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Morelli L, Serra L, Ricciardiello F, Gligora I, Donadio V, Caprini M, Liguori R, Giannoccaro MP. The role of antibodies in small fiber neuropathy: a review of currently available evidence. Rev Neurosci 2024; 0:revneuro-2024-0027. [PMID: 38865989 DOI: 10.1515/revneuro-2024-0027] [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: 02/16/2024] [Accepted: 05/26/2024] [Indexed: 06/14/2024]
Abstract
Small fiber neuropathy (SFN) is a peripheral nerve condition affecting thin myelinated Aδ and unmyelinated C-fibers, characterized by severe neuropathic pain and other sensory and autonomic symptoms. A variety of medical disorders can cause SFN; however, more than 50% of cases are idiopathic (iSFN). Some investigations suggest an autoimmune etiology, backed by evidence of the efficacy of IVIG and plasma exchange. Several studies suggest that autoantibodies directed against nervous system antigens may play a role in the development of neuropathic pain. For instance, patients with CASPR2 and LGI1 antibodies often complain of pain, and in vitro and in vivo studies support their pathogenicity. Other antibodies have been associated with SFN, including those against TS-HDS, FGFR3, and Plexin-D1, and new potential targets have been proposed. Finally, a few studies reported the onset of SFN after COVID-19 infection and vaccination, investigating the presence of potential antibody targets. Despite these overall findings, the pathogenic role has been demonstrated only for some autoantibodies, and the association with specific clinical phenotypes or response to immunotherapy remains to be clarified. The purpose of this review is to summarise known autoantibody targets involved in neuropathic pain, putative attractive autoantibody targets in iSFN patients, their potential as biomarkers of response to immunotherapy and their role in the development of iSFN.
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Affiliation(s)
- Luana Morelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Lucrezia Serra
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Fortuna Ricciardiello
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Ilaria Gligora
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Vincenzo Donadio
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Marco Caprini
- Department of Pharmacy and Biotechnology (FaBiT), Laboratory of Human and General Physiology, University of Bologna, Via San Donato, 19/2 - 40126, Bologna, Italy
| | - Rocco Liguori
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura, 3 - 40139, Bologna, Italy
| | - Maria Pia Giannoccaro
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3 - 40139, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura, 3 - 40139, Bologna, Italy
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Silsby M, Feldman EL, Dortch RD, Roth A, Haroutounian S, Rajabally YA, Vucic S, Shy ME, Oaklander AL, Simon NG. Advances in diagnosis and management of distal sensory polyneuropathies. J Neurol Neurosurg Psychiatry 2023; 94:1025-1039. [PMID: 36997315 PMCID: PMC10544692 DOI: 10.1136/jnnp-2021-328489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
Distal sensory polyneuropathy (DSP) is characterised by length-dependent, sensory-predominant symptoms and signs, including potentially disabling symmetric chronic pain, tingling and poor balance. Some patients also have or develop dysautonomia or motor involvement depending on whether large myelinated or small fibres are predominantly affected. Although highly prevalent, diagnosis and management can be challenging. While classic diabetes and toxic causes are well-recognised, there are increasingly diverse associations, including with dysimmune, rheumatological and neurodegenerative conditions. Approximately half of cases are initially considered idiopathic despite thorough evaluation, but often, the causes emerge later as new symptoms develop or testing advances, for instance with genetic approaches. Improving and standardising DSP metrics, as already accomplished for motor neuropathies, would permit in-clinic longitudinal tracking of natural history and treatment responses. Standardising phenotyping could advance research and facilitate trials of potential therapies, which lag so far. This review updates on recent advances and summarises current evidence for specific treatments.
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Affiliation(s)
- Matthew Silsby
- Neurology, Westmead Hospital, Westmead, New South Wales, Australia
- Brain and Nerve Research Centre, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard D Dortch
- Division of Neuroimaging Research, Barrow Neurological Institute, Phoenix, Arizona, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Science, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University Institute of Imaging Science, Nashville, Tennessee, USA
| | - Alison Roth
- Division of Neuroimaging Research, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Aston Medical School, Aston University, Birmingham, UK
| | - Steve Vucic
- Brain and Nerve Research Centre, Sydney Medical School, The University of Sydney, New South Wales, Australia
| | - Michael E Shy
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Anne Louise Oaklander
- Nerve Unit, Departments of Neurology and Pathology (Neuropathology), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Frenchs Forest, New South Wales, Australia
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3
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Daifallah O, Farah A, Dawes JM. A role for pathogenic autoantibodies in small fiber neuropathy? Front Mol Neurosci 2023; 16:1254854. [PMID: 37799730 PMCID: PMC10547903 DOI: 10.3389/fnmol.2023.1254854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
The immune system has a role in neuropathic pain which includes autoimmune mechanisms (e.g., autoantibodies). Clinical studies have identified a number of conditions where neuropathic pain is common and that are associated with autoantibodies targeting antigens within the nervous system. Interestingly sensory symptoms can be relieved with immunotherapies or plasma exchange, suggesting that pain in these patients is antibody-mediated. Recent preclinical studies have directly addressed this. For example, passive transfer of CASPR2 autoantibodies from patients cause increased pain sensitivity and enhanced sensory neuron excitability in mice confirming pathogenicity and demonstrating that patient autoantibodies are a mechanism to cause neuropathic pain. Small fiber neuropathy (SFN) exclusively affects small sensory fibers (typically nociceptors) and is characterized by severe neuropathic pain. Known causes include diabetes, B12 deficiency and rare variants in sodium channel genes, although around 50% of cases are idiopathic. SFN is associated with autoimmune conditions such as Sjorgen's syndrome, Sarcoidosis and Celiac disease and immunotherapy in the form of Intravenous immunoglobulin (IVIG) has proved an effective treatment. Autoantibodies have been identified and, in some cases, passive transfer of SFN patient IgG in mice can recapitulate neuropathic pain-like behavior. Here we will discuss clinical and preclinical data relating to the idea that pathogenic autoantibodies contribute to SNF. We discuss putative pathogenic antibodies, cellular targets and the molecular mechanisms by which they cause sensory neuron damage and the development of neuropathic pain. Finally, we will comment on future directions which may provide further insights into the mechanisms underlying SFN in patients.
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Affiliation(s)
- Omar Daifallah
- Department of Zoology, King Saud University, Riyadh, Saudi Arabia
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Adham Farah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - John M. Dawes
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Bayraktutar BN, Atocha V, Farhad K, Soto O, Hamrah P. Autoantibodies Against Trisulfated Heparin Disaccharide and Fibroblast Growth Factor Receptor-3 May Play a Role in the Pathogenesis of Neuropathic Corneal Pain. Cornea 2023; 42:821-828. [PMID: 36256257 PMCID: PMC10106522 DOI: 10.1097/ico.0000000000003142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/29/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to describe cases of patients with presumable dysimmune small-fiber neuropathy (SFN)-related neuropathic corneal pain (NCP), presenting with autoantibodies against trisulfated heparin disaccharide (TS-HDS) or fibroblast growth factor receptor-3 (FGFR-3). METHODS This study was a case series of 3 patients with NCP with positive anti-TS-HDS and/or anti-FGFR-3 autoantibodies and systemic SFN as confirmed by positive skin biopsy results. RESULTS All 3 patients were women with a mean age of 34.3± 6.1 years. They suffered from moderate to severe persistent chronic ocular discomfort (10/10, 10/10, and 9/10 on a visual analogue scale, respectively). Although 1 patient suffered from ocular pain and photophobia alone, the other 2 patients experienced additional non-ocular pain. One of the patients had pain on her face and head, and 1 patient reported neck and lower back pain. Two patients had high anti-TS-HDS IgM titers, whereas 1 patient had both high anti-TS-HDS IgM and anti-FGFR-3 IgG titers. Skin biopsy confirmed the presence of SFN in all patients by demonstrating decreased intraepidermal nerve fiber density. CONCLUSIONS The presence of anti-TS-HDS and anti-FGFR-3 autoantibodies in patients with NCP with positive skin biopsy findings for SFN highlights the potential role of dysimmune SFN in the pathogenesis of this disease.
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Affiliation(s)
- Betul N. Bayraktutar
- Cornea Service, New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
- Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Vanessa Atocha
- Cornea Service, New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Khosro Farhad
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oscar Soto
- Department of Neurology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Pedram Hamrah
- Cornea Service, New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
- Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
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5
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Zeidman LA, Saini P, Mai P. Immune-Mediated Small Fiber Neuropathy With Trisulfated Heparin Disaccharide, Fibroblast Growth Factor Receptor 3, or Plexin D1 Antibodies: Presentation and Treatment With Intravenous Immunoglobulin. J Clin Neuromuscul Dis 2022; 24:26-37. [PMID: 36005471 DOI: 10.1097/cnd.0000000000000423] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Up to 50% of small fiber neuropathy (SFN) cases are idiopathic, but novel antibodies to Trisulfated Heparin Disaccharide (TS-HDS) and fibroblast growth factor receptor 3 (FGFR-3) have been implicated in half of these cases; the role of anti-Plexin D1 is less clear. We aimed to clarify presentation and management of these patients. METHODS An 18-month retrospective analysis revealed 54 cases of cryptogenic SFN who had testing for the 3 autoantibodies. Demographics, clinical features, epidermal nerve fiber density, and Quantitative Sudomotor Axon Reflex Test results were analyzed. Intravenous immunoglobulin (IVIG) treatment response was assessed. RESULTS In total, 44.4% of patients had antibodies (62.5% TS-HDS, 29.2% FGFR-3, and 20.8% Plexin D1). Male patients were more likely to be FGFR-3 positive (P = 0.014). Facial involvement was more common in seropositive patients (P = 0.034), and patients with a higher Utah Early Neuropathy Scale score had a higher TS-HDS titer (P = 0.0469), but other clinical features were not significantly different. Seropositive patients trended toward a higher SFN screening list score (P = 0.16), abnormal Quantitative Sudomotor Axon Reflex Test (P = 0.052), and prior erroneous diagnosis (P = 0.19). In patients who completed IVIG, examinations and questionnaires improved and mean epidermal nerve fiber density increased by 297%. CONCLUSIONS TS-HDS, FGFR-3, and Plexin D1 antibodies are present in a high proportion of cryptogenic SFN cases with more facial involvement, and greater disease severity is associated with higher antibody titers. They are often misdiagnosed but may respond subjectively and objectively to IVIG.
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Affiliation(s)
- Lawrence A Zeidman
- Arlington Heights, IL; Stritch School of Medicine, Loyola University Chicago, Maywood, IL; Department of Neurology, University of Southern California, Los Angeles, CA; and Department of Neurology, Barrow Neurological Institute, Phoenix, AZ
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6
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Bartley CM, Parikshak NN, Ngo TT, Alexander JA, Zorn KC, Alvarenga BA, Kang MK, Pedriali M, Pleasure SJ, Wilson MR. Case Report: A False Negative Case of Anti-Yo Paraneoplastic Myelopathy. Front Neurol 2021; 12:728700. [PMID: 34744969 PMCID: PMC8570369 DOI: 10.3389/fneur.2021.728700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/16/2021] [Indexed: 11/22/2022] Open
Abstract
The development of autoimmune antibody panels has improved the diagnosis of paraneoplastic neurological disorders (PNDs) of the brain and spinal cord. Here, we present a case of a woman with a history of breast cancer who presented with a subacute sensory ataxia that progressed over 18 months. Her examination and diagnostic studies were consistent with a myelopathy. Metabolic, infectious, and autoimmune testing were non-diagnostic. However, she responded to empirical immunosuppression, prompting further workup for an autoimmune etiology. An unbiased autoantibody screen utilizing phage display immunoprecipitation sequencing (PhIP-Seq) identified antibodies to the anti-Yo antigens cerebellar degeneration related protein 2 like (CDR2L) and CDR2, which were subsequently validated by immunoblot and cell-based overexpression assays. Furthermore, CDR2L protein expression was restricted to HER2 expressing tumor cells in the patient's breast tissue. Recent evidence suggests that CDR2L is likely the primary antigen in anti-Yo paraneoplastic cerebellar degeneration, but anti-Yo myelopathy is poorly characterized. By immunostaining, we detected neuronal CDR2L protein expression in the murine and human spinal cord. This case demonstrates the diagnostic utility of unbiased assays in patients with suspected PNDs, supports prior observations that anti-Yo PND can be associated with isolated myelopathy, and implicates CDR2L as a potential antigen in the spinal cord.
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Affiliation(s)
- Christopher M Bartley
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Neelroop N Parikshak
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Thomas T Ngo
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Jessa A Alexander
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Kelsey C Zorn
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, United States
| | - Bonny A Alvarenga
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Min K Kang
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Massimo Pedriali
- Operative Unit of Surgical Pathology, Azienda Ospedaliera-Universitaria, Ferrara, Italy
| | - Samuel J Pleasure
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Michael R Wilson
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
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7
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Maintenance therapy with subcutaneous immunoglobulin in a patient with immune-mediated neuropathic postural tachycardia syndrome. J Transl Autoimmun 2021; 4:100112. [PMID: 34471867 PMCID: PMC8387908 DOI: 10.1016/j.jtauto.2021.100112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/14/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Aims We describe the disease course of a 35-year-old female with an autoimmune mediated neuropathic postural tachycardia syndrome (PoTS), who responded to immunoglobulin therapy and stabilized on maintenance therapy with subcutaneous immunoglobulin (SCIg). Methods We provide longitudinal data of clinical scores, tilt-table results and antibody titers. Results Initial treatment with intravenous immunoglobulin caused infusion-related side-effects whereas SCIg was well tolerated and improved clinical symptoms and quality of life. Clinical improvement correlated with the reduction of serum antibody titers 22 months after first infusion. Conclusions These findings suggest that autoimmune-mediated neuropathic PoTS can be treated sufficiently with IVIg whereas SCIg minimizes side-effects.
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8
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Clinical Features and Treatment Response in Immune-Mediated Small Fiber Neuropathy with Trisulfated Heparin Disaccharide or Fibroblast Growth Factor Receptor 3 Antibodies. J Clin Neuromuscul Dis 2021; 22:192-199. [PMID: 34019003 DOI: 10.1097/cnd.0000000000000355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Novel antibodies to trisulfated heparin disaccharide (TS-HDS) and fibroblast growth factor receptor 3 (FGFR-3) have been recently described in otherwise cryptogenic small fiber neuropathy (SFN) cases. Our goal was to further describe clinical features in such cases and to analyze treatment responses. METHODS In a retrospective analysis, 40 cases of cryptogenic SFN in a university neuropathy clinic were identified. Of these, TS-HDS and FGFR-3 cases were identified, and clinical features and treatment responses were analyzed. RESULTS In this cohort, 95% were women, and 55% had either TS-HDS or FGFR-3 antibodies (77% of these had TS-HDS). Of the seropositive group, 41% had a nonlength dependent epidermal nerve fiber density on skin punch biopsy (OR = 1.80). In the seropositive group, 82% had neuropathic pain as their primary symptom (OR = 1.73). Also 32% of seropositive patients reported widespread pain (OR = 1.63). 63% of seropositive cases presented acutely (OR = 11.0). In the seropositive group, 23% had an initial erroneous diagnosis (OR = 1.47). Eight seropositive patients improved on intravenous immunoglobulin treatment, with a 42% reduction in pain scores (P = 0.02), a 44% reduction in the Utah Neuropathy Score, and improved epidermal nerve fiber density post-treatment. CONCLUSIONS TS-HDS and FGFR-3 antibodies may be present in a high proportion of cryptogenic SFN cases with acute onset, nonlength dependent pathology, and primary neuropathic and widespread pain. They are often misdiagnosed as other conditions including fibromyalgia. These cases may be responsive to immune treatment, especially with intravenous immunoglobulin.
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9
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Trevino JA, Novak P. TS‐HDS
and
FGFR3
antibodies in small fiber neuropathy and Dysautonomia. Muscle Nerve 2021; 64:70-76. [DOI: 10.1002/mus.27245] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Jorge A. Trevino
- Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
| | - Peter Novak
- Department of Neurology Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
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10
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Nagarajan E, Kang SA, Holmes C, Govindarajan R. Clinical features with anti fibroblast growth factor receptor 3 (FGFR3) antibody-related polyneuropathy: a retrospective study. BMC Neurol 2021; 21:74. [PMID: 33588772 PMCID: PMC7883452 DOI: 10.1186/s12883-021-02090-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background Despite its initial association with sensory neuropathies, anti-fibroblast growth factor receptor 3 (FGFR3) antibodies have been since reported with a broad range of neuropathies and clinical features. The aim of the study is to report the clinical and electro diagnostic findings in a cohort of patients with sensory or sensorimotor polyneuropathy and anti-FGFR3 antibodies. Methods We performed a retrospective chart review to assess the clinical characteristics of patients with sensory or sensorimotor neuropathy related to FGFR3 antibodies. Descriptive statistics were reported using frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables. Results This study included 14 patients (9 women) with a median age of 51.9 years (IQR 48–57). The most common presenting symptoms were painful paresthesia (100%), gait instability (42.9%), constitutional symptoms (42.9%), and autonomic symptoms (28.6%). Onset of symptoms was chronic (≥12 weeks) in eight patients (57.1%). Examination showed a distal loss of sensation to pin prick (100%), as well as impaired vibration sensation (78.6%) and proprioception (35.7%), in the distal extremities. We also observed mild weakness in the distal lower-extremities (42.9%). Three patients (21.4%) had trigeminal neuralgia, three patients (21.4%) had co-existing autoimmune disease, and one patient (7.1%) had a history of renal cell carcinoma. The mean titer of FGFR3 antibody was 14,285.71 (IQR 5000–16,750). All 14 patients produced normal results in the neuropathy workup. Nerve conduction study and electromyography showed sensory axonal neuropathy in four patients (28.6%), sensorimotor axonal neuropathy in seven patients (50%), and a normal result in three patients (21.4%). For those with a normal NCS/EMG, a skin biopsy showed a non-length-dependent small fiber neuropathy. Conclusions Neuropathy related to FGFR3 antibodies can potentially involve small and large fibers, sensory and motor fibers, and even the trigeminal nerve, which contributes to a highly variable clinical presentation. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02090-2.
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Affiliation(s)
- Elanagan Nagarajan
- Department of Neurology, University of Missouri School of Medicine, Columbia, MO, 65212, USA
| | - Seung Ah Kang
- Department of Neurology, University of Missouri School of Medicine, Columbia, MO, 65212, USA.
| | - Carmen Holmes
- Department of Neurology, University of Missouri School of Medicine, Columbia, MO, 65212, USA
| | - Raghav Govindarajan
- Department of Neurology, University of Missouri School of Medicine, Columbia, MO, 65212, USA
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11
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Abstract
Small fiber neuropathy has a broad array of presentations. Length-dependent symptoms and findings present little diagnostic difficulty, but non-length-dependent or multifocal symptoms can be challenging. Intraepidermal nerve fiber density (IENFD) testing in apparent fibromyalgia warrants further study, but skin biopsy testing of this patient population is reasonable. Avoidance of IENFD testing in situations where diagnosis of neuropathy is already clear or where neuropathy is not the cause of symptoms helps to prevent incorrect conclusions. Careful history and physical examination plus pretest probability are important factors to consider when assessing the results of an IENFD test report.
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Affiliation(s)
- David S Saperstein
- Center for Complex Neurology, EDS & POTS, University of Arizona College of Medicine, 1010 East McDowell Road, Suite 101, Phoenix, AZ 85006, USA.
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12
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Abstract
Small fiber neuropathy (SFN) is a prevalent neurologic syndrome. Testing methods have emerged in recent years to better diagnose it, including autonomic tests and skin punch biopsy. SFN can present in a non-length-dependent fashion and can be mistaken for syndromes such as fibromyalgia and complex regional pain syndrome. SFN is caused by a variety of metabolic, infectious, genetic, and inflammatory diseases. Recently treatments have emerged for TTR amyloid neuropathy and Fabry disease, and novel biomarkers have been found both in genetic and inflammatory SFN syndromes. Ongoing trials attempt to establish the efficacy of intravenous immunoglobulin in inflammatory SFN syndromes.
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Affiliation(s)
- Lawrence A Zeidman
- Neuromuscular-EMG Division, Department of Neurology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, 2160 South First Avenue, Maguire Building - Room 2700, Maywood, IL 60153-3328, USA.
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13
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Affiliation(s)
- Anthony A Amato
- From Brigham and Women's Hospital and Harvard Medical School, Boston (A.A.A.)
| | - Allan H Ropper
- From Brigham and Women's Hospital and Harvard Medical School, Boston (A.A.A.)
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14
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Kovvuru S, Cardenas YC, Huttner A, Nowak RJ, Roy B. Clinical characteristics of fibroblast growth factor receptor 3 antibody-related polyneuropathy: a retrospective study. Eur J Neurol 2020; 27:1310-1318. [PMID: 32068339 DOI: 10.1111/ene.14180] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 02/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Autoantibodies are increasingly being used as a diagnostic biomarker of chronic inflammatory neuropathies. However, their role and associated clinical syndrome are not well defined. METHODS This retrospective chart review evaluated the clinical presentation, diagnostic workup and therapeutic responses in fibroblast growth factor receptor 3 (FGFR3) antibody-associated neuropathy. RESULTS A total of 27 patients [14 men, aged 29-87 (65 ± 14) years] with positive FGFR3 antibody were included. Distal lower-extremity paresthesia (66%), unsteady gait (26%) and foot drop (11%) were common presenting symptoms. Symptom onset was acute in four (15%) cases. Distal lower-extremity weakness (mild in eight and severe in three patients) was the most frequent motor finding. Decreased distal sensation to pinprick (59%) and loss of vibration sensation (37%) were observed. Titer of FGFR3 ranged between 3100 and 30 000 (normal < 3000) with a mean of 10 688 ± 7284. Apart from the occasional association of other neuropathy-related autoantibodies, comprehensive neuropathy workup was otherwise unrevealing. Six patients had other autoimmune disease and seven patients had a history of cancer. Electromyography reflected sensorimotor neuropathy with mixed axonal and demyelinating features in 11 cases. Pure sensory neuropathy was noted in three patients. Demyelination was found in five of six nerve biopsies. Intravenous immunoglobulin response was observed in 8/10 treated patients. CONCLUSIONS The FGFR3 antibody appears not to be restricted to sensory neuropathy only. Its role in the pathogenicity of chronic inflammatory neuropathies is not yet well established and, although there may be a role for immunotherapy, larger studies are warranted.
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Affiliation(s)
- S Kovvuru
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.,Department of Neurology, University of Arkansas, Little Rock, AR, USA
| | - Y C Cardenas
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - A Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - R J Nowak
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - B Roy
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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Tholance Y, Moritz CP, Rosier C, Ferraud K, Lassablière F, Reynaud-Federspiel E, França MC, Martinez ARM, Camdessanché JP, Antoine JC. Clinical characterisation of sensory neuropathy with anti-FGFR3 autoantibodies. J Neurol Neurosurg Psychiatry 2020; 91:49-57. [PMID: 31690697 DOI: 10.1136/jnnp-2019-321849] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/15/2019] [Accepted: 10/28/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Sensory neuropathies (SNs) are often classified as idiopathic even if immunological mechanisms can be suspected. Antibodies against the intracellular domain of the fibroblast growth factor receptor 3 (FGFR3) possibly identify a subgroup of SN affecting mostly the dorsal root ganglion (DRG). The aim of this study was to identify the frequency of anti-FGFR3 antibodies and the associated clinical pattern in a large cohort of patients with SN. METHODS A prospective, multicentric, European and Brazilian study included adults with pure SN. Serum anti-FGRF3 antibodies were analysed by ELISA. Detailed clinical and paraclinical data were collected for each anti-FGFR3-positive patient and as control for anti-FGFR3-negative patients from the same centres ('center-matched'). RESULTS Sixty-five patients out of 426 (15%) had anti-FGFR3 antibodies, which were the only identified autoimmune markers in 43 patients (66%). The neuropathy was non-length dependent in 89% and classified as sensory neuronopathy in 64%, non-length-dependent small fibre neuropathy in 17% and other neuropathy in 19%. Specific clinical features occurred after 5-6 years of evolution including frequent paresthesia, predominant clinical and electrophysiological involvement of the lower limbs, and a less frequent mixed large and small fibre involvement. Brazilians had a higher frequency of anti-FGFR3 antibodies than Europeans (36% vs 13%, p<0.001), and a more frequent asymmetrical distribution of symptoms (OR 169, 95% CI 3.4 to 8424). CONCLUSIONS Anti-FGFR3 antibodies occur in a subgroup of SN probably predominantly affecting the DRG. Differences between Europeans and Brazilians could suggest involvement of genetic or environmental factors.
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Affiliation(s)
- Yannick Tholance
- Laboratory of Biochemistry, CHU Saint-Etienne, Saint-Etienne, France .,Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France
| | - Christian Peter Moritz
- Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France
| | - Carole Rosier
- Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France.,Department of Neurology, CHU Saint-Etienne, Saint-Etienne, France
| | - Karine Ferraud
- Department of Neurology, CHU Saint-Etienne, Saint-Etienne, France
| | - François Lassablière
- Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France
| | | | - Marcondes C França
- Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Alberto R M Martinez
- Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Jean-Philippe Camdessanché
- Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France.,Department of Neurology, CHU Saint-Etienne, Saint-Etienne, France
| | - Jean-Christophe Antoine
- Synaptopathies et autoanticorps (synatac), Institut Neuromyogène, Saint-Priest-en-Jarez, France.,Department of Neurology, CHU Saint-Etienne, Saint-Etienne, France
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