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Varrassi G, Tamburin S, Zis P, Guardamagna VA, Paladini A, Rekatsina M. What's New in Neuropathy? Cureus 2023; 15:e44952. [PMID: 37818524 PMCID: PMC10561699 DOI: 10.7759/cureus.44952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/06/2023] [Indexed: 10/12/2023] Open
Abstract
Neuropathic pain presents diagnostic and treatment challenges. Despite recent advances in our understanding of the diagnosis and treatment of neuropathy, much remains to be elucidated. Familiar with neuropathy is the paradox that aberrant nerve signaling causes both sensory loss and pain. Voltage-gated sodium channels play an important role in neuronal electrogenesis and communication among neurons, and their dysregulation leads to hyperexcitability and pain. While numerous validated diagnostic assessment tools are available for neuropathy, patients often experience a diagnostic delay about the cause of their neuropathy. New research is defining more specific types of neuropathy beyond peripheral and central forms. The prevalence of pain varies by type of neuropathy, with chronic idiopathic axonal polyneuropathy associated with the highest proportion of patients experiencing pain. In the majority of types, it exceeds 50%. Gluten neuropathy, a form of peripheral neuropathy, is a new diagnostic consideration. It may require electrochemical conductance testing of hands and feet to test for sudomotor dysfunction. Among those with serologically confirmed gluten sensitivity or celiac disease, gluten neuropathy is a common neurological manifestation and may be addressed at least partially by a gluten-free diet. In Greece, a new neuropathic pain registry was created in 2014 in order to help gather data from real-world neuropathic pain patients. While still in its earliest phase, this registry has already produced demographic and treatment data that suggest suboptimal prescribing and less than recommended use of interventional procedures. Awareness campaigns are underway to encourage more Greek pain clinics to participate in this important registry.
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Affiliation(s)
| | | | - Panagiotis Zis
- Department of Neurology, University of Cyprus, Nicosia, CYP
| | | | - Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Martina Rekatsina
- Department of Anesthesiology and Pain Management, University of Athens, Athens, GRC
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Hinduja A, Nevoret ML, Calvet JH. Improvement in small fiber neuropathy after a gluten-free diet, demonstrated in a patient with celiac disease by measurement of electrochemical skin conductance. Neurophysiol Clin 2022; 52:404-406. [PMID: 36210257 DOI: 10.1016/j.neucli.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Anand Hinduja
- Aarti Clinic, 10, Monarch Fortune CHS, Sector 18, Kharghar, Navi Mumbai 410210, India.
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Finsterer J, Scorza FA. Small fiber neuropathy. Acta Neurol Scand 2022; 145:493-503. [PMID: 35130356 DOI: 10.1111/ane.13591] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/19/2022] [Accepted: 01/24/2022] [Indexed: 11/01/2022]
Abstract
Small fiber neuropathy (SFN) is a peripheral nervous system disease due to affection of A-delta or C-fibers in a proximal, distal, or diffuse distribution. Selective SFN (without large fiber affection) manifests with pain, sensory disturbances, or autonomic dysfunction. Though uniform diagnostic criteria are unavailable, most of them request typical clinical features and reduced intra-epidermal nerve fiber density on proximal or distal skin biopsy. Little consensus has been reached about the treatment of SFN, why this narrative review aims at summarizing and discussing treatment options for SFN. Treatment of SFN can be classified as symptomatic, pathophysiologic, or causal. Prerequisites for treating SFN are an established diagnosis, knowledge about the symptoms and signs, and the etiology. Pain usually responds to oral/intravenous pain killers, antidepressants, anti-seizure drugs, or topical, transdermal specifications. Some of the autonomic disturbances respond favorably to symptomatic treatment. SFN related to Fabry disease or hATTR are accessible to pathogenesis-related therapy. Immune-mediated SFN responds to immunosuppression or immune-modulation. Several of the secondary SFNs respond to causal treatment of the underlying disorder. In conclusion, treatment of SFN relies on a multimodal concept and includes causative, pathophysiologic, and symptomatic measures. It strongly depends on the clinical presentation, diagnosis, and etiology, why it is crucial before initiation of treatment to fix the diagnosis and etiology. Due to the heterogeneous clinical presentation and multi-causality, treatment of SFN should be individualized with the goal of controlling the underlying cause, alleviating pain, and optimizing functionality.
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Affiliation(s)
- Josef Finsterer
- Neurology & Neurophysiology Center Vienna Austria
- Disciplina de Neurociência Escola Paulista de Medicina/Universidade Federal de São Paulo/. (EPM/UNIFESP) São Paulo Brasil
| | - Fulvio A. Scorza
- Disciplina de Neurociência Escola Paulista de Medicina/Universidade Federal de São Paulo/. (EPM/UNIFESP) São Paulo Brasil
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Hadjivassiliou M, Zis P. Neurological manifestations of gluten-related disorders. COELIAC DISEASE AND GLUTEN-RELATED DISORDERS 2022:209-222. [DOI: 10.1016/b978-0-12-821571-5.00008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Bardakov SN, Tran MD, Lapin SV, Moshnikova AN, Kalinina EU, Bogdanova EG, Bolekhan AV, Gavriluk BL. Acrodystrophic axonal polyneuropathy with celiac disease: a case report. J Med Case Rep 2021; 15:615. [PMID: 34920762 PMCID: PMC8684204 DOI: 10.1186/s13256-021-03171-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patients with celiac disease present with not only gastrointestinal symptoms but also extraintestinal manifestations such as anemia, osteopathy, dermatitis herpetiformis, and celiac neuropathy. Despite a fairly wide range of celiac neuropathies, we report a case of the acrodystrophic variant of celiac polyneuropathy, which has not been previously described. Case presentation A 41-year-old Ukrainian male suffered from symmetric, sensorimotor axonal polyneuropathy and encephalopathy associated with celiac disease, which is characterized by severe trophic disorders in the lower extremities (trophic ulcers, hyperkeratosis, and anhidrosis). Acrodystrophic changes in the lower extremities were due to both neurogenic and direct immunoinflammatory damaging effects. Clinical–electrophysiological dissociation was also noted, which was represented by a gross axonal lesion with the preservation of muscle strength. The absence of enteropathic manifestations was accompanied by the pronounced histological changes in the duodenal mucosa by IIIb stage of Marsh. A gluten-free diet in combination with membrane plasma exchange and intravenous pulse methylprednisolone was prescribed to reduce the severity of sensory disorders and regression of encephalopathy within 7 months. Conclusion Celiac disease may be a potential cause of neuropathy and encephalopathy in adult patients. Further immunosuppressive treatment protocols for both intestinal and extraintestinal manifestations of celiac disease are required.
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Affiliation(s)
- S N Bardakov
- S.M. Kirov Military Medical Academy, Akademika Lebedeva Street, 6., Saint Petersburg, 194044, Russia
| | - Minh Duc Tran
- Peoples' Friendship University of Russia, Miklukho-Maklaya Street, 6, Moscow, 117198, Russia.
| | - S V Lapin
- Pavlov First Saint Petersburg State Medical University, L'va Tolstogo Street, 6-8, Saint Petersburg, 197022, Russia
| | - A N Moshnikova
- Pavlov First Saint Petersburg State Medical University, L'va Tolstogo Street, 6-8, Saint Petersburg, 197022, Russia
| | - E U Kalinina
- Saint-Petersburg State Pediatric Medical University, Litovskaya Street, 2, Saint Petersburg, 194100, Russia
| | - E G Bogdanova
- S.M. Kirov Military Medical Academy, Akademika Lebedeva Street, 6., Saint Petersburg, 194044, Russia
| | - A V Bolekhan
- S.M. Kirov Military Medical Academy, Akademika Lebedeva Street, 6., Saint Petersburg, 194044, Russia
| | - B L Gavriluk
- S.M. Kirov Military Medical Academy, Akademika Lebedeva Street, 6., Saint Petersburg, 194044, Russia
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Zis P, Shafique F, Sarrigiannis PG, Artemiadis A, Rao DG, Sanders DS, Hadjivassiliou M. Sudomotor dysfunction in patients with gluten neuropathy. Neurol Sci 2021; 43:3381-3385. [PMID: 34791566 PMCID: PMC9018627 DOI: 10.1007/s10072-021-05751-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Gluten neuropathy (GN) is a common neurological manifestation of gluten sensitivity (GS), characterized by serological evidence of GS, while other risk factors for developing neuropathy are absent. The degree of small fiber dysfunction in GN has not been studied in depth to date. Small fiber involvement may lead to pain, thermal perception abnormalities, and sweat gland dysfunction. Sudomotor innervation refers to the cholinergic innervation of the sympathetic nervous system through small fibers in the sweat glands. The aim of our study was to assess the sudomotor function of GN patients. METHODS Patients with GN were recruited. Clinical and neurophysiological data were obtained. HLA-DQ genotyping was performed. The skin electrochemical conductance (ESC) was measured with SUDOSCANTM. RESULTS Thirty-two patients (25 males, mean age 69.5±10.2 years) were recruited. Thirteen patients (40.6%) had abnormal sudomotor function of the hands. Sixteen patients (50%) had abnormal sudomotor function of the feet. Twenty-one patients (65.6%) had abnormal sudomotor function of either the hands or feet. Sudomotor dysfunction did not correlate with the type of neuropathy (length-dependent neuropathy or sensory ganglionopathy), gluten-free diet adherence, severity of neuropathy, and duration of disease or HLA-DQ genotype. No differences in the ESC were found between patients with painful and patients with painless GN. CONCLUSION Sudomotor dysfunction affects two-thirds of patients with GN. The lack of correlation between pain and sudomotor dysfunction suggests different patterns of small fiber involvement in patients with GN.
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Affiliation(s)
- Panagiotis Zis
- Medical School, University of Cyprus, Nicosia, Cyprus. .,Medical School, University of Sheffield, Sheffield, UK.
| | - Faiza Shafique
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Dasappaiah G Rao
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David S Sanders
- Medical School, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Marios Hadjivassiliou
- Medical School, University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Gemignani F, Bellanova MF, Saccani E, Pavesi G. Non-length-dependent small fiber neuropathy: Not a matter of stockings and gloves. Muscle Nerve 2021; 65:10-28. [PMID: 34374103 DOI: 10.1002/mus.27379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/11/2021] [Accepted: 07/18/2021] [Indexed: 12/17/2022]
Abstract
The clinical spectrum of small fiber neuropathy (SFN) encompasses manifestations related to the involvement of thinly myelinated A-delta and unmyelinated C fibers, including not only the classical distal phenotype, but also a non-length-dependent (NLD) presentation that can be patchy, asymmetrical, upper limb-predominant, or diffuse. This narrative review is focused on NLD-SFN. The diagnosis of NLD-SFN can be problematic, due to its varied and often atypical presentation, and diagnostic criteria developed for distal SFN are not suitable for NLD-SFN. The topographic pattern of NLD-SFN is likely related to ganglionopathy restricted to the small neurons of dorsal root ganglia. It is often associated with systemic diseases, but about half the time is idiopathic. In comparison with distal SFN, immune-mediated diseases are more common than dysmetabolic conditions. Treatment is usually based on the management of neuropathic pain. Disease-modifying therapy, including immunotherapy, may be effective in patients with identified causes. Future research on NLD-SFN is expected to further clarify the interconnected aspects of phenotypic characterization, diagnostic criteria, and pathophysiology.
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Affiliation(s)
- Franco Gemignani
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria F Bellanova
- Laboratory of Neuromuscular Histopathology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Saccani
- Neurology Unit, Department of Specialized Medicine, University Hospital of Parma, Parma, Italy
| | - Giovanni Pavesi
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Gad H, Saraswathi S, Al-Jarrah B, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Hussain K, Hendaus MA, Al-Mudahka F, Abouhazima K, McGrogan P, Malik RA, Akobeng AK. Corneal confocal microscopy demonstrates minimal evidence of distal neuropathy in children with celiac disease. PLoS One 2020; 15:e0238859. [PMID: 32956371 PMCID: PMC7505458 DOI: 10.1371/journal.pone.0238859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The aim of this study was to utilise corneal confocal microscopy to quantify corneal nerve morphology and establish the presence of sub-clinical small fibre damage and peripheral neuropathy in children with celiac disease. METHODS This is a cross-sectional cohort study of twenty children with celiac disease and 20 healthy controls who underwent clinical and laboratory assessments and corneal confocal microscopy. Corneal nerve fiber density (no.mm2), corneal nerve branch density (no.mm2), corneal nerve fiber length (mm.mm2), corneal nerve fiber tortuosity and inferior whorl length (mm.mm2) were quantified manually. RESULTS Corneal nerve fiber density (34.7±8.6 vs. 32.9±8.6; P = 0.5), corneal nerve branch density (47.2±24.5 vs. 47.3±20.0; P = 0.1) and corneal nerve fiber length (20.0±5.1 vs. 19.5±4.5; P = 0.8) did not differ between children with celiac disease and healthy controls. Corneal nerve fiber tortuosity (11.4±1.9 vs 13.5±3.0; P = 0.01) was significantly lower and inferior whorl length (20.0±5.5 vs 23.0±3.8; P = 0.06) showed a non-significant reduction in children with celiac disease compared to healthy controls. Inferior whorl length correlated significantly with corneal nerve fiber density (P = 0.005), corneal nerve branch density (P = 0.04), and corneal nerve fiber length (P = 0.002). CONCLUSION Corneal confocal microscopy demonstrates minimal evidence of neuropathy in children with celiac disease.
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Affiliation(s)
- Hoda Gad
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saras Saraswathi
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Bara Al-Jarrah
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Adnan Khan
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Hatim Abdelrahman
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Fatma Al-Mudahka
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Khaled Abouhazima
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Paraic McGrogan
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Rayaz A. Malik
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, United Kingdom
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
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Aamir A, Girach A, Sarrigiannis PG, Hadjivassiliou M, Paladini A, Varrassi G, Zis P. Repetitive Magnetic Stimulation for the Management of Peripheral Neuropathic Pain: A Systematic Review. Adv Ther 2020; 37:998-1012. [PMID: 31989485 DOI: 10.1007/s12325-020-01231-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Repetitive magnetic stimulation (rMS) is a safe and well-tolerated intervention. Transcranial magnetic stimulation (TMS) is used for the treatment of depression and for the treatment and prevention of migraine. Over the last few years, several reports and randomised controlled studies of the use of rMS for the treatment of pain have been published. The aim of this systematic review was to identify the available literature regarding the use of rMS in the treatment of peripheral neuropathic pain. METHODS After a systematic Medline search we identified 12 papers eligible to be included in this review. RESULTS The majority of the studies were on patients with phantom limb pain, followed by radiculopathy, plexopathy, post-traumatic pain and peripheral neuropathy. The treatment protocols vary significantly from study to study and, therefore, pooling the results together is currently difficult. However, rMS has a definite immediate effect in pain relief which, in the majority of studies, is maintained for a few weeks. CONCLUSION rMS seems to be a promising intervention in the treatment of peripheral neuropathic pain. Further research is in the field is needed. Use of neuronavigation might increase the precision of stimulation and subsequently its effectiveness.
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Affiliation(s)
| | - Ayesha Girach
- Medical School, University of Sheffield, Sheffield, UK
| | | | - Marios Hadjivassiliou
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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