotent stem cell derived nociceptors), the application of high throughput technologies such as transcriptomics, the in vitro and in vivo electrophysiological characterization through microneurography, and the correlation with pain percepts provided by quantitative sensory testing. Genome editing in human induced pluripotent stem cell-derived nociceptors enables the interrogation of the causal role of genes in the regulation of nociceptor function. Both human and rodent nociceptors are more heterogeneous at a molecular level than previously appreciated, and while we find that there are broad similarities between human and rodent nociceptors there are also important differences involving ion channel function, expression, and cellular excitability. These technological advances have emphasized the maladaptive plastic changes occurring in human nociceptors following injury that contribute to chronic pain. Studying human nociceptors has revealed new therapeutic targets for the suppression of chronic pain and enhanced repair. Cellular models of human nociceptors have enabled the screening of small molecule and gene therapy approaches on nociceptor function, and in some cases have enabled correlation with clinical outcomes. Undoubtedly, challenges remain. Many of these techniques are difficult to implement at scale, current induced pluripotent stem cell differentiation protocols do not generate the full diversity of nociceptor populations, and we still have a relatively poor understanding of inter-individual variation in nociceptors due to factors such as age, sex, or ethnicity. We hope our ability to directly investigate human nociceptors will not only aid our understanding of the fundamental neurobiology underlying acute and chronic pain but also help bridge the translational gap.
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Affiliation(s)
- Steven J Middleton
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Allison M Barry
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Maddalena Comini
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Yan Li
- Department of Anesthesia and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Pradipta R Ray
- Department of Neuroscience and Center for Advanced Pain Studies, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Stephanie Shiers
- Department of Neuroscience and Center for Advanced Pain Studies, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Andreas C Themistocleous
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK.,Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Megan L Uhelski
- Department of Anesthesia and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xun Yang
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Patrick M Dougherty
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Theodore J Price
- Department of Neuroscience and Center for Advanced Pain Studies, University of Texas at Dallas, Richardson, TX 75080, USA
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
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9
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Chang CH, Chang YS, Hsieh YL. Transient receptor potential vanilloid subtype 1 depletion mediates mechanical allodynia through cellular signal alterations in small-fiber neuropathy. Pain Rep 2021; 6:e922. [PMID: 34585035 PMCID: PMC8462592 DOI: 10.1097/pr9.0000000000000922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/22/2021] [Accepted: 02/22/2021] [Indexed: 12/27/2022] Open
Abstract
Transient receptor potential vanilloid subtype 1 (TRPV1) is a polymodal nociceptor that monitors noxious thermal sensations. Few studies have addressed the role of TRPV1 in mechanical allodynia in small-fiber neuropathy (SFN) caused by sensory nerve damage. Accordingly, this article reviews the putative mechanisms of TRPV1 depletion that mediates mechanical allodynia in SFN. The intraepidermal nerve fibers (IENFs) degeneration and sensory neuronal injury are the primary characteristics of SFN. Intraepidermal nerve fibers are mainly C-polymodal nociceptors and Aδ-fibers, which mediated allodynic pain after neuronal sensitization. TRPV1 depletion by highly potent neurotoxins induces the upregulation of activating transcription factor 3 and IENFs degeneration which mimics SFN. TRPV1 is predominately expressed by the peptidergic than nonpeptidergic nociceptors, and these neurochemical discrepancies provided the basis of the distinct pathways of thermal analgesia and mechanical allodynia. The depletion of peptidergic nociceptors and their IENFs cause thermal analgesia and sensitized nonpeptidergic nociceptors respond to mechanical allodynia. These distinct pathways of noxious stimuli suggested determined by the neurochemical-dependent neurotrophin cognate receptors such as TrkA and Ret receptors. The neurogenic inflammation after TRPV1 depletion also sensitized Ret receptors which results in mechanical allodynia. The activation of spinal TRPV1(+) neurons may contribute to mechanical allodynia. Also, an imbalance in adenosinergic analgesic signaling in sensory neurons such as the downregulation of prostatic acid phosphatase and adenosine A1 receptors, which colocalized with TRPV1 as a membrane microdomain also correlated with the development of mechanical allodynia. Collectively, TRPV1 depletion-induced mechanical allodynia involves a complicated cascade of cellular signaling alterations.
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Affiliation(s)
- Chin-Hong Chang
- Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Ying-Shuang Chang
- Department of Anatomy, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Lin Hsieh
- Department of Anatomy, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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10
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Talagas M, Lebonvallet N, Leschiera R, Sinquin G, Elies P, Haftek M, Pennec JP, Ressnikoff D, La Padula V, Le Garrec R, L'herondelle K, Mignen O, Le Pottier L, Kerfant N, Reux A, Marcorelles P, Misery L. Keratinocytes Communicate with Sensory Neurons via Synaptic-like Contacts. Ann Neurol 2020; 88:1205-1219. [PMID: 32951274 DOI: 10.1002/ana.25912] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Pain, temperature, and itch are conventionally thought to be exclusively transduced by the intraepidermal nerve endings. Although recent studies have shown that epidermal keratinocytes also participate in sensory transduction, the mechanism underlying keratinocyte communication with intraepidermal nerve endings remains poorly understood. We sought to demonstrate the synaptic character of the contacts between keratinocytes and sensory neurons and their involvement in sensory communication between keratinocytes and sensory neurons. METHODS Contacts were explored by morphological, molecular, and functional approaches in cocultures of epidermal keratinocytes and sensory neurons. To interrogate whether structures observed in vitro were also present in the human epidermis, in situ correlative light electron microscopy was performed on human skin biopsies. RESULTS Epidermal keratinocytes dialogue with sensory neurons through en passant synaptic-like contacts. These contacts have the ultrastructural features and molecular hallmarks of chemical synaptic-like contacts: narrow intercellular cleft, keratinocyte synaptic vesicles expressing synaptophysin and synaptotagmin 1, and sensory information transmitted from keratinocytes to sensory neurons through SNARE-mediated (syntaxin1) vesicle release. INTERPRETATION By providing selective communication between keratinocytes and sensory neurons, synaptic-like contacts are the hubs of a 2-site receptor. The permanent epidermal turnover, implying a specific en passant structure and high plasticity, may have delayed their identification, thereby contributing to the long-held concept of nerve endings passing freely between keratinocytes. The discovery of keratinocyte-sensory neuron synaptic-like contacts may call for a reassessment of basic assumptions in cutaneous sensory perception and sheds new light on the pathophysiology of pain and itch as well as the physiology of touch. ANN NEUROL 2020;88:1205-1219.
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Affiliation(s)
- Matthieu Talagas
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Department of Pathology, Brest University Hospital, Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Nicolas Lebonvallet
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Raphael Leschiera
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Gerard Sinquin
- Univ Brest, Imagery and Microscopic Measures Facility, Brest University, F-29200 Brest, France
| | - Philippe Elies
- Univ Brest, Imagery and Microscopic Measures Facility, Brest University, F-29200 Brest, France
| | - Marek Haftek
- Laboratory of Tissue Biology and Therapeutic Engineering, University of Lyon 1, UMR 5305 CNRS-UCBL1, Lyon, France
| | - Jean-Pierre Pennec
- Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France.,Univ Brest, Movement Sport and Health (EA1274), Brest University, F-29200 Brest, France
| | - Denis Ressnikoff
- East Lyon Center of Quantitative Imagery, University of Lyon 1, INSERM US 7-CNRS UMS 3453, Lyon, France
| | - Veronica La Padula
- Technological Center of Microstructures, University of Lyon 1, Lyon, France
| | - Raphaele Le Garrec
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Killian L'herondelle
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Olivier Mignen
- Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France.,Univ Brest, INSERM, UMR 1227, Brest University, F-29200 Brest, France
| | - Laetitia Le Pottier
- Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France.,Univ Brest, INSERM, UMR 1227, Brest University, F-29200 Brest, France
| | - Nathalie Kerfant
- Department of Plastic, Reconstructive, and Esthetic Surgery, Brest University Hospital, Brest, France
| | - Alexia Reux
- Univ Brest, LIEN, Brest University, F-29200 Brest, France
| | - Pascale Marcorelles
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Department of Pathology, Brest University Hospital, Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France
| | - Laurent Misery
- Univ Brest, LIEN, Brest University, F-29200 Brest, France.,Univ Brest, Brest Institute of Health Agro Matter, Brest University, F-29200 Brest, France.,Department of Dermatology, Brest University Hospital, Brest, France
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11
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Frasquet M, Camacho A, Vílchez R, Argente‐Escrig H, Millet E, Vázquez‐Costa JF, Silla R, Sánchez‐Monteagudo A, Vílchez JJ, Espinós C, Lupo V, Sevilla T. Clinical spectrum of
BICD2
mutations. Eur J Neurol 2020; 27:1327-1335. [DOI: 10.1111/ene.14173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- M. Frasquet
- Neuromuscular Diseases Unit Neurology Department Hospital Universitari i Politècnic La Fe ValenciaSpain
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
| | - A. Camacho
- Division of Child Neurology Hospital Universitario 12 de Octubre MadridSpain
- Faculty of Medicine Complutense University of Madrid Madrid Spain
| | - R. Vílchez
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
| | - H. Argente‐Escrig
- Neuromuscular Diseases Unit Neurology Department Hospital Universitari i Politècnic La Fe ValenciaSpain
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) ValenciaSpain
| | - E. Millet
- Department of Clinical Neurophysiology Hospital Universitari i Politècnic La Fe ValenciaSpain
| | - J. F. Vázquez‐Costa
- Neuromuscular Diseases Unit Neurology Department Hospital Universitari i Politècnic La Fe ValenciaSpain
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) ValenciaSpain
- Department of Medicine Universitat de València ValenciaSpain
| | - R. Silla
- Neurology Department Hospital Clínico Universitario ValenciaSpain
| | - A. Sánchez‐Monteagudo
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Service of Genomics and Translational Genetics Centro de Investigación Príncipe Felipe (CIPF) ValenciaSpain
| | - J. J. Vílchez
- Neuromuscular Diseases Unit Neurology Department Hospital Universitari i Politècnic La Fe ValenciaSpain
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) ValenciaSpain
| | - C. Espinós
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Service of Genomics and Translational Genetics Centro de Investigación Príncipe Felipe (CIPF) ValenciaSpain
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders ValenciaSpain
- Department of Genetics Universitat de València Valencia Spain
| | - V. Lupo
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Service of Genomics and Translational Genetics Centro de Investigación Príncipe Felipe (CIPF) ValenciaSpain
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders ValenciaSpain
| | - T. Sevilla
- Neuromuscular Diseases Unit Neurology Department Hospital Universitari i Politècnic La Fe ValenciaSpain
- Neuromuscular & Ataxias Research Group Instituto de Investigación Sanitaria La Fe ValenciaSpain
- Joint Unit for Research on Rare Diseases CIPF‐IISLa Fe Valencia Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) ValenciaSpain
- Department of Medicine Universitat de València ValenciaSpain
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12
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Rasmussen VF, Karlsson P, Drummond PD, Schaldemose EL, Terkelsen AJ, Jensen TS, Knudsen LF. Bilaterally Reduced Intraepidermal Nerve Fiber Density in Unilateral CRPS-I. PAIN MEDICINE 2019; 19:2021-2030. [PMID: 30299507 DOI: 10.1093/pm/pnx240] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective Findings regarding small nerve fiber damage in complex regional pain syndrome type I (CRPS-I) are not uniform, and studies have not included a matched healthy control group. The aim was to assess intraepidermal nerve fiber density (IENFD) in relation to thermal sensitivity of the same skin areas in CRPS-I patients and a gender- and age-matched healthy control group. Methods IENFD was investigated in skin biopsies from the CRPS-affected and contralateral limbs of eight CRPS-I patients and from an equivalent site in eight gender- and age-matched healthy controls (HCs). Thermal thresholds (cold/warm detection, cold- and heat-pain detection) were assessed on the affected limb, the matching contralateral limb, and on the equivalent limbs of HCs, and participants rated the intensity of cold/heat and pain to static thermal stimuli (5 °C and 40 °C). Results IENFD was significantly lower in both the affected and contralateral limbs of CRPS-I patients than HCs, but IENFD did not differ between the affected and contralateral limbs of patients. The heat pain threshold was lower in the affected CRPS-I limb than in HCs, but all other thermal thresholds were similar in both groups. CRPS-I patients rated the cold stimulus as colder and more painful in the affected limb, and the warm stimulus as hotter, bilaterally, than the HCs. Conclusions CRPS-I may be associated with bilateral small fiber damage, and perhaps small fiber neuropathy and bilateral disturbances in thermo-sensory perception. These disturbances could stem from a systemic response to injury or might increase the risk of developing CRPS-I after physical trauma.
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Affiliation(s)
- Vinni F Rasmussen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
| | - Páll Karlsson
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Stereology and Electron Microscopy Laboratory, Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Aarhus, Denmark
| | - Peter D Drummond
- School of Psychology and Exercise Science, Centre for Research on Chronic Pain and Inflammatory Diseases, Murdoch University, Perth, Western Australia
| | | | - Astrid J Terkelsen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
| | - Troels S Jensen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
| | - Lone F Knudsen
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Spinal Cord Injury Centre of Western Denmark, Viborg Regional Hospital, Viborg, Denmark
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13
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Jayaraj ND, Bhattacharyya BJ, Belmadani AA, Ren D, Rathwell CA, Hackelberg S, Hopkins BE, Gupta HR, Miller RJ, Menichella DM. Reducing CXCR4-mediated nociceptor hyperexcitability reverses painful diabetic neuropathy. J Clin Invest 2018. [PMID: 29533926 DOI: 10.1172/jci92117] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Painful diabetic neuropathy (PDN) is an intractable complication of diabetes that affects 25% of patients. PDN is characterized by neuropathic pain and small-fiber degeneration, accompanied by dorsal root ganglion (DRG) nociceptor hyperexcitability and loss of their axons within the skin. The molecular mechanisms underlying DRG nociceptor hyperexcitability and small-fiber degeneration in PDN are unknown. We hypothesize that chemokine CXCL12/CXCR4 signaling is central to this mechanism, as we have shown that CXCL12/CXCR4 signaling is necessary for the development of mechanical allodynia, a pain hypersensitivity behavior common in PDN. Focusing on DRG neurons expressing the sodium channel Nav1.8, we applied transgenic, electrophysiological, imaging, and chemogenetic techniques to test this hypothesis. In the high-fat diet mouse model of PDN, we were able to prevent and reverse mechanical allodynia and small-fiber degeneration by limiting CXCR4 signaling or neuronal excitability. This study reveals that excitatory CXCR4/CXCL12 signaling in Nav1.8-positive DRG neurons plays a critical role in the pathogenesis of mechanical allodynia and small-fiber degeneration in a mouse model of PDN. Hence, we propose that targeting CXCR4-mediated DRG nociceptor hyperexcitability is a promising therapeutic approach for disease-modifying treatments for this currently intractable and widespread affliction.
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Affiliation(s)
| | | | - Abdelhak A Belmadani
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dongjun Ren
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Craig A Rathwell
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Brittany E Hopkins
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Herschel R Gupta
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard J Miller
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniela M Menichella
- Department of Neurology and.,Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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14
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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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15
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Puonti HK, Broth TA, Soinila SO, Hallikainen HK, Jääskeläinen SK. How to Assess Sensory Recovery After Breast Reconstruction Surgery? Clin Breast Cancer 2017; 17:471-485. [DOI: 10.1016/j.clbc.2017.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 04/17/2017] [Accepted: 04/23/2017] [Indexed: 10/19/2022]
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16
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Langlois V, Bedat Millet AL, Lebesnerais M, Miranda S, Marguet F, Benhamou Y, Marcorelles P, Lévesque H. [Small fiber neuropathy]. Rev Med Interne 2017; 39:99-106. [PMID: 28410768 DOI: 10.1016/j.revmed.2017.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 03/11/2017] [Indexed: 12/15/2022]
Abstract
Small fiber neuropathy (SFN) is still unknown. Characterised by neuropathic pain, it typically begins by burning feet, but could take many other expression. SFN affects the thinly myelinated Aδ and unmyelinated C-fibers, by an inherited or acquired mechanism, which could lead to paresthesia, thermoalgic disorder or autonomic dysfunction. Recent studies suggest the preponderant role of ion channels such as Nav1.7. Furthermore, erythromelalgia or burning mouth syndrome are now recognized as real SFN. Various aetiologies of SFN are described. It could be isolated or associated with diabetes, impaired glucose metabolism, vitamin deficiency, alcohol, auto-immune disease, sarcoidosis etc. Several mutations have recently been identified, like Nav1.7 channel leading to channelopathies. Diagnostic management is based primarily on clinical examination and demonstration of small fiber dysfunction. Laser evoked potentials, Sudoscan®, cutaneous biopsy are the main test, but had a difficult access. Treatment is based on multidisciplinary management, combining symptomatic treatment, psychological management and treatment of an associated etiology.
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Affiliation(s)
- V Langlois
- Service de médecine interne et maladies infectieuses, CH Le Havre, 29, avenue Pierre-Mendès, 76290 Montivilliers, France; U1096, service de médecine interne, Normandie univ, UNIROUEN, 76000 Rouen, France.
| | - A-L Bedat Millet
- Département de neurophysiologie, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - M Lebesnerais
- U1096, service de médecine interne, Normandie univ, UNIROUEN, 76000 Rouen, France
| | - S Miranda
- U1096, service de médecine interne, Normandie univ, UNIROUEN, 76000 Rouen, France
| | - F Marguet
- Département d'anatomie et cytologie pathologiques, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - Y Benhamou
- U1096, service de médecine interne, Normandie univ, UNIROUEN, 76000 Rouen, France
| | - P Marcorelles
- Département d'anatomie et cytologie pathologiques, hôpital Morvan, centre hospitalier régional et universitaire de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - H Lévesque
- U1096, service de médecine interne, Normandie univ, UNIROUEN, 76000 Rouen, France
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17
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Weis J, Claeys KG, Roos A, Azzedine H, Katona I, Schröder JM, Senderek J. Towards a functional pathology of hereditary neuropathies. Acta Neuropathol 2017; 133:493-515. [PMID: 27896434 DOI: 10.1007/s00401-016-1645-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 11/10/2016] [Accepted: 11/13/2016] [Indexed: 12/11/2022]
Abstract
A growing number of hereditary neuropathies have been assigned to causative gene defects in recent years. The study of human nerve biopsy samples has contributed substantially to the discovery of many of these neuropathy genes. Genotype-phenotype correlations based on peripheral nerve pathology have provided a comprehensive picture of the consequences of these mutations. Intriguingly, several gene defects lead to distinguishable lesion patterns that can be studied in nerve biopsies. These characteristic features include the loss of certain nerve fiber populations and a large spectrum of distinct structural changes of axons, Schwann cells and other components of peripheral nerves. In several instances the lesion patterns are directly or indirectly linked to the known functions of the mutated gene. The present review is designed to provide an overview on these characteristic patterns. It also considers other aspects important for the manifestation and pathology of hereditary neuropathies including the role of inflammation, effects of chemotherapeutic agents and alterations detectable in skin biopsies.
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Affiliation(s)
- Joachim Weis
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Kristl G Claeys
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
- Department of Neurology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
- Department of Neurology, University Hospitals Leuven and University of Leuven (KU Leuven), Leuven, Belgium
| | - Andreas Roos
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
- Leibniz-Institut für Analytische Wissenschaften-ISAS-e.V., Otto-Hahn-Str. 6b, 44227, Dortmund, Germany
| | - Hamid Azzedine
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Istvan Katona
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
| | - J Michael Schröder
- Institute of Neuropathology, RWTH Aachen University Medical School, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Jan Senderek
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University, Ziemssenstr. 1a, 80336, Munich, Germany.
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19
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Wu Y, Nieuwenhoff MD, Huygen FJPM, van der Helm FCT, Niehof S, Schouten AC. Characterizing human skin blood flow regulation in response to different local skin temperature perturbations. Microvasc Res 2016; 111:96-102. [PMID: 28011052 DOI: 10.1016/j.mvr.2016.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 11/18/2022]
Abstract
Small nerve fibers regulate local skin blood flow in response to local thermal perturbations. Small nerve fiber function is difficult to assess with classical neurophysiological tests. In this study, a vasomotor response model in combination with a heating protocol was developed to quantitatively characterize the control mechanism of small nerve fibers in regulating skin blood flow in response to local thermal perturbation. The skin of healthy subjects' hand dorsum (n=8) was heated to 42°C with an infrared lamp, and then naturally cooled down. The distance between the lamp and the hand was set to three different levels in order to change the irradiation intensity on the skin and implement three different skin temperature rise rates (0.03°C/s, 0.02°C/s and 0.01°C/s). A laser Doppler imager (LDI) and a thermographic video camera recorded the temporal profile of the skin blood flow and the skin temperature, respectively. The relationship between the skin blood flow and the skin temperature was characterized by a vasomotor response model. The model fitted the skin blood flow response well with a variance accounted for (VAF) between 78% and 99%. The model parameters suggested a similar mechanism for the skin blood flow regulation with the thermal perturbations at 0.03°C/s and 0.02°C/s. But there was an accelerated skin vasoconstriction after a slow heating (0.01°C/s) (p-value<0.05). An attenuation of the skin vasodilation was also observed in four out of the seven subjects during the slow heating (0.01°C/s). Our method provides a promising way to quantitatively assess the function of small nerve fibers non-invasively and non-contact.
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Affiliation(s)
- Y Wu
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628CD Delft, The Netherlands.
| | - M D Nieuwenhoff
- Department of Anesthesiology and Pain Medicine, Erasmus MC University Medical Center, P.O. box 2040, 3000CA Rotterdam, The Netherlands.
| | - F J P M Huygen
- Department of Anesthesiology and Pain Medicine, Erasmus MC University Medical Center, P.O. box 2040, 3000CA Rotterdam, The Netherlands.
| | - F C T van der Helm
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628CD Delft, The Netherlands.
| | - S Niehof
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628CD Delft, The Netherlands; Department of Anesthesiology and Pain Medicine, Erasmus MC University Medical Center, P.O. box 2040, 3000CA Rotterdam, The Netherlands; Department of Information, Medical Technology and Services, Maasstad Hospital, Haastrechtstraat 7D, 3079DC Rotterdam, The Netherlands.
| | - A C Schouten
- Department of Biomechanical Engineering, Delft University of Technology, Mekelweg 2, 2628CD Delft, The Netherlands; Department of Biomechanical Engineering, MIRA Institute, University of Twente, Building Zuidhorst, P.O. box 217, 7500AE Enschede, The Netherlands.
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20
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Hiew FL, Douis H, Rajabally YA. Testing nerves: an overview of investigations for neuropathy. Br J Hosp Med (Lond) 2016; 77:508-15. [PMID: 27640653 DOI: 10.12968/hmed.2016.77.9.508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reviews the main investigations available to assess and diagnose patients with neuropathy. It details the most commonly used as well as investigations now becoming routine in neuromuscular centres, and those which are less widely available. Current practice and recent developments are discussed.
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Affiliation(s)
- Fu Liong Hiew
- Overseas Neuromuscular Fellow in the Department of Neurology, University Hospitals of Birmingham NHS Foundation Trust, Birmingham
| | - Hassan Douis
- Consultant Radiologist and Honorary Senior Lecturer in the School of Life and Health Sciences, Aston University, Birmingham
| | - Yusuf A Rajabally
- Consultant Neurologist and Honorary Professor of Neurology in the School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham B4 7ET
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21
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Springer J, Karlsson P, Madsen C, Johnsen B, Finnerup N, Jensen T, Nikolajsen L. Functional and structural assessment of patients with and without persistent pain after thoracotomy. Eur J Pain 2016; 21:238-249. [DOI: 10.1002/ejp.919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Affiliation(s)
- J.S. Springer
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
- Department of Neurology; Aarhus University Hospital; Denmark
| | - P. Karlsson
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
| | - C.S. Madsen
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
| | - B. Johnsen
- Department of Clinical Neurophysiology; Aarhus University Hospital; Denmark
| | - N.B. Finnerup
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
| | - T.S. Jensen
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
- Department of Neurology; Aarhus University Hospital; Denmark
| | - L. Nikolajsen
- Danish Pain Research Center; Department of Clinical Medicine; Aarhus University; Denmark
- Department of Anaesthesiology; Aarhus University Hospital; Denmark
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22
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Havrdova T, Boucek P, Saudek F, Voska L, Lodererova A, Üçeyler N, Vondrova H, Skibova J, Lipar K, Sommer C. Severe Epidermal Nerve Fiber Loss in Diabetic Neuropathy Is Not Reversed by Long-Term Normoglycemia After Simultaneous Pancreas and Kidney Transplantation. Am J Transplant 2016; 16:2196-201. [PMID: 26751140 DOI: 10.1111/ajt.13715] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 12/16/2015] [Accepted: 01/02/2016] [Indexed: 01/25/2023]
Abstract
Whether nerve fiber loss, a prominent feature of advanced diabetic neuropathy, can be reversed by reestablishment of normal glucose control remains questionable. We present 8-year follow-up data on epidermal nerve fiber (ENF) density and neurological function in patients with type 1 diabetes after simultaneous pancreas and kidney transplantation (SPK) with long-term normoglycemia. Distal thigh skin biopsies with ENF counts, vibration perception thresholds (VPTs), autonomic function testing (AFT) and electrophysiological examinations were performed at time of SPK and 2.5 and 8 years after SPK in 12 patients with type 1 diabetes. In comparison to controls, baseline ENF density, VPT and AFT results of patients indicated severe neuropathy. At follow-up, all SPK recipients were insulin independent with excellent glycemic control and kidney graft function; however, the severe ENF depletion present at baseline had not improved, with total ENF absence in 11 patients at 8-year follow-up. Similarly, no amelioration occurred in the VPT and AFT results. Numerical improvement was seen in some electrophysiological parameters; however, statistical significance was achieved only in median motor nerve conduction velocity. ENF loss and functional deficits in advanced diabetic peripheral neuropathy are rarely reversible, even by long-term normoglycemia, which underscores the importance of neuropathy prevention by early optimal glycemic control.
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Affiliation(s)
- T Havrdova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - P Boucek
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - F Saudek
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - L Voska
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Lodererova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - N Üçeyler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - H Vondrova
- Department of Neurology, Thomayer Hospital, Prague, Czech Republic
| | - J Skibova
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - K Lipar
- Diabetes and Transplant Centers, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - C Sommer
- Department of Neurology, University of Würzburg, Würzburg, Germany
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23
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Van Acker N, Ragé M, Sluydts E, Knaapen MWM, De Bie M, Timmers M, Fransen E, Duymelinck C, De Schepper S, Anand P, Meert T, Plaghki L, Cras P. Automated PGP9.5 immunofluorescence staining: a valuable tool in the assessment of small fiber neuropathy? BMC Res Notes 2016; 9:280. [PMID: 27215701 PMCID: PMC4878004 DOI: 10.1186/s13104-016-2085-4] [Citation(s) in RCA: 20] [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] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In this study we explored the possibility of automating the PGP9.5 immunofluorescence staining assay for the diagnosis of small fiber neuropathy using skin punch biopsies. The laboratory developed test (LDT) was subjected to a validation strategy as required by good laboratory practice guidelines and compared to the well-established gold standard method approved by the European Federation of Neurological Societies (EFNS). To facilitate automation, the use of thinner sections. (16 µm) was evaluated. Biopsies from previously published studies were used. The aim was to evaluate the diagnostic performance of the LDT compared to the gold standard. We focused on technical aspects to reach high-quality standardization of the PGP9.5 assay and finally evaluate its potential for use in large scale batch testing. RESULTS We first studied linear nerve fiber densities in skin of healthy volunteers to establish reference ranges, and compared our LDT using the modifications to the EFNS counting rule to the gold standard in visualizing and quantifying the epidermal nerve fiber network. As the LDT requires the use of 16 µm tissue sections, a higher incidence of intra-epidermal nerve fiber fragments and a lower incidence of secondary branches were detected. Nevertheless, the LDT showed excellent concordance with the gold standard method. Next, the diagnostic performance and yield of the LDT were explored and challenged to the gold standard using skin punch biopsies of capsaicin treated subjects, and patients with diabetic polyneuropathy. The LDT reached good agreement with the gold standard in identifying small fiber neuropathy. The reduction of section thickness from 50 to 16 µm resulted in a significantly lower visualization of the three-dimensional epidermal nerve fiber network, as expected. However, the diagnostic performance of the LDT was adequate as characterized by a sensitivity and specificity of 80 and 64 %, respectively. CONCLUSIONS This study, designed as a proof of principle, indicated that the LDT is an accurate, robust and automated assay, which adequately and reliably identifies patients presenting with small fiber neuropathy, and therefore has potential for use in large scale clinical studies.
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Affiliation(s)
- Nathalie Van Acker
- />Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | - Michael Ragé
- />Institute of Neuroscience, Université Catholique de Louvain, Avenue Mounier 53, B1.53.04, 1200 Brussels, Belgium
| | - Ellen Sluydts
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | | | - Martine De Bie
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | - Maarten Timmers
- />Janssen Research and Development, Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340 Beerse, Belgium
- />Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Erik Fransen
- />StatUa Center for Statistics, University of Antwerp, Antwerp, Belgium
| | - Carla Duymelinck
- />HistoGeneX NV, Pr J Charlottelaan 10, Berchem, 2600 Antwerp, Belgium
| | | | - Praveen Anand
- />Peripheral Neuropathy Unit, Hammersmith Hospital, Du Cane Road, London, W12 0HS UK
| | - Theo Meert
- />Janssen Research and Development, Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340 Beerse, Belgium
| | - Léon Plaghki
- />Institute of Neuroscience, Université Catholique de Louvain, Avenue Mounier 53, B1.53.04, 1200 Brussels, Belgium
| | - Patrick Cras
- />Department of Neurology, Antwerp University Hospital, Born Bunge Institute, University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
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24
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Truini A, Haanpaa M, Provitera V, Biasiotta A, Stancanelli A, Caporaso G, Santoro L, Cruccu G, Nolano M. Differential myelinated and unmyelinated sensory and autonomic skin nerve fiber involvement in patients with ophthalmic postherpetic neuralgia. Front Neuroanat 2015; 9:105. [PMID: 26300742 PMCID: PMC4523825 DOI: 10.3389/fnana.2015.00105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 07/22/2015] [Indexed: 01/03/2023] Open
Abstract
Postherpetic neuralgia (PHN) is a common and exceptionally drug-resistant neuropathic pain condition. In this cross-sectional skin biopsy study, seeking information on the responsible pathophysiological mechanisms we assessed how ophthalmic PHN affects sensory and autonomic skin innervation. We took 2-mm supraorbital punch skin biopsies from the affected and unaffected sides in 10 patients with ophthalmic PHN. Using indirect immunofluorescence and a large panel of antibodies including protein gene product (PGP) 9.5 we quantified epidermal unmyelinated, dermal myelinated and autonomic nerve fibers. Although skin biopsy showed reduced epidermal and dermal myelinated fiber density in specimens from the affected side, the epidermal/dermal myelinated nerve fiber ratio was lower in the affected than in the unaffected side (p < 0.001), thus suggesting a predominant epidermal unmyelinated nerve fiber loss. Conversely, autonomic skin innervation was spared. Our study showing that ophthalmic PHN predominantly affects unmyelinated nerve fiber and spares autonomic nerve fiber might help to understand the pathophysiological mechanisms underlying this difficult-to-treat condition.
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Affiliation(s)
- Andrea Truini
- Department of Neurology and Psychiatry, Sapienza University of Rome Rome, Italy
| | - Maija Haanpaa
- Department of Neurosurgery, Helsinki University Central Hospital Helsinki, Finland
| | - Vincenzo Provitera
- Neurology Division "Salvatore Maugeri" Foundation-Institute of Telese Terme (BN) Italy Telese Terme, Italy
| | - Antonella Biasiotta
- Department of Neurology and Psychiatry, Sapienza University of Rome Rome, Italy
| | - Annamaria Stancanelli
- Neurology Division "Salvatore Maugeri" Foundation-Institute of Telese Terme (BN) Italy Telese Terme, Italy
| | - Giuseppe Caporaso
- Neurology Division "Salvatore Maugeri" Foundation-Institute of Telese Terme (BN) Italy Telese Terme, Italy
| | - Lucio Santoro
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II of Naples Naples, Italy
| | - Giorgio Cruccu
- Department of Neurology and Psychiatry, Sapienza University of Rome Rome, Italy
| | - Maria Nolano
- Neurology Division "Salvatore Maugeri" Foundation-Institute of Telese Terme (BN) Italy Telese Terme, Italy
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Skorna M, Kopacik R, Vlckova E, Adamova B, Kostalova M, Bednarik J. Small-nerve-fiber pathology in critical illness documented by serial skin biopsies. Muscle Nerve 2015; 52:28-33. [PMID: 25307783 DOI: 10.1002/mus.24489] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/28/2014] [Accepted: 10/09/2014] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Small-fiber pathology can develop in the acute phase of critical illness and may explain chronic sensory impairment and pain in critical care survivors. METHODS Eleven adult ischemic stroke patients in a neurocritical care unit were enrolled in an observational cohort study. Intraepidermal nerve fiber density (IENFD) in the distal leg was assessed on admission to the intensive care unit and 10-14 days later, together with electrophysiological testing. RESULTS Of the 11 patients recruited, 9 (82%) had sepsis or multiple-organ failure. Median IENFD on admission (5.05 fibers/mm) decreased significantly to 2.18 fibers/mm (P < 0.001), and abnormal IENFD was found in 6 patients (54.5%). Electrodiagnostic signs of large-fiber neuropathy and/or myopathy were found in 6 patients (54.5%), and autonomic dysfunction was found in 2 patients (18.2%). CONCLUSION Serial IENFD measurements confirmed the development of small-fiber sensory involvement in the acute phase of critical illness.
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Affiliation(s)
- Miroslav Skorna
- Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Roman Kopacik
- Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Eva Vlckova
- Central European Institute of Technology, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Blanka Adamova
- Central European Institute of Technology, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Milena Kostalova
- Central European Institute of Technology, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Josef Bednarik
- Central European Institute of Technology, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
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Abstract
Neuropathic pain is caused by lesions in the somatosensory system. Characteristic but not exclusive features are spontaneous burning pain, electrifying and shooting pain, hyperalgesia, and allodynia. The basic concept of the pathophysiology of neuropathic pain is the combination of peripheral and central sensitization. Knowledge on the molecular mechanisms has grown exponentially in recent years. The problem lies in identifying the individual mechanisms and in determining a comprehensive concept. Progress has also been made in assessment, e.g., methods for detecting dysfunction of nociceptors have significantly improved. In addition, there are many more therapeutic options available than 15 years ago. The drugs available include antidepressants, anticonvulsants, opioids, and topical medications. Data from controlled trials and recommendations from guidelines are available.
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Affiliation(s)
- C Sommer
- Neurologische Klinik, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland,
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27
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Merkies ISJ, Faber CG, Lauria G. Advances in diagnostics and outcome measures in peripheral neuropathies. Neurosci Lett 2015; 596:3-13. [PMID: 25703220 DOI: 10.1016/j.neulet.2015.02.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 02/05/2015] [Accepted: 02/17/2015] [Indexed: 12/13/2022]
Abstract
Peripheral neuropathies are a group of acquired and hereditary disorders presenting with different distribution and nerve fiber class involvement. The overall prevalence is 2.4%, increasing to 8% in the elderly population. However, the frequency may vary depending on the underlying pathogenesis and association with systemic diseases. Distal symmetric polyneuropathy is the most common form, though multiple mononeuropathies, non-length dependent neuropathy and small fiber neuropathy can occur and may require specific diagnostic tools. The use of uniform outcome measures in peripheral neuropathies is important to improve the quality of randomized controlled trials, enabling comparison between studies. Recent developments in defining the optimal set of outcome measures in inflammatory neuropathies may serve as an example for other conditions. Diagnostic and outcome measure advances in peripheral neuropathies will be discussed.
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Affiliation(s)
- Ingemar S J Merkies
- Department of Neurology, Spaarne Hospital, Hoofddorp, The Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Catharina G Faber
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Giuseppe Lauria
- 3rd Neurology Unit, IRCCS Foundation "Carlo Besta" Neurological Institute, Milan, Italy.
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Wong CS, Hui GK, Chung EK, Wong SH. Diagnosis and management of neuropathic pain. Pain Manag 2015; 4:221-31. [PMID: 24953074 DOI: 10.2217/pmt.14.7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A recent revision in the definition of neuropathic pain has highlighted this condition as a distinct disease entity. More accurate search for a lesion in the somatosensory nervous system as the pain-generating mechanism will help target the treatment by pharmacological agents. A multidisciplinary approach is recommended, with pharmacotherapy supplemented by psychological therapy and physical rehabilitation, and appropriate interventional treatment for selected refractory cases.
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Affiliation(s)
- Clara Sm Wong
- Department of Anaesthesiology, Queen Elizabeth Hospital, Hong Kong
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Karlsson P, Nyengaard JR, Polydefkis M, Jensen TS. Structural and functional assessment of skin nerve fibres in small-fibre pathology. Eur J Pain 2014; 19:1059-70. [PMID: 25546653 DOI: 10.1002/ejp.645] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2014] [Indexed: 01/19/2023]
Abstract
Damage to nociceptor nerve fibres may give rise to peripheral neuropathies, some of which are pain free and some are painful. A hallmark of many peripheral neuropathies is the loss of small nerve fibres in the epidermis, a condition called small-fibre neuropathy (SFN) when it is predominantly the small nerve fibres that are damaged. Historically, SFN has been very difficult to diagnose as clinical examination and nerve conduction studies mainly detect large nerve fibres, and quantitative sensory testing is not sensitive enough to detect small changes in small nerve fibres. However, taking a 3-mm punch skin biopsy from the distal leg and quantification of the nerve fibre density has proven to be a useful method to diagnose SFN. However, the correlation between the nerve fibre loss and other test results varies greatly. Recent studies have shown that it is possible not only to extract information about the nerve fibre density from the biopsies but also to get an estimation of the nerve fibre length density using stereology, quantify sweat gland innervation and detect morphological changes such as axonal swelling, all of which may be additional parameters indicating diseased small fibres relating to symptoms reported by the patients. In this review, we focus on available tests to assess structure and function of the small nerve fibres, and summarize recent advances that have provided new possibilities to more specifically relate structural findings with symptoms and function in patients with SFN.
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Affiliation(s)
- P Karlsson
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - J R Nyengaard
- Stereology and Electron Microscopy Laboratory and Centre for Stochastic Geometry and Advanced Bioimaging, Aarhus University Hospital, Denmark
| | - M Polydefkis
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - T S Jensen
- Danish Pain Research Center and Stereology & EM Laboratory, Aarhus University Hospital, Denmark.,Department of Neurology, Aarhus University Hospital, Denmark
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30
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Neuropathies douloureuses et atteinte des petites fibres. Rev Neurol (Paris) 2014; 170:825-36. [DOI: 10.1016/j.neurol.2014.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/10/2014] [Indexed: 12/16/2022]
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Haensch CA, Tosch M, Katona I, Weis J, Isenmann S. Small-fiber neuropathy with cardiac denervation in postural tachycardia syndrome. Muscle Nerve 2014; 50:956-61. [PMID: 24647968 DOI: 10.1002/mus.24245] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2014] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Postural tachycardia syndrome (POTS) is a disorder of orthostatic intolerance characterized by excessive tachycardia of unknown etiology. Our objective in this study was to evaluate the correlation between C-fiber involvement as shown by skin biopsy and adrenergic cardiac metaiodobenzylguanadine (MIBG) uptake in POTS patients. METHODS Skin biopsies of 84 patients with POTS were examined by Protein Gene Product 9.5 (PGP9.5) immunohistochemistry and were compared with MIBG myocardial scintigraphy imaging data. RESULTS Mean intraepidermal nerve fiber (IENF) density was in the lower normal age-adjusted range, 7.2 ± 2.9/mm (normal ≥ 7/mm), and was slightly below the normal range in 45% of POTS patients. MIBG uptake was reduced in 21% of patients. Low IENF density correlated with reduced cardiac MIBG uptake (r = 0.39, P = 0.001). CONCLUSIONS A subset of neuropathic POTS patients may harbor mild small fiber neuropathy with abnormalities of unmyelinated nerve fibers in the skin associated with reduced myocardial postganglionic sympathetic innervation.
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Affiliation(s)
- Carl-Albrecht Haensch
- Department of Neurology, Kliniken Maria Hilf Mönchengladbach, Faculty of Health, University of Witten/Herdecke, Viersenerstrasse 450, D-41063, Mönchengladbach, Germany
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32
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Kluger N, Fraitag S, Roguedas AM, Misery L. [Normal skin biopsy as a tool for extra-cutaneous disorders]. Ann Dermatol Venereol 2014; 141:192-200. [PMID: 24635953 DOI: 10.1016/j.annder.2014.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/28/2013] [Accepted: 01/09/2014] [Indexed: 12/14/2022]
Abstract
Biopsies of apparently healthy skin can contribute to the diagnosis of an internal disorder in a patient or in the detection of a potential disease carrier. Herein, we review those diseases for which dermatologists may be asked to perform a biopsy on normal skin where analysis by optical microscopy, immunofluorescence or electronic microscopy may result in diagnosis of an "internal" disease. Diseases for which biopsies are required for cell cultures (e.g. fibroblasts cultures), clonality testing or chromosomal analysis are not discussed here.
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Affiliation(s)
- N Kluger
- Department of dermatology, venereology and allergology, skin and allergies hospital, Helsinki University Central Hospital, Meilahdentie 2, PO Box 160, 00029 HUS, Finlande.
| | - S Fraitag
- Service d'anatomo-pathologie, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - A-M Roguedas
- Service de dermatologie, CHU, 2, avenue Foch, 29200 Brest, France
| | - L Misery
- Service de dermatologie, CHU, 2, avenue Foch, 29200 Brest, France
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Clinical and diagnostic features of small fiber damage in diabetic polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2014; 126:275-90. [DOI: 10.1016/b978-0-444-53480-4.00019-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Decorps J, Saumet JL, Sommer P, Sigaudo-Roussel D, Fromy B. Effect of ageing on tactile transduction processes. Ageing Res Rev 2014; 13:90-9. [PMID: 24373814 DOI: 10.1016/j.arr.2013.12.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 12/02/2013] [Accepted: 12/16/2013] [Indexed: 01/09/2023]
Abstract
With advancing age, a decline in the main sensory modalities including touch sensation and perception is well reported to occur. This review mainly outlines the peripheral components of touch perception highlighting ageing influences on morphological and functional features of cutaneous mechanical transducers and mechanosensitive ion channels, sensory innervation, neurotransmitters and even vascular system required to ensure efferent function of the afferent nerve fibres in the skin. This, in conjunction with effect of ageing on the skin per se and central nervous system, could explain the tactile deficit seen among the ageing population. We also discuss appropriate tools and experimental models available to study the age-related tactile decline.
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Affiliation(s)
- Johanna Decorps
- Laboratory of Tissue Biology and Therapeutic Engineering, Centre National de la Recherche Scientifique (CNRS) UMR 5305, Lyon, France; University of Lyon 1, UMR 5305, Lyon, France.
| | - Jean Louis Saumet
- Laboratory of Tissue Biology and Therapeutic Engineering, Centre National de la Recherche Scientifique (CNRS) UMR 5305, Lyon, France; University of Lyon 1, UMR 5305, Lyon, France.
| | - Pascal Sommer
- Laboratory of Tissue Biology and Therapeutic Engineering, Centre National de la Recherche Scientifique (CNRS) UMR 5305, Lyon, France; University of Lyon 1, UMR 5305, Lyon, France.
| | - Dominique Sigaudo-Roussel
- Laboratory of Tissue Biology and Therapeutic Engineering, Centre National de la Recherche Scientifique (CNRS) UMR 5305, Lyon, France; University of Lyon 1, UMR 5305, Lyon, France.
| | - Berengere Fromy
- Laboratory of Tissue Biology and Therapeutic Engineering, Centre National de la Recherche Scientifique (CNRS) UMR 5305, Lyon, France; University of Lyon 1, UMR 5305, Lyon, France.
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35
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Axer H, Grimm A, Porzelius C, Teschner U, Schumacher U, Witte OW, Brunkhorst FM. Impairment of small somatic and autonomic nerve fibres in intensive care unit patients with severe sepsis and critical illness polyneuropathy--a single center controlled observational study. BMC Neurol 2013; 13:159. [PMID: 24176121 PMCID: PMC4228411 DOI: 10.1186/1471-2377-13-159] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/30/2013] [Indexed: 11/26/2022] Open
Abstract
Background Axonal damage in large myelinated nerve fibres occurs in about 70% of patients with severe sepsis, known as critical illness polyneuropathy and contributes significantly to an increased short- and long-term morbidity and mortality in this population. Among other pathophysiological mechanisms, autonomic dysregulation, characterized by high concentrations of circulating catecholamines in the presence of impaired sympathetic modulation of heart and vessels have been discussed. We hypothesize that autonomic small fibre neuropathy play an important role in autonomic failure. Methods/Design Single center, non-randomized, controlled, observational study. Skin biopsies of patients with severe sepsis and/or septic shock are compared with those of age-matched controls. In order to assess impairment of small nerve fibres, skin biopsies are taken at onset of severe sepsis, and two and 16 weeks later. Intraepidermal nerve fibre densities are histologically analyzed using anti protein gene product (PGP) 9.5 immunostaining. In addition, standardized clinical examinations, as Medical Research Council (MRC) scores of muscle strength, Rankin scores, and standardized nerve conduction studies of the right median nerve, the right tibial nerve, the left fibular nerve, and both sural nerves are performed, to identify critical illness polyneuropathy and to neurophysiologically quantify the damage of large nerve fibres. Discussion The study will allow to describe the frequency of small fibre neuropathy in patients with severe sepsis up to four months after onset of severe sepsis and to evaluate its relationship to critical illness polyneuropathy. Trial registration The trial has been registered to the German Clinical Trials Register. The trial registration number is DRKS-ID: DRKS00000642.
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Affiliation(s)
- Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich-Schiller-University Jena, Erlanger Allee 101, D-07747 Jena, Germany.
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Andersson DA, Gentry C, Light E, Vastani N, Vallortigara J, Bierhaus A, Fleming T, Bevan S. Methylglyoxal evokes pain by stimulating TRPA1. PLoS One 2013; 8:e77986. [PMID: 24167592 PMCID: PMC3805573 DOI: 10.1371/journal.pone.0077986] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/16/2013] [Indexed: 12/13/2022] Open
Abstract
Diabetic neuropathy is a severe complication of long-standing diabetes and one of the major etiologies of neuropathic pain. Diabetes is associated with an increased formation of reactive oxygen species and the electrophilic dicarbonyl compound methylglyoxal (MG). Here we show that MG stimulates heterologously expressed TRPA1 in CHO cells and natively expressed TRPA1 in MDCK cells and DRG neurons. MG evokes [Ca2+]i-responses in TRPA1 expressing DRG neurons but is without effect in neurons cultured from Trpa1−/− mice. Consistent with a direct, intracellular action, we show that methylglyoxal is significantly more potent as a TRPA1 agonist when applied to the intracellular face of excised membrane patches than to intact cells. Local intraplantar administration of MG evokes a pain response in Trpa1+/+ but not in Trpa1−/− mice. Furthermore, persistently increased MG levels achieved by two weeks pharmacological inhibition of glyoxalase-1 (GLO-1), the rate-limiting enzyme responsible for detoxification of MG, evokes a progressive and marked thermal (cold and heat) and mechanical hypersensitivity in wildtype but not in Trpa1−/− mice. Our results thus demonstrate that TRPA1 is required both for the acute pain response evoked by topical MG and for the long-lasting pronociceptive effects associated with elevated MG in vivo. In contrast to our observations in DRG neurons, MG evokes indistinguishable [Ca2+]i-responses in pancreatic β-cells cultured from Trpa1+/+ and Trpa1−/− mice. In vivo, the TRPA1 antagonist HC030031 impairs glucose clearance in the glucose tolerance test both in Trpa1+/+ and Trpa1−/− mice, indicating a non-TRPA1 mediated effect and suggesting that results obtained with this compound should be interpreted with caution. Our results show that TRPA1 is the principal target for MG in sensory neurons but not in pancreatic β-cells and that activation of TRPA1 by MG produces a painful neuropathy with the behavioral hallmarks of diabetic neuropathy.
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Affiliation(s)
| | - Clive Gentry
- Wolfson CARD, King’s College London, London, United Kingdom
| | - Emily Light
- Wolfson CARD, King’s College London, London, United Kingdom
| | - Nisha Vastani
- Wolfson CARD, King’s College London, London, United Kingdom
| | | | - Angelika Bierhaus
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Fleming
- Department of Medicine I and Clinical Chemistry, University Hospital Heidelberg, Heidelberg, Germany
| | - Stuart Bevan
- Wolfson CARD, King’s College London, London, United Kingdom
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Latronico N, Filosto M, Fagoni N, Gheza L, Guarneri B, Todeschini A, Lombardi R, Padovani A, Lauria G. Small nerve fiber pathology in critical illness. PLoS One 2013; 8:e75696. [PMID: 24098716 PMCID: PMC3787101 DOI: 10.1371/journal.pone.0075696] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 08/19/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Degeneration of intraepidermal nerve fibers (IENF) is a hallmark of small fiber neuropathy of different etiology, whose clinical picture is dominated by neuropathic pain. It is unknown if critical illness can affect IENF. METHODS We enrolled 14 adult neurocritical care patients with prolonged intensive care unit (ICU) stay and artificial ventilation (≥ 3 days), and no previous history or risk factors for neuromuscular disease. All patients underwent neurological examination including evaluation of consciousness, sensory functions, muscle strength, nerve conduction study and needle electromyography, autonomic dysfunction using the finger wrinkling test, and skin biopsy for quantification of IENF and sweat gland innervation density during ICU stay and at follow-up visit. Development of infection, sepsis and multiple organ failure was recorded throughout the ICU stay. RESULTS Of the 14 patients recruited, 13 (93%) had infections, sepsis or multiple organ failure. All had severe and non-length dependent loss of IENF. Sweat gland innervation was reduced in all except one patient. Of the 7 patients available for follow-up visit, three complained of diffuse sensory loss and burning pain, and another three showed clinical dysautonomia. CONCLUSIONS Small fiber pathology can develop in the acute phase of critical illness and may explain chronic sensory impairment and pain in neurocritical care survivors. Its impact on long term disability warrants further studies involving also non-neurologic critical care patients.
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Affiliation(s)
- Nicola Latronico
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, Italy
- * E-mail:
| | - Massimiliano Filosto
- Department of Clinical Neurology, Section for Neuromuscular Diseases and Neuropathies, University of Brescia at Spedali Civili, Brescia, Italy
| | - Nazzareno Fagoni
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, Italy
| | - Laura Gheza
- Department of Anesthesia and Critical Care Medicine, Section of Neuroanesthesia and Neurocritical Care, University of Brescia at Spedali Civili, Brescia, Italy
| | - Bruno Guarneri
- Department of Clinical Neurophysiology, University of Brescia at Spedali Civili, Brescia, Italy
| | - Alice Todeschini
- Department of Clinical Neurology, Section for Neuromuscular Diseases and Neuropathies, University of Brescia at Spedali Civili, Brescia, Italy
| | - Raffaella Lombardi
- Neuromuscular Diseases Unit, “Carlo Besta” Neurological Institute, IRCCS Foundation, Milan, Italy
| | - Alessandro Padovani
- Department of Clinical Neurology, Section for Neuromuscular Diseases and Neuropathies, University of Brescia at Spedali Civili, Brescia, Italy
| | - Giuseppe Lauria
- Neuromuscular Diseases Unit, “Carlo Besta” Neurological Institute, IRCCS Foundation, Milan, Italy
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Misery L, Pavy-Le Traon A, Genestet S, Le Bec R, Marcorelles P. Diagnosis of small-fibre neuropathies: comparison between quantitative sensory testing and the measurement of intraepidermal nerve fibre density. J Eur Acad Dermatol Venereol 2013; 28:825-6. [PMID: 24813245 DOI: 10.1111/jdv.12274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/07/2013] [Accepted: 08/14/2013] [Indexed: 11/29/2022]
Affiliation(s)
- L Misery
- Breton Competence Centre of Rare Neuro-Muscular Diseases and Neuropathies with Cutaneous-Mucosal Symptoms, Brest, France
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39
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How to explore a patient with a chronic axonal polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2013. [PMID: 23931784 DOI: 10.1016/b978-0-444-52902-2.00014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Chronic axonal polyneuropathies are very frequently encountered by physicians. It is important to take a systematic approach when evaluating these patients. In this chapter we present such an approach. We present the diagnostic recommendations based on previously published evidence-based reviews and guidelines.
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40
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Myers MI, Peltier AC. Uses of skin biopsy for sensory and autonomic nerve assessment. Curr Neurol Neurosci Rep 2013; 13:323. [PMID: 23250768 DOI: 10.1007/s11910-012-0323-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Skin biopsy is a valuable diagnostic tool for small-fiber-predominant neuropathy by the quantification of intraepidermal nerve fiber density (IENFD). It has the unique advantage of being a minimally invasive procedure with the potential for longitudinal evaluation of both sensory and autonomic fibers. Unmyelinated small fibers are not otherwise quantified objectively with such a level of sensitivity as has been reported with IENFD. Recent advances include an expansion of the skin punch biopsy technique to evaluate larger myelinated fibers and mechanoreceptors, and recent work has also focused on additional methods of quantifying dermal fibers and densely innervated autonomic structures. This review discusses current work using skin biopsy for the pathologic analysis of peripheral nerve fibers in neuropathy of various causes as well as its use in clinical trials.
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Affiliation(s)
- M Iliza Myers
- Department of Neurology, Vanderbilt University School of Medicine, A-0118 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232, USA
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41
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Mellgren SI, Nolano M, Sommer C. The cutaneous nerve biopsy: technical aspects, indications, and contribution. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:171-188. [PMID: 23931780 DOI: 10.1016/b978-0-444-52902-2.00010-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Skin biopsy with a 3mm disposable circular punch is easy to perform and allows, after proper processing, the visualization of epidermal, dermal, and sweat gland nerve fibers. A technique of sampling the epidermis alone by applying a suction capsule, the "blister" technique, has also been developed. It is most common to stain immunohistochemically for the pan-axonal marker protein gene product 9.5 (PGP 9.5), an ubiquitin C-terminal hydroxylase. The sections are then observed and analyzed with bright-field microscopy or with indirect immunofluorescence with or without confocal microscopy. Most studies report quantification of intraepidermal nerve fiber density displayed in bright-field microscopy. Normative values have been established, particularly from the distal part of the leg, 10cm above the external malleolus. In diabetes mellitus early degeneration of intraepidermal nerve fibers is induced and there is slower regeneration even when there is no evidence of neuropathy. Skin biopsy is of particular value in the diagnosis of small fiber neuropathy when nerve conduction studies are normal. It may also be repeated in order to study the progressive nature of the disease and also has the potential of studying regeneration of nerve fibers and thus the effects of treatment. Inflammatory demyelinating neuropathies may also involve loss of small-diameter nerve fibers and IgM deposits in dermal myelinated nerve fibers in anti-MAG neuropathy. In some cases the presence of vasculitis in skin may indicate a nonsystemic vasculitic neuropathy and in HIV neuropathy intraepidermal nerve fiber density is reduced in a length-dependent manner. In several hereditary neuropathies intraepidermal nerve fiber density may be reduced but other abnormalities can also be demonstrated in dermal myelinated fibers. Some small swellings and varicosities may be present in the distal leg skin biopsy of healthy individuals but large axonal swellings are considered as evidence of a pathological process affecting the normal structure of nerves. The indirect immunofluorescence technique with confocal microscopy provides the opportunity to study the complex structure of sensory receptors and cutaneous myelinated fibers and the innervation of sweat glands, arrector pilorum muscles, and vessels.
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Affiliation(s)
- Svein Ivar Mellgren
- Department of Clinical Medicine - Neurology, University of Tromsø and University Hospital of North Norway, Tromsø, Norway.
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Kokotis P, Schmelz M, Papadimas GK, Skopelitis EE, Aroni K, Kordossis T, Karandreas N. Polyneuropathy induced by HIV disease and antiretroviral therapy. Clin Neurophysiol 2012; 124:176-82. [PMID: 22766629 DOI: 10.1016/j.clinph.2012.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 05/07/2012] [Accepted: 05/28/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate the underlying mechanisms of polyneuropathy induced by HIV infection or antiretroviral drugs. METHODS We tested 100 HIV patients (59 with AIDS). Ninety-three patients received antiretroviral drugs. Forty-four were treated with neurotoxic compounds (ddI, ddC, d4T). Nerve conduction velocities and the sympathetic skin response (SSR) in palms and soles were measured in all patients. In skin biopsies (ankle and thigh), the intraepidermal nerve fiber density (IENFD) and the number of epidermal fibers without contact to the basal membrane (fragments) were quantified using PGP9.5 staining. RESULTS Severity of the disease (CD4 +count) correlated to conduction velocities of peroneal (p < 0.01, Spearmans rank correlation), sural (p < 0.01) and median nerves (p < 0.05/p < 0.001, sensory/motor). In contrast, the duration of neurotoxic treatment did not impair conduction velocities (p > 0.3) but correlated to reduced IENFD in the ankle (r = -0.24, p < 0.05). Despite their reduced IENFD, patients with long neurotoxic treatment had a high number of fragments irrespective of their CD4 +count. CONCLUSIONS Neurotoxic treatment appears to primarily impair thin fiber conduction, whereas HIV neuropathy is linked to large fiber impairment and reduction of fragments of nerve fibers. SIGNIFICANCE These findings emphasize the differential pattern of polyneuropathy in HIV patients caused by the infection or induced by antiretroviral treatment.
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Affiliation(s)
- Panagiotis Kokotis
- Department of Neurology, Aeginition Hospital, Medical School of Athens, Athens, Greece.
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Isoardo G, Stella M, Cocito D, Risso D, Migliaretti G, Cauda F, Palmitessa A, Faccani G, Ciaramitaro P. Neuropathic pain in post-burn hypertrophic scars: A psychophysical and neurophysiological study. Muscle Nerve 2012; 45:883-90. [DOI: 10.1002/mus.23259] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lauria G, Faber CG, Merkies ISJ, Waxman SG. Diagnosis of neuropathic pain: challenges and possibilities. ACTA ACUST UNITED AC 2012; 6:89-93. [PMID: 23480652 DOI: 10.1517/17530059.2012.661712] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Neuropathic pain complicates many diseases of the peripheral and central nervous system and is frequently encountered in clinical practice. The mechanisms underlying its occurrence and chronification remain poorly understood. As a consequence, symptomatic treatment is frequently the only available therapeutic option. An appropriate diagnostic workup is an important prelude to treatment. Moreover, identification of the site of damage in the somatosensory pathway represents a mandatory step in the process of deciding on a disease-modifying therapy for any given patient. The recent revision of the definition of neuropathic pain has introduced the concept of a nosologic-based approach to the diagnosis, which is expected to be supported by the demonstration of a relationship between the clinical picture and a lesion or disease. This underscores the need for precise diagnostic assessment of the patient. In the last decade, a number of tools including validated scales, psychophysical tests and morphometric analysis of small nerve fibers carrying thermal and nociceptive sensation have been developed; these can provide important information about the quality and intensity of the multiple features that characterize neuropathic pain. More recently, advances on the recognition of a molecular substrate for neuropathic pain, both in terms of susceptibility and novel gene mutations, have provided the potential for new diagnostic perspectives and a path toward a better comprehension of the pathogenetic mechanisms. This editorial addresses briefly the impact of these developments on the diagnosis of neuropathic pain in clinical practice.
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Affiliation(s)
- Giuseppe Lauria
- "Carlo Besta" Neurological Institute, Neuromuscular Diseases Unit, IRCCS Foundation , Via Celoria, 11, 20133, Milan , Italy +39 02 2394 2378 ; +39 02 2394 4057 ;
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Scherens A, Maier C, Haussleiter IS, Schwenkreis P, Vlckova-Moravcova E, Baron R, Sommer C. Painful or painless lower limb dysesthesias are highly predictive of peripheral neuropathy: Comparison of different diagnostic modalities. Eur J Pain 2012; 13:711-8. [DOI: 10.1016/j.ejpain.2008.07.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 06/19/2008] [Accepted: 07/29/2008] [Indexed: 11/15/2022]
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Ruts L, van Doorn PA, Lombardi R, Haasdijk ED, Penza P, Tulen JHM, Hempel RJ, van den Meiracker AH, Lauria G. Unmyelinated and myelinated skin nerve damage in Guillain-Barré syndrome: correlation with pain and recovery. Pain 2011; 153:399-409. [PMID: 22154920 DOI: 10.1016/j.pain.2011.10.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 10/12/2011] [Accepted: 10/28/2011] [Indexed: 11/17/2022]
Abstract
We performed a prospective study in 32 patients with Guillain-Barré syndrome (GBS) or its variants to correlate intraepidermal nerve fiber density (IENFD) at the distal leg and lumbar region with pain, autonomic dysfunction, and outcome. In the acute phase, IENFD was reduced in 60% and 61.9% of patients at the distal leg and lumbar region, respectively. In the acute phase, 43.7% of patients complained of neuropathic pain. Their IENFD at the distal leg was significantly lower than in patients without pain (P<.001) and correlated with pain intensity (r(s)=-0.51; P=.003). Intriguingly, also patients with the pure motor variant of GBS and pain had low IENFD. At 6-month follow-up, only 3 patients complained of persisting neuropathic pain, whereas 3 patients reported late-onset pain symptoms. IENFD in the acute phase did not predict presence or intensity of pain at 6-month follow-up. IENFD in the acute phase did not correlate with clinical dysautonomia or GBS severity at nadir. However, it correlated with poorer GBS disability score at 6 months (P=.04), GBS score at nadir (P=.03), and clinically probable dysautonomia (P=.004). At 6-month follow-up, median IENFD remained significantly low both at the distal leg (P=.024) and lumbar region (P=.005). Double and triple staining confocal microscope studies showed diffuse damage of myelinated dermal nerves along with axonal degeneration, and mononuclear cell infiltration. Unmyelinated and myelinated skin nerves are diffusely affected in GBS and its variants, including the pure motor form. IENFD declines early, remains low over time, correlates with pain severity in the acute phase, and may predict long-term disability.
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Affiliation(s)
- Liselotte Ruts
- Department of Neurology, Erasmus MC, University of Rotterdam, 's-Gravendijkwal 230, 3015CE Rotterdam, The Netherlands Neuromuscular Diseases Unit, IRCCS Foundation, "Carlo Besta" Neurological Institute, via Celoria, 11, 20133 Milan, Italy Department of Neuroscience, Erasmus MC, University of Rotterdam, 's-Gravendijkwal 230, 3015CE Rotterdam, The Netherlands Department of Psychiatry, Erasmus MC, University of Rotterdam, 's-Gravendijkwal 230, 3015CE Rotterdam, The Netherlands School of Psychology, Mood Disorders Centre Psychology, College of Life and Environmental Sciences, Washington Singer Laboratories, University of Exeter, Perry Road, Exeter EX4 4QG, UK Department of Internal Medicine, Erasmus MC, University of Rotterdam, 's-Gravendijkwal 230, 3015CE Rotterdam, The Netherlands
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Jääskeläinen SK. Pathophysiology of primary burning mouth syndrome. Clin Neurophysiol 2011; 123:71-7. [PMID: 22030140 DOI: 10.1016/j.clinph.2011.07.054] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 06/18/2011] [Accepted: 07/05/2011] [Indexed: 10/15/2022]
Abstract
Primary burning mouth syndrome (BMS) is severe, disabling and chronic intraoral pain condition for which no local or systemic cause can be found and clinical examination is normal. It mostly affects elderly citizens, especially postmenopausal women with prevalence up to 12-18%. In addition to spontaneous burning pain, patients may complain of taste alterations. Recent neurophysiologic, psychophysical, neuropathological, and functional imaging studies have elucidated that several neuropathic mechanisms, mostly subclinical, act at different levels of the neuraxis and contribute to the pathophysiology of primary BMS. Demonstration of loss of small diameter nerve fibres in the tongue epithelium explains thermal hypoesthesia and increase in taste detection thresholds found in quantitative sensory testing. As in neuropathic pain, decreased brain activation to heat stimuli has been demonstrated with fMRI in BMS patients. However, it seems that the clinical diagnosis of primary BMS encompasses at least three distinct, subclinical neuropathic pain states that may overlap in individual patients. The first subgroup (50-65%) is characterized by peripheral small diameter fibre neuropathy of intraoral mucosa. The second subgroup (20-25%) consists of patients with subclinical lingual, mandibular, or trigeminal system pathology that can be dissected with careful neurophysiologic examination but is clinically indistinguishable from the other two subgroups. The third subgroup (20-40%) fits the concept of central pain that may be related to hypofunction of dopaminergic neurons in the basal ganglia. The neurogenic factors acting in these subgroups differ, and will require different treatment strategies. In the future, with proper use of diagnostic tests, BMS patients may benefit from interventions specifically targeted at the underlying pathophysiological mechanisms.
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Affiliation(s)
- Satu K Jääskeläinen
- Department of Clinical Neurophysiology, University of Turku and Turku University Hospital, Postal Box 52, 20521 Turku, Finland.
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Sommer CL, Brandner S, Dyck PJ, Harati Y, LaCroix C, Lammens M, Magy L, Mellgren SI, Morbin M, Navarro C, Powell HC, Schenone AE, Tan E, Urtizberea A, Weis J. Peripheral Nerve Society Guideline on processing and evaluation of nerve biopsies. J Peripher Nerv Syst 2010; 15:164-75. [DOI: 10.1111/j.1529-8027.2010.00276.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sène D, Authier FJ, Amoura Z, Cacoub P, Lefaucheur JP. Neuropathie des petites fibres : approche diagnostique et traitement, et place de son association au syndrome de Gougerot-Sjögren primaire. Rev Med Interne 2010; 31:677-84. [DOI: 10.1016/j.revmed.2010.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 06/28/2010] [Accepted: 07/28/2010] [Indexed: 12/18/2022]
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Haanpää M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D, Cruccu G, Hansson P, Haythornthwaite JA, Iannetti GD, Jensen TS, Kauppila T, Nurmikko TJ, Rice ASC, Rowbotham M, Serra J, Sommer C, Smith BH, Treede RD. NeuPSIG guidelines on neuropathic pain assessment. Pain 2010; 152:14-27. [PMID: 20851519 DOI: 10.1016/j.pain.2010.07.031] [Citation(s) in RCA: 712] [Impact Index Per Article: 50.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Revised: 07/02/2010] [Accepted: 07/29/2010] [Indexed: 01/01/2023]
Abstract
This is a revision of guidelines, originally published in 2004, for the assessment of patients with neuropathic pain. Neuropathic pain is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system either at peripheral or central level. Screening questionnaires are suitable for identifying potential patients with neuropathic pain, but further validation of them is needed for epidemiological purposes. Clinical examination, including accurate sensory examination, is the basis of neuropathic pain diagnosis. For more accurate sensory profiling, quantitative sensory testing is recommended for selected cases in clinic, including the diagnosis of small fiber neuropathies and for research purposes. Measurement of trigeminal reflexes mediated by A-beta fibers can be used to differentiate symptomatic trigeminal neuralgia from classical trigeminal neuralgia. Measurement of laser-evoked potentials is useful for assessing function of the A-delta fiber pathways in patients with neuropathic pain. Functional brain imaging is not currently useful for individual patients in clinical practice, but is an interesting research tool. Skin biopsy to measure the intraepidermal nerve fiber density should be performed in patients with clinical signs of small fiber dysfunction. The intensity of pain and treatment effect (both in clinic and trials) should be assessed with numerical rating scale or visual analog scale. For future neuropathic pain trials, pain relief scales, patient and clinician global impression of change, the proportion of responders (50% and 30% pain relief), validated neuropathic pain quality measures and assessment of sleep, mood, functional capacity and quality of life are recommended.
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Affiliation(s)
- Maija Haanpää
- Rehabilitation ORTON, Helsinki, Finland Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, Hôpital Ambroise Paré, APHP, Boulogne-Billancourt, France Université Versailles Saint-Quentin, France Department of Neurology, University of Wisconsin, Madison, WI, USA Division of Neurological Pain Research and Therapy, Department of Neurology, Universitatsklinikum Schleswig-Holstein, Kiel, Germany Institute of Health Research, Lancaster University, Lancaster University, Lancaster, UK Department of Neurology, La Sapienza University, Rome, Italy Pain Center, Department of Anesthesiology and Intensive Care, Clinical Pain Research, Karolinska University Hospital/Institutet, Stockholm, Sweden Johns Hopkins University, Baltimore, MD, USA Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK Danish Pain Research Center and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark Korso-Koivukylä Health Centre, Vantaa, Finland Network of Academic Health Centres, Departments of General Practice and Primary Healthcare, Institute of Clinical Medicine and Department of National Public Health, University of Helsinki, Helsinki, Finland Pain Research Institute, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK Department of Neurology, QCSF Pain Clinic Research Center, University of California, San Francisco, CA, USA Department of Neurology, MC Mutual & Neuroscience Technologies, Barcelona Science Park, Barcelona, Spain Department of Neurology, University of Würzburg, Germany Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK Center for Biomedicine and Medical Technology Mannheim, Heidelberg University, Mannheim, Germany
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