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Finsterer J. Myocarditis, Coagulopathy, and Small Fibre, Sensory, and Multiple Cranial Nerve Neuropathy Complicating BNT162b2 Vaccination: A Case Report. Cureus 2024; 16:e55205. [PMID: 38558730 PMCID: PMC10981078 DOI: 10.7759/cureus.55205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
SARS-CoV-2 vaccinations can lead to complications, including post-acute COVID-19 vaccination syndrome (PACVS). There has been no report of a patient with PACVS presenting with Guillain-Barre syndrome (GBS), myocarditis/pericarditis, immunodeficiency, or coagulopathy after the second BNT162b2 dose. The patient is a 51-year-old woman with chronic myopericarditis, coagulopathy due to factor-VIII increase and protein-S deficiency, GBS, and a number of other ocular, dermatological, immunological, and central nervous system abnormalities related to the second dose of the BNT172b2 vaccine. GBS manifested with mild, multiple cranial nerve lesions, small fibre neuropathy (SFN) affecting the autonomic system with postural tachycardia syndrome (POTS) and orthostatic hypotension, and sensory disturbances in the upper and lower limbs. PACVS was diagnosed months after onset, but despite the delayed diagnosis, the patient benefited from glucocorticoids, repeated HELP apheresis, and multiple symptomatic treatments. The case shows that SARS-CoV-2 vaccination can be complicated by PACVS manifesting as chronic myopericarditis, coagulopathy, GBS with predominant dysautonomia, and impaired immune competence, and that diagnosis of PACVS can be delayed for months. Delayed diagnosis of PACVS may result in a delay in appropriate treatment and the prolongation of disabling symptoms. Patients and physicians should be made aware of PACVS to improve diagnostic and therapeutic management in terms of patient and healthcare system costs.
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Affiliation(s)
- Josef Finsterer
- Neurology, Neurology and Neurophysiology Center, Vienna, AUT
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Geerts M, de Greef BTA, Sopacua M, van Kuijk SMJ, Hoeijmakers JGJ, Faber CG, Merkies ISJ. Intravenous Immunoglobulin Therapy in Patients With Painful Idiopathic Small Fiber Neuropathy. Neurology 2021; 96:e2534-e2545. [PMID: 33766992 PMCID: PMC8205474 DOI: 10.1212/wnl.0000000000011919] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
Objective This is the first double-blind randomized controlled trial evaluating the efficacy and safety of IV immunoglobulin (IVIG) vs placebo in patients with idiopathic small fiber neuropathy (I-SFN). Methods Between July 2016 and November 2018, 60 Dutch patients with skin biopsy–proven I-SFN randomly received a starting dose of IVIG (2 g/kg body weight) or matching placebo (0.9% saline). Subsequently, 3 additional infusions of IVIG (1 g/kg) or placebo were administered at 3-week intervals. The primary outcome was a 1-point change in Pain Intensity Numerical Rating Scale score at 12 weeks compared to baseline. Results Thirty patients received IVIG, and 30 received placebo. In both groups, 29 patients completed the trial. In 40% of patients receiving IVIG, the mean average pain was decreased by at least 1 point compared to 30% of the patients receiving placebo (p = 0.588, odds ratio 1.56, 95% confidence interval 0.53–4.53). No significant differences were found on any of the other prespecified outcomes, including general well-being, autonomic symptoms, and overall functioning and disability. Conclusions This randomized controlled trial showed that IVIG treatment had no significant effect on pain in patients with painful I-SFN. Trial Registration Information ClinicalTrials.gov Identifier: NCT02637700, EudraCT 2015-002624-31. Classification of Evidence This study provides Class I evidence that for patients with painful I-SFN, IVIG did not significantly reduce pain compared to placebo.
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Affiliation(s)
- Margot Geerts
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Bianca T A de Greef
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Maurice Sopacua
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Sander M J van Kuijk
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Janneke G J Hoeijmakers
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
| | - Catharina G Faber
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao.
| | - Ingemar S J Merkies
- From the Department of Neurology (M.G., B.T.A.d.G., M.S., J.G.J.H., C.G.F., I.S.J.M.), School of Mental Health and Neuroscience, and Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Center+; Department of Rehabilitation Adelante/Maastricht University Medical Center+ (M.S.), the Netherlands; and Department of Neurology (I.S.J.M.), Curaçao Medical Center, Willemstad, Curaçao
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Acute monophasic erythromelalgia pain in five children diagnosed as small-fiber neuropathy. Eur J Paediatr Neurol 2020; 28:198-204. [PMID: 32723684 PMCID: PMC10021072 DOI: 10.1016/j.ejpn.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
The small-fiber polyneuropathies (SFN) are a class of diseases in which the small thin myelinated (Aδ) and/or unmyelinated (C) fibers within peripheral nerves malfunction and can degenerate. SFN usually begins in the farthest, most-vulnerable axons, so distal neuropathic pain and symptoms from microvascular dysregulation are common. It is well known in adults, e.g. from diabetes, human immunodeficiency virus, or neurotoxins, but considered extremely rare in children, linked mostly with pathogenic genetic variants in voltage-gated sodium channels. However, increasing evidence suggests that pediatric SFN is not rare, and that dysimmunity is the most common cause. Because most pediatric neurologists are unfamiliar with SFN, we report the diagnosis and management of 5 Swiss children, aged 6-11y, who presented with severe paroxysmal burning pain in the hands and feet temporarily relieved by cooling-the erythromelalgia presentation. Medical evaluations revealed autoimmune diseases in 3 families and 3/5 had preceding or concomitant infections. The standard diagnostic test (PGP9.5-immunolabeled lower-leg skin biopsy) confirmed SFN diagnoses in 3/4, and autonomic function testing (AFT) was abnormal in 2/3. Blood testing for etiology was unrevealing, including genetic testing in 3. Paracetamol and ibuprofen were ineffective. Two children responded to gabapentin plus mexiletine, one to carbamazepine, two to mexiletine plus immunotherapy (methylprednisolone/IVIg). All recovered within 6 months, remaining well for years. These monophasic tempos and therapeutic responses are most consistent with acute post-infectious immune-mediated causality akin to Guillain-Barré large-fiber polyneuropathy. Skin biopsy and AFT for SFN, neuropathic-pain medications and immunotherapy should be considered for acute sporadic pediatric erythromelalgia.
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Levine TD, Kafaie J, Zeidman LA, Saperstein DS, Massaquoi R, Bland RJ, Pestronk A. Cryptogenic small‐fiber neuropathies: Serum autoantibody binding to trisulfated heparan disaccharide and fibroblast growth factor receptor‐3. Muscle Nerve 2019; 61:512-515. [DOI: 10.1002/mus.26748] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 10/15/2019] [Accepted: 10/18/2019] [Indexed: 01/16/2023]
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Tiamkao S, Boonsong A, Saepeung K, Kasemsap N, Apiwattanakul M, Suanprasert N, Hemachudha T, Pithak P, Juntee K, Waisaen C, Madha S, Buathong R, Sawanyawisuth K. An Outbreak of Peripheral Neuropathy in a Prison. Case Rep Neurol 2019; 11:53-60. [PMID: 31543786 PMCID: PMC6739697 DOI: 10.1159/000496536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/20/2022] Open
Abstract
Prisoners are at risk for both physical and psychological diseases. Here, we report an outbreak of peripheral neuropathy in a prison in northeast Thailand. Between July and December 2014, there were 88 male prisoners at Bueng Kan Provincial Prison in Bueng Kan, Thailand suffering from peripheral neuropathy out of a total of 1,464 prisoners (6.01%). The common age range was 20–39 years (58 patients; 65.91%). The three most common features were hyporeflexia/areflexia of the lower extremities (36 patients; 83.72%). On laboratory vitamin B1 deficiency was detected in 4/5 patients, positive rhinovirus polymerase chain reaction in 3/4 patients, positive Mycoplasma pneumoniae IgM in 1/12 patients, and positive urinary arsenic in 4/7 patients. A dT vaccination was given on October 14 during the outbreak. This was a large outbreak of peripheral neuropathy in male prisoners. There are several possible causes of this outbreak including vitamin B1 deficiency, dT vaccination, arsenic toxicity, rhinovirus, and Mycoplasma infection.
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Affiliation(s)
- Somsak Tiamkao
- Division of Neurology, Department of Medicine, Faculty of Medicine, and Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Anuwat Boonsong
- Division of Neurology, Department of Medicine, Faculty of Medicine, and Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | | | - Narongrit Kasemsap
- Division of Neurology, Department of Medicine, Faculty of Medicine, and Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Thiravat Hemachudha
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Prakai Pithak
- Epidemiology of Communicable Disease Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kittiphit Juntee
- Office of Disease Prevention and Control Region 6, Khon Kaen, Thailand
| | | | - Supat Madha
- Bueng Kan Provincial Prison, Bueng Kan, Thailand
| | - Rome Buathong
- Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Bangkok, Thailand
| | - Kittisak Sawanyawisuth
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine, Sleep Apnea Research Group, Research Center in Back, Neck, and Other Joint Pain and Human Performance, Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases, Khon Kaen University, Khon Kaen, Thailand
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Gondim FDAA, Barreira AA, Claudino R, Cruz MW, Cunha FMBD, Freitas MRGD, França MC, Gonçalves MVM, Marques W, Nascimento OJM, Oliveira ASB, Pereira RC, Pupe C, Rotta FT, Schestatsky P. Definition and diagnosis of small fiber neuropathy: consensus from the Peripheral Neuropathy Scientific Department of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:200-208. [PMID: 29809227 DOI: 10.1590/0004-282x20180015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/15/2018] [Indexed: 01/20/2023]
Abstract
The aim of this study was to describe the results of a Brazilian Consensus on Small Fiber Neuropathy (SFN). Fifteen neurologists (members of the Brazilian Academy of Neurology) reviewed a preliminary draft. Eleven panelists got together in the city of Fortaleza to discuss and finish the text for the manuscript submission. Small fiber neuropathy can be defined as a subtype of neuropathy characterized by selective involvement of unmyelinated or thinly myelinated sensory fibers. Its clinical picture includes both negative and positive manifestations: sensory (pain/dysesthesias/pruritus) or combined sensory and autonomic complaints, associated with an almost entirely normal neurological examination. Standard electromyography is normal. A growing list of medical conditions is associated with SFN. The classification of SFN may also serve as a useful terminology to uncover minor discrepancies in the normal values from different neurophysiology laboratories. Several techniques may disclose sensory and/or autonomic impairment. Further studies are necessary to refine these techniques and develop specific therapies.
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Affiliation(s)
| | - Amilton Antunes Barreira
- Departamento de Neurociências e Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Rinaldo Claudino
- Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Márcia Waddington Cruz
- Departamento de Neurologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | | | | | | | | | - Wilson Marques
- Departamento de Neurociências e Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | | | | | | | - Camila Pupe
- Departamento de Neurologia, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brasil
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Terkelsen AJ, Karlsson P, Lauria G, Freeman R, Finnerup NB, Jensen TS. The diagnostic challenge of small fibre neuropathy: clinical presentations, evaluations, and causes. Lancet Neurol 2017; 16:934-944. [DOI: 10.1016/s1474-4422(17)30329-0] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 07/31/2017] [Accepted: 08/09/2017] [Indexed: 12/15/2022]
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Farbu E, Rudolph T, Stefansdottir S. Guillain Barré syndrome--Incidence and clinical course in Southern Rogaland, Norway. Clin Neurol Neurosurg 2015; 141:33-7. [PMID: 26724429 DOI: 10.1016/j.clineuro.2015.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/05/2015] [Accepted: 12/13/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To establish the incidence and clinical course of Guillain Barré syndrome (GBS) in a well-defined geographical area. PATIENTS AND METHODS All patients older than 16 years of age diagnosed with GBS were prospectively invited to join a follow-up study for two years. RESULTS Seventeen patients were diagnosed with GBS; an incidence rate of 2.28/100,000 in 2006/2007, and 3.19/100,000 in 2007/2008 with an equal gender distribution. Eleven patients accepted follow up, and more than 50% had milder forms of GBS with preserved walking ability and a Hughes score ≤ 2. None required assisted ventilation in this period, and only one patient had a MRC score <40. Three patients were simultaneously diagnosed with SIADH. Nine patients received IvIg treatment and clinical improvement measured by MRC and INCAT was seen during the first three months, but the patients subjective perceptions of health and symptoms measured using VAS, FSS, and SF-36 were reduced the first 12 months after diagnosis. CONCLUSION Incidence of GBS in a well-defined area varied between 2.28-3.19/100 000, and more than 50% of patients were mildly affected. Despite a good clinical recovery after three months and subsequent improvement on self-assessed health items, patients with GBS rated their health lower than expected after one year.
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Affiliation(s)
- Elisabeth Farbu
- Neuroscience Research Group, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Norway.
| | - Thomas Rudolph
- Neuroscience Research Group, Stavanger University Hospital, Norway; Department of Neurology, Stadtspital Triemli, Zurich, Switzerland
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Sim GY, Kim WS. Clinical variants of Guillain-Barré syndrome in children. J Biomed Res 2014. [DOI: 10.12729/jbr.2014.15.3.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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