1
|
Rahbar M, Dolatkhah N. Vasculitis presenting as carpal tunnel syndrome: a case report. J Med Case Rep 2023; 17:84. [PMID: 36872340 PMCID: PMC9987105 DOI: 10.1186/s13256-023-03801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/01/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Carpal tunnel syndrome is the most common focal mononeuropathy which presents with pain in the wrist and hand, paresthesia, loss of sensation in the distribution of the median nerve, and in more severe cases, weakness and atrophy of the thenar muscles. Meanwhile, carpal tunnel syndrome can present as an initial manifestation of underlying systemic vasculitis disorder and result in severe physical disabilities. CASE PRESENTATION A 27-year-old Iranian man was referred to our electrodiagnosis center with a clinical diagnosis of carpal tunnel syndrome in April 2020. Surgical intervention had been taken into account for him because of unsuccessful conservative therapies. On admission, thenar eminence was reduced. Electrodiagnostic findings were not compatible with median nerve entrapment at the wrist. All sensory modalities in the distribution of the right median nerve were decreased. Additionally, a mild increase in erythrocyte sedimentation rate was noted in laboratory tests. Because of the high vasculitis suspicion, we recommended the nerve biopsy and/or starting a high-dose corticosteroid. However, the surgery release was performed. After 6 months, the patient was referred for progressive weakness and numbness in the upper and lower limbs. After documentation of vasculitis neuropathy by biopsy, a diagnosis of non-systemic vasculitic neuropathy was confirmed. A rehabilitation program started immediately. Rehabilitation led to gradual improvement and recovery of function and muscle strength, and no complications remained, except mild leg paralysis. CONCLUSIONS Physicians should be suspicious of the median nerve vasculitis mononeuropathy in a patient with carpal tunnel syndrome-like symptoms. Median nerve vasculitis mononeuropathy as an initial presenting feature of vasculitis neuropathy can further result in severe physical impairments and disabilities.
Collapse
Affiliation(s)
- Mohammad Rahbar
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Dolatkhah
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
2
|
Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [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: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
Collapse
Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
3
|
Emerging Role of Neuron-Glia in Neurological Disorders: At a Glance. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3201644. [PMID: 36046684 PMCID: PMC9423989 DOI: 10.1155/2022/3201644] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022]
Abstract
Based on the diverse physiological influence, the impact of glial cells has become much more evident on neurological illnesses, resulting in the origins of many diseases appearing to be more convoluted than previously happened. Since neurological disorders are often random and unknown, hence the construction of animal models is difficult to build, representing a small fraction of people with a gene mutation. As a result, an immediate necessity is grown to work within in vitro techniques for examining these illnesses. As the scientific community recognizes cell-autonomous contributions to a variety of central nervous system illnesses, therapeutic techniques involving stem cells for treating neurological diseases are gaining traction. The use of stem cells derived from a variety of sources is increasingly being used to replace both neuronal and glial tissue. The brain's energy demands necessitate the reliance of neurons on glial cells in order for it to function properly. Furthermore, glial cells have diverse functions in terms of regulating their own metabolic activities, as well as collaborating with neurons via secreted signaling or guidance molecules, forming a complex network of neuron-glial connections in health and sickness. Emerging data reveals that metabolic changes in glial cells can cause morphological and functional changes in conjunction with neuronal dysfunction under disease situations, highlighting the importance of neuron-glia interactions in the pathophysiology of neurological illnesses. In this context, it is required to improve our understanding of disease mechanisms and create potential novel therapeutics. According to research, synaptic malfunction is one of the features of various mental diseases, and glial cells are acting as key ingredients not only in synapse formation, growth, and plasticity but also in neuroinflammation and synaptic homeostasis which creates critical physiological capacity in the focused sensory system. The goal of this review article is to elaborate state-of-the-art information on a few glial cell types situated in the central nervous system (CNS) and highlight their role in the onset and progression of neurological disorders.
Collapse
|
4
|
Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:biomedicines9111626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
Collapse
Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
- Correspondence:
| |
Collapse
|
5
|
Pandey S, Chaudhari D, Renjen PN, Ahmad K. Guillain-Barre' Syndrome Following Scrub Typhus: A Rare Case. Ann Indian Acad Neurol 2021; 24:451-452. [PMID: 34447024 PMCID: PMC8370181 DOI: 10.4103/aian.aian_471_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Shishir Pandey
- Department of Neurology, Institute of Neurosciences, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| | - Dinesh Chaudhari
- Department of Neurology, Institute of Neurosciences, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| | - Pushpendra N Renjen
- Department of Neurology, Institute of Neurosciences, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| | - Kamal Ahmad
- Department of Internal Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, India
| |
Collapse
|
6
|
Hajiasgharzadeh K, Khabbazi A, Mokhtarzadeh A, Baghbanzadeh A, Asadzadeh Z, Adlravan E, Baradaran B. Cholinergic anti-inflammatory pathway and connective tissue diseases. Inflammopharmacology 2021; 29:975-986. [PMID: 34125373 DOI: 10.1007/s10787-021-00812-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Connective tissue diseases (CTDs) consist of an extensive range of heterogeneous medical conditions, which are caused by immune-mediated chronic inflammation and influences the various connective tissues of the body. They include rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, vasculitis, Sjögren's syndrome, Behcet's disease, and many other autoimmune CTDs. To date, several anti-inflammatory approaches have been developed to reduce the severity of inflammation or its subsequent organ manifestations. As a logical mechanism to harnesses the undesired inflammation, some studies investigated the role of the intrinsic cholinergic anti-inflammatory pathway (CAP) in the modulation of chronic inflammation. Many different experimental and clinical models have been developed to evaluate the therapeutic significance of the CAP in CTDs. On the other hand, an issue that is less emphasized in this regard is the presence of autonomic neuropathy in CTDs, which influences the efficiency of CAP in such clinical settings. This condition occurs during CTDs and is a well-known complication of patients suffering from them. The advantages and limitations of CAP in the control of inflammatory responses and its possible therapeutic benefits in the treatment of CTDs are the main subjects of the current study. Therefore, this narrative review article is provided based on the recent findings of the complicated role of CAP in CTDs which were retrieved by searching Science Direct, PubMed, Google Scholar, and Web of Science. It seems that delineating the complex influences of CAP would be of great interest in designing novel surgical or pharmacological therapeutic strategies for CTDs therapy.
Collapse
Affiliation(s)
- Khalil Hajiasgharzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran.,Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614756, Tabriz, Iran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614756, Tabriz, Iran.
| | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran
| | - Amir Baghbanzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran
| | - Zahra Asadzadeh
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran
| | - Elham Adlravan
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Golgasht St, Postcode: 5166614766, Tabriz, Iran. .,Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
7
|
Ajiboye O, Vohra I, Attar B, Katiyar V, Mba B. Cryoglobulinemic Vasculitis Masquerading as Bilateral Carpal Tunnel Syndrome. Cureus 2019; 11:e6423. [PMID: 31988822 PMCID: PMC6970103 DOI: 10.7759/cureus.6423] [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: 10/16/2019] [Accepted: 12/15/2019] [Indexed: 11/05/2022] Open
Abstract
Cryoglobulinemic vasculitis (CV) is a systemic inflammatory syndrome involving small- to medium-sized vessels. Almost half of hepatitis C-infected patients have detectable cryoglobulins levels, but only very few develop clinical manifestations. In this case report, we bring forth a diagnostic challenge of CV. A 52-year-old man with untreated hepatitis C (high viral load), diabetes mellitus, hypertension, and chronic kidney disease 4 (CKD) with solitary left kidney presented with one month of bilateral hand pain that started in his right hand, progressed to involve the left with numbness more on the palmer aspects and lateral three fingers. Physical exam was significant for bilateral positive Phalen and Tinel's sign. CV occurs due to precipitation of immune complexes within the vessels. Palpable purpura, arthralgia, and weakness have been described as the core symptoms of CV. However, progressive acute to subacute neuropathy, especially bilateral, should raise concerns for vasculitic neuropathy.
Collapse
Affiliation(s)
- Oyintayo Ajiboye
- Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Ishaan Vohra
- Internal Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Bashar Attar
- Gastroenterology and Hepatology, Rush University Medical Center, Chicago, USA
| | - Vatsala Katiyar
- Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Benjamin Mba
- Internal Medicine, John H Stroger Jr Hospital of Cook County, Chicago, USA
| |
Collapse
|
8
|
Golovach IY, Yehudina YD. [Peripheral nervous system lesion in systemic vasculitis - issues of diagnosis and treatment]. TERAPEVT ARKH 2019; 91:63-69. [PMID: 32598591 DOI: 10.26442/00403660.2019.12.000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
Vasculitis is a clinically diverse group of diseases with histopathological signs of blood vessel inflammation, which contributes to vascular damage and ischemic damage to the affected tissues. Vasculitic neuropathy is a common complication of the primary systemic vasculitides, such as polyartertis nodosa and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, systemic diseases of the connective tissue - systemic lupus erythematosus and Sjogren syndrome, vasculitis associated with infection, most often viral hepatitis C and B and non - systemic vasculitis neuropathy. Vessels of medium and small caliber are involved in the pathological process in these diseases. With all vasculitis, except for those caused by the direct effect of the infectious trigger on the blood vessel walls, the main pathogenetic mechanism is an autoimmune process with the development of vasa nervorum vasculitis - small arteries and vessels that supply peripheral nerves, and the outcome - nerve ischemia. The classic clinical presentation is an acute or subacute painful multifocal neuropathy that has a predilection for the lower extremities, affects two or more named nerves, and progresses in a step wise manner. However, vasculitic neuropathy can manifest in a variety of ways, including asymmetric polyneuropathies and distal symmetric sensory neuropathies, and it also can be slowly progressive, particularly in cases of nonsystemic vasculitic neuropathy (NSVN), a form of vasculitis that clinically remains restricted to peripheral nerves. Nerve biopsy can help establish the diagnosis of a systemic vasculitis, particularly when other organ involvement is not clinically apparent, and is required for diagnosis of NSVN. Neuropathy due to systemic vasculitis should be treated in accordance with the recommendations for the treatment of the underlying disease. In NSVH, the main medicine of choice are glucocrticoids, and in severe/progressive cases, pulse therapy with cyclophosphamide.
Collapse
Affiliation(s)
- I Y Golovach
- Feofaniya Clinical hospital State Management of Affairs
| | | |
Collapse
|
9
|
Technically successful ultrasound-guided percutaneous sural nerve needle biopsy in a patient with indeterminate peripheral neuropathy. Skeletal Radiol 2019; 48:1105-1109. [PMID: 30377731 DOI: 10.1007/s00256-018-3109-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether ultrasound-guided percutaneous sural nerve needle biopsy yields sufficient tissue for analysis in a patient with suspected vasculitis-related peripheral neuropathy. MATERIALS AND METHODS With real-time ultrasound guidance, a hydrodissection of the sural nerve from the adjacent small saphenous vein was first performed. A 14-gauge biopsy needle was then manipulated under real-time ultrasound guidance to obtain two transverse samples of the sural nerve at the lateral distal calf. RESULTS The biopsy was technically successful and yielded adequate tissue for routine processing. The specimen showed mild epineurial perivascular chronic inflammation with marked loss of myelinated axons. These histologic findings are not diagnostically definitive for vasculitis-related peripheral neuropathy but were supportive of the diagnosis in combination with the patient's physical examination, laboratory, and electromyography findings. The patient suffered no immediate complications after the procedure. CONCLUSIONS This ultrasound-guided sural nerve needle biopsy, like many surgical biopsies, did not yield a definitive result in a patient with suspected vasculitis-related peripheral neuropathy; however, the procedure was technically successful. Given that percutaneous needle procedures offer many advantages over surgical procedures, we believe that this procedure warrants further investigation.
Collapse
|
10
|
Ibrahim IK, Medani SH, El-Hameed MMA, Imam MH, Shaaban MMA. Tarsal tunnel syndrome in patients with rheumatoid arthritis, electrophysiological and ultrasound study. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ibrahim Khalil Ibrahim
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
| | - Sameh Hafez Medani
- Diagnostic Radiology, Faculty of Medicine , Alexandria University , Egypt
| | | | - Mohamed Hassan Imam
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
| | - Mohamed Magdy Aly Shaaban
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
| |
Collapse
|
11
|
|
12
|
Hui M, Meena AK, Rajasekhar L, Sireesha Y, Afshan J, Mridula R, Borgohain R, Uppin MS. Vasculitic Neuropathy: A Retrospective Analysis of Nerve Biopsies and Clinical Features from a Single Tertiary Care Center. Ann Indian Acad Neurol 2019; 22:180-186. [PMID: 31007430 PMCID: PMC6472243 DOI: 10.4103/aian.aian_47_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Vasculitic neuropathy can be either restricted to the peripheral nerves or associated with systemic involvement of other organs. The objective of this study was to analyze the nerve biopsies reported as "vasculitic neuropathy" with clinical features. Materials and Methods All cases diagnosed with vasculitic neuropathy were retrospectively analyzed and categorized as systemic vasculitis and nonsystemic vasculitic neuropathy based on the clinical features. The histological features were further evaluated and classified according to the Peripheral Nerve Society Guidelines. Results Of the 126 cases, there were 65 nonsystemic vasculitis, 45 secondary systemic vasculitis, and 16 primary systemic vasculitis. Definite vasculitis was more common in the systemic vasculitis group. The epineurial vessels were predominantly involved with chronic axonal changes. Conclusion The sensitivity of definite vasculitis on nerve biopsy was 54.76%. The sensitivity increases when the diagnostic criteria of definite and probable vasculitis were applied taking into account perivascular inflammation accompanied by vascular changes and axonopathy.
Collapse
Affiliation(s)
- Monalisa Hui
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - A K Meena
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Yareeda Sireesha
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jabeen Afshan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rukmini Mridula
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rupam Borgohain
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
13
|
|
14
|
Liu X, Treister R, Lang M, Oaklander AL. IVIg for apparently autoimmune small-fiber polyneuropathy: first analysis of efficacy and safety. Ther Adv Neurol Disord 2018; 11:1756285617744484. [PMID: 29403541 PMCID: PMC5791555 DOI: 10.1177/1756285617744484] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Small-fiber polyneuropathy (SFPN) has various underlying causes, including associations with systemic autoimmune conditions. We have proposed a new cause; small-fiber-targeting autoimmune diseases akin to Guillain-Barré and chronic inflammatory demyelinating polyneuropathy (CIDP). There are no treatment studies yet for this 'apparently autoimmune SFPN' (aaSFPN), but intravenous immunoglobulin (IVIg), first-line for Guillain-Barré and CIDP, is prescribed off-label for aaSFPN despite very high cost. This project aimed to conduct the first systematic evaluation of IVIg's effectiveness for aaSFPN. METHODS With IRB approval, we extracted all available paper and electronic medical records of qualifying patients. Inclusion required having objectively confirmed SFPN, autoimmune attribution and other potential causes excluded. IVIg needed to have been dosed at ⩾1 g/kg/4 weeks for ⩾3 months. We chose two primary outcomes - changes in composite autonomic function testing (AFT) reports of SFPN and in ratings of pain severity - to capture objective as well as patient-prioritized outcomes. RESULTS Among all 55 eligible patients, SFPN had been confirmed by 3/3 nerve biopsies, 62% of skin biopsies, and 89% of composite AFT. Evidence of autoimmunity included 27% of patients having systemic autoimmune disorders, 20% having prior organ-specific autoimmune illnesses and 80% having ⩾1/5 abnormal blood-test markers associated with autoimmunity. A total of 73% had apparent small-fiber-restricted autoimmunity. IVIg treatment duration averaged 28 ± 25 months. The proportion of AFTs interpreted as indicating SFPN dropped from 89% at baseline to 55% (p ⩽ 0.001). Sweat production normalized (p = 0.039) and the other four domains all trended toward improvement. Among patients with pre-treatment pain ⩾3/10, severity averaging 6.3 ± 1.7 dropped to 5.2 ± 2.1 (p = 0.007). Overall, 74% of patients rated themselves 'improved' and their neurologists labeled 77% as 'IVIg responders'; 16% entered remissions that were sustained after IVIg withdrawal. All adverse events were expected; most were typical infusion reactions. The two moderate complications (3.6%) were vein thromboses not requiring discontinuation. The one severe event (1.8%), hemolytic anemia, remitted after IVIg discontinuation. CONCLUSION These results provide Class IV, real-world, proof-of-concept evidence suggesting that IVIg is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality. They provide rationale for prospective trials, inform trial design and indirectly support the discovery of small-fiber-targeting autoimmune/inflammatory illnesses.
Collapse
Affiliation(s)
- Xiaolei Liu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
- Department of Neurology, Dayi Hospital of Shanxi Medical University, China
| | - Roi Treister
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Magdalena Lang
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, 275 Charles Street/Warren Building 310, Boston, MA 02114, USA
| |
Collapse
|
15
|
McCoy SS, Baer AN. Neurological Complications of Sjögren's Syndrome: Diagnosis and Management. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2017; 3:275-288. [PMID: 30627507 DOI: 10.1007/s40674-017-0076-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Opinion statement Purpose of review Neurologic disease is a common extraglandular manifestation of Sjögren's syndrome (SS), the study of which has been hampered both by the lack of uniform definitions for specific neurologic complications and by the imprecision of the tools used to diagnose SS. There is a great need to develop consensus criteria for classifying these varied neurologic manifestations, as has been done in systemic lupus erythematosus (SLE) "Arthritis and rheumatism 42:599-608, 1999". SS patients with certain forms of neurologic involvement, such as small fiber neuropathy and sensory ataxic ganglionopathy, frequently lack anti-SSA and anti-SSB antibodies and other serologic abnormalities. In these patients, neurologic disease is often their presenting manifestation, triggering a search for underlying SS. Given the frequent seronegativity of such patients, their diagnosis of SS rests heavily on the interpretation of a labial gland biopsy. However, these biopsies are prone to misinterpretation "Vivino etal. J Rheumatol 29:938-44, 2002", and "positive" ones are found in up to 15% of healthy volunteers "Radfar et al. Arthrit Rheumatu 47:520-4, 2002". Better diagnostic tools are needed to determine if the frequent seronegative status of these SS patients may be related to a unique disease pathogenesis. Recent findings Recent advances in diagnostic techniques have served to define a likely pathogenetic basis for certain neurologic manifestations of SS. The advent of punch skin biopsies to analyze intraepidermal nerve fiber density and morphology has helped define pure sensory small fiber neuropathy as common in SS and the basis for both length- and non-length-dependent patterns of neuropathic pain. New protocols for magnetic resonance imaging (MRI) have enabled the recognition of dorsal root ganglionitis, a finding originally detected in pathologic studies. The advent of the anti-aquaporin-4 (AQP4) antibody test in 2004 has Led to the appreciation that demyelinating disease in SS is often related to the presence of neuromyelitis optica spectrum disorder. The anti-AQP4 antibody is considered to be directly pathogenic in the brain, targeting the primary water channel proteins in the brain, expressed prominently on astrocytic foot processes. Summary There are no clinical trials evaluating the efficacy of systemic immune suppressive therapy for peripheral or central nervous system involvement. With the recent increase in clinical trials of biologic agents for SS, which utilize systemic disease manifestations as standardized outcome measures, there is an urgency to deveLop appropriate definitions of neuroLogic compLications of SS and cLear parameters for clinical improvement.
Collapse
Affiliation(s)
- Sara S McCoy
- School of Medicine and Public Health, University of Wisconsin, Madison, USA
| | - Alan N Baer
- School of Medicine and Public Health, University of Wisconsin, Madison, USA
| |
Collapse
|
16
|
Involvement of the Peripheral Nervous System in Polyarteritis Nodosa and Antineutrophil Cytoplasmic Antibodies-Associated Vasculitis. Rheum Dis Clin North Am 2017; 43:633-639. [PMID: 29061248 DOI: 10.1016/j.rdc.2017.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Peripheral nerve involvement is common in polyarteritis nodosa and the antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. The underlying mechanism is arteritis of the vasa nervorum, leading to ischemic neuropathy. The classic presentation is stepwise involvement of peripheral nerves with ongoing antecedent constitutional symptoms. This article reviews the pathologic findings, clinical syndromes, diagnosis, and treatment of ANCA-associated vasculitides.
Collapse
|
17
|
El-Moghazi Sultan H, El-Latef GA, El-Ghani HMA, El-Moez Heiba DA, Abdalla DM. Clinical and electrophysiological study of peripheral and central neuromuscular changes in connective tissue diseases in children. THE EGYPTIAN RHEUMATOLOGIST 2016; 38:233-239. [DOI: 10.1016/j.ejr.2015.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
18
|
Vasculitic Mononeuritis Multiplex May Be Misdiagnosed as Carpal Tunnel Syndrome. Am J Phys Med Rehabil 2016; 96:e44-e47. [PMID: 27362698 DOI: 10.1097/phm.0000000000000562] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vasculitis is a group of disorders characterized by inflammation and destruction of blood vessels, resulting in ischemic injury to the involved tissue. Sometimes, peripheral neuropathy is one of the first symptoms of systemic vasculitis. Although the classic form of peripheral nervous system vasculitis is mononeuritis multiplex, it can also present as a mononeuritis. In this case report, the patient presented with progressive rapid onset numbness in her right hand for 2 months. She underwent carpal tunnel decompression surgery with initial diagnosis of acute carpal tunnel syndrome but failed to respond to the surgery, and two month later, she presented with foot drop. The final diagnosis was vasculitic mononeuritis multiplex. The present case report demonstrates the importance of identification of median mononeuritis as one of the first presentations of vasculitic disorders and distinction from acute carpal tunnel syndrome. The natural history of many of the systemic vasculitides is rapidly progressive, and they are likely to be fatal without early treatment. In this regard, timely diagnosis of vasculitis is critical because of the vital role of early immunosuppressive therapy in preventing multiorgan damage and decreasing mortality rate.
Collapse
|
19
|
Abstract
Peripheral neuropathies are diseases of the peripheral nervous system that can be divided into mononeuropathies, multifocal neuropathies, and polyneuropathies. Symptoms usually include numbness and paresthesia. These symptoms are often accompanied by weakness and can be painful. Polyneuropathies can be divided into axonal and demyelinating forms, which is important for diagnostic reasons. Most peripheral neuropathies develop over months or years, but some are rapidly progressive. Some patients only suffer from mild, unilateral, slowly progressive tingling in the fingers due to median nerve compression in the wrist (carpal tunnel syndrome), while other patients can be tetraplegic, with respiratory insufficiency within 1-2 days due to Guillain-Barré syndrome. Carpal tunnel syndrome, with a prevalence of 5% and incidence of 1-2 per 1000 person-years, is the most common mononeuropathy. Population-based data for chronic polyneuropathy are relatively scarce. Prevalence is estimated at 1% and increases to 7% in persons over 65 years of age. Incidence is approximately 1 per 1000 person-years. Immune-mediated polyneuropathies like Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy are rare diseases, with an annual incidence of approximately 1-2 and 0.2-0.5 per 100 000 persons respectively. Most peripheral neuropathies are more prevalent in older adults and in men, except for carpal tunnel syndrome, which is more common in women. Diabetes is a common cause of peripheral neuropathy and is associated with both mono- and polyneuropathies. Among the group of chronic polyneuropathies, in about 20-25% no direct cause can be found. These are slowly progressive axonal polyneuropathies.
Collapse
Affiliation(s)
- R Hanewinckel
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - M A Ikram
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - P A Van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
20
|
Joaquim AF, Appenzeller S. Neuropsychiatric manifestations in rheumatoid arthritis. Autoimmun Rev 2015; 14:1116-22. [PMID: 26238502 DOI: 10.1016/j.autrev.2015.07.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/27/2015] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic disease characterized by persistent synovitis, systemic inflammation, and the presence of autoantibodies. Neuropsychiatric manifestations are quite common in RA, including depression, cognitive dysfunction, behavior changes, spinal cord compression and peripheral nerve involvement. Potential causes include systemic inflammatory process, neural compression due to bone and joint destruction, side effects of medications and copying difficulties due to the chronicity of the disease. A high level of suspicious is required for an adequate diagnosis and treatment. In this review, we will discuss topographically the main neuropsychiatric manifestations described in RA patients, in an attempt to help in the management of these complex and multifaceted disease.
Collapse
Affiliation(s)
- Andrei F Joaquim
- Department of Neurology, State University of Campinas (UNICAMP), 13083-970 Campinas SP, Brazil.
| | - Simone Appenzeller
- Department of Medicine, State University of Campinas (UNICAMP), 13083-970 Campinas SP, Brazil
| |
Collapse
|
21
|
Grimm A, Décard BF, Bischof A, Axer H. Ultrasound of the peripheral nerves in systemic vasculitic neuropathies. J Neurol Sci 2014; 347:44-9. [PMID: 25262016 DOI: 10.1016/j.jns.2014.09.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/05/2014] [Accepted: 09/12/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Ultrasound of the peripheral nerves (PNUS) can be used to visualize nerve pathologies in polyneuropathies (PNP). The aim of this study was to investigate, whether PNUS provides additional information in patients with proven systemic vasculitic neuropathies (VN). MATERIAL AND METHODS Systematic ultrasound measurements of several peripheral nerves, the vagal nerve and the 6th cervical nerve root were performed in 14 patients and 22 healthy controls. Nerve conduction studies of the corresponding nerves were undertaken. Finally, the measured results were compared to a study population of demyelinating immune-mediated and axonal neuropathies. RESULTS Patients with VN displayed significant smaller amplitudes of compound muscle action potentials (CMAP) (p<0.05) and sensory nerve action potentials (SNAP) compared to healthy controls, while conduction velocity did not differ between groups. The mean nerve cross-sectional areas (CSA) were increased in several peripheral nerves compared to the controls, most prominent in tibial and fibular nerve (p<0.01). PNUS revealed nerve enlargement in most of the clinically and electrophysiologically affected nerves (22 out of 31) in VN. Nerve enlargement was more often seen in vasculitic neuropathies than in other axonal neuropathies, but significantly rarer than in demyelinating neuropathies. CONCLUSION Focal CSA enlargement in one or more nerves in electrophysiologically axonal neuropathies can be a hint for VN and thus facilitate diagnostic and therapeutic procedures.
Collapse
Affiliation(s)
- Alexander Grimm
- Department of Neurology, Basel University Hospital, Switzerland; Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
| | | | - Antje Bischof
- Department of Neurology, Basel University Hospital, Switzerland; Clinical Immunology, Basel University Hospital Basel, Switzerland
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Sepsis Control and Care (CSCC), Jena University Hospital, Germany
| |
Collapse
|
22
|
Abstract
The vasculitic neuropathies are a diverse group of disorders characterised by the acute-to-subacute onset of painful sensory and motor deficits that result from inflammatory destruction of nerve blood vessels and subsequent ischaemic injury. They are common in patients with primary systemic vasculitis and are seen in vasculitis secondary to disorders such as rheumatoid arthritis, viral infections, and diabetic inflammatory neuropathies. It is imperative that neurologists recognise these disorders to initiate treatment promptly and thereby prevent morbidity and mortality. To simplify the approach to patients with vasculitis of the peripheral nerves, a straightforward, dichotomous classification scheme can be used in which the vasculitic neuropathies are divided into two groups-nerve large arteriole vasculitis and nerve microvasculitis-on the basis of the size of the involved vessels. The size of the affected blood vessels correlates with the clinical course and prognosis in patients with vasculitic neuropathy.
Collapse
|
23
|
Emmi L, Squatrito D, Emmi G, Beccastrini E, Silvestri E. The "multifaceted" onset of vasculitis neuropathy. Intern Emerg Med 2013; 8:551-2. [PMID: 23254469 DOI: 10.1007/s11739-012-0894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 12/03/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Lorenzo Emmi
- Center for autoimmune diseases, Lupus Clinic Unit, Careggi Hospital, Florence, Italy,
| | | | | | | | | |
Collapse
|
24
|
Zafar SF, Goodman JC, Ubogu EE. A man with small vessel vasculitis presenting with brachial diplegia, multiple cranial mononeuropathies and severe orthostatic hypotension in diabetes mellitus: a case report. J Med Case Rep 2013; 7:229. [PMID: 24083508 PMCID: PMC4015480 DOI: 10.1186/1752-1947-7-229] [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: 02/13/2013] [Accepted: 08/12/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION We report a rare case of fulminant vasculitic mononeuropathy resulting in brachial diplegia, with suspected brainstem and autonomic nervous system involvement in a patient with diabetes mellitus. CASE PRESENTATION A 58-year-old Hispanic Caucasian man with diabetes mellitus presented with a 1-year history of progressive bilateral upper extremity weakness, orthostatic intolerance and progressive memory decline. Diagnostic evaluation including laboratory tests for progressive encephalopathies, systemic inflammatory and non-inflammatory neuropathies, cerebrospinal fluid analyses, electrodiagnostic studies, and nerve biopsy were performed. Clinical examination revealed moderate cognitive deficits on the Montreal Cognitive Assessment scale, bilateral facial weakness and weakness of bilateral shoulder girdle and intrinsic hand muscles. Cerebrospinal fluid analyses revealed elevated protein and an elevated immunoglobulin G synthesis rate, suggesting an immune-mediated process. Further laboratory work up was non-diagnostic. Electrodiagnostic studies demonstrated chronic asymmetric axonal mononeuropathies with ongoing denervation. A superficial radial nerve biopsy showed a chronic vasculitic neuropathy. Glucocorticosteroid treatment, symptomatic pharmacologic and supportive non-pharmacologic therapies resulted in improved clinical outcomes despite challenges with glycemic control. CONCLUSIONS This case report emphasizes the importance of a thorough evaluation of atypical or uncommon neuromuscular presentations in diabetic patients without etiological presumptions. This is necessary in order to promptly establish a diagnosis, initiate appropriate therapies and prevent irreversible nerve injury.
Collapse
Affiliation(s)
- Sahar F Zafar
- Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB 302, Houston, TX 77030, USA.
| | | | | |
Collapse
|
25
|
Lozeron P, Lacroix C, Michon M, Theaudin M, Petit Lacour MC, Denier C, Adams D. Vasculitis neuropathy mimicking lower limb mono-radiculopathy: a study and follow-up of 8 cases. Intern Emerg Med 2013; 8:601-9. [PMID: 23054406 DOI: 10.1007/s11739-012-0858-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/15/2012] [Indexed: 11/28/2022]
Abstract
The aim of this study was to describe misleading lower limb mono radiculopathy revealing peripheral nerve vasculitis. Retrospective review of eight patients with biopsy confirmed vasculitis presenting as mono-radicululopathy in a tertiary referral centre dedicated to patients with rare peripheral neuropathies. Patients presented with chronic (6/8) or acute (n = 2) radiculopathy in L4, L5 or S1 territories associated with subtle systemic signs. A diagnostic workup was performed because of secondary motor deficit, the absence of clear radicular compression or failure of initial treatment focused on pain relief. In all, nerve conduction studies showed signs of asymmetrical axonal peripheral neuropathy (mononeuritis multiplex). Necrotizing vasculitis was eventually confirmed by peripheral nerve biopsy. Biological markers of inflammation or eosinophilia were present in 5/8 and a progressive motor deficit (7/8) is suggestive of the diagnosis. Under steroid treatment, all patients improved during a mean of 2 years 6 months of follow-up (Mean Rankin score improvement 1.9 point), but five relapsed including three mononeuritis multiplex, and one had acral necrosis. Vasculitis presenting as LL radiculopathy is rare; EMG studies with signs of mononeuritis multiplex and nerve biopsy studies are useful for making the diagnosis.
Collapse
Affiliation(s)
- Pierre Lozeron
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris-Sud, Paris, France,
| | | | | | | | | | | | | |
Collapse
|
26
|
Pego PM, Câmara IA, Andrade JP, Costa JM. Intravenous immunoglobulin therapy in vasculitic ulcers: a case of polyarteritis nodosa. AUTOIMMUNITY HIGHLIGHTS 2013; 4:95-9. [PMID: 26000148 PMCID: PMC4389026 DOI: 10.1007/s13317-013-0048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 01/21/2013] [Indexed: 11/16/2022]
Abstract
Introduction Polyarteritis nodosa (PAN) is a systemic necrotizing medium-size-vessel vasculitis with variable clinical manifestations. Diagnosis is confirmed by histology or angiography. The mainstay of treatment is corticosteroids alone or combined with cyclophosphamide (CYF). Case report Seventy-one-year-old female, follow-up started in 1997 at the age of 56 for suspected relapsing febrile viral exanthema. Skin biopsy was performed and the diagnosis of lymphomatoid papulosis was made, with complete response to treatment with dapsone. In 2005, she presented with arthralgia, lower limb (LL) edema, livedo reticularis and elevated erythrocyte sedimentation rate (ESR). PAN was confirmed on histology and visceral angiography; antineutrophil cytoplasmic antibodies (ANCA) were negative. She responded to prednisolone but relapsed in 2006. Twelve cycles of CYF were administered, with clinical, angiographic and analytical improvement. In 2008, a new relapse occured with LL neuropathic pain and ESR elevation. Electromyogram (EMG) confirmed axonal sensory polyneuropathy (PNP). Azathioprine was started with a poor response. A second EMG, 12 months later in 2009 still evidenced PNP, and nerve biopsy confirmed vasculitic neuropathy. In 2010, she had ulcers in LL and iron-deficient anemia. She started intravenous immunoglobulin (IVIG) for six cycles, achieving ulcer healing, absence of pain, no anemia and ESR normalization. Discussion IVIG therapy has proven benefit in Kawasaki disease, also showing efficacy in refractory ANCA-associated vasculitis. In PAN, only very few case reports show benefit. In this case, IVIG therapy induced total remission of LL ulcers and PNP, suggesting that it may be useful in selected cases of refractory PAN.
Collapse
Affiliation(s)
- Petra M Pego
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - Inês Aguiar Câmara
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - José Pedro Andrade
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| | - João Matos Costa
- 3rd Department of Internal Medicine, Hospital Distrital de Santarém, 2005-177 Santarém, Portugal
| |
Collapse
|
27
|
Llewellyn R, Scott S, Meara N, Salim A. Lesson of the month. (1). What lies beneath the surface? Diagnosis. Churg-Strauss syndrome. Clin Med (Lond) 2013; 13:103-5. [PMID: 23472506 PMCID: PMC5873682 DOI: 10.7861/clinmedicine.13-1-103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
28
|
Pavlakis P, Alexopoulos H, Kosmidis M, Mamali I, Moutsopoulos H, Tzioufas A, Dalakas M. Peripheral neuropathies in Sjögren’s syndrome: A critical update on clinical features and pathogenetic mechanisms. J Autoimmun 2012; 39:27-33. [DOI: 10.1016/j.jaut.2012.01.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/07/2012] [Indexed: 10/14/2022]
|
29
|
|
30
|
|
31
|
Ali E, Colaço R, Gillespie P, Colaço CB. Inflammatory posterior interosseous nerve palsy in a patient with psoriatic arthropathy. J Plast Reconstr Aesthet Surg 2011; 64:e205-7. [DOI: 10.1016/j.bjps.2011.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 03/27/2011] [Indexed: 10/18/2022]
|
32
|
Malipeddi A, Reddy VRM, Kallarackal G. Posterior Interosseous Nerve Palsy: An Unusual Complication of Rheumatoid Arthritis: Case Report and Review of the Literature. Semin Arthritis Rheum 2011; 40:576-9. [DOI: 10.1016/j.semarthrit.2010.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 07/28/2010] [Accepted: 07/29/2010] [Indexed: 11/30/2022]
|
33
|
Pazzaglia C, Briani C, Nobile-Orazio E, Orazio EN, Caliandro P, Granata G, Tonali PA, Padua L. Occurrence and characterization of Pain in immune-mediated neuropathies: a multicentre prospective study. Eur J Neurol 2011; 18:177-83. [PMID: 20561036 DOI: 10.1111/j.1468-1331.2010.03108.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND pain is a common symptom of peripheral neuropathies that may severely affect patients' Quality of Life. Pain questionnaires, based on verbal descriptors, are a useful way to investigate it. METHODS we performed a multicentre study through validated measures to characterize pain in a sample of consecutive patients affected by immune-mediated neuropathies. RESULTS ninety-three patients were enrolled in 16 Italian centres. Based on the numeric rating scale, almost half of the patients complained of moderate pain and one-third of the patients severe pain. Overall, up to 50% of our patients with immune-mediated neuropathies complained of neuropathic pain. The most common neuropathic symptoms were paraesthesia/dysesthesia and superficial spontaneous pain. Surprisingly, also patients with neuropathies commonly thought to be painless (such as multifocal motor neuropathy) reported discomfort and painful symptoms. CONCLUSIONS pain questionnaires should be considered in the clinical evaluation of immune-mediated neuropathies, also when evaluating therapy efficacy, because they may provide clinicians with useful information on painful symptoms and patients' quality of life.
Collapse
Affiliation(s)
- C Pazzaglia
- Department of Neurosciences, Institute of Neurology, Catholic University, Rome, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
A fatal case of Churg-Strauss syndrome presenting with acute polyneuropathy mimicking Guillain-Barré syndrome. Neurol Sci 2011; 32:937-40. [PMID: 21533561 DOI: 10.1007/s10072-011-0591-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 02/16/2011] [Indexed: 10/18/2022]
Abstract
A 64-year-old woman, with asthma and sinusal polyposis in her history, suddenly developed a painful polyneuropathy with diplopia. Nerve conduction studies, performed at the very onset of the neuropathy, could not definitely rule out a Guillain-Barré syndrome (GBS) and high-dose i.v. immunoglobulins were administered. Clinical and laboratory findings subsequently supported the diagnosis of Churg-Strauss syndrome; corticosteroid therapy was started and clinical stabilisation of neuropathy was apparently achieved. No indicators of unfavourable outcome were present at that time. Nevertheless, 30 days after the onset the patient acutely worsened with severe polyneuropathy relapse and fatal systemic diffusion to heart, kidney and mesenteric district, which a single cyclophosphamide pulse failed to control. This case highlights the possibility that a GBS-like onset of Churg-Strauss syndrome neuropathy should be regarded as a part of multiorgan, severe or even life-threatening vasculitic involvement, requiring the most aggressive treatments, regardless of the presence of recognised factors of poor outcome.
Collapse
|
35
|
Lenglet T, Haroche J, Schnuriger A, Maisonobe T, Viala K, Michel Y, Chelbi F, Grabli D, Seror P, Garbarg-Chenon A, Amoura Z, Bouche P. Mononeuropathy multiplex associated with acute parvovirus B19 infection: characteristics, treatment and outcome. J Neurol 2011; 258:1321-6. [PMID: 21287183 DOI: 10.1007/s00415-011-5931-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 01/18/2011] [Accepted: 01/18/2011] [Indexed: 10/18/2022]
Abstract
To describe the characteristics of peripheral neuropathy related to acute parvovirus B19 (B19V) infection. We reviewed clinical, electrophysiological and histological data of three patients with peripheral neuropathy and positive B19V detection (IgG, IgM and PCR) compatible with acute infection. The neuropathy fulfilled criteria for mononeuropathy multiplex (MM). It could be preceded by or concurrent with a limited purpuric eruption, but systemic manifestations were absent. The first neurological symptoms were always sensory and localized in a hand. Neuropathy was initially limited to a restricted sensory part of a nerve trunk territory. The course was subacute with successive and asymmetric injury of the limb and cranial nerves. Electromyographic study confirmed the diagnosis of MM with multifocal asymmetric sensory and motor axonal loss in two patients, whereas the neuropathy was purely sensory and limited to two nerves in the other patient. Nerve biopsies showed no evidence of necrotizing vasculitis but, in one patient, revealed a lymphocytic perivascular infiltrate evocative of hypersensitivity vasculitis secondary to an infectious agent. Intravenous immunoglobulin (IVIg) was systematically administered. Long-term outcome was good but with incomplete sensory recovery and, for one patient, persistence of a functional disability. B19 V infection should be considered in the etiological assessment of MM, especially in the event of a progressive sensory disorder in the hands and a concomitant history of rash. IVIg may be an effective treatment for this inflammatory disorder.
Collapse
Affiliation(s)
- Timothée Lenglet
- Département de Neurologie, Hôpital de la Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris (APHP), 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Kang Y, Jang HW, Han SH, Jeong SJ, Ku NS, Baek JH, Kim CO, Choi JY, Song YG, Lee S, Park YB, Lee SK, Kim SM, Kim JM. ANCA-associated Vasculitis after Scrub Typhus. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.1.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yoon Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hui Won Jang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Han
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Su Ku
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Hyeon Baek
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Oh Kim
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Song
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sarah Lee
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Beom Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Kon Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - June-Myung Kim
- The AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
37
|
Birnbaum J. Peripheral nervous system manifestations of Sjögren syndrome: clinical patterns, diagnostic paradigms, etiopathogenesis, and therapeutic strategies. Neurologist 2010; 16:287-97. [PMID: 20827117 DOI: 10.1097/nrl.0b013e3181ebe59f] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Sjögren syndrome is among the most common autoimmune diseases affecting adults in the United States, and is frequently regarded as an immune-mediated exocrinopathy exclusively causing dry eyes and dry mouth. However, as a systemic rheumatic disease, there can be various "extraglandular" complications. The eclectic permutation of peripheral nervous system (PNS) syndromes which occur in Sjögren patients are among the most common and severe extraglandular complications. This review article highlights the evaluation, differential diagnosis, immunopathogenic mechanisms, and potential treatment options of these PNS complications encountered by neurologists. The sensory neuropathies constitute the most frequent PNS complication. Sjögren patients can suffer from severe neuropathic pain, with small-fiber neuropathy causing lancinating or burning pain which can disproportionately affect the proximal torso or extremities, and the face (ie, in a "non-length-dependent distribution"). The technique of skin biopsy, assessing for the intraepidermal nerve fiber density of unmyelinated nerves, provides a useful technique for neurologists to diagnose small-fiber neuropathies, especially when there is such a non-length-dependent distribution. Other diagnostic techniques (ie, electromyography/nerve-conduction studies, evoked potentials, nerve and muscle biopsy) may be useful in specific subtypes of neuropathies. A rational approach to treatment requires a careful appraisal of the clinical subtype of the neuropathy, as well as a familiarity with such discriminating immunopathogenic mechanisms. The application of the traditional armamentarium used for neuropathic pain can be especially challenging. Sjögren patients can suffer from debilitating fatigue, sicca symptoms, and autonomic findings; as such manifestations can be complications of various neuropathic agents, neurologists should understand how to minimize such iatrogenic complications. Therefore, this article will empower neurologists to more effectively collaborate with rheumatologists, in the diagnosis and treatment of Sjögren patients with PNS complications.
Collapse
Affiliation(s)
- Julius Birnbaum
- Department of Neurology, The Johns Hopkins Jerome Greene Sjögren's Center, Baltimore, MD, USA.
| |
Collapse
|
38
|
Landis BN, Arlettaz L. Chronic cough and hypoglossal palsy. Intern Med J 2010; 40:463. [PMID: 20636830 DOI: 10.1111/j.1445-5994.2010.02251.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- B N Landis
- Department of Otolaryngology Head and Neck Surgery, University of Geneva Medical School, Geneva, Switzerland
| | | |
Collapse
|
39
|
Affiliation(s)
- Sun-Young Oh
- Department of Neurology, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Jeonju, Korea
| | - Ji-Hoon Kang
- Department of Preventive Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Chang-Seop Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine, Jeonju, Korea
| |
Collapse
|
40
|
Chan J, Kennett R, Smith G. Posterior interosseous nerve palsy in rheumatoid arthritis: case report and literature review. J Plast Reconstr Aesthet Surg 2009; 62:e556-60. [DOI: 10.1016/j.bjps.2008.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 08/14/2008] [Accepted: 10/22/2008] [Indexed: 10/21/2022]
|
41
|
Rogo T, Kamat R, Arabshahi B, Lateef T. An adolescent with fever, weakness, and pain. Clin Pediatr (Phila) 2009; 48:786-8. [PMID: 19264715 DOI: 10.1177/0009922809333096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Tanya Rogo
- Inova Fairfax Hospital for Children, Falls Church, Virginia 22030, USA
| | | | | | | |
Collapse
|
42
|
Abstract
The purpose of this study was to investigate the recovery of burn-related neuropathies by electrodiagnostic testing. Burn patients who presented to an American Burn Association verified burn center were interviewed and examined for clinical evidence of peripheral neuropathies by a physiatrist. Patients whom consented to participate were tested for electrodiagnostic evidence of peripheral neuropathy. Repeated studies were performed to assess for evidence of recovery. A total of 370 patients were screened. Thirty-six (9.73%) patients had clinical evidence of neuropathy. Eighteen male patients with a mean TBSA burn of 42% had nerve conduction studies performed. Etiologies of the injuries included eight flame, eight electrical, and three others. Seventy-three nerve conduction studies were performed and 58 of the tests were abnormal. The most commonly affected nerve was the median sensory (10). For patients with repeated tests, the mean time between tests was 169 days (SD, 140 days). There was a significant difference between the initial and follow-up test (McNemar's change test P=.009). In subset analysis of motor and sensory abnormalities, there was no significant difference (P=.07). The most common neuropathy identified in this cohort was the median sensory. Overall, there was improvement in the nerve conduction abnormalities examined. This study suggests that the prognosis for recovery after burn-related neuropathy is good.
Collapse
|
43
|
Rheumatoid vasculitis of crural muscles confirmed by muscle biopsy in the absence of inflammatory myopathy: histologic and MRI study. Rheumatol Int 2009; 30:1381-3. [PMID: 19639318 DOI: 10.1007/s00296-009-1076-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 07/12/2009] [Indexed: 10/20/2022]
Abstract
A 60-year-old man who had been diagnosed as rheumatoid arthritis admitted to our hospital by dysesthesia on his legs with edema. Nerve conduction velocity test led to diagnosis of mononeuritis multiplex. Magnetic resonance imaging (MRI) of lower legs showed high intensity in slow tau inversion recovery. Typical vasculitis with neutrophil-dominant cell infiltration was observed by muscle biopsy without inflammatory myopathy or fascitis. Diagnosis was made by rheumatoid vasculitis found in crural muscles. Intravenous cyclophosphamide with oral tacrolimus effectively improved dysesthesia with reduction of inflammatory response.
Collapse
|
44
|
Ahdab R, Michel M, Neves DO, Andre C, Lefaucheur JP. Persistent multifocal pseudo-conduction blocks in vasculitic neuropathy without antiganglioside antibodies. Muscle Nerve 2009; 40:290-3. [DOI: 10.1002/mus.21337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
45
|
Abstract
Vasculitis can occur either as a primary condition or secondary to CTDs, infection, medication or malignancy. This article reviews the clinical presentation and management of vascular disease associated with SLE and SS, as well as the primary necrotizing vasculitides. Although pulmonary arterial hypertension (PAH) has traditionally been considered a rare complication of SLE, estimates of its prevalence range from 0.5% to 14% and it has a significant impact on prognosis. In contrast to PAH associated with other CTDs, patients with SLE respond well to immunosuppressive agents (cyclophosphamide in conjunction with corticosteroids). Improvements or stabilization of PAH symptoms and quality of life have also been observed with the oral, dual endothelin receptor antagonist, bosentan. SS is associated with a range of cutaneous and systemic signs of vasculitis. Immunosuppressive agents are effective, but are associated with an increased risk of lymphoma. The necrotizing vasculitides include WG, Churg-Strauss syndrome and microscopic polyangiitis, and are characterized by autoantibodies to neutrophil cytoplasmic constituents. WG is one of the most common forms of vasculitis; patients usually present with signs of respiratory disease. All three necrotizing vasculitides respond to cyclophosphamide and corticosteroids, while the less toxic AZA and MTX are effective for maintenance therapy. Future therapeutic approaches may include rituximab, plasma exchanges, the TNF antagonist infliximab and haematopoietic stem cell transplantation.
Collapse
Affiliation(s)
- L Guillevin
- Service de Médecine Interne, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris René Descartes, Paris, France.
| |
Collapse
|
46
|
Filosto M, Cavallaro T, Pasolini G, Broglio L, Tentorio M, Cotelli M, Ferrari S, Padovani A. Idiopathic hypocomplementemic urticarial vasculitis-linked neuropathy. J Neurol Sci 2009; 284:179-81. [PMID: 19375087 DOI: 10.1016/j.jns.2009.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 03/14/2009] [Accepted: 03/20/2009] [Indexed: 11/30/2022]
Abstract
Hypocomplementemic urticarial vasculitis (HUV) is a rare form of cutaneous small-vessel vasculitis characterized by recurrent episodes of urticaria and painful, tender, burning or itchy skin lesions, often associated with extracutaneous involvement but usually with no significant peripheral nerve damage. We describe a patient with an HUV of undetermined cause that developed a progressive multifocal sensory neuropathy whose symptoms were temporarily relieved by intravenous immunoglobulin treatment. Sural nerve biopsy showed asymmetrical multifocal nerve fiber loss and axon degeneration in nerve fascicles, a picture suggestive of ischemic damage as a likely result of a vasculitic process. We point out that an axonal neuropathy may complicate idiopathic HUV and suggest looking for peripheral nerve involvement in HUV patients.
Collapse
Affiliation(s)
- Massimiliano Filosto
- Clinical Neurology, Section for Neuromuscular Diseases and Neuropathies, University Hospital Spedali Civili, Brescia, Italy
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Cranial nerve palsy in Wegener’s granulomatosis – Lessons from clinical cases. J Neurol 2009; 256:299-304. [DOI: 10.1007/s00415-009-0121-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 09/24/2008] [Accepted: 10/01/2008] [Indexed: 12/13/2022]
|
48
|
Lee SH, Jung SI, Park KH, Choi SM, Park MS, Kim BC, Kim MK, Cho KH. Guillain-Barré syndrome associated with scrub typhus. ACTA ACUST UNITED AC 2007; 39:826-8. [PMID: 17701724 DOI: 10.1080/00365540701266755] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We report a 42-y-old female with Guillain-Barré syndrome (GBS) who presented with scrub typhus for a duration of 2 weeks. Subsequently, ascending paralysis and facial diplegia developed. GBS was confirmed with nerve conduction studies and cerebrospinal fluid examinations. After administration of intravenous immunoglobulin, symptoms gradually disappeared.
Collapse
Affiliation(s)
- Seung-Han Lee
- Department of Neurology, Chonnam National University Medical School, Gwangju, South Korea.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Stalos S. Vision Loss in a 22-Year-Old Woman. Lab Med 2007. [DOI: 10.1309/v7wj9dwv2b8e6yu3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
50
|
Prasad K, Bhatia R. Rheumatoid neuropathy. INDIAN JOURNAL OF RHEUMATOLOGY 2007. [DOI: 10.1016/s0973-3698(10)60036-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|