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Moritz CP, Tholance Y, Rosier C, Reynaud-Federspiel E, Svahn J, Camdessanché JP, Antoine JC. Completing the Immunological Fingerprint by Refractory Proteins: Autoantibody Screening via an Improved Immunoblotting Technique. Proteomics Clin Appl 2019; 13:e1800157. [PMID: 30768763 DOI: 10.1002/prca.201800157] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/30/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Identifying autoantigens of serological autoantibodies requires expensive methods, such as protein microarrays or IP+MS. Thus, sera are commonly pre-screened for interesting immunopatterns via immunocytochemistry/immunohistochemistry. However, distinguishing immunopatterns can be difficult and intracellular antigens are less accessible. Therefore, a simple and cheap immunoblot screening able to distinguish immunopatterns and to detect refractory proteins is presented. EXPERIMENTAL DESIGN Five steps of immunoblotting-based autoantigen screening are revised: (1) choice of protein source, (2) protein extraction, (3) protein separation, (4) protein transfer, (5) antigen detection. Thereafter, 52 patients' sera with chronic inflammatory demyelinating polyneuropathy (CIDP) and 45 controls were screened. RESULTS The protein source impacts the detected antigen set. Steps 2-4 can be adapted for refractory proteins. Furthermore, longitudinal cutting of protein lanes saves ≥75% of time and material and allows for exact comparison of band patterns. As the latter are individually specific and temporarily constant, we call them "immunological fingerprints". In a proof-of-principle, a 155 kDa immunoband was detected with two anti-neurofascin-155-positive CIDP sera and two further immunobands (120/220 kDa) specific to a subgroup of 3-6 of 52 CIDP patients. CONCLUSIONS AND CLINICAL RELEVANCE Adapted immunoblotting is a cheap and simple method for accurate serum screening including refractory and intracellular antigens.
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Affiliation(s)
- Christian P Moritz
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Yannick Tholance
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Biochemistry Laboratory, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Carole Rosier
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Evelyne Reynaud-Federspiel
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Juliette Svahn
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France
| | - Jean-Philippe Camdessanché
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
| | - Jean-Christophe Antoine
- Synaptopathies and Autoantibodies, Faculty of Medicine Jacques Lisfranc, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Institut NeuroMyoGene INSERM U1217/CNRS UMR 5310, University Jean Monnet, University of Lyon, 42270, Saint-Priest en Jarez, France.,Neurology Department, Centre Hospitalier Universitaire de Saint-Étienne, 42055, Saint-Étienne, France
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2
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Gürcan HM, Ahmed AR. Efficacy of Various Intravenous Immunoglobulin Therapy Protocols in Autoimmune and Chronic Inflammatory Disorders. Ann Pharmacother 2016; 41:812-23. [PMID: 17440006 DOI: 10.1345/aph.1k037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective: To determine the efficacy of various intravenous immunoglobulin (IVIG) protocols used in the treatment of autoimmune and chronic inflammatory disorders. Data Sources: Literature retrieval was accessed through MEDLINE (November 1984–March 2007) and a search was conducted using the term intravenous immunoglobulin. References cited in the selected articles were also reviewed. Study Selection and Data Extraction: Inclusion criteria for studies were (1) English language, (2) randomized controlled trials, (3) defined protocols, (4) a minimum of 15 patients, and (5) objective criteria provided to assess clinical outcomes and course. Data Synthesis: The therapeutic efficacy of IVIG therapy is well established, and defined protocols exist for treatment of Kawasaki disease, immune thrombocytopenic purpura, Guillain–Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and autoimmune mucocutaneous blistering diseases. In the absence of a defined protocol, studies have demonstrated that IVIG therapy is effective in the treatment of myasthenia gravis, dermatomyositis, stiff person syndrome, antineutrophil cytoplasmic antibody positive systemic vasculitides, Graves' ophthalmopathy, and certain forms of systemic lupus erythematosus. It might also be of benefit in some patients with relapsing–remitting multiple sclerosis. The outcomes are variable in these studies. In toxic epidermal necrolysis and Stevens–Johnson syndrome, use of IVIG has dramatically influenced clinical response and reduced mortality. Conclusions: The cumulative evidence suggests that the clinical outcomes observed are significantly influenced by the use of a defined protocol. There is a need for multicenter trials approved by the Food and Drug Administration to better define the role of IVIG in many disease states. Such studies would be able to establish the indications for use, optimal dose, frequency of infusions, duration of therapy, and need for gradual withdrawal versus sudden cessation. Defined protocols resulting from the study of a large cohort of patients often convince insurance companies to create policies that provide access to IVIG therapy.
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Affiliation(s)
- Hakan M Gürcan
- Department of Medicine, Center for Blistering Diseases, New England Baptist Hospital, Boston, MA 02120, USA
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3
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Lagarde J, Moncharmont F, Bouibede F, Maisonobe T. Acute bilateral radial palsy responsive to intravenous immunoglobulins. J Neurol Sci 2014; 345:257-9. [DOI: 10.1016/j.jns.2014.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/18/2014] [Accepted: 07/04/2014] [Indexed: 11/17/2022]
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Chan YC, Wilder-Smith E. Predicting treatment response in chronic, acquired demyelinating neuropathies. Expert Rev Neurother 2014; 6:1545-53. [PMID: 17078793 DOI: 10.1586/14737175.6.10.1545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy is an immune-mediated neuropathy that was first described approximately 30 years ago. Since that time an increasingly wide spectrum of chronic acquired demyelinating polyneuropathies exhibiting different phenotypes, clinical course and treatment responses to immunomodulatory treatment have been described. Several new therapeutic agents have been prescribed for such conditions, some with promising results. This review summarizes what is presently known about the clinical courses, treatment responses and predictors of response of the chronic inflammatory demyelinating polyradiculopathy subgroups.
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Affiliation(s)
- Yee-Cheun Chan
- National University Hospital, Division of Neurology, 5 Lower Kent Ridge Road, 119074 Sinagpore.
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Hobson-Webb LD. Neuromuscular ultrasound in polyneuropathies and motor neuron disease. Muscle Nerve 2013; 47:790-804. [DOI: 10.1002/mus.23737] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2012] [Indexed: 12/12/2022]
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Abstract
The identification of autoantibodies associated with dysimmune neuropathies was a major contribution to the characterization of peripheral nerve disorders, the understanding of their pathophysiology, and the clinical diagnosis of neuropathies. Antibodies directed to GM1, GQ1b, and disyalilated gangliosides, and anti-MAG antibodies are very useful in the diagnosis of acute or chronic motor or sensory-motor neuropathies with or without monoclonal IgM. Anti-onconeural anti-Hu and anti-CV2/CRMP antibodies allow when they are detected the diagnosis of paraneoplastic neuropathies. This chapter focuses on the description of these antibodies as diagnostic markers and on their immunopathogenesis. We give a background overview on the origin of these antibodies, their detection, and review those studies, which clearly show that these antibodies are capable of binding to the target tissues in peripheral nerve and thereby can exert a variety of pathophysiological effects. The corresponding electrophysiological and histological changes observed both in human and animal models are exemplified in order to get a better understanding of the immune mechanisms of these antibody-mediated neuropathies.
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Affiliation(s)
- Andreas Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland.
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Hobson-Webb LD, Padua L, Martinoli C. Ultrasonography in the diagnosis of peripheral nerve disease. ACTA ACUST UNITED AC 2012; 6:457-71. [PMID: 23480810 DOI: 10.1517/17530059.2012.692904] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION High-resolution ultrasound (US) of the peripheral nerves is now a standard means of assessing neuromuscular disorders in many centers. Currently used in conjunction with electrodiagnostic (EDX) studies, nerve US is especially effective in the diagnosis of entrapment neuropathies. AREAS COVERED This article reviews the basic physics of peripheral nerve US, guidelines for its current use and future directions. Advantages of using nerve US alongside EDX studies are outlined along with current limitations of testing. The role of US in the diagnosis of entrapment neuropathy is emphasized, particularly in carpal tunnel syndrome (CTS). US assisted diagnosis of peripheral nerve tumors, hereditary neuropathy and dysimmune neuropathy and traumatic injuries is also described. EXPERT OPINION US is a powerful tool in the assessment of peripheral nerve disease. Nerve US is an evolving, young discipline. There is still much to learn, but current evidence supports US imaging of all patients presenting for evaluation of possible mononeuropathy. With improvements in resolution, the introduction of US contrast agents and objective measures of nerve echogenicity, there is promise for further expanding its role in the diagnosis of all peripheral neuropathies.
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Affiliation(s)
- Lisa D Hobson-Webb
- Duke University Medical Center, Department of Neurology , Durham, NC 27710 , USA +1 919 668 2277 ; +1 919 660 3853 ;
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Abstract
Autoimmune-mediated diseases targeting the peripheral nerve represent a group of disorders often associated with high clinical disability. At present, therapeutic options are limited. The application of innovative and cutting-edge technologies to the study of immune-mediated disorders of the peripheral nervous system (PNS) have generated a better understanding of underlying principles of the organization of the immune network present in the peripheral nerve and its dialogue with the systemic immune system. These insights may foster the development of specific and highly effective therapies for autoimmune diseases of the peripheral nerve. Of great interest in this context is the application of monoclonal antibodies, such as rituximab or alemtuzumab, which in small observational studies provided promising clinical results. But also other immunomodulatory or immunosuppressive drugs used in other indications currently find their way to PNS autoimmunity. Clearly, prospective controlled clinical trials are warranted before making firm conclusions on the feasibility of these innovative therapeutic approaches for treating immune-mediated disease of the peripheral nerve.
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Abstract
This review focuses on recent developments in the treatment of inflammatory neuropathies arising from immune dysregulation, rather than from infectious causes. The dysimmune inflammatory neuropathies are diseases of the peripheral nerves that have varying etiologies and may respond to immunomodulatory therapies. They are characterized by inflammatory changes in the nerve with associated destruction of myelin and axons. The underlying immune mechanisms are better understood in some of these conditions than others. Correct diagnosis and treatment is important to prevent clinical progression. Randomized controlled trials of some treatments in the more common inflammatory neuropathies have clarified their effectiveness; however, there are still groups of patients who are resistant to currently available treatments and for whom little effective treatment is available. Newer, targeted biologics and larger controlled trials of existing and novel therapies in these conditions offer promise of improved morbidity and mortality in this group of diseases.
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Affiliation(s)
- Elspeth J Hutton
- Centre for Neuromuscular Diseases and Department of Molecular Neuroscience, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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10
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Recombinant interferon-beta therapy and neuromuscular disorders. J Neuroimmunol 2009; 212:132-41. [DOI: 10.1016/j.jneuroim.2009.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 04/21/2009] [Accepted: 04/22/2009] [Indexed: 11/20/2022]
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11
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Abstract
The inflammatory neuropathies are a large diverse group of immune-mediated neuropathies that are amenable to treatment and may be reversible. Their accurate diagnosis is essential for informing the patient of the likely course and prognosis of the disease, informing the treating physician of the appropriate therapy and informing the scientific community of the results of well-targeted, designed and performed clinical trials. With the advent of biological therapies able to manipulate the immune response more specifically, an understanding of the pathogenesis of these conditions is increasingly important. This review presents a broad overview of the pathogenesis, diagnosis and therapy of inflammatory neuropathies, concentrating on the most commonly encountered conditions.
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Affiliation(s)
- M P T Lunn
- Centre for Neuromuscular Disease and Department of Molecular Neuroscience, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
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12
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Neuropathie motrice multifocale : existe-t-il une altération de la conduction sensitive au long cours ? Une étude rétrospective chez 21 patients. Rev Neurol (Paris) 2009; 165:243-8. [DOI: 10.1016/j.neurol.2008.10.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 09/03/2008] [Accepted: 10/08/2008] [Indexed: 11/21/2022]
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13
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Acute neuropathy with multiple motor conduction blocks: A variant of Guillain-Barré syndrome or multifocal motor neuropathy with conduction blocks with acute onset? Neurophysiol Clin 2008; 38:209-10. [DOI: 10.1016/j.neucli.2008.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 04/09/2008] [Indexed: 11/18/2022] Open
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14
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Hoffman-Snyder C, Smith BE. Neuromuscular Disorders Associated with Paraproteinemia. Phys Med Rehabil Clin N Am 2008; 19:61-79, vi. [DOI: 10.1016/j.pmr.2007.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Lunn MP, Léger JM, Merkies IS, Van den Bergh P, van Schaik IN. 151st ENMC International Workshop: Inflammatory Neuropathy Consortium 13th–15th April 2007, Schiphol, The Netherlands. Neuromuscul Disord 2008; 18:85-9. [PMID: 17869518 DOI: 10.1016/j.nmd.2007.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 07/30/2007] [Accepted: 08/10/2007] [Indexed: 11/19/2022]
Affiliation(s)
- M P Lunn
- Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom.
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Abstract
PURPOSE OF REVIEW Two disorders, Lewis-Sumner syndrome and multifocal motor neuropathy, are defined by the demonstration of conduction block. These two entities have been intertwined since their description but there are important distinctions between them. It is therefore timely to reconsider these disorders and the physiologic process that defines them. RECENT FINDINGS Understanding of the pathophysiology of conduction block has evolved with better understanding of the structure of the node of Ranvier and surrounding apparatus. Axonal excitability studies have begun to give insights into why multifocal motor neuropathy has only motor conduction block. The many published criteria for conduction block vary in sensitivity and specificity and the electromyographer must be aware of the difficulties in determining physiologic block. The distinctions between Lewis-Sumner syndrome and multifocal motor neuropathy have become increasingly clear. Evidence suggests that Lewis-Sumner syndrome is a multifocal variant of chronic inflammatory demyelinating polyneuropathy but that multifocal motor neuropathy is distinct. SUMMARY It is important to recognize the distinctions between these disorders, not only because there are important therapeutic issues, but also because a true understanding of the nature of these illnesses will only be accomplished if the overlaps and differences are carefully considered.
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Affiliation(s)
- Richard Alan Lewis
- Wayne State University School of Medicine, Department of Neurology, Detroit, Michigan 48201, USA.
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Leger JM, Vargas S, Lievens I. Efficacy of Intravenous Immunoglobulin in Multifocal Motor Neuropathy. Ann N Y Acad Sci 2007; 1110:248-55. [PMID: 17911439 DOI: 10.1196/annals.1423.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Multifocal motor neuropathy is a distinct entity, whose treatment differs from that of other chronic immune-mediated neuropathies, mainly chronic inflammatory demyelinating polyradiculoneuropathy, and its variant, multifocal acquired demyelinating sensory and motor neuropathy, although they share some electrophysiological characteristics. From the first descriptions, intravenous immunoglobulins (IVIg) have been considered to be the gold standard of treatment for multifocal motor neuropathy. However, if the effectiveness of IVIg has been confirmed by several randomized, double-blind, placebo-controlled trials, only a few patients experience persistent improvement after a single or few courses of therapy, and the long-term efficacy of IVIg in this disease is currently debated. Consequently, there is a need for new therapeutic strategies that focus on the effects and the costs of this therapy over long-term follow-up.
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Affiliation(s)
- Jean-Marc Leger
- Reference Center for Neuromuscular Diseases, Bâtiment Babinski, Hôpital de la Salpêtrière, 47 boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Meyer zu Hörste G, Hartung HP, Kieseier BC. From bench to bedside--experimental rationale for immune-specific therapies in the inflamed peripheral nerve. ACTA ACUST UNITED AC 2007; 3:198-211. [PMID: 17410107 DOI: 10.1038/ncpneuro0452] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Accepted: 02/06/2007] [Indexed: 12/28/2022]
Abstract
Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy are autoimmune-mediated inflammatory diseases of the PNS. In recent years, substantial progress has been made towards understanding the immune mechanisms that underlie these conditions, in large part through the study of experimental models. Here, we review the available animal models that partially mimic human Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy, and discuss the wide range of therapeutic approaches that have been successfully established in these models of inflammatory neuropathies. Transfer of this preclinical knowledge to patients has been far less successful, and inflammatory neuropathies are still associated with significant morbidity and mortality. We will summarize successful therapeutic trials in human autoimmune neuropathies to provide a vantage point for the transfer of experimental treatment strategies to clinical practice in immune-mediated diseases of the peripheral nerve.
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Kieseier BC, Wiendl H, Hartung HP. The inflamed peripheral nervous system: update on immune therapies. Curr Opin Neurol 2007; 19:433-6. [PMID: 16969151 DOI: 10.1097/01.wco.0000245364.51823.3b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
This review gives an overview of various neuroimmunological diseases in terms of incidence and prevalence rates, age and sex distribution, and the frequency of subtypes, if applicable. The disorders selected for review are inflammatory muscle disorders (polymyositis, dermatomyositis and inclusion body myositis), myasthenia gravis, immune-mediated polyneuropathies (Guillain-Barré syndrome, chronic polyneuritis and vasculitic neuropathies), and multiple sclerosis.
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Affiliation(s)
- Peter Flachenecker
- Neurological Rehabilitation Center "Quellenhof", Kuranlagenallee 2, 75323, Bad Wildbad, Germany.
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Léger JM, Beaudet R, Bonnélye G. Prise en charge des neuropathies motrices multifocales avec blocs de conduction en France en 2005. Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- J-M Léger
- Centre de Référence des Maladies Neuro-musculaires rares Paris-Est, Hôpital de la Salpêtrière, Paris
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Abstract
Multifocal motor neuropathy with persistent conduction blocks was first specifically identified in 1986. Its major criterion is conduction blocks in motor nerves only. Clinically, this is a multifocal, thus asymmetric, neuropathy that begins and predominant touches upper limbs; it especially affects men after the age of 50 years and has a chronic course with relapses. Approximately 40-50% of patients also have IgM serum antibodies directed against GM1 ganglioside. There are no other laboratory criteria, although moderately high protein levels are found in cerebrospinal fluid. Its course is unpredictable, because the neuropathy may remain limited to one or two motor nerves or extend progressively to all the motor nerves of all four limbs. In general, there is no damage to sensory or cranial nerves or to the autonomic or central nervous systems. Intravenous polyvalent immunoglobulins at high doses are remarkably effective in the short term in 70 to 80% of cases. Corticosteroids and plasma exchange are generally ineffective and may aggravate the neuropathy. The long-term efficacy of intravenous immunoglobulins in delaying motor decline and axon loss in the affected motor nerves is controversial. No information is currently available about the long-term efficacy of other immunomodulatory treatment.
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Affiliation(s)
- Jean-Marc Léger
- Centre de Référence Maladies Neuromusculaires Rares, CHU Pitié-Salpêtrière, Paris.
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